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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Mental Health of Nurses Working at a Government-designated Hospital During a MERS-CoV Outbreak: A Cross-sectional Study</title><author><name sortKey="Park, Ji Seon" sort="Park, Ji Seon" uniqKey="Park J" first="Ji-Seon" last="Park">Ji-Seon Park</name><affiliation><nlm:aff id="af0005">Seoul National University Bundang Hospital, Bundang, Republic of Korea</nlm:aff></affiliation></author><author><name sortKey="Lee, Eun Hyun" sort="Lee, Eun Hyun" uniqKey="Lee E" first="Eun-Hyun" last="Lee">Eun-Hyun Lee</name><affiliation><nlm:aff id="af0010">Graduate School of Public Health, Ajou University, Suwon, Republic of Korea</nlm:aff></affiliation></author><author><name sortKey="Park, No Rye" sort="Park, No Rye" uniqKey="Park N" first="No-Rye" last="Park">No-Rye Park</name><affiliation><nlm:aff id="af0015">Graduate School of Public Health, Inje University, Seoul, Republic of Korea</nlm:aff></affiliation></author><author><name sortKey="Choi, Young Hwa" sort="Choi, Young Hwa" uniqKey="Choi Y" first="Young Hwa" last="Choi">Young Hwa Choi</name><affiliation><nlm:aff id="af0020">Department of Infectious Disease, School of Medicine, Ajou University, Suwon, Republic of Korea</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">29413067</idno><idno type="pmc">7127092</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7127092</idno><idno type="RBID">PMC:7127092</idno><idno type="doi">10.1016/j.apnu.2017.09.006</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">000A79</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000A79</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Mental Health of Nurses Working at a Government-designated Hospital During a MERS-CoV Outbreak: A Cross-sectional Study</title><author><name sortKey="Park, Ji Seon" sort="Park, Ji Seon" uniqKey="Park J" first="Ji-Seon" last="Park">Ji-Seon Park</name><affiliation><nlm:aff id="af0005">Seoul National University Bundang Hospital, Bundang, Republic of Korea</nlm:aff></affiliation></author><author><name sortKey="Lee, Eun Hyun" sort="Lee, Eun Hyun" uniqKey="Lee E" first="Eun-Hyun" last="Lee">Eun-Hyun Lee</name><affiliation><nlm:aff id="af0010">Graduate School of Public Health, Ajou University, Suwon, Republic of Korea</nlm:aff></affiliation></author><author><name sortKey="Park, No Rye" sort="Park, No Rye" uniqKey="Park N" first="No-Rye" last="Park">No-Rye Park</name><affiliation><nlm:aff id="af0015">Graduate School of Public Health, Inje University, Seoul, Republic of Korea</nlm:aff></affiliation></author><author><name sortKey="Choi, Young Hwa" sort="Choi, Young Hwa" uniqKey="Choi Y" first="Young Hwa" last="Choi">Young Hwa Choi</name><affiliation><nlm:aff id="af0020">Department of Infectious Disease, School of Medicine, Ajou University, Suwon, Republic of Korea</nlm:aff></affiliation></author></analytic><series><title level="j">Archives of Psychiatric Nursing</title><idno type="ISSN">0883-9417</idno><idno type="eISSN">1532-8228</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>BACKGROUND</title><p>During an epidemic of a novel infectious disease, many healthcare workers suffer from mental health problems.</p></sec><sec><title>OBJECTIVES</title><p>The aims of this study were to test the following hypotheses: stigma and hardiness exert both direct effects on mental health and also indirect (mediated) effects on mental health through stress in nurses working at a government-designated hospital during a Middle East Respiratory Syndrome coronavirus (MERS-CoV) epidemic.</p></sec><sec><title>METHODS</title><p>A total of 187 participants were recruited using a convenience sampling method. The direct and indirect effects related to the study hypotheses were computed using a series of ordinary least-squares regressions and 95% bootstrap confidence intervals with 10,000 bootstrap resamples from the data.</p></sec><sec><title>DISCUSSIONS</title><p>The influences of stigma and hardiness on mental health were partially mediated through stress in nurses working at a hospital during a MERS-CoV epidemic. Their mental health was influenced more by direct effects than by indirect effects.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Bai, Y" uniqKey="Bai Y">Y. Bai</name></author><author><name sortKey="Lin, C C" uniqKey="Lin C">C.-C. Lin</name></author><author><name sortKey="Lin, C Y" uniqKey="Lin C">C.-Y. Lin</name></author><author><name sortKey="Chen, J Y" uniqKey="Chen J">J.-Y. Chen</name></author><author><name sortKey="Chue, C M" uniqKey="Chue C">C.-M. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Arch Psychiatr Nurs</journal-id><journal-id journal-id-type="iso-abbrev">Arch Psychiatr Nurs</journal-id><journal-title-group><journal-title>Archives of Psychiatric Nursing</journal-title></journal-title-group><issn pub-type="ppub">0883-9417</issn><issn pub-type="epub">1532-8228</issn><publisher><publisher-name>Elsevier Inc.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">29413067</article-id><article-id pub-id-type="pmc">7127092</article-id><article-id pub-id-type="publisher-id">S0883-9417(17)30044-4</article-id><article-id pub-id-type="doi">10.1016/j.apnu.2017.09.006</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Mental Health of Nurses Working at a Government-designated Hospital During a MERS-CoV Outbreak: A Cross-sectional Study</article-title></title-group><contrib-group><contrib contrib-type="author" id="au0005"><name><surname>Park</surname><given-names>Ji-Seon</given-names></name><email>sondreamer@snubh.org</email><xref rid="af0005" ref-type="aff">a</xref></contrib><contrib contrib-type="author" id="au0010"><name><surname>Lee</surname><given-names>Eun-Hyun</given-names></name><email>ehlee@ajou.ac.kr</email><xref rid="af0010" ref-type="aff">b</xref><xref rid="cr0005" ref-type="corresp">⁎</xref></contrib><contrib contrib-type="author" id="au0015"><name><surname>Park</surname><given-names>No-Rye</given-names></name><xref rid="af0015" ref-type="aff">c</xref></contrib><contrib contrib-type="author" id="au0020"><name><surname>Choi</surname><given-names>Young Hwa</given-names></name><email>Yhwa1805@aumc.ac.kr</email><xref rid="af0020" ref-type="aff">d</xref></contrib></contrib-group><aff id="af0005"><label>a</label>Seoul National University Bundang Hospital, Bundang, Republic of Korea</aff><aff id="af0010"><label>b</label>Graduate School of Public Health, Ajou University, Suwon, Republic of Korea</aff><aff id="af0015"><label>c</label>Graduate School of Public Health, Inje University, Seoul, Republic of Korea</aff><aff id="af0020"><label>d</label>Department of Infectious Disease, School of Medicine, Ajou University, Suwon, Republic of Korea</aff><author-notes><corresp id="cr0005"><label>⁎</label>Corresponding author at: Graduate School of Public Health, Ajou University, 164 Worldcup-ro, Yeongtong-Gu, Suwon-si, Gyeonggi-do 443-380, Republic of Korea. <email>ehlee@ajou.ac.kr</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>5</day><month>9</month><year>2017</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="ppub"><month>2</month><year>2018</year></pub-date><pub-date pub-type="epub"><day>5</day><month>9</month><year>2017</year></pub-date><volume>32</volume><issue>1</issue><fpage>2</fpage><lpage>6</lpage><history><date date-type="received"><day>24</day><month>1</month><year>2017</year></date><date date-type="rev-recd"><day>27</day><month>8</month><year>2017</year></date><date date-type="accepted"><day>3</day><month>9</month><year>2017</year></date></history><permissions><copyright-statement>© 2017 Elsevier Inc. All rights reserved.</copyright-statement><copyright-year>2017</copyright-year><copyright-holder>Elsevier Inc.</copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="ab0005"><sec><title>BACKGROUND</title><p>During an epidemic of a novel infectious disease, many healthcare workers suffer from mental health problems.</p></sec><sec><title>OBJECTIVES</title><p>The aims of this study were to test the following hypotheses: stigma and hardiness exert both direct effects on mental health and also indirect (mediated) effects on mental health through stress in nurses working at a government-designated hospital during a Middle East Respiratory Syndrome coronavirus (MERS-CoV) epidemic.</p></sec><sec><title>METHODS</title><p>A total of 187 participants were recruited using a convenience sampling method. The direct and indirect effects related to the study hypotheses were computed using a series of ordinary least-squares regressions and 95% bootstrap confidence intervals with 10,000 bootstrap resamples from the data.</p></sec><sec><title>DISCUSSIONS</title><p>The influences of stigma and hardiness on mental health were partially mediated through stress in nurses working at a hospital during a MERS-CoV epidemic. Their mental health was influenced more by direct effects than by indirect effects.</p></sec></abstract><abstract abstract-type="author-highlights" id="ab0010"><title>HIGHLIGHTS</title><p><list list-type="simple" id="l0005"><list-item id="li0005"><label>•</label><p id="p0005">During an epidemic of a novel infectious disease, nurses can suffer from mental health problems.</p></list-item><list-item id="li0010"><label>•</label><p id="p0010">Stigma and hardiness exert both direct effects on mental health in nurses.</p></list-item><list-item id="li0015"><label>•</label><p id="p0015">Stigma and hardiness exert both indirect effects on mental health via stress in nurses.</p></list-item><list-item id="li0020"><label>•</label><p id="p0020">The mental health of nurses was affected more by direct effects than by indirect effects.</p></list-item></list></p></abstract><kwd-group id="ks0005"><title>KEYWORDS</title><kwd>Middle East Respiratory Syndrome coronavirus</kwd><kwd>Mental health</kwd><kwd>Stigma</kwd><kwd>Hardiness</kwd><kwd>Stress</kwd><kwd>Nurse</kwd></kwd-group></article-meta></front><body><sec id="s0005"><title>INTRODUCTION</title><p id="p0025">Middle East Respiratory Syndrome coronavirus (MERS-CoV) is a novel respiratory infection that was first reported in Saudi Arabia in 2012 (<xref rid="bb0275" ref-type="bibr">Zaki, van Bestebroer, & Osterhaus, 2012</xref>). The first case was discovered in Korea in May 2015, after which the rapid transmission of the MERS-CoV resulted in 186 patients being diagnosed within 6 weeks. On December 23, 2015, the Korean Ministry of Health and Welfare officially declared that the MERS-CoV outbreak had ended, with 186 laboratory-confirmed patients and 38 deaths. Among the MERS-confirmed Korean patients, 39 (21.0%) people were healthcare workers, 15 of whom (40%) were nurses (<xref rid="bb0175" ref-type="bibr">Korean Centers for Disease Control and Prevention, 2015</xref>). This was the largest MERS-CoV outbreak outside of the Arabian Peninsula (<xref rid="bb0060" ref-type="bibr">Cowling et al., 2015</xref>).</p><p id="p0030">During an epidemic of an infectious disease, many healthcare workers including nurses on the front lines caring for patients with the disease suffer from mental health problems (<xref rid="bb0155" ref-type="bibr">Khee et al., 2004</xref>). At the peak of the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic in Taiwan, nurses at a hospital caring for 27 suspected cases had trouble with psychological problems, such as anxiety, depression, and hostility (<xref rid="bb0035" ref-type="bibr">Chen, Cheng, Chung, & Lin, 2005</xref>). In Singapore, 27% of healthcare workers during the SARS outbreak were reported to have psychiatric symptoms (<xref rid="bb0025" ref-type="bibr">Chan & Huak, 2004</xref>). Fear and nervousness were the distressful experiences reported by healthcare workers taking care of patients with MERS-CoV in Saudi Arabia (<xref rid="bb0150" ref-type="bibr">Khalid, Khalid, Qabajap, Barnard, & Qushmaq, 2016</xref>). These findings indicate that mental health problems of nurses fighting such novel infectious diseases need to be considered.</p><p id="p0035">Stigma is also a prominent issue to be considered among healthcare workers associated with infectious disease due to its transmission characteristics (<xref rid="bb0210" ref-type="bibr">Maunder et al., 2003</xref>). About 20% of healthcare workers involved with the SARS outbreak in Taiwan felt stigmatization and rejection from their neighborhood (<xref rid="bb0005" ref-type="bibr">Bai et al., 2004</xref>). In Singapore, 49% healthcare workers during the SARS outbreak experienced social stigmatization because of their jobs (<xref rid="bb0170" ref-type="bibr">Koh et al., 2005</xref>). In a similar vein, Korean nurses working at hospitals with MERS-CoV patients were distanced by from their significant others (e.g., family or friends) and prohibited from using elevators at their apartments, and even their children were not allowed to attend kindergartens and schools (<xref rid="bb0145" ref-type="bibr">Jung & Cho, 2015</xref>).</p><p id="p0040">Stigma has been reported to adversely affect the mental health mainly of patients or their family caregivers (<xref rid="bb0050" ref-type="bibr">Cluver et al., 2008</xref>, <xref rid="bb0070" ref-type="bibr">Demi et al., 1997</xref>, <xref rid="bb0085" ref-type="bibr">Furlotte and Schwartz, 2016</xref>, <xref rid="bb0245" ref-type="bibr">Tsutsumi et al., 2004</xref>). There is also rare empirical evidence of stigma among primary healthcare providers during the SARS outbreak in Singapore (<xref rid="bb0255" ref-type="bibr">Verma et al., 2004</xref>). Stigma was also considered as a source of perceived stress (<xref rid="bb0065" ref-type="bibr">Crocker et al., 1998</xref>, <xref rid="bb0220" ref-type="bibr">Rűsch et al., 2009</xref>). Consistent with this, previous studies have found stigma to be related to stress not only in people living with infectious disease (<xref rid="bb0030" ref-type="bibr">Charles et al., 2012</xref>) but also in the nurses caring for them (<xref rid="bb0125" ref-type="bibr">Hernandez, Morgan, & Parshall, 2016</xref>). Considering that perceived stress is well known to a predictor of mental health (<xref rid="bb0095" ref-type="bibr">Gomes et al., 2016</xref>, <xref rid="bb0185" ref-type="bibr">Lazarus and Folkman, 1984</xref>), stigma may indirectly influence mental health via stress. With a similar perspective, <xref rid="bb0105" ref-type="bibr">Hatzenbuehler, Phelan, and Link (2013)</xref> noticed that stress might mediate the linkage of stigma to health outcomes. Based on all of these findings, it was proposed in the present study that stigma exerts both direct effects on mental health and also indirect (mediated) effects on mental health via stress in nurses caring for patients with MERS-CoV.</p><p id="p0045">Hardiness has been characterized by the following personality disposition: “persons high in hardiness involve themselves in whatever they are doing (commitment), believe and act as if they can influence the events forming their lives (control), and consider change to be not only normal but also a stimulus to development (challenge)” (<xref rid="bb0165" ref-type="bibr">Kobasa, Maddi, & Zola, 1983</xref>, p. 42). Previous studies have found, hardy nurses to have better mental health (<xref rid="bb0090" ref-type="bibr">Gito et al., 2013</xref>, <xref rid="bb0270" ref-type="bibr">Woo and Suh, 2008</xref>), and that hardiness is inversely related to stress (<xref rid="bb0215" ref-type="bibr">McCalister et al., 2006</xref>, <xref rid="bb0235" ref-type="bibr">Soderstrom et al., 2000</xref>). It might therefore also be conjectured that the personal characteristic of hardiness influences mental health directly and also indirectly via stress. To the best of our knowledge, hardiness has never been explored in nurses caring for patients with a novel communicable disease.</p><p id="p0050">A simple partial-mediation model with two independent variables was hypothesized in this study: stigma and hardiness exert both direct effects on mental health and also indirect (mediated) effects on mental health via stress. The aims of this study were to identify the direct and indirect effects among the study variables in nurses working at a government-designated hospital during a MERS-CoV epidemic.</p></sec><sec id="s0010"><title>METHODS</title><sec id="s0015"><title>DESIGN</title><p id="p0055">A cross-sectional exploratory design was used.</p></sec><sec id="s0020"><title>PARTICIPANTS AND PROCEDURES</title><p id="p0060">Participants were recruited from a government-designated hospital in Gyeonggi-do, South Korea from August 30 to September 21, 2015 using a convenience sampling method. The hospital has 1328 beds (1221 for general care and 107 for intensive care) and 28 operating rooms. The inclusion criterion was being a registered nurse working in high-risk areas for the MERS-CoV, such as isolation wards, intensive care units, emergency departments, infection-control office, respiratory words, and outpatient walk-in clinics. Those working in departments providing indirect support were excluded. A total of 187 nurses participated in this study. This sample size satisfied the required number for a multiple regression at a significance level of 0.05, an effect size of <italic>f</italic><sup>2</sup> = 0.15, and a statistical power of 0.80, as calculated using G-Power 3.1.</p><p id="p0065">After receiving approval from the institutional ethics committees (B-1508/312-306, AJIRB-SBR-SUR-15-277), one of the researchers met the chief director of a nursing service to explain the importance of this study. A list of potential participants was obtained from a nursing administration office. A researcher then met the potential participants and explained about the purpose of the study, its voluntary nature, and the maintenance of confidentiality. If they agreed to participate, they were asked to sign a written informed consent form and to complete a pack of questionnaires.</p></sec><sec id="s0025"><title>MEASURES</title><sec id="s0030"><title>MENTAL COMPONENT SUMMARY</title><p id="p0070">The Short Form-36 (SF-36) is a self-reported instrument that is widely used to measure the overall health status of general populations (<xref rid="bb0260" ref-type="bibr">Ware, 1994</xref>). It consists of 36 items in the following 8 subscales: physical function (PF), role physical (RP), bodily pain (BP), general health (GH), validity (VT), social functioning (SF), role emotional (RE), and mental health (MH). The first four subscales are categorized into the physical component summary, while the second four are categorized into the mental component summary (MCS). The MCS was used in this study to measure the mental health of nurses. The MCS score ranged from 0 to 100, with higher scores indicating a better mental health status. Cronbach's alpha of each subscale in the MCS ranged from 0.65 to 0.84 in this study: 0.77 for VT, 0.65 for SF, 0.84 for RE, and 0.80 for MH. The MCS was used with permission from QualityMetric Incorporated, and scored using Scoring Software (version 4.0).</p></sec><sec id="s0035"><title>PERCEIVED STRESS SCALE-10</title><p id="p0075">The Perceived Stress Scale-10 (PSS-10) was developed to measure the degree to which situations in one's life are appraised as stressful (<xref rid="bb0055" ref-type="bibr">Cohen & Williamson, 1988</xref>). This scale comprises 10 items, each of which is scored on a 5-point Likert-type scale, with a higher score indicating higher perceived stress. In a systematic review of its measurement properties, <xref rid="bb0190" ref-type="bibr">Lee (2012)</xref> found that the PSS-10 was short, easy to use, and exhibited acceptable psychometric properties. The present study used the Korean version of the PSS-10 to measure the perceived stress of nurses. It exhibited excellent reliability and validity (<xref rid="bb0195" ref-type="bibr">Lee, Chung, Suh, & Jung, 2015</xref>), and its Cronbach's alpha was 0.73 in this study.</p></sec><sec id="s0040"><title>DISPOSITIONAL RESILIENCE SCALE-15</title><p id="p0080">Hardiness was measured with the Dispositional Resilience Scale-15 (DRS-15) (<xref rid="bb0015" ref-type="bibr">Bartone, 2007</xref>). This 15-item scale comprises the 3 subscales of commitment, control, and challenge. The overall score ranges from 0 to 45, with higher scores indicating greater hardiness. In this study the DRS-15 was used with permission from KBmetric, which is the sole authorized distributor of this scale. The English version was translated into Korean using a translation and back-translation technique, with final acceptance received from the original developer (Paul T. Barton, PhD). In this study Cronbach's alpha of the Korean version of the DRS-15 was 0.78.</p></sec><sec id="s0045"><title>STIGMA</title><p id="p0085">The scale for the perceived stigma of nurses regarding the MERS-CoV was newly developed to use in this study. The stigma scale comprises 13 items, each of which is scored on a 5-point Likert-type scale, with a higher score indicating that the nurses perceived greater stigma. The content validity of the scale was established by the content validity index exceeding 0.78 (<xref rid="bb0200" ref-type="bibr">Lynn, 1986</xref>). The stigma scale satisfied factorial construct validity using both exploratory factor analysis (explaining 71% of the variance) and confirmatory factor analysis (the ratio of the chi-square value to the degrees of freedom, comparative fit index, normed fit index, and standardized root mean square residual were 2.65, 0.95, 0.92, and 0.04, respectively), which indicates a good fit to the data (<xref rid="bb0020" ref-type="bibr">Browne & Cudeck, 1993</xref>) (see Supplementary File for the detailed results). Cronbach's alpha of the stigma questionnaire was 0.94.</p></sec><sec id="s0050"><title>DEMOGRAPHIC VARIABLES</title><p id="p0090">Age, marital status, gender, marital status, work position, and the duration of clinical experience were examined.</p></sec></sec><sec id="s0055"><title>ANALYSIS</title><p id="p0095">Data were analyzed using SPSS Windows (version 22) and the PROCESS macro (version 2.16) for SPSS (<xref rid="bb0115" ref-type="bibr">Hays, 2013</xref>). Descriptive statistics was applied to the general characteristics and study variables. Correlations and mean differences between general characteristics and mental health were analyzed using Pearson's correlation, the <italic>t</italic>-test, and ANOVA. Pearson's coefficients were also computed for the bivariate correlations of study variables. Regarding the hypotheses of this study, the direct and indirect effects were computed using a series of ordinary least-squares regressions and 95% bootstrap confidence intervals (95% Boot CIs) with 10,000 bootstrap resamples from the data, based on Model Template for the SPSS PROCESS macro (<xref rid="bb0115" ref-type="bibr">Hays, 2013</xref>). As shown in the statistical diagram in <xref rid="f0005" ref-type="fig">Fig. 1</xref>, stigma and hardiness were entered as independent variables, mental health was entered as a dependent variable, and stress as a mediator. In addition, the effect size in <xref rid="f0005" ref-type="fig">Fig. 1</xref> was calculated by the ratio of the indirect effect to direct effect of each sigma and hardiness on mental health (<xref rid="bb0230" ref-type="bibr">Sobel, 1982</xref>).<fig id="f0005"><label>Fig. 1</label><caption><p>Statistical diagram of a simple mediation model with two independent variables.</p><p><italic>a</italic><sub>1</sub>, <italic>a</italic><sub>2</sub>, <italic>b</italic>, <italic>c</italic><sub>1</sub>, and <italic>c</italic><sub>2</sub>: unstandardized regression coefficients; <italic>e</italic><sub>1</sub> and <italic>e</italic><sub>2</sub>: unexplained parts of stress and mental health, respectively.</p><p>Two regression models: stress = constrant<sub>1</sub> + <italic>a</italic><sub>1</sub>·stigma + <italic>a</italic><sub>2</sub>·hardiness + <italic>e</italic><sub>1</sub>; mental health = constrant<sub>2</sub> + <italic>c</italic><sub>1</sub>·stigma + <italic>c</italic><sub>2</sub>·hardiness + <italic>b</italic>·stress + <italic>e</italic><sub>2</sub></p><p>Indirect effect of stigma on mental health through stress was <italic>a</italic><sub>1</sub> × <italic>b</italic>, and the direct effect was <italic>c</italic><sub>1</sub>; indirect effect of hardiness on mental health through stress was <italic>a</italic><sub>2</sub> × <italic>b</italic>, and the direct effect was <italic>c</italic><sub>2</sub>.</p></caption><alt-text id="al0005">Fig. 1</alt-text><graphic xlink:href="gr1_lrg"></graphic></fig></p></sec></sec><sec id="s0060"><title>RESULTS</title><sec id="s0065"><title>PARTICIPANTS</title><p id="p0100">The participants were aged 31.15 ± 6.75 years (mean ± standard deviation), and all of them were female. Most of the participants were unmarried (<italic>n</italic> = 123, 65.8%) and worked as general nurses (<italic>n</italic> = 176, 94.1%). They had 8.4 ± 6.8 years of clinical experience.</p><p id="p0105">The age and duration of clinical experience were not significantly correlated with mental health in Pearson's correlation analysis. The gender, marital status, and work position did not differ significantly with the mental health status in a <italic>t</italic>-test or ANOVA.</p></sec><sec id="s0070"><title>DESCRIPTIVE STATISTICS AND BIVARIATE CORRELATIONS OF STUDY VARIABLES</title><p id="p0110">Descriptive statistics for the study variables are presented in <xref rid="t0005" ref-type="table">Table 1</xref>. Bivariate correlations among the study variables were all significant at <italic>p</italic> < 0.01, with the exception of the relationship between stigma and hardiness.<table-wrap position="float" id="t0005"><label>Table 1</label><caption><p>Descriptive statistics and bivariate correlations among study variables.</p></caption><alt-text id="al0010">Table 1</alt-text><table frame="hsides" rules="groups"><thead><tr><th></th><th>Mean ± SD</th><th>1</th><th>2</th><th>3</th></tr></thead><tbody><tr><td>1. Stigma</td><td>24.60 ± 11.94</td><td>–</td><td></td><td></td></tr><tr><td>2. Stress</td><td>19.98 ± 4.25</td><td>0.229 (<italic>p</italic> = 0.002)</td><td>–</td><td></td></tr><tr><td>3. Hardiness</td><td>24.59 ± 5.37</td><td>− 0.046 (<italic>p</italic> = 0.533)</td><td>− 0.401 (<italic>p</italic> < 0.001)</td><td>–</td></tr><tr><td>4. Mental health</td><td>40.89 ± 9.48</td><td>− 0.481 (<italic>p</italic> < 0.001)</td><td>− 0.562 (<italic>p</italic> < 0.001)</td><td>0.439 (<italic>p</italic> < 0.001)</td></tr></tbody></table></table-wrap></p></sec><sec id="s0075"><title>HYPOTHESIS TESTING</title><p id="p0115">The estimated regression coefficients of the simple partial-mediation model with two independent variables are summarized in <xref rid="t0010" ref-type="table">Table 2</xref>. There was a significant direct effect of stigma on mental health when controlling for hardiness and stress (<italic>c</italic><sub>1</sub> = − 0.306, <italic>t</italic> = − 7.2376, <italic>p</italic> < 0.001); that is, greater stigma was directly associated with worse mental health when hardiness and stress were constant. The 95% Boot CI for the indirect effect of stigma on mental health through stress ranged from − 0.107 to − 0.026, implying that stigma uniquely exerts an effect on mental health indirectly through stress (indirect effect = − 0.061, Boot SE = 0.020).<table-wrap position="float" id="t0010"><label>Table 2</label><caption><p>Estimated regression coefficients from a simple mediation analysis with two independent variables.</p></caption><alt-text id="al0015">Table 2</alt-text><table frame="hsides" rules="groups"><thead><tr><th rowspan="3"></th><th colspan="8">Consequent<hr></hr></th></tr><tr><th rowspan="2"></th><th colspan="3">Stress<hr></hr></th><th rowspan="2"></th><th colspan="3">Mental health<hr></hr></th></tr><tr><th><italic>B</italic></th><th>SE</th><th><italic>p</italic></th><th><italic>B</italic></th><th>SE</th><th><italic>p</italic></th></tr></thead><tbody><tr><td>Stigma</td><td><italic>a</italic><sub>1</sub></td><td>0.075</td><td>0.023</td><td>0.002</td><td><italic>c</italic><sub>1</sub></td><td>− 0.306</td><td>0.042</td><td>< 0.001</td></tr><tr><td>Stress</td><td></td><td>–</td><td>–</td><td>–</td><td><italic>b</italic></td><td>− 0.810</td><td>0.130</td><td>< 0.001</td></tr><tr><td>Hardiness</td><td><italic>a</italic><sub>2</sub></td><td>− 0.310</td><td>0.051</td><td>< 0.001</td><td><italic>c</italic><sub>2</sub></td><td>0.487</td><td>0.100</td><td>< 0.001</td></tr><tr><td>Constant</td><td></td><td>25.751</td><td>1.455</td><td>< 0.001</td><td></td><td>52.649</td><td>4.202</td><td>< 0.001</td></tr><tr><td></td><td></td><td colspan="3"><italic>R</italic><sup>2</sup> = 0.205</td><td></td><td colspan="3"><italic>R</italic><sup>2</sup> = 0.510</td></tr><tr><td></td><td></td><td colspan="3"><italic>F</italic>(2, 184) = 23.701, <italic>p</italic> < 0.001</td><td></td><td colspan="3"><italic>F</italic>(3, 183) = 63.476, <italic>p</italic> < 0.001</td></tr></tbody></table><table-wrap-foot><fn id="sp0035"><p><italic>B</italic> = unstandardized coefficient; SE = standard error.</p></fn><fn id="sp0040"><p><italic>a</italic><sub>1</sub>, <italic>a</italic><sub>2</sub>, <italic>b</italic>, <italic>c</italic><sub>1</sub>, and <italic>c</italic><sub>2</sub>: unstandardized regression coefficients; <italic>e</italic><sub>1</sub> and <italic>e</italic><sub>2</sub>: unexplained parts of stress and mental health, respectively.</p></fn><fn id="sp0045"><p>Two regression models: stress = constrant<sub>1</sub> + <italic>a</italic><sub>1</sub>·stigma + <italic>a</italic><sub>2·</sub>hardiness + <italic>e</italic><sub>1</sub>; mental health = constrant<sub>2</sub> + <italic>c</italic><sub>1</sub>·stigma + <italic>c</italic><sub>2</sub>·hardiness + <italic>b</italic>·stress + <italic>e</italic><sub>2</sub>.</p></fn></table-wrap-foot></table-wrap></p><p id="p0120">Hardiness exerted a significant direct effect on mental health when the other variables were kept constant (<italic>c</italic><sub>2</sub> = 0.487, <italic>t</italic> = 4.8692, <italic>p</italic> < 0.001). The 95% Boot CI for the indirect effect of hardiness on mental health through stress was 0.146 to 0.401, and hence did not include 0, indicating a significant indirect effect of hardiness on mental health that was unique to hardiness (indirect effect = 0.251, Boot SE = 0.638). As hypothesized, the stigma and hardiness of nurses exerted direct effects on mental health and indirect effects on mental health via stress. In other words, the relationships of stigma and hardiness to mental health were partially mediated through stress.</p><p id="p0125">The ratios of the indirect effects to the direct effects of stigma and hardiness on mental health were 0.199, and 0.516, respectively. In other words, the indirect effect of stigma on mental health was 19.9% of its direct effect on mental health, while the indirect effect of hardiness was 51.6% of its direct effect on the mental health of nurses working at a government-designated hospital during a MERS-CoV epidemic.</p></sec></sec><sec id="s0080"><title>DISCUSSION</title><p id="p0130">This study investigated the relationships of stigma, hardiness, and stress with mental health in nurses working at a government-designated hospital during a MERS-CoV epidemic in South Korea. The MERS-CoV was an unfamiliar communicable disease in South Korea before its outbreak in 2015. During the outbreak, 16 hospitals were designated to treat patients with the novel MERS-CoV. Nurses working at these hospitals were required to care for patients diagnosed with the disease or suspected of having the disease. Previous studies have found that staff nurses working at hospitals treating patients with infectious diseases (e.g., SARS and MERS-CoV) suffer from deteriorated mental health (<xref rid="bb0035" ref-type="bibr">Chen et al., 2005</xref>, <xref rid="bb0150" ref-type="bibr">Khalid et al., 2016</xref>). In a similar vein, the mental health score in the present study was worse than those of shift-work nurses (<xref rid="bb0160" ref-type="bibr">Kim, 2004</xref>) and scrub nurses (<xref rid="bb0140" ref-type="bibr">Jung, 2002</xref>) working at university hospitals not associated with a novel infectious disease in South Korea when their mental health was measured using the same instrument.</p><p id="p0135">With the recent occurrences of novel contagious diseases (e.g., avian influenza, SARS, and MERS-CoV), the stigma and its consequences for front-line health providers have emerged as an important issue that needs to be addressed (<xref rid="bb0045" ref-type="bibr">Choi and Kim, 2016</xref>, <xref rid="bb0210" ref-type="bibr">Maunder et al., 2003</xref>). The present study has identified how stigma is linked to the mental health of nurses working at a hospital treating patients with the MERS-CoV—stigma was related to mental health not only directly but also indirectly via stress. The direct linkage between stigma and mental health was congruent with the findings of an investigation of a SARS outbreak (<xref rid="bb0255" ref-type="bibr">Verma et al., 2004</xref>). The indirect linkage was similarly supported by stigma having a mediation effect on depression through stress in people with disabilities (<xref rid="bb0225" ref-type="bibr">Shin, Lee, Kim, & Lee, 2011</xref>). From these findings, it is suggested that hospital administrators and policymakers should make efforts to ensure that nurses do not suffer from infectious-disease-related stigma (e.g., social rejection, prejudice, or discrimination) during the early stages of an epidemic. This might result in the nurses perceiving less stress and maintaining better mental health, enabling them to concentrate on caring for their patients.</p><p id="p0140">Hardiness has been studied in nurses at various workplaces, such as critical care units, emergency departments, and home care (<xref rid="bb0040" ref-type="bibr">Cho and Kim, 2014</xref>, <xref rid="bb0120" ref-type="bibr">Henderson, 2015</xref>, <xref rid="bb0135" ref-type="bibr">Judkins and Rind, 2005</xref>, <xref rid="bb0265" ref-type="bibr">Whitmer et al., 2009</xref>). The hardiness of nurses working in such settings was reported as an important direct predictor of their mental health (<xref rid="bb0100" ref-type="bibr">Harrison et al., 2002</xref>, <xref rid="bb0180" ref-type="bibr">Lambert et al., 2007</xref>). This is consistent with the findings of the present study involving nurses working at hospitals treating patients with the MERS-CoV; this study is the first to investigate the hardiness of nurses working at hospitals treating patients with novel contagious diseases. In this study hardiness was also found to indirectly influence mental health via stress. Such a partial mediation effect of hardiness on a health outcome via stress was also found in a study of employees working in a corporate environment in the USA (<xref rid="bb0235" ref-type="bibr">Soderstrom et al., 2000</xref>). This personal trait of hardiness can be enhanced by ongoing education (<xref rid="bb0130" ref-type="bibr">Judkins, Massey, & Huff, 2006</xref>). It is therefore recommended to develop an educational program that strengthens the personal characteristics of commitment, control, and challenge among nurses.</p><p id="p0145">Considering the effect sizes for how hardiness influenced mental health, the indirect effect through stress was about a half (51.6%) that for the direct effect. Combining a stress-reduction intervention with an educational program for enhancing hardiness might therefore be more effective in improving the mental health status of nurses during an infectious epidemic.</p><sec id="s0085"><title>STRENGTHS AND LIMITATIONS</title><p id="p0150">This study exhibited several strengths and limitations. A mediation effect refers to how an independent variable influences a dependent variable through a mediator (<xref rid="bb0080" ref-type="bibr">Field, 2013</xref>). The first strength of this study was therefore in identifying the mechanism underlying how stigma and hardiness influence the mental health of nurses working at hospitals treating patients with the MERS-CoV. The second strength was that a simple partial-mediation model of the influences of stigma and hardiness on mental health via stress was assessed using the powerful approach of bootstrapping. The most widely used approach is that suggested by <xref rid="bb0010" ref-type="bibr">Baron and Kenny (1986)</xref>, but that approach has been criticized as having a low statistical power (<xref rid="bb0080" ref-type="bibr">Field, 2013</xref>, <xref rid="bb0205" ref-type="bibr">MacKinnon et al., 2002</xref>). An alternative is the Sobel test, which requires the assumption that the indirect effect is normally distributed (<xref rid="bb0110" ref-type="bibr">Hays, 2009</xref>). However, the distribution actually tends to exhibit skewness and kurtosis (<xref rid="bb0075" ref-type="bibr">Edwards & Lambert, 2007</xref>). Currently the most powerful approach for a mediating-effect model involves the application of bootstrapping, which provides the advantage of not needing to make any assumptions about the sampling distribution (<xref rid="bb0110" ref-type="bibr">Hays, 2009</xref>).</p><p id="p0155">The participants were recruited from a single institute in this study. This limited the external validity for generalizing the findings. The mediation model in this study was tested with cross-sectional corrected data, which makes it difficult to identify the temporal sequence between exposure to the independent and mediating variables preceding the outcome variable of the mental health of the nurses.</p><p id="p0160">Care is also needed when interpreting the effect sizes found in this study. The effect size was calculated as the ratio of an indirect effect to a direct effect. This approach is easy to estimate and is currently the most widely used measure; however, a very large sample is required to obtain stable estimations of this ratio measure (<xref rid="bb0240" ref-type="bibr">Tofighi, MacKinnon, & Yoon, 2009</xref>).</p></sec><sec id="s0090"><title>IMPLICATIONS FOR FURTHER RESEARCH</title><p id="p0165">This study only involved nurses, whereas other kinds of healthcare workers were also involved in treating patients with the MRES-CoV. Studies of future outbreaks of MRES-CoV or other infectious diseases could include other health professionals such as physicians. In terms of the study design, future prospective longitudinal surveys are recommended for identifying the temporal sequence of the variables in the mediation model. An instrument is already available for measuring stigma related to chronic infectious diseases (e.g., HIV/AIDS) experienced by nurses providing healthcare services (<xref rid="bb0250" ref-type="bibr">Uys et al., 2009</xref>). However, there is no such instrument related to the MERS-CoV for nurses. The present study is the first to develop a scale for the stigma perceived by nurses related to the MERS-CoV, and the scale satisfies content validity, factorial-construct validity, and internal consistency reliability. Future studies should evaluate other psychometric properties of the scale, such as its convergent/discriminant validity, known-groups validity, and test–retest reliability. This instrument may also be suitable for application by infection control nurses or other healthcare providers at community health centers.</p></sec></sec><sec id="s0095"><title>CONCLUSIONS</title><p id="p0170">Stigma and hardiness influence mental health both directly and also indirectly via stress in nurses working at government-designated hospitals during a MERS-CoV epidemic. The mental health of nurses was more strongly determined by direct effects than by indirect effects. 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| This area was generated with Dilib version V0.6.33. |  |