The promotion of occupational health and safety has been identified as a key goal of health promotion in the 21st century by the World Health Organization (WHO)[1]. In healthcare careers, nurses, who represent a significant portion of the global healthcare workforce, are universally acknowledged to have a stressful occupation due to the work environment, the nature of their work, and the specific population they care for. The multitude of complex stressors and challenges that nurses face in clinical settings, if not effectively addressed in the long term, can deplete individual psychological resources and lead to a vicious cycle of psychological issues such as anxiety, depression, and burnout[2], further leading to their own physiological pathology, decreased quality of care, reduced patient satisfaction and increased turnover rates [3].
The operating room(OR) is a critical department in hospitals for surgical procedures and for the resuscitation of emergency and critical care patients.[4]. Nurses in the OR face particularly prominent work pressure in the nursing workforce due to the particularity of their nursing work. They work in confined spaces for extended periods, participate in invasive procedures across various specialties, maintain high levels of concentration, and are often faced with work pressures brought about by time-pressure-related techniques, tasks, and interactions[5, 6]. Additionally, they must navigate the diverse technical and personality traits of surgeons and anaesthetists, resulting in limited job control [7]. Studies have shown that OR nurses perceive less autonomy than nurses in other departments [7]. With the growing number of surgeries and the shortage of human resources for OR nurses, the workload of OR nurses is escalating[8]. Studies have indicated that OR nursing ranks among the most stressful departments in hospitals [9]. According to a survey, the incidence of subhealth among OR nurses in China is 76.9%, which is higher than that reported in a global statistical survey conducted by the WHO. It is therefore particularly important to establish a good internal experience for OR nurses to reduce their workload, improve their well-being and ensure patient safety. And research into mental health status and influencing factors is key to developing targeted interventions.
In recent years, the "third wave" of cognitive behavioral therapy(CBT) has gradually become a research hotspot in the field of psychology. Among them, acceptance and commitment therapy(ACT) is the latest development direction of CBT. Developed by Hayes et al. [10], ACT relates to a core goal of improving psychological flexibility. Psychological flexibility (PF), a fundamental aspect of health, refers to the ability of a conscious individual to be aware of and accept his or her own experiences, thoughts, emotions and feelings, and to choose to maintain or abandon certain behaviours in accordance with the reality and values of the situation[11]. Studies have shown that PF contributes to the explanation of negative variables and moderates various stressors, and it has been proposed that improving PF could be a desirable public health target[12, 13]. According to the Hexaflex model proposed by Hayes et al., PF consists of 6 core components, namely, present moment awareness, acceptance, cognitive defusion, self as context, values, and committed action, all of which are mutually reinforcing and influential[14], and reflect how individuals cope with negative thoughts, feelings, and events to modify their internal experiential functioning. The opposite concept of PF is psychological inflexibility(PI), which includes lack of contact with the present moment, experiential avoidance, cognitive fusion, self as content, lack of contact with values and inaction, and represents a common maladaptive and reactive behavioural response of individuals to unwanted thoughts and feelings. In reality, negative beliefs and suffering are inevitable, and repression and avoidance not only do not enable individuals to work through their suffering, but also lead to the creation, maintenance, and exacerbation of more psychological issues[15]. Conversely, when individuals are instructed to adapt flexibly to the situation and accept painful experiences in a nonjudgemental manner, their attitudes toward these events can undergo fundamental transformation. [16]. As Renshaw et al. noted[17], psychological well-being is maintained through psychologically flexible behavior, while mental health difficulties can arise from psychologically inflexible behavior. In recent years, PF has garnered attention in occupational health research as a positive psychological trait that plays a crucial role in psychological well-being and behavioral effectiveness in the workplace.[18]. Studies have shown that high levels of PF are associated with lower levels of nurse burnout, anxiety, and depression, as well as higher levels of work engagement. [19–23]. Nurses with high PF are able to interact with stressors in different ways while simultaneously establishing new ways of behaving[16, 18, 22]. However, limited research has been conducted on PF among OR nurses.
Currently, the use of PF assessment tools in the field is a topic of debate[24]. Many studies on PF in nurses have used the Acceptance and Action Questionnaire-2nd (AAQ-II) as a measure. However, it has been criticized for oversimplifying the concepts of the Hexaflex model into a single dimension, potentially limiting its ability to fully capture an individual's PF[25]. In addition, the AAQ-II indirectly reflects the PF primarily by reflecting the PI. Previous studies have used neuroticism and negative affect as indicators of the discriminant validity of the AAQ-II, showing that it is more closely related to measures of neuroticism and psychological distress[25–27]. To address these limitations, Rolffs et al.(2016) developed the Multidimensional Psychological Flexibility Inventory(MPFI-24), which includes the PF and PI subscales. Each consists of six dimensions corresponding to the six aspects of PF and PI. The full scale consists of 60 items, and both the total scale and the subscales show good psychometric properties [28]. However, due to the excessive number of items in the MPFI [14], a simplified version (MPFI-24) was created by selecting items with the highest factor loadings from the original MPFI. Reliability and validity tests of the MPFI-24 in China have shown good psychometric properties[29]. Therefore, the MPFI-24 was used to measure PF in OR nurses in our study. However, the quantitative approach to PF is mainly based on a variable-centered approach, which ignores the existence of heterogeneity in the study population[30], despite aiding in the understanding of the relationship between variables and PF. In reality, almost all the variables in the study cannot meet the characteristics of homogeneity. Latent profile analysis(LPA), a person-centered approach, accounts for group heterogeneity by categorizing individuals with similar characteristics into distinct subgroups based on the shared response model among individuals[31]. Previous studies have utilized the LPA to identify heterogeneity in the PF of college students[32, 33], and social groups[30, 34], indicating the possible existence of subgroups within OR nurses. Therefore, this study used LPA to identify heterogeneity among OR nurses.
Furthermore, the current literature on the influencing factors of nurses' PF is limited, with a predominant focus on demographic variables. According to the psychological stress theory of Shelley[35], when faced with a stressful event, individuals can integrate their internal and external resources and respond accordingly to reduce the adverse effects of the stressful event. The theory emphasizes the mediating role of internal and external resources. Among them, social support, as an external resource, involves perceived comfort, happiness, respect, or assistance from others or groups. Coping, as an internal resource, refers to the cognitive and behavioural choices that individuals make in response to difficulties or setbacks, including negative and positive coping styles[36]. Good social support and positive coping style play crucial roles in buffering the effects of stressful events on physical and mental health. PF refers to an individual's ability to dynamically adjust to negative events. It is equally influenced by internal and external resources.
Therefore, objectives of this study were to use LPA to explore the latent profiles of PF in OR nurses and to further explore their characteristics. Second, in combination with demographic factors, this research introduced social support and coping based on psychological stress theory to explore their impact on PF in different latent profiles. This study aimed to enrich relevant research and providing a reference for nursing managers to develop targeted interventional strategies and improve PF among OR nurses.