This study found the relatively low level of symptoms of mental indisposition in HCWs and determined the mediated effect of mental health in the relationship between workload and burnout, which contributed to lower hand hygiene behavior. However, only the effect of burnout was found in ProQOL, with the relation regarding to secondary traumatic stress and compassion satisfaction insignificant.
Contributors of hand hygiene behavior
Burnout is found to be associated with hand hygiene, while the effect of workload and mental health is indirect in our study, which has been explored by previous findings. Just as burnout is frequently associated with poor practice, communication, quality and safety in health care[4], the effect works in hand hygiene behavior similarly. And researchers indicated that burnout was an incremental predictor of nurses’ self-reported adherence with infection control measures (covering hand hygiene)[23, 24]. The indirect effect of workload on hand hygiene was also found to be significant in our study, which provides more explanation on how workload influence hand hygiene compared to previous studies. For example, Ataiyero and Smith found that workload is one of the main barriers to hand hygiene, especially in developing countries based on narrative review and Theoretical Domains Framework [30, 31], while Zhang found that high nursing workload is confirmed to be a main associated factor of poor hand hygiene in China[32]. Furthermore, the indirect effect of mental health on hand hygiene was also found to be significant in our study, while the direct effect was insignificant, which was different from previous studies. For example, Tan found that the less severe mental health syndrome were directly associated with more personal psychoneuroimmunity prevention measures including hand hygiene in HCWs[13]. Similarly, mental health is found the ability to directly enhance the behavior apart from hand hygiene, including career-sustaining behavior and co-creation behavior[15, 16].
Relationship of Mental health, workload and ProQOL
The relationship between workload and mental health with ProQOL (burnout) were, as hypothesized, consistent with previous studies in different context. Xiao also indicated workload is a contributor to mental health among Chinese petroleum industry workers, which should take effective preventive measures[33]. Aiken found that the nurse burnout increases when the workload augments with less patient-to-nurse ratios in America[11]. Meanwhile, Győrffy also found that increased workload has a clear impact on mental health (sleep disorders) and burnout based on two nationally representative surveys of female doctors in Hungary[34]. In addition, Neville suggested the promotion of health is effective to counteract compassion fatigue and burnout and enhancing compassion satisfaction[35]. Meanwhile, Lawson found that counselors with better health reported higher positive ProQOL factors (compassion satisfaction)[15].
Relationship of burnout, secondary traumatic stress and compassion satisfaction
We found that higher burnout is associated with higher secondary traumatic stress and less compassion satisfaction, which is in line with previous studies[36]. Previous studies found that the overload work, inappropriate working processes and organizational structure are the drivers of more burnout and less compassion satisfaction[18, 37]. The relative intervention is the approach to reduce burnout, secondary traumatic stress and increase compassion satisfaction, including mindfulness-based technique, emotions empowerment, improving the work environment, etc.[38].
Implication and limitation
The significant relationship between mental health, workload, ProQOL and hand hygiene behavior can provide an approach to promote the adherence of hand hygiene through decrease the workload, burnout and enhance mental health, by means of increasing human resources and relevant interventions for HCWs who are working in COVID-19 period and under intensive pressure. Stress from work itself (i.e. patient care) reflecting on secondary traumatic stress is also crucial, for the close connection with burnout which focusing on working environment (i.e. work situation and colleague relationship) [18]. The study has limitation. As our SEM was constructed using cross-sectional data, those relationships should be tested by further longitudinal data to generalize the relationships between those factors.