1.1 Research objective
From January to April 2021, a convenience sampling method was used to select nurses who had returned to work after giving birth to their second child. Participants were selected from 23 Chinese Grade A general hospitals in 10 provinces and municipalities directly under the Central Government.
Inclusion criteria: (1) registered nurses in tertiary A general hospitals; (2) returning to work within one year after their second maternity leave; (3) voluntarily agreeing to participate in this study.
Exclusion criteria: (1) after returning to the post, they asked for leave again for more than 1 month due to their own illness; (2) they were clearly diagnosed with depression before or after delivery.
1.2 Research tools
Three research tools were used in this study: a general information questionnaire, a postnatal return-to-work stress scale, and a self-rating depression scale.
(1) General information questionnaire
The general information questionnaire was designed by the researchers on the basis of a literature review and included the age, educational background, mode of appointment, department, family income, birth order, children’s sex, and length of maternity leave.
(2) The work stress scale
Participants’ present level of work stress was measured by the work stress scale developed by our research team.[14] Guided by Cognitive Phenomenological Transactional (CPT) theory, the scale adopted the methods of literature review, semi-structured interviews, and group discussions to form the item pool. A total of 24 experts in nursing management, clinical nursing, and psychology were consulted from 10 tertiary A general hospitals in 8 provinces including Beijing, Anhui, Shandong, Liaoning, Shanxi, Guangdong, Henan, and Yunnan. The items of the scale were adjusted and screened using the Delphi method, and by item analysis and exploratory factor analysis. The final scale consists of a total of 30 items reflecting five dimensions: nursing work, family and work conflict, interpersonal relationship, patient nursing, and maternal role commitment. All items were scored on a five point Likert scale, and the scores ranged from one to five according to the frequency of “never,” “rarely,” “sometimes,” “often,” and “always”. The higher the score, the greater the work stress. The reliability and validity of the scale has been tested among the postpartum returning nurses in China’s Tertiary A general hospitals. The investigation of 635 postpartum nurses showed that the Cronbach’s α coefficient of the total scale was 0.94, and the Cronbach’s α coefficient of each dimension was 0.73–0.89. The content validity was 0.81–1.00, the confirmatory factor analysis showed that the five-factor model fitted well (χ2/df=2.92, RMSEA=0.06, GFI=0.89, NFI=0.89, IFI=0.93, TLI=0.92, CFI=0.93), and the content validity was 0.81–1.00.
(3) Self-rating Depression Scale
A Self-rating Depression Scale (SDS)[15] was used to evaluate the depression level of participants. The scale included 20 items and was scored using a four point Likert scale. The frequency of symptoms was rated as “never or rarely,” “occasionally,” “frequently,” and “most of the time/always” with one to four points respectively. It contained 10 reverse scoring entries, and the integer part of the total score multiplied by 1.25 was the standard score. According to the results of the Chinese norm, the SDS scored 53–62 points as mild depression, 63–71 points as moderate depression, and 72 points or more as severe depression.[16] The Cronbach’s α coefficient of the scale is 0.94 and the reliability is good.[17]
1.3 Data collection
Because the subjects were distributed all over the country, the researchers made all the scales into electronic questionnaires so that they could be answered anonymously online. The participants clicked on the link or scanned the QR code on their computer or mobile phone terminal to fill in the electronic questionnaires. After completing the questionnaires, they uploaded the results directly.
Before the investigation, the researchers contacted the heads of the nursing departments in the hospitals concerned to introduce the contents and cooperation methods of this study and to screen for participants who met the exclusion criteria. After obtaining the informed consent of each participant, researchers sent them a link to the questionnaires. The introduction to the questionnaires explained in detail the purpose, significance and content of the study, and emphasized the confidentiality of participants’ data and responses. Submit all questions after filling in, and there were no limits placed on the time and place of answering the questions, but each subject was only allowed to answer once.
After the questionnaires were collected, in order to ensure their validity and the authenticity and integrity of the data, we used double verification to delete abnormal questionnaires in which participants’ answers were obviously regular or illogical.