Chain mediating effect of gratitude and meaning in life between nurses’ psychological response and emergency capability-a multicenter cross-sectional study

Abstract

Background

Clinical nurses face high-pressure situations requiring rapid decision-making and skilled intervention, impacting their psychological responses and emergency capabilities. Understanding the relationships between psychological factors like gratitude and meaning in life is crucial for improving nurses’ performance in emergencies. This study explores the mediating role of gratitude and meaning in life in the impact of psychological responses on clinical nurses’ emergency capabilities, aiming to enhance their effectiveness in such situations.

Methods

This study is a multi-center cross-sectional survey. A questionnaire survey was conducted among 1833 clinical nurses in five tertiary hospitals in Anhui Province, China including general information questionnaire, nurses’ emergency capability scale, Meaning in life scale, Gratitude scale and Psychological response questionnaire. According to the results of the questionnaire survey, a chain mediating model was constructed and tested.

Results

The total score of emergency capability of 1833 clinical nurses was (71.65 ± 10.77), the total score of meaning in life was (50.67 ± 9.04), the total score of gratitude was (30.96 ± 3.57), and the total score of psychological response was 13.00 (6.00, 20.00). The emergency capability of subjects was positively correlated with the meaning in life, the total score of gratitude scale and the scores of each dimension of the two scales, and negatively correlated with the total score of psychological response scale and each dimension of this scale (all P < 0.05). The total effect coefficient, direct effect coefficient and indirect effect coefficient of psychological response on nurses’ emergency capability are − 0.230, -0.110 and − 0.120 respectively, that is, the indirect effect accounts for 52.17% of the total effect. Among the indirect effects, the specific mediating effects of gratitude and meaning in life account for 22.50% and 62.50% respectively, and the chain mediating effects of gratitude and meaning in life account for 15.00%.

Conclusion

Gratitude and meaning in life have multiple mediating roles in the mechanism of psychological response that affecting clinical nurses’ emergency capability. Therefore, it is very important to pay attention to dynamically evaluating the psychological response level of clinical nurses, and strive to improve their gratitude and meaning in life, so as to further enhance their emergency response ability.

Background

Nurses are faced with special medical environment, with emergencies, shouldering the responsibility of caring for patients by providing nursing interventions during the process of medical treatment and promoting patients’ recovery, and are prone to negative psychological responses such as anxiety and depression [1]. Emergency capability refers to the ability of nurses to effectively evaluate and make decisions and skillfully use skills to respond to emergencies. Higher emergency capability can help nurses to deal with emergencies at work more efficiently and take effective measures to ensure the patients safety. In addition, nurses with higher emergency capability can adapt to the complex and changeable medical environment and are expected to get more career development opportunities [2]. Gratitude means that when individuals experience positive results, they tend to respond to others’ good deeds through grateful cognition, emotion and behavior [3]. It is reported that gratitude is easily influenced by negative psychological responses such as anxiety [4]. In addition, gratitude can affect individual’s subjective well-being, emergency capability and work engagement level [5], and reduce individual job burnout [6]. Therefore, hypothesis 1 of this study is put forward: Gratitude plays an mediating role between psychological response and emergency capability.

The meaning in life refers to an individual’s perception of what he thinks is important, which plays an important role in his growth and development [7]. One Study(or some studies) have pointed out that [8]the higher the individual’s meaning in life, the more optimistic his mentality and the stronger his happiness; In addition, individuals with a higher sense of life will respond to challenges more actively, have higher psychological resilience and positive emotions, pursue their own values harder and achieve self-improvement. However, when the individual’s negative psychological responses such as anxiety, depression and suicidal beliefs are high, it will negatively affect the quality of life and the meaning in life [9]. The meaning in life will positively affect individual’s professional identity, emergency capability, career adaptability and career decision-making self-efficacy [10,11,12]. Therefore, hypothesis 2 of this study is put forward: The meaning in life plays an mediating role between psychological response and emergency capability.

Individuals with higher gratitude level can adopt positive coping styles when facing the surrounding environment, enhance their positive emotional experience, and enhance their meaning in life [13]. In addition, the study also confirmed that the level of nurses’ emergency capability is affected by their psychological state, and the emergency capability of nurses with psychological responses such as anxiety and depression is weak [14]. There is a certain correlation between the improvement of emergency capability and the individual’s understanding of the meaning of life and the formation of a correct view of life [15]. Based on the comprehensive analysis presented above, we propose that gratitude and meaning in life may play a chain mediating role between nurses’ psychological response and emergency capability. Therefore, hypothesis 3 of this study is put forward: Gratitude and meaning in life play a chain mediating effect between clinical nurses’ psychological response and emergency capability.

Methods

Subjects

This study is a multi-center cross-sectional survey. During May-September, 2022, the researchers conducted a cluster sampling online questionnaire survey among clinical nurses in five tertiary hospitals in Anhui Province, China. The inclusion criteria of clinical nurses in this survey are: ①Registered clinical nurses who have worked for one year or more; ②Informed consent and voluntary participation in this research and investigation. Exclusion criteria: ①Not on duty during the investigation; ② Nurses undergoing training, further study and rotation; ③Clinical nurse trainee. The sample size was determined based on the influencing factors of the variables, which is the value multiplied by ten [16]. In this survey, the general data questionnaire consisted of 12 items, while four survey questionnaires contained 58 items. Therefore, we should collect 700 questionnaires from nurses and expand the sample size by 20% to compensate for insufficient responses. Consequently, the minimum sample size for this study should be at least 840. The research described in this protocol was conducted in accordance with the principles outlined in the Declaration of Helsinki. The study received ethical clearance from the Institutional Ethics Review Committee of the First Affiliated Hospital of the University of Science and Technology of China (approval number:2022-KY-042). Additionally, all participants provided their consent electronically prior to their involvement in the study.

Research methods

Survey tools

General information questionnaire

This questionnaire is designed by the researchers, including age, personal monthly income level, marital status, mode of residence, gender, workplace hospital, working years, educational level, number of children, employment status, professional titles and job titles.

Nurses’ emergency capacity scale

This self- reported scale was developed by Wang et al. in 2015, and includes 18 items in total, which were divided into three factors: emergency knowledge (5 items), first aid ability (4 items) and comprehensive ability (9 items). Each item on the scale employs a five-point Likert scale, ranging from 1 (very poor performance) to 5 (very good performance), and the total score of this scale ranges from 18 to 90 points. The higher the total score, the stronger the emergency response ability, and vice versa. The Cronbach’s α coefficient of the scale is 0.950, and the half-reliability is 0.913 [17]. The Cronbach’s α coefficient of the scale in present study is 0.822.

The meaning in life questionnaire (MLQ)

This questionnaire was compiled by Steger et al. in 2006 and revised in Chinese by Liu et al. in 2010, both were initially tested on a sample of university students. This scale was designed to measure two dimensions of individual perception of meaning in life: the presence of meaning (Presence of meaning) and the pursuit of meaning (Search for meaning). During the revision process, Liu et al. standardized the scale, which included reliability testing, validity testing, and norm establishment, to ensure its reliability and validity among the Chinese population, and the Chinese version of MLQ was finally obtained [17]. The Chinese version of MLQ includes 2 dimensions (Presence of Meaning and Search for meaning)and 9 items, and each item adopts a 7-point scoring method from “never” (1 point) to “always” (7 points). The total score of this questionnaire is 9–63 [18]. The higher the total score, the stronger the meaning in life. The Cronbach’s α coefficient of the questionnaire is 0.80 [19]. The Cronbach’s α coefficient of the scale in present study is 0.774.

The gratitude questionnaire-6(GQ-6)

The Chinese version of GQ-6 was obtained after the questionnaire was compiled by McCullough et al. in 2002 and revised by Wei et al. in Chinese in 2011 [20]. This scale is used to measure individuals’ tendency towards gratitude. In the process of revising the Chinese version, Chinese scholars have made appropriate linguistic and cultural adaptations to the original scale to ensure its applicability among Chinese speakers. The Chinese version of GQ-6 maintains the same number of items and scoring method as the English version of GQ-6. The questionnaire is a one-dimensional scale, which contains 6 items, all of which are scored by 7 points from “very different” (1 point) to “very agree” (7 points). The total score of this questionnaire is 6–42. The higher the total score, the higher the degree of gratitude. The Cronbach’s α coefficient of the scale is 0.91 [19]. The Cronbach’s α coefficient of the scale in present study is 0.849.

Psychological response questionnaire

The psychological response questionnaire was developed by China Behavioral Medicine Editorial Committee in 2005 [21]. This questionnaire is used to reflect the psychological response characteristics of individuals in emergency situations. The questionnaire covered five dimensions and 25 items. The five dimensions were depression, neurasthenia, fear, obsessive-compulsive anxiety and hypochondriasis. Each item was scored using a four-level scoring method ranging from 1 to 4, representing “not at all,” “somewhat,” “moderately,” and “very much,” respectively, and the total score of the scale was 25–100. The higher the score, the stronger the psychological response. Study have shown [22] the questionnaire has good application effect, reliability and validity in medical staff. The Cronbach’s α coefficient of the scale in present study is 0.763.

Survey methods

In order to conduct this survey, the research director contacted the heads of nursing departments in selected hospitals via telephone and provided them with a detailed explanation of the survey’s purpose. After obtaining their consent to participate in the research, a WeChat group was established and all the heads of nursing departments were added to facilitate communication. Prior to officially distributing the questionnaire, the research director sent the electronic questionnaire link to the WeChat group for them to review. Through discussion, each head of the nursing department was able to fully understand and grasp the purpose, importance, process evaluation, and precautions of the survey. Subsequently, these heads of nursing departments forwarded the questionnaire link to the head nurses of various departments within their hospital through establishing another WeChat group, where they provided a detailed introduction to the purpose, importance, process evaluation, and precautions of the survey. Then, after fully understanding the research objectives, importance, and other content of the questionnaire, the head nurses once again forwarded the electronic questionnaire link to potential nurse participants through establishing another WeChat groups, providing a detailed introduction to the purpose, importance, process evaluation, and precautions of the survey, ensuring that every potential participant was informed about the relevant aspects of the survey. The preface of the survey clearly stated the research objectives, inclusion and exclusion criteria, informed consent form, instructions, and contact information of the principal investigator. Only after nurses had read the relevant information in the questionnaire and signed the electronic informed consent form on the first page of the electronic questionnaire could they anonymously complete the questionnaire. It was pointed out that response to all the questions are mandatory and repeated answers are not allowed. At the same time, if all the answers in the questionnaire have the same serial number, the questionnaire will be considered invalid. After eliminating the invalid questionnaires, this study finally collected 1833 valid questionnaires, the response rate was 91.70%(1833/2000).

Statistical methods

Statistical software SPSS23.0 and Amos 22.0 were used to analyze and process the data. The measurement with normal distribution is represented by (Mean ± standard deviation), and datawith skewed distribution is represented by M(Q1,Q3), and the categorical and graded data are represented by numbers and percentages. Independent sample t test was used to compare the measurement data of normal distribution between the two groups, and one-way ANOVA was used to compare the measurement data of three or more groups of normal distribution. Pearson correlation analysis is used to evaluate the correlation between different indicators, multiple linear hierarchical regression analysis is used to analyze the model of mediation effect, Bootstrap method with deviation correction is used to repeatedly extract 1000 times to verify the significance of mediation effect and calculate 95%CI of the coefficient of mediation effect, and Amos 22.0 is used to draw the relationship model diagram between different indicators. P < 0.05 was considered as a statistically significant difference.

Results

Baseline characteristics of subjects

In this study, 1833 subjects were aged from 18 to 60, with an average age of (34.63 ± 7.60) years. The working years are 1–41 years, and the median working years are 11.00 (6.00,17.00) years. Majority of subjects (96.24%) were female. In terms of educational background, the vast majority of participants (83.58%) were undergraduates. With regard to marital status, the majority (76.16%) were married; See Table 1 for other baseline characteristics.

Table 1 Demographic characteristics of subjects

The total scores of emergency capability, meaning in life, gratitude and psychological response of subjects

The total Mean ± SD score of emergency capability, meaning in life, and gratitude of all subjects were (71.65 ± 10.77), (50.67 ± 9.04), (30.96 ± 3.57) respectively, and the total score of psychological response were 13.00 (6.00, 20.00) (Table 2).

Table 2 The total scores of nurses’ emergency capability, meaning in life, gratitude and psychological response (n = 1833)

Comparison of total score of emergency capability of all subjects with with demographic characteristics

The comparison results of total score of emergency capability of 1833 nurses with different characteristics show that there are statistical differences among nurses with ages, marital status, Having a child/Children, Mode of residence, working years, personal monthly income, employment status, professional titles and job titles (all P < 0.05), as shown in Table 3.

Table 3 Comparison of total score of emergency capability of all subjects with demographic charactristics

The correlation of subjects emergency capability, meaning in life, gratitude and, psychological response

Pearson correlation analysis demonstated that the correlation coefficient between the total score of emergency capability and the total score of meaning in life of 1833 nurses were (r = 0.360, P < 0.01), and the correlation coefficient between the total score of emergency capability and the score of each dimension of meaning in life scale were (r = 0.233 ∼ 0.356, P < 0.01). The correlation coefficient between the total score of emergency capability and the total score of gratitude was (r = 0.236, P < 0.05). The correlation coefficient between the total score of emergency capability and the total score of psychological response scale is r=-0.232, and the correlation coefficient between the total score of emergency capability and the scores of each dimension of psychological response scale is r =-0.237 ∼-0.072, all P < 0.01. As shown in Table 4.

Table 4 Correlation analysis of emergency capability, gratitude, meaning in life and psychological response of subjects (n = 1833)

Chain mediating analysis of gratitude and meaning in life between nurses’ psychological response and emergency capability

Common method deviation test

According to Harman single factor test, the common method deviation is tested. The results show that there are three factors with characteristic roots greater than 1 in 11 dimensions of four scales, and the variance explained by the first factor is 39.00%, which is less than the critical standard of 40% [23]. It shows that there is no serious common method deviation in this study.

Chain mediating model and its multiple linear hierarchical regression analysis

Taking total score of emergency capability of 1833 nurses as the dependent variable, total score of nurses’ psychological response as the independent variable, total score of gratitude and meaning in life as the mediating variables, and taking the nine statistically significant variables in Table 3 as covariates, all continuous variables were standardized. Multiple linear hierarchical regression analysis was used to investigate the mediating effects of gratitude and meaning in life between psychological response and emergency response, and the test results of the mediating effect model are shown in Table 5.

Table 5 Test results of mediating effect model (n = 1833)

Chain mediating effect test

Under the condition that emergency response ability is the dependent variable and nurses’ psychological response is the independent variable, this study analyzes the mediating role of gratitude and meaning in life, and establishes a structural equation model by using Amos 22.0 [24]. The Bootstrap method with deviation correction is used to test the mediating effect by self-sampling for 1000 times [25]. The results indicated that the fitting effect of the model is good (Fig. 1). The direct effect between clinical nurses’ psychological response and emergency capability accounts for 47.83% of the total effect, and the analysis results of the total effect and direct effect between clinical nurses’ psychological response and emergency capability are shown in Table 6. The indirect effect between clinical nurses’ psychological response and emergency capability accounted for 52.17% of the total effect, and 95%CI of the three mediating effect paths did not include 0 after Bootstrap analysis, which confirmed that the mediating effect was significant. Analysis of the mediating effect between gratitude and meaning in life are shown in Table 6. The indirect effect composed of psychological response → gratitude → emergency capability accounts for 22.50% of the total indirect effect, which supports hypothesis 1; The indirect effect composed of psychological response → meaning in life → emergency capability accounts for 62.50% of the total indirect effect, which supports hypothesis 2; The indirect effect composed of psychological response → gratitude → meaning in life → emergency capability accounts for 15.00% of the total indirect effect, which supports hypothesis 3. Analysis results of mediating effects of gratitude and meaning in life between nurses’ psychological response and emergency capability are shown in Table 7. See Fig. 1 for the relationship model between different indicators.

Fig. 1

Chain mediating model diagram of gratitude and meaning in life between psychological response and emergency capability. Note: ^**P < 0.01

Table 6 Analysis of total effect and direct effect between psychological response and emergency capability of subjects

Table 7 Analysis results of mediating effects of gratitude and meaning in life between nurses’ psychological response and emergency capability

Discussion

This study found that gratitude played a partial mediating role between nurses’ psychological response and emergency capability, accounting for 22.50%. He Hong et al.‘s research found that perceived social support partially mediated the relationship between nurses’ emergency response capabilities and psychological burden, with a mediation effect proportion of 26.8% [26]. Comparing the two studies, it can be seen that the mediation effect of perceived social support is slightly higher than that of gratitude. However, both variables to some extent explain the relationship between emergency response capabilities and psychological factors. While gratitude and perceived social support represent different personal traits and coping resources, they are both related to nurses’ emergency response capabilities and mental health. Gratitude is more closely associated with positive emotions and personal well-being, while perceived social support is more closely linked to social resources and emotional support. Despite differences in specific mediating variables, both studies indicate that there is a mediating mechanism between nurses’ emergency response capabilities and mental health. This suggests that mediating variables play an important role in explaining these relationships. However, due to differences in mediating variables and specific effect sizes, the two studies may reveal different mediation pathways and mechanisms. Specifically, gratitude may enhance personal positive emotions while improving emergency response capabilities, whereas perceived social support may increase the effective utilization of social support networks while reducing psychological burden. The main reason for this research finding is that, on the one hand, gratitude can enhance the individual’s psychological resilience [27]. To help individuals better cope with stress and challenges. A grateful nurse may be more able to keep calm and cope with difficulties, thus showing better emergency response ability. On the other hand, gratitude can enhance the individual’s sense of self-efficacy and improve the individual’s confidence in their own abilities [28]. A grateful nurse may be more confident in her own ability, so that she will be more confident and decisive in the face of emergencies and show better emergency response ability. In addition, gratitude also plays an important role in the process of personal growth and self-realization. Individuals with a higher level of gratitude will pursue their goals harder, face challenges bravely and realize their self-worth. Gratitude can also enhance individuals’ understanding of social support and help them get support and help from others [29]. Grateful nurses may be able to establish good relationships with colleagues, patients and their families, so as to get more support and help in dealing with emergencies.

At the same time, this study demostrated that the meaning in life plays a partial mediating role between nurses’ psychological response and emergency capability, accounting for 62.50%. The main reason is that the meaning in life can effectively improve the individual’s psychological recovery ability and affect the process of cognition and evaluation when people face pressure [30]. Nurses with a strong meaning in life can start their resilience and re-examine and adjust the negative beliefs and emotions brought about by stress when facing adversity, pressure or negative emotions. Through positive cognitive way, nurses can turn stress and negative emotions into positive factors and reduce stress perception and negative psychological response [31]. In the process of pressure transformation, nurses will adjust their goals to adapt to the existing pressure environment, and explore the value according to the adjusted goals, so as to obtain personal growth and inner satisfaction, which makes them feel the meaning of life and career better, and then improve their professional identity [10], and enhance their emergency capability.

This study also found that gratitude and meaning in life play a chain mediating role between nurses’ psychological response and emergency capability, with the mediating effect accounting for 15.00%. Zhang Zeyu et al.‘s research found that nurses’ career adaptability and positive coping styles act as a chain mediator between work-family support and mental health, with the chain mediation effect accounting for 13.89% [32]. Although the specific mediators and research backgrounds differ between the two studies, they both reveal the significant role of psychological factors in nursing work. Both studies indicate that enhancing specific psychological qualities or coping strategies can effectively improve nurses’ job performance and mental health.

The rationale for this research finding is that: The impact of psychological responses on emergency response capabilities primarily manifests in two aspects: stress management and decision-making abilities. When nurses face emergency situations, their psychological state directly affects their ability to cope with stress. Positive psychological responses, such as lower levels of anxiety and depression, help nurses manage stress more effectively under emergency conditions, thereby enhancing their emergency response capabilities. Nurses with good mental health can make decisions faster in emergency environments because they can maintain clear thinking and rapid response capabilities. The mediating role of gratitude mainly manifests in two aspects: improving mood and enhancing teamwork. Gratitude can elevate an individual’s emotional state, enabling nurses to maintain a positive attitude at work. This positive emotion helps them stay calm under high-pressure environments, thereby improving their ability to handle emergencies. Gratitude also promotes positive interactions among team members, enhancing team spirit. During the emergency response process, good teamwork is crucial for improving overall emergency response capabilities and treatment outcomes. The mediating role of meaning in life mainly manifests in two aspects: goal orientation and professional satisfaction. When nurses feel that their work is meaningful, they are more likely to adopt goal-oriented behaviors, which include acting quickly and accurately in emergency situations. The sense of meaning in life is also closely related to professional satisfaction. A nurse who feels that their work is meaningful is more likely to remain motivated and focused when facing challenges, thereby improving their emergency response capabilities. The chain mediating effect of gratitude and the sense of meaning in life mainly manifests in two aspects: mutual reinforcement and comprehensive impact. Gratitude and the sense of meaning can reinforce each other and jointly influence the psychological state and emergency response capabilities of nurses. For example, a grateful nurse may find it easier to find meaning in their work, and vice versa. The comprehensive impact is reflected in the fact that by simultaneously cultivating gratitude and seeking meaning in life, it is possible to more effectively enhance nurses’ mental health and emergency response capabilities.

The reason for this research finding is that gratitude and meaning in life can help nurses actively adjust their emotions and improve their negative psychological responses. When facing difficulties and pressures, nurses may feel depressed, anxious or disappointed. However, when they can feel the importance of their work to patients and society and realize their help and influence on others, they are more likely to have positive emotions, such as professional happiness [33]. These positive emotions can help them better cope with difficulties and pressures, enhance their ability to resist pressure, treat their work more intently and seriously, constantly strive to improve their professional quality and skills, pursue higher career goals, and reduce the impact of negative psychological responses on themselves. In addition, in the medical environment, nurses often need to face emergencies, and need to make decisions and actions quickly. When nurses can realize that their work is vital to patients’ life and health, they will be more focused and devoted to their work, and improve the speed and accuracy of emergency capability [34]. Gratitude and meaning in life can enhance nurses’ professional satisfaction. The work of nurses often requires great efforts and dedication, and may face challenges and difficulties. However, when nurses can feel the value and significance of their work to others, they will be more motivated and willing to devote themselves to their work, thus enhancing their professional satisfaction [35]. The improvement of professional satisfaction can promote nurses to give full play to their abilities and skills and improve the performance of emergency response ability.

The study has several limitations: It is a cross-sectional survey, which cannot establish a cause and effect relationship between variables. The results only provide a snapshot of the current situation and cannot reflect the changes over time. The sample size is relatively large, but it is still limited in terms of representativeness. The study focuses on clinical nurses in tertiary hospitals in Anhui Province, China, which may not be generalizable to other populations or regions. The measurement of variables is mainly through questionnaires, which may be subject to response bias. The study only investigates the mediating roles of gratitude and meaning in life, and does not consider other possible mediators or moderators. The study does not explore the potential influence of confounding factors such as age, education, and working years on the relationship between psychological response and emergency capability. The research only examines the relationship between psychological response, gratitude, meaning in life, and emergency capability among clinical nurses, but does not consider the potential impact of other factors such as organizational culture, leadership, and support systems on emergency capability. Despite these limitations, the study provides valuable insights into the role of psychological response, gratitude, and meaning in life in the emergency capability of clinical nurses. Future research can address these limitations by using longitudinal designs, larger and more diverse samples, and exploring the potential influence of other factors.

Conclusion

The study concludes that gratitude and meaning in life play significant mediating roles in the mechanism by which psychological response affects the emergency capability of clinical nurses. The findings suggest that the way nurses psychologically respond to situations can be mediated by their levels of gratitude and the meaning they find in their work, which in turn influences their ability to respond effectively to emergencies. These findings highlight the importance of addressing psychological response and fostering a sense of gratitude and purpose among clinical nurses. Nursing managers are encouraged to proactively evaluate and support the emotional well-being of their staff, recognizing that cultivating a positive and grateful attitude, along with a strong sense of meaning in their work, can significantly enhance nurses’ emergency response capabilities. Implications for practice suggest that interventions aimed at improving emergency response skills should include components that promote gratitude and meaning in life among clinical nurses. This could involve training programs that focus on emotional intelligence, resilience building, and gratitude practices, as well as creating a work environment that nurtures a sense of purpose and fulfillment. Future research could explore the long-term effects of such interventions and examine the potential for gratitude and meaning in life to serve as protective factors against burnout and compassion fatigue, further contributing to the overall well-being and job performance of clinical nurses.