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. 2025 Apr 5;12(4):e70180. doi: 10.1002/nop2.70180

The Roles of Parental Psychological Flexibility, Mindfulness, and Self‐Compassion in Affecting Mental Health and Self‐Efficacy in Parents of Children With or Without Hearing Loss: An Analysis of the Parallel Mediation Model

Jiao Xie 1,2, Li Yang 1, Sini Li 3,✉
PMCID: PMC11972014  PMID: 40186878

ABSTRACT

Aim

The study aimed to investigate the factors that influence parental self‐efficacy and to examine the roles of psychological flexibility, mindful awareness, and self‐compassion in promoting parental mental health outcomes and self‐efficacy in providing care for children with or without congenital hearing loss (HL).

Design

A descriptive, cross‐sectional study.

Methods

Cross‐sectional data from 540 parents of children with (Sample 1; n = 204) or without (Sample 2; n = 336) congenital HL were collected through online questionnaires. The researchers constructed a mediation model and conducted various statistical analyses, including stepwise regressions, t tests, correlations, and mediation analyses.

Results

The results indicated that for parents of children both with and without congenital HL, parental mental health symptoms (e.g., parental stress, depression, and anxiety) were negatively associated with parental self‐efficacy, psychological flexibility, mindful awareness, and self‐compassion (r values ranged from 0.68 to 0.27, all p values < 0.01). The results revealed that parental mental health symptoms had direct (β ranging from −0.29 to −0.18) and indirect effects (β ranging from −0.85 to −0.33) on parental self‐efficacy in both groups. Psychological inflexibility (β ranging from −0.39 to −0.18), mindful awareness (β ranging from −0.22 to −0.07), and self‐compassion (β ranging from −0.29 to −0.08) mediated the relationship between mental health symptoms and parental self‐efficacy. Among these factors, psychological inflexibility emerged as the strongest mediator and predictor (with the proportion mediated ranging from 32.50% to 38.10%).

Patient or Public Contribution

The participation of parents in this study provided valuable insights into the factors that influence parental mental health outcomes and self‐efficacy in providing care for children with or without congenital HL. Nurses could develop interventions such as workshops, support groups, and individualised care plans that target psychological flexibility, mindful awareness, self‐compassion, and mental health support, which have the potential to increase parental well‐being and improve confidence in caregiving.

Keywords: congenital hearing loss, mental health, mindful awareness, psychological flexibility, self‐compassion, self‐efficacy

1. Introduction

Parents' influence on children's lives is significant and long‐lasting. Parents play a crucial role in fostering children's physical, cognitive, and socioemotional growth (Frosch et al. 2021). However, being a parent also involves a range of emotions, described by (Kabat‐Zinn and Hanh 2013) as the “full catastrophe,” that encompasses everything from happiness to despair and from pride to anger. Unfortunately, parenting a child with a medical condition, such as congenital hearing loss (HL), presents even greater challenges than raising a child without such a condition (Zaidman‐Zait et al. 2015).

Congenital HL refers to hearing impairments that are present at birth and typically result from damage to the ear's ability to convert mechanical energy from sound vibrations into electrical impulses for neural transmission (Korver et al. 2017). Congenital HL has various degrees (from mild [26–40 dB] to profound [> 91 dB]), types (conductive, sensorineural, or mixed), laterality (unilateral or bilateral), and permanence (temporary or permanent) (Renauld and Basch 2021). Congenital HL is a highly widespread chronic condition in children worldwide and impacts almost 34 million children (World Health Organization 2023). This medical issue can significantly impair children's ability to develop effective communication and interpersonal skills, acquire language, and perform well in social, emotional, cognitive, educational, and occupational areas throughout their entire life (Wong et al. 2018).

Parents of children with congenital HL face numerous challenges and difficulties, such as psychological distress, communication difficulties, educational navigation, social adaptation issues, and complex medical decisions, all of which can adversely affect their mental health and the effectiveness of their caregiving (Gunjawate et al. 2023). These parents often experience high levels of mental health symptoms, such as parental stress, depression, and anxiety (Sarant and Garrard 2014; Spahn et al. 2003). Furthermore, they may lack self‐efficacy to effectively address their children's communication needs due to their limited understanding of congenital HL, parenting skills, and available rehabilitation interventions and information (Marie et al. 2023). Parental self‐efficacy is an important internal resource that refers to parents' belief about their ability to effectively fulfil their responsibilities in raising their children (Albanese et al. 2019). In the context of raising children with hearing loss, parental self‐efficacy plays a crucial role in influencing parents' mental health and various psychosocial outcomes. According to the conceptual model of family‐centered early intervention for families of children with HL (Holzinger et al. 2022), the negative effects of parents' mental health symptoms and diminished parenting self‐efficacy extend to family coping, adjustment, interactions, parenting behaviour, and strategies and ultimately impact the health outcomes of children with HL. This conceptual model suggests that parents of children with congenital HL who possess higher levels of parental mental health and self‐efficacy may have greater resources and abilities to cope with the stressors associated with their children's conditions and to effectively manage those conditions. Providing support to these parents in addressing their emotional difficulties can help them navigate their child's condition and challenges, improve their parental self‐efficacy and effectiveness, and ultimately enhance the health outcomes of their child.

1.1. Psychological Flexibility, Mindful Awareness, and Self‐Compassion

Studies have increasingly investigated the potential benefits of embracing internal sensations and experiences to facilitate parents' psychological adjustment and adaptation as they navigate their children's chronic conditions (Cousineau et al. 2019; Li et al. 2023). Leeming and Hayes (2016) demonstrated that fostering psychological resources such as psychological flexibility, mindful awareness, and self‐compassion in parents' daily caregiving practices enhances their psychological well‐being and their ability to cultivate healthier family environments with a particular focus on the therapeutic processes of acceptance. These three constructs prioritise being fully present and cultivating nonjudgmental awareness of personal experiences while redirecting attention toward one's relationship with these experiences rather than their specific details (Harris and Hayes 2009). Recent studies have highlighted the importance of exploring the combined effects of these three therapeutic components on parental mental health and self‐efficacy among parents of children with typical development (Chorão et al. 2022) and parents of children with chronic illnesses (Pyszkowska and Górnik‐Durose 2023).

Parental psychological flexibility involves parents' ability to skillfully manage the complex psychological demands of parenting while simultaneously aligning their parenting practices with their personal values and their values related to parenting (Leeming and Hayes 2016). Research has indicated that parents of children with HL who possess higher levels of parental psychological flexibility tend to experience lower levels of mental health issues, including stress, anxiety, and depressive symptoms (Ong et al. 2019; Xiao et al. 2024) than parents of children with normal hearing (Fonseca et al. 2020) as well as greater overall well‐being (Benjamin et al. 2020; Munoz et al. 2021). Additionally, greater parental psychological flexibility enables parents of children both with and without HL to redefine parenting, adjust their parenting priorities, actively acquire parenting skills, rationally select suitable treatments, sensitively engage in parent–child interactions, and effectively respond to their children's needs (Drouillard 2019; Whittingham and Coyne 2019). In turn, this enhances parents' self‐efficacy and improves their children's health outcomes through adaptive parenting practices and styles (Byrne et al. 2021; Li et al. 2023).

Parental mindful awareness, a cognitive state characterised by moment‐to‐moment, nonjudgmental awareness, allows parents to recognise and embrace their emotions, thoughts, and physical sensations associated with parenting (Kabat‐Zinn 2005). Numerous studies have demonstrated the positive impact of parental mindful awareness on the mental health and well‐being of both parents (Xie et al. 2021) and children with various chronic diseases (e.g., developmental disabilities or delays) (Osborn et al. 2021). Integrating mindful awareness into parenting approaches has been shown to reduce reactivity and increase patience when addressing challenging behaviours and emotions in children (Li, Yong et al. 2024). Additionally, mindful awareness enhances parents' awareness and enables them to recognise and genuinely appreciate their children's strengths, adaptive behaviours, and prosocial activities (Cheung and Wang 2022).

Self‐compassion, which is rooted in Buddhist psychology, entails cultivating a gentle and compassionate stance toward oneself amidst suffering, recognising that one's experiences are part of the shared human condition, and mindfully acknowledging challenging experiences without becoming excessively attached to them (Neff 2003). Previous studies have consistently demonstrated a significant and inverse relationship between self‐compassion and symptoms of mental health as well as a positive correlation with quality of life (Chong et al. 2023). Cultivating and strengthening this skill through practical exercises can be beneficial for parents of children with or without HL (Azizi et al. 2021; Jefferson et al. 2020). Parents who possess a high level of self‐compassion are attuned to their emotional states and demonstrate kindness and warmth toward themselves (Reilly and Stuyvenberg 2023). They prioritise self‐care and perceive their challenges as common experiences, which protects them from stressors and adverse psychological outcomes (Sirois et al. 2019).

Given the aforementioned advantages, enhancing parents' mental health and well‐being through evidence‐based interventions is crucial. According to our previous systematic reviews and meta‐analyses (Li et al. 2023; Li, Yong et al. 2024; Li, Chien et al. 2024), an increasing number of randomised controlled trials aimed at enhancing parents' psychological resources and mental health, such as acceptance and commitment therapy (ACT)‐based interventions and mindfulness‐based interventions, are being conducted by well‐trained mental health nurses. Mental health nurses are uniquely positioned to support parents by implementing these interventions in clinical settings, providing education, and facilitating access to mental health resources (Vives‐Espelta et al. 2022). Their involvement can significantly enhance the effectiveness of interventions and programs for parental support and can ultimately contribute to better psychological outcomes for parents, healthier family dynamics, and improved overall well‐being for children with and without congenital HL. By integrating nursing perspectives into this research, we can better understand the multifaceted support systems necessary to promote parental mental health.

1.2. The Present Study

The importance of psychological flexibility, mindful awareness, and self‐compassion in enhancing the mental health and parental self‐efficacy of parents of children with medical conditions and special healthcare needs is consistently emphasised in theoretical frameworks and empirical studies. Research in a variety of caring scenarios has shown that these psychological resources have beneficial impacts, such as lowering psychological distress and enhancing general well‐being. The precise roles of these elements in families of children with congenital HL, however, have not been explored. Comprehending these relationships is essential for developing parent‐focused interventions that address the distinct psychological obstacles encountered by these parents. Furthermore, there are two reasons to research parental mental health symptoms, such as stress, depression, anxiety, and self‐efficacy, in this population. To reduce the detrimental psychological effects that are frequently associated with providing long‐term care, it is necessary to identify the possible protective effects of psychological flexibility, mindful awareness, and self‐compassion. Furthermore, examining these symptoms offers a thorough grasp of parents' mental health and provides insightful information on the difficulties parents face and ways to help them.

The objective of this study is to examine whether parental psychological flexibility, mindful awareness, and self‐compassion mediate the association between parental mental health symptoms (such as parental stress, depression, and anxiety) and parental self‐efficacy. Additionally, this study aims to explore the distinct contributions of each of these factors to parental self‐efficacy in parents of children with or without congenital HL. The outcomes of this study offer valuable insights for the development of tailored family support interventions that enhance both mental health and self‐efficacy in parents, regardless of their children's congenital HL status.

2. Methods

2.1. Participants

The present study utilised a cross‐sectional online survey design that followed the guidelines outlined in the STrengthening the Reporting of Observational studies in Epidemiology (STROBE) statement (von Elm et al. 2007) to collect data. Convenience sampling was used to recruit parents from four kindergartens and the outpatient and inpatient departments of the otolaryngology department in two tertiary hospitals in Changsha, Hunan Province, mainland China, between May and October 2023. The data analysed in this study originated from two distinct samples that represented parents of children with (sample 1) and without (sample 2) congenital HL.

Participants were recruited if they (1) were over 18 years old; (2) were fathers or mothers of preschool‐aged children (aged ≤ 6 years) with or without congenital HL; (3) lived with their children and were primarily responsible for the daily care of their children (at least 4 h per day devoted to caregiving); and (4) were able to understand and complete questionnaires online with a mobile phone or computer. Participants were excluded if they (1) were diagnosed with severe psychiatric or medical diseases that prevented them from engaging and participating in the study; (2) were taking care of one or more other family members with acute/severe/chronic illnesses; (3) had a planned or current hospital admission of their children; or (4) were currently enrolled in parent support interventions.

2.2. Procedure

Parents who expressed interest in participating were provided with access to the online questionnaires by scanning the QR code on the recruitment information sheet. A set of pretest questions was administered to determine the eligibility of the respondents on the basis of the study criteria. Ineligible participants were unable to proceed with the study questionnaire and received a message acknowledging their interest in the study. All participants who met the inclusion criteria were required to read and comprehend the information sheet. Research assistants were available to provide assistance and address any questions or concerns raised by the participants. The data were collected after participants signed the consent form.

2.3. Ethical Considerations

Ethical approval for this study was obtained from the Survey and Behavioural Research Ethics Committee of Second Xiangya Hospital, Central South University (Reference No. LYF2022219). Eligible participants were required to provide informed consent by signing a consent form before data collection. The research assistant emphasised the protection of human dignity as well as the participants' rights to self‐determination and informed consent to potential eligible participants. They had the autonomy to decide whether to partake in the research without the concern of facing discrimination. All electronic data are stored on a password‐protected USB drive and backed up in a password‐protected cloud service (i.e., Google Drive). To ensure confidentiality, access to the research data was restricted to the researcher, and personal data were encrypted to maintain anonymity. All data will be retained for 6 years and will be eliminated after this period.

2.4. Measures

A self‐developed sociodemographic and clinical data sheet was used to collect the information and characteristics of parents and children.

The Chinese version of the Parenting Stress Index‐Short Form (PSI‐SF‐15) is a concise self‐report questionnaire derived from the original PSI‐SF (36 items). It is designed to assess three domains: parental distress (PD), parent–child dysfunctional interaction (PCDI), and difficult children (DC) (Abidin et al. 2006). Respondents rate the items on a 5‐point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). The Chinese version of the PSI‐SF‐15 has demonstrated good internal consistency in Chinese parents, with Cronbach's α values of 0.87/0.86 for the total scale and 0.71/0.72, 0.82/0.78, and 0.79/0.78 for PD, PCDI, and DC, respectively (Luo et al. 2021).

The Patient Health Questionnaire (PHQ‐9) is a self‐report questionnaire consisting of nine items that measure depressive symptoms on a 4‐point Likert scale (0—“not at all” to 3—“nearly every day”) (Kroenke et al. 2001). Higher scores indicate greater severity of depressive symptoms. The Chinese version of the PHQ‐9 has been validated in community‐dwelling adults and has shown good internal consistency reliability (α = 0.86) (Wang et al. 2014).

The Generalised Anxiety Disorder‐7 (GAD‐7) is a self‐report questionnaire with seven items that assess anxiety symptoms on a 4‐point Likert scale (0—“not at all” to 3—“nearly every day”) (Spitzer et al. 2006). Higher scores indicate greater severity of anxiety disorders. The Chinese version of the GAD‐7 has been validated in outpatients from traditional Chinese internal departments and has demonstrated excellent internal consistency reliability (α = 0.91) (Zeng et al. 2013).

The Parenting Sense of Competence Scale (PSOC) (Johnston and Mash 1989) is a self‐report questionnaire comprising 17 items that evaluate parental self‐efficacy on a 6‐point Likert scale (1 = “strongly disagree” to 6 = “strongly agree”). It includes two subscales: the efficacy subscale (eight items assessing parents' perceived competence in the parenting role) and the satisfaction subscale (nine items examining parents' satisfaction and comfort with the parenting role). Higher scores indicate a greater sense of parental self‐efficacy and satisfaction in parenting. The Chinese version of the PSOC has been validated in Chinese mothers of preschool children and has shown excellent internal consistency (α = 0.87) (Li et al. 2021).

The Parent Assessment Questionnaire (6‐PAQ) is an 18‐item self‐report questionnaire that measures PF on a 4‐point Likert scale (1 = “strongly disagree/never” to 4 = “strongly agree/almost always”) (Greene et al. 2015). It includes six domains: acceptance, cognitive defusion, being present, self‐as‐context, values, and committed action. Higher scores indicate greater parental psychological inflexibility. The Chinese version of the 6‐PAQ (6‐PAQ‐C) has been validated in parents of children with or without congenital HL and has demonstrated excellent internal consistency reliability (α = 0.936 for the total sample).

The Mindful Attention Awareness Scale (MAAS) (Brown and Ryan 2003) is a 15‐item self‐report questionnaire that assesses dispositional (or trait) mindful awareness on a 6‐point Likert scale (1—“almost always” to 6—“almost never”). Higher scores indicate a higher level of mindful awareness in the present moment. The Chinese version of the MAAS has been validated in Chinese college students and has good internal consistency reliability (α = 0.89) (Chen et al. 2012).

The Self‐Compassion Scale, Short Form (SCS‐SF) (Raes et al. 2011) is a 12‐item self‐report questionnaire that measures self‐compassion across six subscales, including self‐kindness, mindfulness, isolation, overidentification, common humanity, and self‐judgement. The items are rated on a 5‐point Likert scale ranging from 1 (“almost never”) to 5 (“almost always”). Higher scores indicate higher levels of self‐compassion. The Chinese version of the SCS‐SF has been validated with Chinese college students with good internal consistency ranging from 0.77 to 0.8 (Huang et al. 2023).

2.5. Data Analysis

We employed SPSS statistical software version 25 to conduct descriptive statistics and correlational analyses. The means, standard deviations, and percentages were used to describe the sociodemographic variables of parents and children. Bivariate Pearson's correlation coefficients (r) were utilised to examine the associations between parental stress, depression, anxiety, self‐efficacy, psychological inflexibility, mindful awareness, and self‐compassion. To explore potential confounding variables, univariate association analyses were conducted to identify the demographic variables of parent–child dyads and the parental variables of interest for inclusion as controlled variables in the hierarchical regression models. To interpret the effect sizes for absolute r, the following guidelines were adopted: > 0.10 indicated a small effect, > 0.30 indicated a medium effect, and > 0.50 indicated a large effect (Cohen 2013). In cases where item‐level responses were missing by less than 25%, the missing data were prorated. Pairwise deletion was employed for entirely missing data. We tested the normality of all variables using kurtosis statistics and scatterplots. Statistical significance for all analyses was determined using a significance level of p < 0.05.

To investigate the relationship between mental health symptoms (e.g., parental stress, depression, and anxiety) and parental self‐efficacy, we constructed a parallel mediation model. In this model, parental psychological inflexibility, mindful awareness, and self‐compassion served as mediating variables. Hierarchical regression analyses were used to explore the relationships between potential predictors. To examine the mediating effects, we employed the bias‐corrected bootstrapping method with the PROCESS macro 4.1 (Model 4) developed by (Hayes 2017), which uses 5000 iterations and bootstrapped 95% confidence intervals (CIs). Mediation was considered significant if the confidence intervals of the indirect effects did not include zero. A variable was considered a potential mediator if there was a significant relationship between the independent variable and the mediator as well as a significant relationship between the mediator and the dependent variable. Notably, the independent variable did not necessarily have to be significantly related to the dependent variable for mediation to occur because mediation can still be present even in the absence of this relationship (MacKinnon and Fairchild 2009). The statistics of the variance inflation factors (VIFs) were applied to evaluate multicollinearity.

3. Results

3.1. Characteristics of the Participants

A total of 736 eligible parents who met the inclusion criteria during the prescreening process were invited to take part in the study. Among these parents, 540 (73.4%) successfully completed the study. The average age of the overall sample (n = 540) was 34.43 years (SD = 5.04); 87.6% of participants were identified as female, and 95.4% were married. The mean age of their children was 4.42 years (SD: 1.30), and 57.2% of the children were male. In Sample 1 (n = 204; parents of children with congenital HL), the majority of parents (88.7%) were female, with an average age of 34.45 years (SD = 6.02). The mean age of their children with congenital HL was 4.56 years (SD: 1.33), and 56.4% of the children were male. For Sample 2 (n = 336; parents of children without congenital HL), the majority of parents (86.9%) were female, with a mean age of 34.41 years (SD = 4.20). The mean age of their children without congenital HL was 4.34 years (SD: 1.29), and 57.7% of the children were male. The baseline sociodemographic characteristics of the participants and their children are listed in Table S1.

3.2. Descriptive Statistics and Correlation Analyses

Satisfactory standard skewness and kurtosis scores of the PSI‐SF‐15, PHQ‐9, GAD‐7, PSOC, 6‐PAQ‐C, MAAS, and SCS‐SF (range: −0.93 and 1.72; Table S2) indicated that the normality of these variables was established.

The descriptive statistics for parental stress, depression, anxiety, self‐efficacy, psychological inflexibility, mindful awareness, and self‐compassion and the Pearson correlations among these variables are presented in Table 1 and Table S3. Compared with Sample 2, Sample 1 presented a nonsignificantly lower level of parental stress (mean difference = 0.85, SE = 0.92, p = 0.053). Conversely, Sample 1 showed nonsignificantly higher levels of parental depression (mean difference = −1.21, SE = 0.49, p = 0.091) and anxiety (mean difference = −1.30, SE = 0.43, p = 0.073). With respect to psychological resources, Sample 1 demonstrated a somewhat nonsignificantly higher level of parental psychological inflexibility (mean difference = −0.86, SE = 0.57, p = 0.23) and nonsignificantly lower levels of parental mindful awareness (mean difference = 0.20, SE = 1.20, p = 0.83) and self‐compassion (mean difference = 1.94, SE = 0.49, p = 0.86). Notably, Sample 1 presented significantly lower levels of parenting self‐efficacy than Sample 2 (mean difference = 4.25, SE = 0.10, p = 0.035).

TABLE 1.

Descriptive statistics and correlations among variables in different samples.

Variables 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7
Total sample (n = 540) Parent of children with congenital hearing loss (n = 204) Parent of children without congenital hearing loss (n = 336)
1. PSI‐SF‐15 1 1 1
2. PHQ‐9 0.65** 1 0.63** 1 0.68** 1
3. GAD‐7 0.57** 0.84** 1 0.61** 0.87** 1 0.57** 0.82** 1
4. PSOC −0.57** −0.53** −0.50** 1 −0.64** −0.52** −0.50** 1 −0.57** −0.52** −0.49** 1
5. 6‐PAQ‐C 0.66** 0.51** 0.48** −0.64** 1 0.65** 0.44** 0.41** −0.65** 1 0.67** 0.56** 0.52** −0.63** 1
6. MAAS −0.34** −0.43** −0.40** 0.53** −0.39** 1 −0.49** −0.54** −0.48** 0.51** −0.41** 1 −0.27** −0.36** −0.36** 0.55** −0.38** 1
7. SCS‐SF −0.43** −0.50** −0.49** 0.58** −0.47** 0.45** 1 −0.47** −0.54** −0.54** 0.57** −0.46** 0.44** 1 −0.43** −0.47** −0.43** 0.57** −0.46** 0.46** 1
Mean 33.59 6.09 4.40 67.35 37.20 63.79 38.72 33.06 6.85 5.21 64.71 37.74 63.67 37.51 33.92 5.63 3.91 68.96 36.88 63.87 39.46
SD 10.39 5.52 4.87 11.41 6.48 13.5 5.55 9.25 5.78 5.16 11.49 6.22 13.1 5.27 11.03 5.32 4.63 11.07 6.62 13.76 5.59
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Abbreviations: 6‐PAQ‐C = The Chinese version of the parental acceptance questionnaire; GAD‐7 = Generalised Anxiety Disorder‐7; MAAS = Mindful Attention Awareness Scale; PHQ‐9 = Patient Health Questionnaire‐9; PSI‐SF‐15 = Parenting Stress Index‐Short Form‐15; PSOC = Parenting Sense of Competence Scale; SCS‐SF = Self‐Compassion Scale‐Short Form.

**

p < 0.01.

Pearson's correlations indicated significant associations between all variables across the samples (refer to Table 1). Parental mental health symptoms such as parental stress, depression, and anxiety were positively associated with psychological inflexibility and negatively associated with parental self‐efficacy, mindful awareness, and self‐compassion in the total sample as well as in Samples 1 and 2. Furthermore, positive associations were found between parental self‐efficacy, psychological flexibility, mindful awareness, and self‐compassion across the samples.

3.3. Univariate Analyses and Hierarchical Regression Analyses

The univariate association analyses between the demographic variables of parent–child dyads and parental outcomes are detailed in Table S4. In Sample 1, significant associations were observed between parental outcomes and parents' age, education level, employment status, monthly household income, and number of diagnosed chronic diseases, the child's gender, and the number of comorbidities. In Sample 2, significant correlations included parents' age, relationship with the child, marital status, education level, monthly household income, number of diagnosed chronic diseases, and weekly caregiving hours and the child's age. Across the total sample, significant correlations with parental outcomes were noted for parents' age, relationship with the child, education level, and employment status, spouse's employment status, monthly household income, number of diagnosed chronic diseases, weekly caregiving hours, and the child's age. These variables were subsequently included as covariates in the hierarchical regression models.

The results of hierarchical regression analysis for the different samples are listed in Tables S5–S13. The VIF values were all < 5, indicating the absence of significant multicollinearity among the variables. In the total sample, the model that evaluated parenting self‐efficacy as the outcome indicated that the identified covariates (e.g., parents' age, relationship with the child, and education level) accounted for 12% of the variance in Step 1. In Step 2, the independent addition of parental stress, depression, and anxiety as predictor variables contributed 26%, 20%, and 18% (all p values < 0.001) of the increase in variance, respectively. In the final model, psychological inflexibility (β ranged from −0.37 to −0.30, all p values < 0.001), mindful awareness (all β values = 0.24, all p values < 0.001), and self‐compassion (all β values = 0.23, all p values < 0.001) significantly improved the model and collectively contributed an additional 47% to 48% of the increase in variance. In Sample 1, the model that evaluated parenting self‐efficacy as the outcome indicated that the identified covariates (e.g., parents' age, education level, and employment status) accounted for 12% of the variance in Step 1. In Sample 2, the identified covariates (e.g., parents' age, relationship with the child, and marital status) accounted for 13% of the variance in Step 1. In Step 2, the independent addition of parental stress, depression, and anxiety as predictor variables contributed an additional 32%, 21%, and 21% (all p values < 0.001) to the increase in variance for Sample 1, respectively, and contributed an additional 23%, 19%, and 17% (all p values < 0.001) for Sample 2, respectively. In the final model, psychological inflexibility (β ranging from −0.42 to −0.28, all p values < 0.001), mindful awareness (β ranging from 0.16 to 0.29, all p values < 0.001), and self‐compassion (β ranging from 0.21 to 0.26, all p values < 0.001) significantly improved the model and collectively contributed 45% to 49% of the increase in variance for both Samples 1 and 2.

3.4. Mediation Effects

The mediation effects of parental mental health symptoms on parental self‐efficacy through parental psychological inflexibility, mindful awareness, and self‐compassion were examined among the different samples (Table 2). In Sample 1, there was a significant total mediation effect for the relationship between parental stress/depression and parental self‐efficacy (indirect effect β ranging from −0.74 to −0.48, all 95% CIs < 0), with parental psychological inflexibility (indirect effect β ranging from −0.32 to −0.25, all 95% CIs < 0, accounting for 32.5% to 33.3% of the total effect), mindful awareness (indirect effect β ranging from −0.16 to −0.09; all 95% CIs < 0, accounting for 11.7% to 16.7% of the total effect), and self‐compassion (indirect effect β ranging from −0.26 to −0.14; all 95% CIs < 0, accounting for 18.2% to 27.1% of the total effect) all individually and partially mediating this relationship. Moreover, there was a significant total mediation effect for the relationship between parental anxiety and self‐efficacy (indirect effect = −0.82, SE = 0.13, 95% CI: [−1.07, −0.56]), with parental psychological inflexibility (indirect effect = −0.36; SE = 0.08, 95% CI: [−0.53, −0.20], accounting for 33.6% of the total effect), mindful awareness (indirect effect = −0.17; SE = 0.07, 95% CI: [−0.31, −0.05], accounting for 15.9% of the total effect), and self‐compassion (indirect effect = −0.29; SE = 0.10, 95% CI: [−0.48, −0.10], accounting for 27.1% of the total effect) fully mediating this relationship.

TABLE 2.

Results of the bootstrap method for testing multiple parallel mediation effects among different samples.

Model Point estimate Product of coefficient Boot 95% CI Proportion mediated
SE Z Lower Upper
Total sample (n = 540)
Parenting stress → Parental self‐efficacy
Total effects −0.58 0.04 −16.16 −0.66 −0.51
Direct effects −0.18 0.04 −4.73 −0.26 −0.10 31.0%
Indirect effects −0.40 0.04 −10.91 −0.47 −0.32 69.0%
Parenting stress → Parental psychological flexibility → Parental self‐efficacy −0.21 0.03 −7.27 −0.27 −0.15 36.2%
Parenting stress → Parental mindful awareness → Parental self‐efficacy −0.09 0.02 −4.75 −0.13 −0.05 15.5%
Parenting stress → Parental self‐compassion → Parental self‐efficacy −0.10 0.03 −4.29 −0.15 −0.05 17.3%
Parental depression → Parental self‐efficacy
Total effects −0.98 0.08 −14.34 −1.13 −0.83
Direct effects −0.19 0.07 −3.17 −0.33 −0.04 19.4%
Indirect effects −0.79 0.07 −11.66 −0.94 −0.66 80.6%
Parental depression → Parental psychological flexibility → Parental self‐efficacy −0.37 0.05 −8.35 −0.47 −0.28 37.8%
Parental depression → Parental mindful awareness → Parental self‐efficacy −0.20 0.04 −4.90 −0.29 −0.13 20.4%
Parental depression → Parental self‐compassion → Parental self‐efficacy −0.22 0.06 −4.35 −0.33 −0.11 22.4%
Parental anxiety → Parental self‐efficacy
Total effects −1.05 0.09 −13.50 −1.22 −0.88
Direct effects −0.20 0.08 −3.06 −0.36 −0.04 19.0%
Indirect effects −0.85 0.08 −11.47 −1.01 −0.70 81.0%
Parental anxiety → Parental psychological flexibility → Parental self‐efficacy −0.39 0.05 −8.44 −0.50 −0.30 37.1%
Parental anxiety → Parental mindful awareness → Parental self‐efficacy −0.22 0.04 −4.96 −0.31 −0.14 21.0%
Parental anxiety → Parental self‐compassion → Parental self‐efficacy −0.24 0.06 −4.35 −0.36 −0.12 22.9%
Sample 1: Parent of children with congenital hearing loss (n = 204)
Parenting stress → Parental self‐efficacy
Total effects −0.77 0.07 −11.89 −0.92 −0.63
Direct effects −0.29 0.08 −3.81 −0.46 −0.12 37.7%
Indirect effects −0.48 0.07 −7.09 −0.62 −0.34 62.3%
Parenting stress → Parental psychological flexibility → Parental self‐efficacy −0.25 0.06 −4.56 −0.37 −0.14 32.5%
Parenting stress → Parental mindful awareness → Parental self‐efficacy −0.09 0.04 −2.68 −0.16 −0.02 11.7%
Parenting stress → Parental self‐compassion → Parental self‐efficacy −0.14 0.05 −2.78 −0.25 −0.05 18.2%
Parental depression → Parental self‐efficacy
Total effects −0.96 0.12 −8.53 −1.20 −0.72
Direct effects −0.22 0.12 −1.69 −0.46 0.03 —
Indirect effects −0.74 0.12 −6.69 −0.98 −0.52 77.1%
Parental depression → Parental psychological flexibility → Parental self‐efficacy −0.32 0.07 −4.81 −0.48 −0.19 33.3%
Parental depression → Parental mindful awareness → Parental self‐efficacy −0.16 0.07 −2.61 −0.31 −0.03 16.7%
Parental depression → Parental self‐compassion → Parental self‐efficacy −0.26 0.09 −2.86 −0.44 −0.09 27.1%
Parental anxiety → Parental self‐efficacy
Total effects −1.07 0.14 −8.16 −1.34 −0.79
Direct effects −0.25 0.14 −1.77 −0.52 0.02 —
Indirect effects −0.82 0.13 −6.74 −1.07 −0.56 76.6%
Parental anxiety → Parental psychological flexibility → Parental self‐efficacy −0.36 0.08 −4.70 −0.53 −0.20 33.6%
Parental anxiety → Parental mindful awareness → Parental self‐efficacy −0.17 0.07 −2.81 −0.31 −0.05 15.9%
Parental anxiety → Parental self‐compassion → Parental self‐efficacy −0.29 0.10 −2.85 −0.48 −0.10 27.1%
Sample 2: Parent of children without congenital hearing loss (n = 336)
Parenting stress → Parental self‐efficacy
Total effects −0.51 0.05 −12.54 −0.61 −0.42
Direct effects −0.18 0.05 −4.25 −0.28 −0.08 35.3%
Indirect effects −0.33 0.05 −7.32 −0.43 −0.24 64.7%
Parenting stress → Parental psychological flexibility → Parental self‐efficacy −0.18 0.03 −5.10 −0.25 −0.11 35.3%
Parenting stress → Parental mindful awareness → Parental self‐efficacy −0.07 0.03 −3.32 −0.12 −0.02 13.7%
Parenting stress → Parental self‐compassion → Parental self‐efficacy −0.08 0.03 −2.99 −0.15 −0.03 15.7%
Parental depression → Parental self‐efficacy
Total effects −0.97 0.10 −11.14 −1.17 −0.77
Direct effects −0.21 0.10 −2.70 −0.41 −0.02 21.6%
Indirect effects −0.76 0.10 −9.11 −0.96 −0.58 78.4%
Parental depression → Parental psychological flexibility → Parental self‐efficacy −0.37 0.06 −6.50 −0.49 −0.27 38.1%
Parental depression → Parental mindful awareness → Parental self‐efficacy −0.19 0.06 −3.72 −0.32 −0.09 19.6%
Parental depression → Parental self‐compassion → Parental self‐efficacy −0.20 0.07 −3.05 −0.35 −0.06 20.6%
Parental anxiety → Parental self‐efficacy
Total effects −1.03 0.12 −10.23 −1.26 −0.80
Direct effects −0.20 0.11 −2.27 −0.41 0.01 —
Indirect effects −0.83 0.10 −8.87 −1.05 −0.64 80.6%
Parental anxiety → Parental psychological flexibility → Parental self‐efficacy −0.40 0.06 −6.70 −0.53 −0.29 38.8%
Parental anxiety → Parental mindful awareness → Parental self‐efficacy −0.22 0.06 −3.85 −0.35 −0.11 21.4%
Parental anxiety → Parental self‐compassion → Parental self‐efficacy −0.21 0.07 −3.06 −0.37 −0.07 20.4%
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In Sample 2, there was a significant total mediation effect for the relationship between parental mental health symptoms (i.e., stress, depression, and anxiety) and self‐efficacy (indirect effect β ranging from −0.83 to −0.33, all 95% CIs < 0), with parental psychological inflexibility (indirect effect β ranging from −0.40 to −0.18; all 95% CIs < 0, accounting for 35.3% to 38.8% of the total effect), mindful awareness (indirect effect β ranging from −0.22 to −0.07; all 95% CIs < 0, accounting for 13.7% to 21.4% of the total effect), and self‐compassion (indirect effect β ranging from −0.21 to −0.08; all 95% CIs < 0, accounting for 15.7% to 20.6% of the total effect) all individually and partially mediating this relationship.

Similar to Samples 1 and 2, the full or partial mediating role of parental psychological inflexibility, mindful awareness, and self‐compassion between mental health symptoms and parental self‐efficacy was observed in the total sample.

4. Discussion

In this study, we examined the effects of psychological flexibility, mindful awareness, and self‐compassion on mental health symptoms (including parental stress, depression, and anxiety) and parental self‐efficacy among parents of children with or without congenital HL. The results demonstrated that these factors acted as mediators in these relationships and significantly enhanced parental self‐efficacy in both samples. Psychological inflexibility had the strongest effect, followed by self‐compassion and mindful awareness. Furthermore, we found that psychological flexibility, mindful awareness, and self‐compassion were negatively correlated with mental health symptoms and positively associated with parental self‐efficacy in parents of children with or without congenital HL.

The results of this study align with those of previous research, which revealed a significant correlation between parental psychological flexibility and both mental health symptoms and parental self‐efficacy. These findings are consistent with studies that have examined parents who care for children with various special health care needs, such as persistent pain (Ruskin et al. 2018), psychiatric problems (Bodden and Matthijssen 2021), eczema (Chong et al. 2023), acquired brain injury (Brown et al. 2015), and typical development (Saasati et al. 2020). Moreover, our study revealed that parental mental health outcomes indirectly influence parental self‐efficacy through psychological flexibility among parents of children with or without congenital HL. This finding suggests that parents with better mental health are more likely to effectively manage negative psychological experiences and adopt coping strategies that align with their values, which is associated with greater satisfaction with parental self‐efficacy. Despite the emphasis in previous research on the mediating role of psychological flexibility in the relationship between mental health outcomes and various parental factors, few studies have specifically investigated its impact on parental self‐efficacy (Kulasinghe et al. 2021). Expanding upon prior findings, our study contributes to the field by illustrating the beneficial effects of parental psychological flexibility on both mental health outcomes and parental self‐efficacy within families, regardless of whether their children have congenital HL. Our study also highlights the importance of parental mental health in improving psychological flexibility and satisfaction with parental self‐efficacy. Therefore, future stress and emotional management programs for parents should focus on equipping them with knowledge and skills to manage their mental health symptoms and cultivate a positive attitude toward life and parenting. This will directly contribute to parents' greater satisfaction with their self‐efficacy.

In line with psychological flexibility, parents who exhibited elevated levels of mindful awareness displayed decreased symptoms of stress, depression, and anxiety, as well as heightened levels of parental self‐efficacy. Moreover, our study revealed that parental mental health outcomes indirectly influenced parental self‐efficacy through mindful awareness among parents of children with or without congenital HL. These findings align with previous research conducted with parents facing similar challenges and contribute to existing knowledge on the importance of these factors for parents of children with or without HL (Aghaziarati et al. 2023; Burke et al. 2020; Dirks and Szarkowski 2022). Parents who experience heightened mental health symptoms frequently exhibit automatic, impulsive, and negative reactions during interactions with their children (Bögels et al. 2014). This activation of the child's defence mechanisms can escalate conflict and exacerbate parents' mental health symptoms (Burt et al. 2005). Mindful awareness facilitated by third‐wave cognitive behaviour therapy approaches such as mindfulness‐based interventions, ACT, and compassion‐focused therapy (CFT) serves as a psychological resource that can effectively prevent or interrupt these problematic patterns of child–parent interaction (Lee et al. 2022; Tercelli and Ferreira 2019; Townshend et al. 2016). Previous studies suggest that when mindful awareness is applied in the context of parenthood, it has the potential to reduce parental emotional reactivity, promote parental behaviours that are aligned with parental values, and cultivate an understanding of suffering as a fundamental aspect of the human experience. Therefore, possessing this skill can improve family harmony and decrease the occurrence of stressful situations for parents. Parents who acquire and apply this skill can effectively navigate challenging situations within the family, which ultimately increases their parental self‐efficacy (Albanese et al. 2019). Therefore, future studies that aim to promote parental mental health and self‐efficacy among parents of children with or without congenital HL and to improve children's outcomes may consider incorporating mindfulness as a component.

Furthermore, we observed a significant association between higher levels of self‐compassion and reduced mental health symptoms as well as increased parental self‐efficacy. Self‐compassion was also found to mediate the relationships among parental stress, depression, and anxiety, and self‐efficacy in parents with and without children with congenital HL. This finding suggests that lower levels of mental health may be linked to challenges faced by parents, which are potentially influenced by their children's conditions or their deficits in parenting skills, both of which are correlated with decreased parenting self‐efficacy. These findings align with those of previous studies that support the positive role of self‐compassion for parental mental health symptoms and self‐efficacy. Numerous studies that have examined parental caregiving have consistently indicated that parents who foster high levels of self‐compassion encounter lower levels of parental stress, depression, anxiety, guilt, stigma, and self‐blame (Jefferson et al. 2020; Walwyn Martin 2011) and report higher levels of parental self‐efficacy, life satisfaction, subjective well‐being, and quality of life (Neff and Faso 2015; Shenaar‐Golan et al. 2023). Therefore, targeting self‐compassion through interventions such as CFT and/or ACT has the potential to improve parental self‐efficacy in parents of children with chronic illnesses (Azizi et al. 2021; Mazdeh et al. 2019; Wright et al. 2023). For example, a previous quasiexperimental study reported that combining ACT with CFT can serve as an effective intervention for mothers of children with HL by leading to a reduction in children's behavioural problems and an increase in positive parent–child interactions and ultimately promoting parental self‐efficacy (Azizi et al. 2021). Future research should focus on establishing the efficacy of supporting parents of children with or without congenital HL through well‐designed randomised controlled trials of ACT and/or CFT.

It is important to acknowledge the limitations of this study. First, while this study included two distinct sample groups, it was conducted in a specific province of mainland China and utilised convenience sampling, which may limit the generalisability of the findings to other regions or cultural contexts. Therefore, further research using random sampling to obtain larger sample sizes from more diverse geographical locations and countries is recommended. This will help to enhance the generalisability of the results and provide a more comprehensive understanding of the topic. Second, the study's cross‐sectional methodology imposed limitations on the examination of causal links among the variables or constructs under consideration. To ascertain directionality and causality, the use of a longitudinal design that incorporates extended durations of follow‐up is imperative. The proposed extended timeframe would enable the investigation of causal relationships between variables and allow for mediation analysis to explore the potential mediating effects of parental psychological flexibility, mindful awareness, and self‐compassion on the relationships between these variables and the targeted outcomes. Finally, it is worth noting that studies involving children with and without congenital HL often involve a limited sample size of fathers (12.4% of the total sampled parents, or n = 67). This is commonly attributed to increased maternal involvement in children's affairs, particularly in developing countries where mothers are traditionally considered the primary caregivers on the basis of gender roles (Bornstein and Putnick 2016). Nevertheless, this disparity has limitations because it impedes the capacity to perform subgroup assessments to investigate potential distinctions between mothers and fathers in relation to psychological adaptability, mindful awareness, and self‐compassion. Therefore, future studies should include a larger sample of fathers to gain a deeper understanding of the applicability of the findings of this study to this demographic population.

4.1. Implications for Nursing Research and Practice

The findings of this study have important implications for nursing research and practice in the field of paediatric care for parents of children both with and without congenital HL.

First, this study underscores the critical influence of parental psychological flexibility, mindful awareness, and self‐compassion on mental health outcomes and self‐efficacy. Mental health nurses can incorporate psychological components such as ACT, mindfulness, and self‐compassion into standard care to increase patients' wellbeing and improve health outcomes (Li et al. 2023). By providing support and guidance in developing these skills (e.g., mindfulness), mental health nurses can assist parents in navigating the emotional challenges associated with raising a child with congenital HL, which will ultimately improve their mental health and confidence in caregiving.

Second, this study emphasised the need to address parental mental health symptoms such as stress, depression, and anxiety for effective caregiving. Mental health nurses can play a crucial role in the early identification and assessment of these symptoms, particularly at the time of the initial diagnosis of the child's condition, to enable timely interventions (Merugumala et al. 2017). By recognising the unique challenges faced by parents of children with congenital HL, mental health nurses can provide targeted support, including mental health counselling, stress reduction techniques, healthcare information related to the child's condition, and referrals to community resources or support services (National Academies of Sciences et al. 2016). Addressing parental mental health can have a positive ripple effect on the well‐being of both parents and children and can lead to better health outcomes for the entire family.

Finally, this study highlights the importance of family‐centered interventions that consider the specific needs of parents of children with congenital HL. Mental health nurses can collaborate with other healthcare professionals to develop comprehensive care plans that address not only the child's medical needs but also the emotional well‐being of the entire family (Seniwati et al. 2023). This may involve providing education about congenital HL, rehabilitation interventions, and information on available support networks, such as government financial assistance and initiatives for social integration. By involving parents in decision‐making processes and empowering them with knowledge and skills, nurses can enhance parental self‐efficacy and promote effective caregiving practices.

5. Conclusions

The findings of this study indicate that parental psychological flexibility, mindful awareness, and self‐compassion play crucial roles in predicting parental self‐efficacy irrespective of whether the children of these parents have congenital HL. These factors mediate the association between parental mental health indicators, including parental stress, depression, anxiety, and self‐efficacy. To increase support for parents, nursing professionals should integrate training programmes or workshops into routine care that focus on ACT techniques, mindfulness, and self‐compassion exercises to equip parents with practical tools to manage psychological distress and improve their mental health. Further investigation is warranted to gain a deeper understanding of the underlying mechanisms that drive these relationships. This knowledge can aid in the development of interventions that are tailored to support vulnerable parents who are raising children with or without congenital HL.

Author Contributions

Conceptualisation, methodology, formal analysis, investigation, project administration, writing – original draft preparation: Sini Li. Validation, data curation: Jiao Xie. Writing – review and editing, writing – revision and editing, supervision: Jiao Xie and Li Yang. All authors have read and agreed to the published version of the manuscript.

Ethics Statement

The study was approved by the Secretary of Survey and Behavioural Research Ethics Committee of the Second Xiangya Hospital, Central South University (Reference No. LYF2022219).

Consent

All the participants were required to read and understand the information sheet and sign a consent form before data collection.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1.

NOP2-12-e70180-s001.docx (83.9KB, docx)

Appendix S2.

NOP2-12-e70180-s002.docx (54.6KB, docx)

Acknowledgements

The authors have nothing to report.

Funding: The authors received no specific funding for this work.

Xie Jiao and Yang Li contributed equally to this work and are considered joint first authors.

Data Availability Statement

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to ethical reasons.

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Associated Data

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

Supplementary Materials

Appendix S1.

NOP2-12-e70180-s001.docx (83.9KB, docx)

Appendix S2.

NOP2-12-e70180-s002.docx (54.6KB, docx)

Data Availability Statement

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to ethical reasons.

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