recommendation in research about stress

• Research Article
• Open access
• Published: 06 April 2021

Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19

• Szabolcs Garbóczy 1 , 2 ,
• Anita Szemán-Nagy 3 ,
• Mohamed S. Ahmad 4 ,
• Szilvia Harsányi 1 ,
• Dorottya Ocsenás 5 , 6 ,
• Viktor Rekenyi 4 ,
• Ala’a B. Al-Tammemi 1 , 7 &
• László Róbert Kolozsvári   ORCID: orcid.org/0000-0001-9426-0898 1 , 7  

BMC Psychology volume  9 , Article number:  53 ( 2021 ) Cite this article

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In the case of people who carry an increased number of anxiety traits and maladaptive coping strategies, psychosocial stressors may further increase the level of perceived stress they experience. In our research study, we aimed to examine the levels of perceived stress and health anxiety as well as coping styles among university students amid the COVID-19 pandemic.

A cross-sectional study was conducted using an online-based survey at the University of Debrecen during the official lockdown in Hungary when dormitories were closed, and teaching was conducted remotely. Our questionnaire solicited data using three assessment tools, namely, the Perceived Stress Scale (PSS), the Ways of Coping Questionnaire (WCQ), and the Short Health Anxiety Inventory (SHAI).

A total of 1320 students have participated in our study and 31 non-eligible responses were excluded. Among the remaining 1289 participants, 948 (73.5%) and 341 (26.5%) were Hungarian and international students, respectively. Female students predominated the overall sample with 920 participants (71.4%). In general, there was a statistically significant positive relationship between perceived stress and health anxiety. Health anxiety and perceived stress levels were significantly higher among international students compared to domestic ones. Regarding coping, wishful thinking was associated with higher levels of stress and anxiety among international students, while being a goal-oriented person acted the opposite way. Among the domestic students, cognitive restructuring as a coping strategy was associated with lower levels of stress and anxiety. Concerning health anxiety, female students (domestic and international) had significantly higher levels of health anxiety compared to males. Moreover, female students had significantly higher levels of perceived stress compared to males in the international group, however, there was no significant difference in perceived stress between males and females in the domestic group.

The elevated perceived stress levels during major life events can be further deepened by disengagement from home (being away/abroad from country or family) and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping methods, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety could be mitigated.

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Introduction

On March 4, 2020, the first cases of coronavirus disease were declared in Hungary. One week later, the World Health Organization (WHO) declared COVID-19 as a global pandemic [ 1 ]. The Hungarian government ordered a ban on outdoor public events with more than 500 people and indoor events with more than 100 participants to reduce contact between people [ 2 ]. On March 27, the government imposed a nationwide lockdown for two weeks effective from March 28, to mitigate the spread of the pandemic. Except for food stores, drug stores, pharmacies, and petrol stations, all other shops and educational institutions remained closed. On April 16, a week-long extension was further announced [ 3 ].

The COVID-19 pandemic with its high morbidity and mortality has already afflicted the psychological and physical wellbeing of humans worldwide [ 4 , 5 , 6 , 7 , 8 , 9 ]. During major life events, people may have to deal with more stress. Stress can negatively affect the population’s well-being or function when they construe the situation as stressful and they cannot handle the environmental stimuli [ 10 ]. Various inter-related and inter-linked concepts are present in such situations including stress, anxiety, and coping. According to the literature, perceived stress can lead to higher levels of anxiety and lower levels of health-related quality of life [ 11 ]. Another study found significant and consistent associations between coping strategies and the dimensions of health anxiety [ 12 ].

Health anxiety is one of the most common types of anxiety and it describes how people think and behave toward their health and how they perceive any health-related concerns or threats. Health anxiety is increasingly conceptualized as existing on a spectrum [ 13 , 14 ], and as an adaptive signal that helps to develop survival-oriented behaviors. It also occurs in almost everyone’s life to a certain degree and can be rather deleterious when it is excessive [ 13 , 14 ]. Illness anxiety or hypochondriasis is on the high end of the spectrum and it affects someone’s life when it interferes with daily life by making people misinterpret the somatic sensations, leading them to think that they have an underlying condition [ 14 ].

According to the American Psychiatric Association—Diagnostic and Statistical Manual of Mental Disorders (fifth edition), Illness anxiety disorder is described as a preoccupation with acquiring or having a serious illness, and it reflects the high spectrum of health anxiety [ 15 ]. Somatic symptoms are not present or if they are, then only mild in intensity. The preoccupation is disproportionate or excessive if there is a high risk of developing a medical condition (e.g., family history) or the patient has another medical condition. Excessive health-related behaviors can be observed (e.g., checking body for signs of illness) and individuals can show maladaptive avoidance as well by avoiding hospitals and doctor appointments [ 15 ].

Health anxiety is indeed an important topic as both its increase and decrease can progress to problems [ 14 ]. Looking at health anxiety as a wide spectrum, it can be high or low [ 16 ]. While people with a higher degree of worry and checking behaviors may cause some burden on healthcare facilities by visiting them too many times (e.g., frequent unnecessary visits), other individuals may not seek medical help at healthcare units to avoid catching up infections for instance. A lower degree of health anxiety can lead to low compliance with imposed regulations made to control a pandemic [ 17 ].

The COVID-19 pandemic as a major event in almost everyone’s life has posed a great impact on the population’s perceived stress level. Several studies about the relation between coping and response to epidemics in recent and previous outbreaks found higher perceived stress levels among people [ 18 , 19 , 20 , 21 ]. Being a woman, low income, and living with other people all were associated with higher stress levels [ 18 ]. Protective factors like being emotionally more stable, having self-control, adaptive coping strategies, and internal locus of control were also addressed [ 19 , 20 ]. The findings indicated that the COVID-19 crisis is perceived as a stressful event. The perceived stress was higher amongst people than it was in situations with no emergency. Nervousness, stress, and loss of control of one’s life are the factors that are most connected to perceived stress levels which leads to the suggestion that unpredictability and uncontrollability take an important part in perceived stress during a crisis [ 19 , 20 ].

Moreover, certain coping styles (e.g., having a positive attitude) were associated with less psychological distress experiences but avoidance strategies were more likely to cause higher levels of stress [ 21 ]. According to Lazarus (1999), individuals differ in their perception of stress if the stress response is viewed as the interaction between the environment and humans [ 22 ]. An Individual can experience two kinds of evaluation processes, one to appraise the external stressors and personal stake, and the other one to appraise personal resources that can be used to cope with stressors [ 22 , 23 ]. If there is an imbalance between these two evaluation processes, then stress occurs, because the personal resources are not enough to cope with the stressor’s demands [ 23 ].

During stressful life events, it is important to pay attention to the increasing levels of health anxiety and to the kind of coping mechanisms that are potential factors to mitigate the effects of high anxiety. The transactional model of stress by Lazarus and Folkman (1987) provides an insight into these kinds of factors [ 24 ]. Lazarus and Folkman theorized two types of coping responses: emotion-focused coping, and problem-focused coping. Emotion-focused coping strategies (e.g., distancing, acceptance of responsibility, positive reappraisal) might be used when the source of stress is not embedded in the person’s control and these strategies aim to manage the individual’s emotional response to a threat. Also, emotion-focused coping strategies are directed at managing emotional distress [ 24 ]. On the other hand, problem-focused coping strategies (e.g., confrontive coping, seeking social support, planful problem-solving) help an individual to be able to endure and/or minimize the threat, targeting the causes of stress in practical ways [ 24 ]. It was also addressed that emotion-focused coping mechanisms were used more in situations appraised as requiring acceptance, whereas problem-focused forms of coping were used more in encounters assessed as changeable [ 24 ].

A recent study in Hunan province in China found that the most effective factor in coping with stress among medical staff was the knowledge of their family’s well-being [ 25 ]. Although there have been several studies about the mental health of hospital workers during the COVID-19 pandemic or other epidemics (e.g., SARS, MERS) [ 26 , 27 , 28 , 29 ], only a few studies from recent literature assessed the general population’s coping strategies. According to Gerhold (2020) [ 30 ], older people perceived a lower risk of COVID-19 than younger people. Also, women have expressed more worries about the disease than men did. Coping strategies were highly problem-focused and most of the participants reported that they listen to professionals’ advice and tried to remain calm [ 30 ]. In the same study, most responders perceived the COVID-19 pandemic as a global catastrophe that will severely affect a lot of people. On the other hand, they perceived the pandemic as a controllable risk that can be reduced. Dealing with macrosocial stressors takes faith in politics and in those people, who work with COVID-19 on the frontline.

Mental disorders are found prevalent among college students and their onset occurs mostly before entry to college [ 31 ]. The diagnosis and timely interventions at an early stage of illness are essential to improve psychosocial functioning and treatment outcomes [ 31 ]. According to research that was conducted at the University of Debrecen in Hungary a few years ago, the students were found to have high levels of stress and the rate of the participants with impacted mental health was alarming [ 32 ]. With an unprecedented stressful event like the COVID-19 crisis, changes to the mental health status of people, including students, are expected.

Aims of the study

In our present study, we aimed at assessing the levels of health anxiety, perceived stress, and coping styles among university students amidst the COVID-19 lockdown in Hungary, using three validated assessment tools for each domain.

Methods and materials

Study design and setting.

This study utilized a cross-sectional design, using online self-administered questionnaires that were created and designed in Google Forms® (A web-based survey tool). Data collection was carried out in the period April 30, 2020, and May 15, 2020, which represents one of the most stressful periods during the early stage of the COVID-19 pandemic in Hungary when the official curfew/lockdown was declared along with the closure of dormitories and shifting to online remote teaching. The first cases of COVID-19 were declared in Hungary on March 4, 2020. On April 30, 2020, there were 2775 confirmed cases, 312 deaths, and 581 recoveries. As of May 15, 2020, the number of confirmed cases, deaths, and recovered persons was 3417, 442, and 1287, respectively.

Our study was conducted at the University of Debrecen, which is one of the largest higher education institutions in Hungary. The University is located in the city of Debrecen, the second-largest city in Hungary. Debrecen city is considered the educational and cultural hub of Eastern Hungary. As of October 2019, around 28,593 students were enrolled in various study programs at the University of Debrecen, of whom, 6,297 were international students [ 33 ]. The university offers various degree courses in Hungarian and English languages.

Study participants and sampling

The target population of our study was students at the University of Debrecen. Students were approached through social media platforms (e.g., Facebook®) and the official student administration system at the University of Debrecen (Neptun). The invitation link to our survey was sent to students on the web-based platforms described earlier. By using the Neptun system, we theoretically assumed that our survey questionnaire has reached all students at the University. The students who were interested and willing to participate in the study could fill out our questionnaire anonymously during the determined study period; thus, employing a convenience sampling approach. All students at the University of Debrecen whose age was 18 years or older and who were in Hungary during the outbreak had the eligibility to participate in our study whether undergraduates or postgraduates.

Study instruments

In our present study, the survey has solicited information about the sociodemographic profile of participants including age (in years), gender (female vs male), study program (health-related vs non-health related), and whether the student stayed in Hungary or traveled abroad during the period of conducting our survey in the outbreak. Our survey has also adopted three international scales to collect data about health anxiety, coping styles, and perceived stress during the pandemic crisis. As the language of instruction for international students at the University of Debrecen is English, and English fluency is one of the criteria for international students’ admission at the University of Debrecen, the international students were asked to fill out the English version of the survey and the scales. On the other hand, the Hungarian students were asked to fill out the Hungarian version of the survey and the validated Hungarian scales. Also, we provided contact information for psychological support when needed. Students who felt that they needed some help and psychological counseling could use the contact information of our peer supporters. Four International students have used this opportunity and were referred to a higher level of care. The original scales and their validated Hungarian versions are described in the following sections.

Perceived Stress Scale (PSS)

The Perceived Stress Scale (PSS) measures the level of stress in the general population who have at least completed a junior high school [ 34 ]. In the PSS, the respondents had to report how often certain things occurred like nervousness; loss of control; feeling of upset; piling up difficulties that cannot be handled; or on the contrary how often the students felt they were able to handle situations; and were on top of things. For the International students, we used the 10-item PSS (English version). The statements’ responses were scored on a 5-point Likert scale (from 0 = never to 4 = very often) as per the scale’s guide. Also, in the 10-item PSS, four positive items were reversely scored (e.g. felt confident about someone’s ability to handle personal problems) [ 34 ]. The PSS has satisfactory psychometric properties with a Cronbach’s alpha of 0.78, and this English version was used for international students in our study.

For the Hungarian students, we used the Hungarian version of the PSS, which has 14 statements that cover the same aspects of stress described earlier. In this version of the PSS, the responses were evaluated on a 5-point Likert scale (0–4) to mark how typical a particular behavior was for a respondent in the last month [ 35 ]. The Hungarian version of the PSS was psychometrically validated in 2006. In the validation study, the Hungarian 14-item PSS has shown satisfactory internal consistency with a Cronbach’s alpha of 0.88 [ 35 ].

Ways of Coping Questionnaire (WCQ)

The second scale we used was the 26-Item Ways of Coping Questionnaire (WCQ) which was developed by Sørlie and Sexton [ 36 ]. For the international students, we used the validated English version of the 26-Item WCQ that distinguished five different factors, including Wishful thinking (hoped for a miracle, day-dreamed for a better time), Goal-oriented (tried to analyze the problem, concentrated on what to do), Seeking support (talked to someone, got professional help), Thinking it over (drew on past experiences, realized other solutions), and Avoidance (refused to think about it, minimized seriousness of it). The WCQ examined how often the respondents used certain coping mechanisms, eg: hoped for a miracle, fantasized, prepared for the worst, analyzed the problem, talked to someone, or on the opposite did not talk to anyone, drew conclusions from past things, came up with several solutions for a problem or contained their feelings. As per the 26-item WCQ, responses were scored on a 4-point Likert scale (from 0 = “does not apply and/or not used” to 3 = “used a great deal”). This scale has satisfactory psychometric properties with Cronbach's alpha for the factors ranged from 0.74 to 0.81[ 36 ].

For the Hungarian students, we used the Hungarian 16-Item WCQ, which was validated in 2008 [ 37 ]. In the Hungarian WCQ, four dimensions were identified, which were cognitive restructuring/adaptation (every cloud has a silver lining), Stress reduction (by eating; drinking; smoking), Problem analysis (I tried to analyze the problem), and Helplessness/Passive coping (I prayed; used drugs) [ 37 ]. The Cronbach’s alpha values for the Hungarian WCQ’s dimensions were in the range of 0.30–0.74 [ 37 ].

Short Health Anxiety Inventory (SHAI)

The third scale adopted was the 18-Items Short Health Anxiety Inventory (SHAI). Overall, the SHAI has two subscales. The first subscale comprised of 14 items that examined to what degree the respondents were worried about their health in the past six months; how often they noticed physical pain/ache or sensations; how worried they were about a serious illness; how much they felt at risk for a serious illness; how much attention was drawn to bodily sensations; what their environment said, how much they deal with their health. The second subscale of SHAI comprised of 4 items (negative consequences if the illness occurs) that enquired how the respondents would feel if they were diagnosed with a serious illness, whether they would be able to enjoy things; would they trust modern medicine to heal them; how many aspects of their life it would affect; how much they could preserve their dignity despite the illness [ 38 ]. One of four possible statements (scored from 0 to 3) must be chosen. Alberts et al. (2013) [ 39 ] found the mean SHAI value to be 12.41 (± 6.81) in a non-clinical sample. The original 18-item SHAI has Cronbach’s alpha values in the range of 0.74–0.96 [ 39 ]. For the Hungarian students, the Hungarian version of the SHAI was used. The Hungarian version of SHAI was validated in 2011 [ 40 ]. The scoring differs from the English version in that the four statements were scored from 1 to 4, but the statements themselves were the same. In the Hungarian validation study, it was found that the SHAI mean score in a non-clinical sample (university students) was 33.02 points (± 6.28) and the Cronbach's alpha of the test was 0.83 [ 40 ].

Data analyses

Data were extracted from Google Forms® as an Excel sheet for quality check and coding then we used SPSS® (v.25) and RStudio statistical software packages to analyze the data. Descriptive and summary statistics were presented as appropriate. To assess the difference between groups/categories of anxiety, stress, and coping styles, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution and for post hoc tests, we used the Mann–Whitney test. Also, we used Spearman’s rank correlation to assess the relationship between health anxiety and perceived stress within the international group and the Hungarian group. Comparison between international and domestic groups and different genders in terms of health anxiety and perceived stress levels were also conducted using the Mann–Whitney test. Binary logistic regression analysis was also employed to examine the associations between different coping styles/ strategies (treated as independent variables) and both, health anxiety level and perceived stress level (treated as outcome variables) using median splits. A p-value less than 5% was implemented for statistical significance.

Ethical considerations

Ethical permission was obtained from the Hungarian Ethical Review Committee for Research in Psychology (Reference number: 2020-45). All methods were carried out following the institutional guidelines and conforming to the ethical standards of the declaration of Helsinki. All participants were informed about the study and written informed consent was obtained before completing the survey. There were no rewards/incentives for completing the survey.

Sociodemographic characteristics of respondents

A total of 1320 students have responded to our survey. Six responses were eliminated due to incompleteness and an additional 25 responses were also excluded as the students filled out the survey from abroad (International students who were outside Hungary during the period of conducting our study). After exclusion of the described non-eligible responses (a total of 31 responses), the remaining 1289 valid responses were included in our analysis. Out of 1289 participants (100%), 73.5% were Hungarian students and around 26.5% were international students. Overall, female students have predominated the sample (n = 920, 71.4%). The median age (Interquartile range) among Hungarian students was 22 years (5) and for the international students was 22 years (4). Out of the total sample, most of the Hungarian students were enrolled in non-health-related programs (n = 690, 53.5%), while most of the international students were enrolled in health-related programs (n = 213, 16.5%). Table 1 demonstrates the sociodemographic profile of participants (Hungarian vs International).

Perceived stress, anxiety, and coping styles

For greater clarity of statistical analysis and interpretation, we created preferences regarding coping mechanisms. That is, we made the categories based on which coping factor (in the international sample) or dimension (in the Hungarian sample) the given person reached the highest scores, so it can be said that it is the person's preferred coping strategy. The four coping strategies among international students were goal-oriented, thinking it over, wishful thinking, and avoidance, while among the Hungarian students were cognitive restructuring, problem analysis, stress reduction, and passive coping.

The 26-item WCQ [ 31 ] contains a seeking support subscale which is missing from the Hungarian 16-item WCQ [ 32 ]; therefore, the seeking support subscale was excluded from our analysis. Moreover, because the PSS contained a different number of items in English and Hungarian versions (10 items vs 14 items), we looked at the average score of the answers so that we could compare international and domestic students.

In the evaluation of SHAI, the scoring of the two questionnaires are different. For the sake of comparability between the two samples, the international points were corrected to the Hungarian, adding plus one to the value of each answer. This may be the reason why we obtained higher results compared to international standards.

Among the international students, the mean score (± standard deviation) of perceived stress among male students was 2.11(± 0.86) compared to female students 2.51 (± 0.78), while the mean score (± standard deviation) of health anxiety was 34.12 (± 7.88) and 36.31 (± 7.75) among males and females, respectively. Table 2 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among international students.

In the Hungarian sample, the mean score (± standard deviation) of perceived stress among male students was 2.06 (± 0.84) compared to female students 2.18 (± 0.83), while the mean score (± standard deviation) of health anxiety was 33.40 (± 7.63) and 35.05 (± 7.39) among males and females, respectively. Table 3 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among Hungarian students.

Concerning coping styles among international students, the statements with the highest-ranked responses were “wished the situation would go away or somehow be finished” and “Had fantasies or wishes about how things might turn out” and both fall into the wishful thinking coping. Among the Hungarian students, the statements with the highest-ranked responses were “I tried to analyze the problem to understand better” (falls into problem analysis coping) and “I thought every cloud has a silver lining, I tried to perceive things cheerfully” (falls into cognitive restructuring coping).

On the other hand, the statements with the least-ranked responses among the international students belonged to the Avoidance coping. Among the Hungarians, it was Passive coping “I tried to take sedatives or medications” and Stress reduction “I staked everything upon a single cast, I started to do something risky” to have the lowest-ranked responses. Table 4 shows a comparison of different coping strategies among international and Hungarian students.

To test the difference between coping strategies, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution. For post hoc tests, we used Mann–Whitney tests with lowered significance levels ( p  = 0.0083). Among Hungarian students, there were significant differences between the groups in stress ( χ 2 (3) = 212.01; p < 0.001) and health anxiety ( χ 2 (3) = 80.32; p  < 0.001). In the post hoc tests, there were significant differences everywhere ( p  < 0.001) except between stress reduction and passive coping ( p  = 0.089) and between problem analysis and passive coping ( p  = 0.034). Considering the health anxiety, the results were very similar. There were significant differences between all groups ( p  < 0.001), except between stress reduction and passive coping ( p  = 0.347) and between problem analysis and passive coping ( p  = 0.205). See Figs.  1 and 2 for the Hungarian students.

Perceived stress differences between coping strategies among the Hungarian students

Health anxiety differences between coping strategies among the Hungarian students

Among the international students, the results were similar. According to the Kruskal–Wallis test, there were significant differences in stress ( χ 2 (3) = 73.26; p  < 0.001) and health anxiety ( χ 2 (3) = 42.60; p  < 0.001) between various coping strategies. The post hoc tests showed that there were differences between the perceived stress level and coping strategies everywhere ( p  < 0.005) except and between avoidance and thinking it over ( p  = 0.640). Concerning health anxiety, there were significant differences between wishful thinking and goal-oriented ( p  < 0.001), between wishful thinking and avoidance ( p  = 0.001), and between goal-oriented and avoidance ( p  = 0.285). There were no significant differences between wishful thinking and thinking it over ( p  = 0.069), between goal-oriented and thinking it over ( p  = 0.069), and between avoidance and thinking it over ( p  = 0.131). See Figs.  3 and 4 .

Perceived stress differences between coping strategies among the international students

Health anxiety differences between coping strategies among the international students

The relationship between coping strategies with health anxiety and perceived stress levels among the international students

We applied logistic regression analyses for the variables to see which of the coping strategies has a significant effect on SHAI and PSS results. In the first model (model a), with the health anxiety as an outcome dummy variable (with median split; median: 35), only two coping strategies had a statistically significant relationship with health anxiety level, including wishful thinking (as a risk factor) and goal-oriented (as a protective factor).

In the second model (model b), with the perceived stress as an outcome dummy variable (with median split; median: 2.40), three coping strategies were found to have a statistically significant association with the level of perceived stress, including wishful thinking (as a risk factor), while goal-oriented and thinking it over as protective factors. See Table 5 .

The relationship between coping strategies with health anxiety and perceived stress levels among domestic students

By employing logistic regression analysis, with the health anxiety as an outcome dummy variable (with median split; median: 33.5) (model a), three coping strategies had a statistically significant relationship with health anxiety level among domestic students, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor).

Similarly, with the perceived stress as an outcome dummy variable (with median split; median: 2.1429) (model b), three coping strategies had a statistically significant relationship with perceived stress level, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor). See Table 6 .

Comparisons between domestic and international students

We compared health anxiety and perceived stress levels of the Hungarian and international students’ groups using the Mann–Whitney test. In the case of health anxiety, the results showed that there were significant differences between the two groups ( W  = 149,431; p  = 0.038) and international students’ levels were higher. Also, there was a significant difference in the perceived stress level between the two groups ( W  = 141,024; p  < 0.001), and the international students have increased stress levels compared to the Hungarian ones.

Comparisons between genders within students’ groups (International vs Hungarian)

Firstly, we compared the international men’s and women’s health anxiety and stress levels using the Mann–Whitney test. The results showed that the international women’s health anxiety ( W  = 11,810; p  = 0.012) and perceived stress ( W  = 10,371; p  < 0.001) levels were both significantly higher than international men’s values. However, in the Hungarian sample, women’s health anxiety was significantly higher than men’s ( W  = 69,643; p  < 0.001), but there was no significant difference in perceived stress levels among between Hungarian women and men ( W  = 75,644.5; p  = 0.064).

Relationship between health anxiety and perceived stress

We correlated the general health anxiety and perceived stress using Spearman’s rank correlation. There was a significant moderate positive relationship between the two variables ( p  < 0.001; ρ  = 0.446). Within the Hungarian students, there was a significant correlation between health anxiety and perceived stress ( p  < 0.001; ρ  = 0.433), similarly among international students as well ( p  < 0.001; ρ  = 0.465).

In our study, we found that individuals who were characterized by a preference for certain coping strategies reported significantly higher perceived stress and/or health anxiety than those who used other coping methods. These correlations can be found in both the Hungarian and international students. In the light of our results, we can say that 48.4% of the international students used wishful thinking as their preferred coping method while around 43% of the Hungarian students used primarily cognitive restructuring to overcome their problems.

Regulation of emotion refers to “the processes whereby individuals monitor, evaluate, and modify their emotions in an effort to control which emotions they have, when they have them, and how they experience and express those emotions” [ 41 ]. There is an overlap between emotion-focused coping and emotion regulation strategies, but there are also differences. The overlap between the two concepts can be noticed in the fact that emotion-focused coping strategies have an emotional regulatory role, and emotion regulation strategies may “tax the individual’s resources” as the emotion-focused coping strategies do [ 23 , 42 ]. However, in emotion-focused coping strategies, non-emotional tools can also be used to achieve non-emotional goals, while emotion regulation strategies may be used for maintaining or reinforcing positive emotions [ 42 ].

Based on the cognitive-behavioral model of health anxiety, emotion-regulating strategies can regulate the physiological, cognitive, and behavioral consequences of a fear response to some degree, even when the person encounters the conditioned stimulus again [ 12 , 43 ]. In the long run, regular use of these dysfunctional emotion control strategies may manifest as functional impairment, which may be associated with anxiety disorders. A detailed study that examined health anxiety in the view of the cognitive-behavioral model found that, regardless of the effect of depression, there are significant and consistent correlations between certain dimensions of health anxiety and dysfunctional coping and emotional regulation strategies [ 12 ].

Similar to our current study, other studies have found that health anxiety was positively correlated with maladaptive emotion regulation and negatively with adaptive emotion regulation [ 44 ], and in the case of state anxiety that emotion-focused coping strategies proved to be less effective in reducing stress, while active coping leads to a sense of subjective well-being [ 17 , 27 , 45 , 46 , 47 ]

SHAI values were found to be high in other studies during the pandemic, and the SHAI results of the international students in our study were found to be even slightly higher compared to those studies [ 44 , 48 ]. Besides, anxiety values for women were found to be higher than for men in several studies [ 44 , 48 , 49 , 50 ]. This was similar to what we found among the international students but not among the Hungarian ones. We can speculate that the ability to contact someone, the closeness of family and beloved ones, familiarity with the living environment, and maybe less online search about the coronavirus news could be factors counting towards that finding among Hungarian students. Also, most international students were enrolled in health-related study programs and his might have affected how they perceived stress/anxiety and their preferred coping strategies as well. Literature found that students of medical disciplines could have obstacles in achieving a healthy coping strategy to deal with stress and anxiety despite their profound medical knowledge compared to non-health-related students [ 51 , 52 ]. Literature also stressed the immense need for training programs to help students of medical disciplines in adopting coping skills and stress-reducing strategies [ 51 ].

The findings of our study may be a starting point for the exploration of the linkage between perceived stress, health anxiety, and coping strategies when people are not in their domestic context. People who are away from their home and friends in a relatively alien environment may tend to use coping mechanisms other than the adequate ones, which in turn can lead to increased levels of perceived stress.

Furthermore, our results seem to support the knowledge that deep-rooted health anxiety is difficult to change because it is closely related to certain coping mechanisms. It was also addressed in the literature that personality traits may have a significant influence on the coping strategy used by a person [ 53 ], revealing sophisticated and challenging links to be considered especially during training programs on effective coping and management skills. On the other hand, perceived stress which has risen significantly above the average level in the current pandemic, can be most effectively targeted by the well-formulated recommendations and advice of major international health organizations if people successfully adhere to them (e.g. physical activity; proper and adequate sleep; healthy eating; avoiding alcohol; meditation; caring for others; relationships maintenance, and using credible information resources about the pandemic, etc.) [ 1 , 54 ]. Furthermore, there may be additional positive effects of these recommendations when published in different languages or languages that are spoken by a wide range of nationalities. Besides, cognitive behavioral therapy techniques, some of which are available online during the current pandemic crisis, can further reduce anxiety. Also, if someone does not feel safe or fear prevails, there are helplines to get in touch with professionals, and this applies to the University of Debrecen in Hungary, and to a certain extent internationally.

Naturally, our study had certain limitations that should be acknowledged and considered. The temporality of events could not be assessed as we employed a cross-sectional study design, that is, we did not have information on the previous conditions of the participants which means that it is possible that some of these conditions existed in the past, while others de facto occurred with COVID-19 crisis. The survey questionnaires were completed by those who felt interested and involved, i.e., a convenience sampling technique was used, this impairs the representativeness of the sample (in terms of sociodemographic variables) and the generalizability of our results. Also, the type of recruitment (including social media) as well as the online nature of the study, probably appealed more to people with an affinity with this kind of instrument. Besides, each questionnaire represented self-reported states; thus, over-reporting or under-reporting could be present. It is also important to note that international students were answering the survey questionnaire in a language that might not have been their mother language. Nevertheless, English fluency is a prerequisite to enroll in a study program at the University of Debrecen for international students. As the options for gender were only male/female in our survey questionnaire, we might have missed the views of students who do not identify themselves according to these gender categories. Also, no data on medical history/current medical status were collected. Lastly, we had to make minor changes to the used scales in the different languages for comparability.

The COVID-19 pandemic crisis has imposed a significant burden on the physical and psychological wellbeing of humans. Crises like the current pandemic can trigger unprecedented emotional and behavioral responses among individuals to adapt or cope with the situation. The elevated perceived stress levels during major life events can be further deepened by disengagement from home and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping strategies, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety might be mitigated.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to compliance with institutional guidelines but they are available from the corresponding author (LRK) on a reasonable request.

Abbreviations

Centers for Disease Control and Prevention

Coronavirus Disease 2019

Perceived Stress Scale

Short Health Anxiety Inventory

Middle East Respiratory Syndrome

Severe Acute Respiratory Syndrome

Ways of Coping Questionnaire

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Acknowledgments

We would like to provide our extreme thanks and appreciation to all students who participated in our study. ABA is currently supported by the Tempus Public Foundation’s scholarship at the University of Debrecen.

This research project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Szabolcs Garbóczy, Szilvia Harsányi, Ala’a B. Al-Tammemi & László Róbert Kolozsvári

Department of Psychiatry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Department of Personality and Clinical Psychology, Institute of Psychology, University of Debrecen, Debrecen, Hungary

Anita Szemán-Nagy

Faculty of Medicine, University of Debrecen, Debrecen, Hungary

Mohamed S. Ahmad & Viktor Rekenyi

Department of Social and Work Psychology, Institute of Psychology, University of Debrecen, Debrecen, Hungary

Dorottya Ocsenás

Doctoral School of Human Sciences, University of Debrecen, Debrecen, Hungary

Department of Family and Occupational Medicine, Faculty of Medicine, University of Debrecen, Móricz Zs. krt. 22, Debrecen, 4032, Hungary

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All authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK have worked on the study design, text writing, revising, and editing of the manuscript. DO, SG, and VR have done data management and extraction, data analysis. Drafting and interpretation of the manuscript were made in close collaboration by all authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK. All authors read and approved the final manuscript.

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Garbóczy, S., Szemán-Nagy, A., Ahmad, M.S. et al. Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19. BMC Psychol 9 , 53 (2021). https://doi.org/10.1186/s40359-021-00560-3

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Stress research during the COVID-19 pandemic and beyond

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• 1 Cognitive Psychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany. Electronic address: [email protected].
• 2 Biopsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany; General Psychology II and Biological Psychology, Institute of Psychology, School of Human Sciences, Osnabrück University, Osnabrück, Germany.
• 3 Biopsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany.
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• PMID: 34599918
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• DOI: 10.1016/j.neubiorev.2021.09.045

The COVID-19 pandemic confronts stress researchers in psychology and neuroscience with unique challenges. Widely used experimental paradigms such as the Trier Social Stress Test feature physical social encounters to induce stress by means of social-evaluative threat. As lockdowns and contact restrictions currently prevent in-person meetings, established stress induction paradigms are often difficult to use. Despite these challenges, stress research is of pivotal importance as the pandemic will likely increase the prevalence of stress-related mental disorders. Therefore, we review recent research trends like virtual reality, pre-recordings and online adaptations regarding their usefulness for established stress induction paradigms. Such approaches are not only crucial for stress research during COVID-19 but will likely stimulate the field far beyond the pandemic. They may facilitate research in new contexts and in homebound or movement-restricted participant groups. Moreover, they allow for new experimental variations that may advance procedures as well as the conceptualization of stress itself. While posing challenges for stress researchers undeniably, the COVID-19 pandemic may evolve into a driving force for progress eventually.

Keywords: COVID-19; Chronic stress; Corona virus; Ecological field research; Online studies; Social-evaluative threat; Stress research; Stress-related mental disorders; Trier social stress test (TSST); Virtual reality.

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Team Stress Research: A Review and Recommendations for Future Investigations

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• Published: 06 June 2018
• Volume 2 , pages 99–125, ( 2018 )

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• Songqi Liu   ORCID: orcid.org/0000-0002-1623-2952 1 &
• Yihao Liu 2  

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Due to the increasing reliance on teamwork in the modern work environment featured by its fast pace and high pressure, research on how work teams perceive and manage stress has garnered growing attention. In an attempt to synthesize this literature, we summarized team stress research ranging from lab studies on ad hoc teams to field studies on intact work groups. We posited that research on team stress could benefit from an integrative overview of the theories and findings regarding teams’ reactions to stressors and their downstream consequences. Accordingly, we reviewed major theoretical frameworks used to explain perceptions and effects of stress in work teams. We then focused on empirical research that examined mediators and/or moderators of the team level stressor-strain relationships, due to their enhanced ability to inform underlying mechanisms. Finally, we concluded our review by proposing new theoretical directions to help guide further advancements in team stress research.

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Liu, S., Liu, Y. Team Stress Research: A Review and Recommendations for Future Investigations. Occup Health Sci 2 , 99–125 (2018). https://doi.org/10.1007/s41542-018-0018-4

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Mind and Body Approaches for Stress and Anxiety: What the Science Says

Clinical Guidelines, Scientific Literature, Info for Patients:  Mind and Body Approaches for Stress and Anxiety

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Relaxation Techniques

Relaxation techniques may be helpful in managing a variety of stress-related health conditions, including anxiety associated with ongoing health problems and in those who are having medical procedures. Evidence suggests that relaxation techniques may also provide some benefit for symptoms of post-traumatic stress disorder (PTSD) and may help reduce occupational stress in health care workers. For some of these conditions, relaxation techniques are used as an adjunct to other forms of treatment.

What Does the Research Show?

• Biofeedback for anxiety and depression in children. A 2018 systematic review included 9 studies—278 participants total—on biofeedback for anxiety and depression in children and adolescents with long-term physical conditions such as chronic pain, asthma, cancer, and headache. The review found that, although biofeedback appears promising, at this point it can’t be recommended for clinical use in place of or in addition to current treatments. 
• Heart rate variability biofeedback. A 2017 meta-analysis looked at 24 studies—484 participants total—on heart rate variability (HRV) biofeedback and general stress and anxiety. The meta-analysis found that HRV biofeedback is helpful for reducing self-reported stress and anxiety, and the researchers saw it as a promising approach with further development of wearable devices such as a fitness tracker.
• Progressive muscle relaxation. A 2015 systematic review , which included two studies on progressive muscle relaxation in adults older than 60 years of age, with a total of 275 participants, found that progressive muscle relaxation was promising for reducing anxiety and depression. The positive effects for depression were maintained 14 weeks after treatment.
• PTSD. A 2018 meta-analysis of 50 studies involving 2,801 participants found that relaxation therapy seemed to be less effective than cognitive behavioral therapy for PTSD and obsessive-compulsive disorder. No difference was found between relaxation therapy and cognitive behavioral therapy for other anxiety disorders, including generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias. The review noted, however, that most studies had a high risk of bias, and there was a small number of studies for some of the individual disorders.
• Anxiety in people with cancer. In the 2023 joint guideline issued by the Society for Integrative Oncology and the American Society for Clinical Oncology on integrative oncology care of symptoms of anxiety and depression in adults with cancer, relaxation therapies may be offered to people with cancer to improve anxiety symptoms during active treatment (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate). 
• Relaxation techniques are generally considered safe for healthy people. In most research studies, there have been no reported negative side effects. However, occasionally, people report negative experiences such as increased anxiety, intrusive thoughts, or fear of losing control. 
• There have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain psychiatric conditions, or with a history of abuse or trauma. 

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A range of research has examined the relationship between exercise and depression. Results from a much smaller body of research suggest that exercise may also affect stress and anxiety symptoms. Even less certain is the role of yoga, tai chi, and qigong—for these and other psychological factors. But there is some limited evidence that yoga, as an adjunctive therapy, may be helpful for people with anxiety symptoms.

• Yoga for children and adolescents. Findings from a 2021 meta-analysis and systematic review of 10 trials involving a total of 1,244 adolescents suggest a potential beneficial effect of tai chi and qigong on reducing anxiety and depression symptoms, and reducing cortisol level in adolescents. However, nonsignificant effects were found for stress, mood, and self-esteem. A  2020 systematic review  of 27 studies involving the effects of yoga on children and adolescents with varying health statuses, and with varying intervention characteristics, found that in studies assessing anxiety and depression, 58 percent showed reductions in both symptoms, while 25 percent showed reductions in anxiety only. Additionally, 70 percent of studies included in the review that assessed anxiety alone showed improvements. However, the reviewers noted that the studies included in the review were of weak-to-moderate methodological quality. 
• Yoga, tai chi, and qigong for anxiety. A  2019 review  concluded that yoga as an adjunctive therapy facilitates treatment of anxiety disorders, particularly panic disorder. The review also found that tai chi and qigong may be helpful as adjunctive therapies for depression, but effects are inconsistent.
• Yoga for anxiety. A  2021 randomized controlled trial examined whether Kundalini yoga and cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) were each more effective than a control condition (stress education) and whether yoga was inferior to CBT for the treatment GAD. The trial found that Kundalini yoga was more efficacious for generalized anxiety disorder than the control, but the results support CBT remaining first-line treatment. A  2018 systematic review and meta-analysis  of 8 studies of yoga for anxiety (involving 319 participants with anxiety disorders or elevated levels of anxiety) found evidence that yoga might have short-term benefits in reducing the intensity of anxiety. However, when only people with diagnosed anxiety disorders were included in the analysis, there was no benefit. 
• Yoga is generally considered a safe form of physical activity for healthy people when performed properly, under the guidance of a qualified instructor. However, as with other forms of physical activity, injuries can occur. The most common injuries are sprains and strains. Serious injuries are rare. The risk of injury associated with yoga is lower than that for higher impact physical activities.
• Older people may need to be particularly cautious when practicing yoga. The rate of yoga-related injuries treated in emergency departments is higher in people age 65 and older than in younger adults.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Meditation and Mindfulness-Based Stress Reduction

Some research suggests that practicing meditation may reduce blood pressure, anxiety and depression, and insomnia.

• Mindfulness-based stress reduction. A  2023 randomized controlled trial involving 208 participants found that mindfulness-based stress reduction (MBSR) is noninferior to escitalopram, a commonly used first-line psychopharmacologic treatment for anxiety disorders. A  2021 randomized controlled trial of 108 adults with generalized social anxiety disorder found that cognitive behavioral group therapy and MBSR may be effective treatments with long-term benefits for patients with social anxiety networks that recruit cognitive and attention-regulation brain networks. The researchers noted that cognitive behavioral therapy and MBSR may both enhance reappraisal and acceptance emotion regulation strategies.
• Mindfulness-based meditation. A  2019 review  concluded that as monotherapy or an adjunctive therapy, mindfulness-based meditation has positive effects on depression, and its effects can last for 6 months or more. Although positive findings are less common in people with anxiety disorders, the evidence supports adjunctive use. A 2019 analysis of 29 studies (3,274 total participants) showed that use of mindfulness-based practices among people with cancer significantly reduced psychological distress, fatigue, sleep disturbance, pain, and symptoms of anxiety and depression. However, most of the participants were women with breast cancer, so the effects may not be similar for other populations or other types of cancer. A  2014 meta-analysis  of 47 trials in 3,515 participants suggests that mindfulness meditation programs show moderate evidence of improving anxiety and depression. But the researchers found no evidence that meditation changed health-related behaviors affected by stress, such as substance abuse and sleep.
• Mindfulness-based programs for workplace stress. A  2018 systematic review and meta-analysis  of nine studies examined mindfulness-based programs with an employee sample, which targeted workplace stress or work engagement, and measured a physiological outcome. The review found that mindfulness-based interventions may be a promising avenue for improving physiological indices of stress. 
• Meditation is generally considered to be safe for healthy people.
• A 2019 review found no apparent negative effects of mindfulness-based interventions and concluded that their general health benefits justify their use as adjunctive therapy for patients with anxiety disorders.

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Hypnosis has been studied for anxiety related to medical or dental procedures. Some studies have had promising results, but the overall evidence is not conclusive.

• A  2022 systematic review and meta-analysis of 19 trials found positive effects of hypnotherapy for reducing dental anxiety and fear during dental treatment. However, the reviewers noted that despite positive effects of hypnotic interventions in the systematic review, the results of the meta-analysis are very heterogeneous. 
• The 2023 joint guideline issued by the Society for Integrative Oncology and the American Society for Clinical Oncology recommends that hypnosis may be offered to people with cancer to improve anxiety symptoms during cancer-related diagnostic and treatment procedures (Type: Evidence based; Quality of evidence: Intermediate; benefits outweigh harms; Strength of recommendation: Moderate).
• Hypnosis is a safe technique when practiced by a trained, experienced, licensed health care provider.

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• Carlson LE, Ismaila N, Addington EL, et al.  Integrative oncology care of symptoms of anxiety and depression in adults with cancer: Society for Integrative Oncology-ASCO guideline .  Journal of Clinical Oncology.  2023;41(28):4562-4591. 
• Chugh-Gupta N, Baldassarre FG, Vrkljan BH.  A systematic review of yoga for state anxiety: considerations for occupational therapy . C anadian Journal of Occupational Therapy . 2013;80(3):150-170.
• Cillessen L, Johannsen M, Speckens AEM, et al . Mindfulness-based interventions for psychological and physical health outcomes in cancer patients and survivors: a systematic review and meta-analysis of randomized controlled trials .  Psychooncology . 2019;28(12):2257-2269. 
• Cramer H, Lauche R, Anheyer D, et al.  Yoga for anxiety: a systematic review and meta-analysis of randomized controlled trials .  Depress Anxiety . 2018;35(9):830-843.
• Goessl VC, Curtiss JE, Hofmann SG.  The effect of heart rate variability of biofeedback training on stress and anxiety: a meta-analysis .  Psychological Medicine . 2017;47(15):2578-2586.
• Goldin PR, Thurston M, Allende S, et al . Evaluation of cognitive behavioral therapy vs mindfulness meditation in brain changes during reappraisal and acceptance among patients with social anxiety disorder: a randomized clinical trial .  JAMA Psychiatry . 2021;78(10):1134-1142.
• Goyal M, Singh S, Sibinga EMS, et al.  Meditation programs for psychological stress and well-being: a systematic review and meta-analysis.   JAMA Internal Medicine . 2014;174(3):357-368.
• Greenlee H, Balneaves LG, Carlson LE, et al.  Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer .  Journal of the National Cancer Institute Monographs.  2014;50:346-358.
• Heckenberg RA, Eddy P, Kent S, et al.  Do workplace-based mindfulness meditation programs improve physiological indices of stress? A systematic review and meta-analysis .  Journal of Psychosomatic Research.  2018;114:62-71.
• Hoge EA, Bui E, Mete M, et al.  Mindfulness-based stress reduction vs escitalopram for the treatment of adults with anxiety disorders: a randomized clinical trial .  JAMA Psychiatry . 2023;80(1):13-21.
• James-Palmer A, Anderson EZ, Zucker L, et al. Yoga as an intervention for the reduction of symptoms of anxiety and depression in children and adolescents: a systematic review .  Frontiers in Pediatrics . 2020;8:78.
• Liu X, Li R, Cui J, et al.  The effects of tai chi and qigong exercise on psychological status in adolescents: a systematic review and meta-analysis .  Frontiers in Psychology . 2021;12:746975.
• Klainin-Yobas P, Oo WN, Suzanne Yew PY, et al.  Effects of relaxation interventions on depression and anxiety among older adults: a systematic review .  Aging and Mental Health . 2015;19(12):1043-1055.
• Montero-Marin J, Garcia-Campayo J, López-Montoyo A, et al.  Is cognitive-behavioural therapy more effective than relaxation therapy in the treatment of anxiety disorders? A meta-analysis .  Psychological Medicine . 2018;48(9):1427-1436.
• Saeed SA, Cunningham K, Bloch RM.  Depression and anxiety disorders: benefits of exercise, yoga, and meditation .  American Family Physician . 2019;99(10):620-627.
• Simon NM, Hofmann SG, Rosenfield D, et al.  Efficacy of yoga vs cognitive behavioral therapy vs stress education for the treatment of generalized anxiety disorder: a randomized clinical trial .  JAMA Psychiatry . 2021;78(1):13-20.
• Thabrew H, Ruppeldt P, Sollers JJ 3rd.  Systematic review of biofeedback interventions for addressing anxiety and depression in children and adolescents with long-term physical conditions .  Applied Psychophysiology and Biofeedback . 2018;43(3):179-192.
• Wolf TG, Schläppi S, Benz CI, et al.  Efficacy of hypnosis on dental anxiety and phobia: a systematic review and meta-analysis .  Brain Sciences . 2022;12(5):521.

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7 Steps to Manage Stress and Build Resilience

When the body senses a threat (or stressor), it goes on high alert, and once the threat passes, the body quickly recovers. At least that’s the way it’s supposed to work. Stressors can include health matters, work, money, family issues, racism or gender inequality, and regular daily hassles. With unrelenting or too many stressors, your body might be on a constant state of high alert, leading to poor concentration, bad moods, professional burnout, and mental and physical health problems. When stress becomes chronic, the body cannot return to normal functioning. Chronic stress can be linked with health conditions such as heart disease, high blood pressure, diabetes, depression and anxiety.

Stress affects women and men differently. Many conditions associated with stress — such as post-traumatic stress disorder, depression and anxiety — are more common in women than men.

Beyond sex and gender differences, there are individual differences, too. Some people are more resilient than others. Stress affects them less or more temporarily, and they might even perform better under stress. “There’s a saying, ‘It’s not how far you fall; it’s how high you bounce.’ For those of us who don’t bounce back so easily, there’s good news. Resilience, to some extent, can be learned and there are some simple, practical things that people can do that may make a noticeable difference,” says Dr. Janine Austin Clayton, Director of the NIH Office of Research on Women’s Health. Clayton explains that some resilient people might also develop a greater appreciation for their lives, family, friends or other matters after stress.

Stress management and resilience building are particularly important to the health of women. Here are several tips to help women as well as men:

• Recognize and counter signs of stress. Your body sends signals that it’s stressed, including difficulty concentrating, headaches, cold hands, tight muscles, a nervous stomach, clenched teeth, feeling on edge, fidgety, irritable or withdrawn. Knowing how your body communicates can help you deal with stressful moments. Learn to not only recognize but also to name these feelings, either to oneself or to a friend. Then, take action to counter their effects. For example, deep breathing, stretching, going for a walk, writing down your thoughts and taking quiet time to focus can help induce relaxation and reduce tension.
• Take time for yourself. Make taking care of yourself a daily routine. It’s not selfish or self-indulgent — and it might require saying “no” to requests or prioritizing yourself along with your responsibilities. Start with small changes in your routine to help build resilience to stressful circumstances. Work in time to exercise, eat healthy foods, participate in relaxing activities and sleep. In fact, including a regimen of exercise, which for some may include yoga or meditation, can be very important when feeling stressed. Also, take time to notice the “good minutes” in each day or to do something that you enjoy, such as reading a book or listening to music, which can be a way to shift your attention and focus on the positive rather than the negative.
• Try new routines. From scheduling bath and bedtimes to blocking off time to plan and prioritize tasks, additional structure can provide a daily framework that allows you to attune to your body’s signals. Then, you can take steps to potentially manage stress earlier than you once did.
• Stay connected and make new friends. Stay in touch with family, friends and groups in your life — technology makes this easier than ever. Having or being a person to talk with can be reassuring and calming. Using video features can enhance the connection in telecommunication or online communications for some people.
• See problems through a different lens. Experts call changing the way we think about and respond to stress “reframing.” View sitting in traffic or around the house as an opportunity to enjoy music, podcasts or pleasant views. Reduce anger in response to rude or aggressive behavior by imagining what might be happening in that person’s life. Keeping situations in perspective is an important way to boost stress resilience. Other steps include positive thinking and creating plans before you begin to resolve problems. You can practice reframing and get better at it over time.
• Seek help with problems. Many people experience the same day-to-day strains related to caregiving, relationships, health, work and money. Look to friends and family, as appropriate, or other trusted individuals or resources for tips and information.
• Talk to a health professional if stress is affecting your well-being, you feel you cannot manage the stress you’re experiencing, or stress has caused you to engage in or increase substance use. Seek appropriate care if stress is harming your relationships or ability to work. If you have suicidal thoughts, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). Lifeline chat is a service available to everyone 24 hours a day, 7 days a week. In addition, if you need help locating a mental health provider, the Substance Abuse and Mental Health Services Administration (SAMHSA) offers a site that can assist you at https://findtreatment.samhsa.gov . People who have experienced traumatic stress (directly or indirectly experiencing life-threatening and dangerous events) should find a treatment provider who practices trauma informed care — see https://go.usa.gov/xvydm for details. Additionally, in times of disasters and other sorts of emergencies, the National Disaster Distress Helpline (Call 1-800-985-5990 or text “TALKWITHUS” to 66746) can provide crisis counseling, emotional support and referrals to care related to disasters and public health emergencies.

Recognizing individual signals of a body’s stress responses and learning to respond to those signals in new ways can help build the emotional, intellectual and physical strength that comprise resilience, which can help you tackle future stressors.

The NIH supports research to understand how stress affects health — and why some are resilient to stress while others have difficulties, as well as how different therapies and resilience-boosting techniques work and have a positive effect on health and well-being. The NIH Office of Research on Women’s Health offers links to information about stress (including anxiety about the coronavirus), wellness, tips on managing common sources of stress, and opportunities to join research projects on stress or other health matters at https://go.usa.gov/xvydm .

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Stress is a normal psychological and physical reaction to the demands of life. A small amount of stress can be good, motivating you to perform well. But many challenges daily, such as sitting in traffic, meeting deadlines and paying bills, can push you beyond your ability to cope.

Your brain comes hard-wired with an alarm system for your protection. When your brain perceives a threat, it signals your body to release a burst of hormones that increase your heart rate and raise your blood pressure. This "fight-or-flight" response fuels you to deal with the threat.

Once the threat is gone, your body is meant to return to a normal, relaxed state. Unfortunately, the nonstop complications of modern life and its demands and expectations mean that some people's alarm systems rarely shut off.

Stress management gives you a range of tools to reset and to recalibrate your alarm system. It can help your mind and body adapt (resilience). Without it, your body might always be on high alert. Over time, chronic stress can lead to serious health problems.

Don't wait until stress damages your health, relationships or quality of life. Start practicing stress management techniques today.

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• How stress affects your health. American Psychological Association. https://www.apa.org/topics/stress/health. Accessed Dec. 8, 2021.
• Manage stress. MyHealthfinder. https://health.gov/myhealthfinder/topics/health-conditions/heart-health/manage-stress. Accessed Dec. 6, 2021.
• What is stress management? American Heart Association. https://www.heart.org/en/healthy-living/healthy-lifestyle/stress-management/what-is-stress-management. Accessed Dec. 7, 2021.
• Managing stress. National Alliance on Mental Illness. https://www.nami.org/Your-Journey/Individuals-with-Mental-Illness/Taking-Care-of-Your-Body/Managing-Stress. Accessed Dec. 8, 2021.
• Stress. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/stress. Accessed Dec. 6, 2021.
• AskMayoExpert. Stress management and resiliency (adult). Mayo Clinic; 2021.
• Stress and your health. U.S. Department of Health & Human Services. https://www.womenshealth.gov/mental-health/good-mental-health/stress-and-your-health. Accessed Dec. 9, 2021.
• Seaward BL. Essentials of Managing Stress. 5th ed. Jones & Bartlett Learning; 2021.

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SYSTEMATIC REVIEW article

This article is part of the research topic.

Beyond audiovisual: novel multisensory stimulation techniques and their applications

Audio-Visual-Olfactory Immersive Digital Nature Exposure for Stress and Anxiety Reduction: A Systematic Review on Systems, Outcomes, and Challenges Provisionally Accepted

• 1 Institut National de la Recherche Scientifique, Université du Québec, Canada

The final, formatted version of the article will be published soon.

Evidence supporting the benefits of immersive virtual reality (VR) and exposure to nature for the well-being of individuals is steadily growing. So-called digital forest bathing experiences take advantage of the immersiveness of VR to make individuals feel like they are immersed in nature, which has led to documented improvements in mental health. The majority of existing studies have relied on conventional VR experiences, which stimulate only two senses: auditory and visual. However, the principle behind forest bathing is to have one stimulate all of their senses to be completely immersed in nature. As recent advances in olfactory technologies have emerged, multisensory immersive experiences which stimulate more than two senses may provide additional benefits. In this systematic literature review, we investigate the multisensory digital nature setups used and their psychological and psychophysiological outcomes; particular focus is placed on the inclusion of smells as the third sensory modality. We searched papers published between 2016 and April 2023 on PubMed, Science Direct, Web of Science, Scopus, Google Scholar, and IEEE Xplore. Results from our quality assessment revealed that the majority of studies (twelve) were of medium or high quality, while two were classified as low quality. Overall, the findings from the reviewed studies indicate a positive effect of including smells to digital nature experiences, with outcomes often comparable to conventional exposure to natural environments.The review concludes with a discussion of limitations observed in the examined studies and proposes recommendations for future research in this domain.

Keywords: virtual reality, natural environment, Olfactory stimuli, Multisensory virtual reality, Psychological outcome, Psychophysiological outcome, stress/anxiety, Relaxation

Received: 03 Jul 2023; Accepted: 08 Apr 2024.

Copyright: © 2024 Lopes and Falk. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Mx. Marilia Lopes, Institut National de la Recherche Scientifique, Université du Québec, Quebec City, Canada Dr. Tiago H. Falk, Institut National de la Recherche Scientifique, Université du Québec, Quebec City, Canada

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Nurses’ job stress and its impact on quality of life and caring behaviors: a cross-sectional study

Ali-reza babapour.

1 Student Research Committee, Tabriz Medical sciences, Islamic Azad University, Tabriz, Iran

Nasrin Gahassab-Mozaffari

2 Department of Nursing, Faculty of Nursing and Midwifery, Tabriz Medical Sciences, Islamic Azad University, Tabriz, Iran

Azita Fathnezhad-Kazemi

3 Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz Medical Sciences, Islamic Azad University, Tabriz, Iran

4 Women’s Reproductive and mental Health Research center, Tabriz Medical Sciences, Islamic Azad University, Tabriz, Iran

Associated Data

The datasets are available from the corresponding authors on request.

Nursing is considered a hard job and their work stresses can have negative effects on health and quality of life. The aim of this study was to investigate the correlation between job stress with quality of life and care behaviors in nurses.

This cross-sectional survey design study was performed with the participation of 115 nurses working in two hospitals. The nurses were selected via the availability sampling method and data were collected by demographic characteristics, nurses ‘job stress, quality of life (SF12), and Caring Dimension Inventory questionnaires.

The mean (SD) total scores of job stress, quality of life and caring behavior were 2.77 (0.54), 56.64 (18.05) and 38.23 (9.39), respectively. There was a statistically significant and negative relationship between total job stress scores with quality of life ( r = -0.44, P  < 0.001, Medium effect) and caring behaviors ( r =-0.26, P  < 0.001, Small effect). Univariate linear regression showed that job stress alone could predict 27.9% of the changes in the total quality of life score (β =-0.534, SE = 0.051, R 2adj  = 0.279, P  < 0.001) and 4.9% of the changes in the total score of caring behaviors (β =-0.098, SE = 0.037, R 2adj  = 0.049 P  < 0.001).

Conclusions

Job stress has a negative effect on the quality of life related to nurses’ health. It can also overshadow the performance of care and reduce such behaviors in nurses, which may be one of the factors affecting the outcome of patients.

Job stress is an interactive situation between the job situation and the working person in that job, which leads to changes in the individual’s psychological and physiological status and affects his/her normal performance [ 1 ]. Work-related stress can damage a person’s physical and mental health and ultimately have a negative effect on job productivity by increasing stress levels [ 2 , 3 ]. Today, job stress has become a common and costly problem in the workplace and, according to the World Health Organization, a pervasive issue [ 4 , 5 ].

Stress is determined as a major cause of 80% of all occupational injuries and 40% of the financial burden in the workplace according to the American Institute of Stress [ 4 ]. Nursing is known as a stressful job since it is associated with complex job demands and needs, and high expectations, excessive responsibility, and minimal authority have been identified as the main stressors [ 6 ]. The results of studies conducted in Iran show that 7.4% of nurses are absent each week due to mental fatigue or physical disability caused by work, which is 80% higher than other professional groups [ 7 ].

According to the statistics provided by the International Council of Nurses, the costs of work-related stress are estimated at $ 200–300 million annually in the United States, and nearly 90% of employees’ medical problems are attributed to job stress [ 8 ]. Job stress among nurses may affect their quality of life, and concurrently, the quality of care. The quality of life of nurses, who deal with human lives, is of particular importance since they can provide more effective services when they have a better quality of life [ 9 ]. Nurses are in close contact with patients and such factors as employment location, variety of hospitalized cases, lack of manpower, forced overtime hours, and the attitude of the ward manager can impose tremendous stress on nurses [ 10 ]. Although stress is a recognized component of modern nursing that is useful in small amounts, in the long run, chronic diseases, such as hypertension, lead to cardiovascular disease, and therefore, affect their quality of life [ 11 ]. Moreover, job stress causes job quit, co-workers conflict, health disorders, job dissatisfaction, reduced creativity, decreased professional satisfaction, reduced correct and timely decision-making, inadequacy and depression feelings, disgust and fatigue from work, reduced energy and work efficiency, and reduced quality of nursing care [ 12 ] and these items increase the likelihood of work-related injuries [ 13 ], regarding which, the results of numerous studies have shown that job stress has a direct or indirect effect on the provision of medical services [ 14 ]. Consequently, due to the inevitability of some stressors in the nursing profession, it is necessary to prevent their psychological and behavioral effects to improve nurses’ quality of life and their care behaviors [ 15 ]. The low caring behaviors can be influenced by several factors including individual and organizational factors like abilities, skills, job design and leadership style, respectively. Work stress can affect caring behavior nurses because of nurse, s excessive activity or workload and more duty [ 16 ]. Job related stress has as a result loss of compassion for patients and increased incidences of practice errors and therefore is unfavorably associated to quality of care [ 17 ]. Numerous studies reported that it has a direct or indirect effect on the delivery of care and on patient results [ 18 , 19 ]. For instance, conflict with colleagues has been found to predict lower caring practice [ 5 ]. And another study explained Job satisfaction as personal satisfaction and satisfaction with nurse management was significantly associated with caring behavior [ 20 ]. However, in study conducted in Indonesia, the results showed that there was no association between workload and job stress with caring behaviors [ 16 ]. Data from Sarafis et al., show that work-related stress impacts nurses’ health-related quality of life negatively, furthermore, it can affect patient outcomes and they have emphasized the need for performing further research in this domain [ 5 ]. Assessment of possible basics and effects of work stress among nurses has been done [ 21 ]. However, factors such as individual differences and working conditions can affect it so that significant conflicts in work-related stress between nurses may be due to workplaces, general and cultural conditions [ 14 ].

Since nurses, as members of the healthcare system, make every effort to improve the quality of care and patients’ quality of life, it is crucial to address the factors affecting their quality of life [ 22 ] It is also important to assess the dimensions of quality of life and job stress, identify psychosocial risk factors, and plan for preventive interventions to increase the efficiency and effectiveness of nurses’ activities. According to our hypotheses, job stress leads to the decline of nurse’s physical and mental health status, while it is negatively affecting nurses’ caring behaviors. Therefore, the present study was designed to achieve the following goals:

1- Assessing the level of job stress, as well as the quality of life, and care behaviors in nurses. 2- Evaluating the relationship of between job stress with quality of life and care behaviors in nurses.

Study Design and participants

This cross-sectional study was carried out in two teaching hospitals, namely the “Artesh” and “29 Bahman” hospitals, Tabriz, Iran, which are in cooperation with a non-governmental university in Tabriz, within December-January 2020. The employed nurses with at least one year of work experience and having contact with patients were entered into the study. The exclusion criteria were unwillingness to partake and failure to complete the questionnaire.

Sample size and sampling method

The maximum sample size was considered after controlling research aims, so the highest sample size was calculated based on the study performed by Sarafis et al. [ 5 ] related to job stress scale with Considering 95% confidence coefficient, 90% statistical power, an acceptable error of 0.06 around the mean (m = 2.22), and the highest standard deviation of (0.65), therefore the necessary sample size was determined to be 96 cases. The final sample size was estimated at 115 subjects after considering a drop-out rate of 20%.

Initially, the necessary permissions were obtained to conduct the research, which was followed by selecting the samples in different shifts using the availability sampling method. Afterward, the researcher referred to the hospital, explained the objectives of the study to the nurses, controlled the inclusion criteria, and obtained the participants’ satisfaction. The researcher provided the questionnaires to the samples to complete as a self-report. The sampling process was continued until reaching the calculated sample size.

1. Demographic characteristics checklist

This instrument included information about age, gender, education, marital status, shift status, employment status, and work experience.

2. Expanded nursing stress scale (ENSS)

This 57-item scale consists of 9 subscales, measuring Death and Dying Stressors (7 items), conflict with physicians (5 items), Inadequate Emotional Preparation Stressors (3 items), Problems with Peers (6 items), Problems with Supervision (7 items), workload (9 items), Uncertainty Concerning Treatment (9 items), patients and their families (8 items), and discrimination (3 items). The items are rated on a 6-point Likert scale of 1 = I have no stress at all, 2 = sometimes I am stressed, 3 = often I am stressed, 4 = I am very stressed, and 5 = this situation does not include my duties, if a person is not faced with such a situation, the number zero is marked. The total scores are estimated at a range of 0-228, with higher scores indicating higher job stress in that particular area. To obtain the mean score of each subscale, the total score of each subscale is divided by the number of items. The range of mean values for the total score and subscales are obtained at 0–4 and no specific cut-off point is determined [ 23 ].

3. Quality of Life Questionnaire-12 (SF-12)

SF-12 was constructed as a shorter alternative of the SF-36 Health Survey. SF-12, which measures physical and mental health status was used for the quality of life assessment. SF-12 includes 12 questions: 2 concerning physical functioning, 2 regarding role limitations caused by physical health problems, 1 question about bodily pain, 1 with reference to general health perceptions, 1 on vitality, 1 in regard to social functioning, 2 in relevance to role limitations because of emotional problems and 2 questions referring to general mental health [ 18 ]. To convert this score to the range of zero to 100, the raw score difference formula obtained from the minimum possible raw score divided by the difference of the maximum possible score of the minimum possible score is used. For the first time, Ware et al. [ 24 ] investigated the reliability and validity of this questionnaire and reported respective Cronbach’s alphas of 0.89 and 0.76 for physical health and mental health dimensions. Montazeri et al. investigated the reliability and validity of this scale in Iran and the reliability of the 12 items of physical and psychological elements was reported as 0.73 and 0.72, respectively [ 25 ].

4. Caring dimension inventory (CDI-25)

The CDI consists of 25 core questions designed to gather perceptions of caring by asking subjects to indicate their agreement to statements about their nursing practice as constituting caring. The respondent is required to indicate on a 5-point Likert scale ranging from “strongly agree” to “strongly disagree” whether or not they perceive caring in this manner. Studies have shown that the CDI-25 is an instrument with acceptable psychometric properties. The tool includes five dimensions: psychosocial (10 items), physical-technical (11 items), professional (1 item), unnecessary (1 item) and inappropriate (2 items). Items 3 and 16 are scored in reverse, so that the strongly agree and strongly disagree options are given the lowest and highest scores, respectively [ 26 ].

The reliability of this instrument was determined using two methods of calculating internal consistency by Cronbach’s alpha coefficient and intraclass correlation coefficient (ICC) by test-retest on 20 nurses. The Cronbach’s alpha coefficient and ICC (confidence interval of 95%) were calculated for job stress quionnaires at 0.78 and 0.82 (0.76–0.84), for quality of life at 0.87 and 0.89 (0.82–0.92), and caring dimension 0.81 and 0.85 (0.79–0.87), respectively.

Data analysis

SPSS-22 software is used to analyze the quantitative data. Sociodemographic, ENSS, SF-12, CDI-25 questionnaires score described by frequency (percent), as well as mean (Standard Deviation). The association between Sociodemographic with ENSS, SF-12 and CDI-25 determined using the t-test, ANOVA and their nonparametric equivalents for abnormally distributed variables (Mann-Whitne U test, Kruskal-Wallis H test). The associations of two continuous variables were analyzed by Spearman correlation tests in the bivariate analysis. Then, independent variables, with P  ≤ 0.05 on bivariate tests inserted into the multivariate linear regression model (enter method). The normality of quantitative data was measured based on kurtosis and skewness, Since the SF-12 and CBI scores were not normally distributed, this values were first converted by use of a natural logarithm(Ln) transformation which yielded distributions that did not significantly deviate from normality then It was used in linear regression. All tests were 2-sided.

The statistical population of the study consisted of 115 nurses (100% response rate) with mean age and work experience scores of 31.81(8.18) and 7.95(7.35), respectively. The demographic information of the samples is presented in Table  1 . The majority of participants (61.7%) were female, more than half of the subjects were married, and more than three-quarters of them had a bachelor’s degree. The employment status of most of the participants (63.5%) was permanent and most of them worked rotating shifts. The participants were selected from a range of different departments and 39.1% were working Internal medicine department.

Sample characteristics ( n  = 115)

a Standard Deviation, b Intensive care units, c Coronary care unit

Mean values of the ENSS, SF-12 and CDI-25

The data related to the main study variables are tabulated in Table  2 . The mean(SD) total scores of job stress, quality of life, and caring behavior were obtained at 2.77(0.54), 56.64(18.05), and 38.23(9.39), respectively. Among the job stress subscales, the highest scores were related to death and dying stressors and inadequate emotional preparation. In this same vein, the lowest score was related to the discrimination subscale. Regarding the quality of life subscale, the highest score was obtained in the field of physical health (m = 62.97 and SD = 19.42). The evaluation of the relationship between demographic characteristics and study parameters showed that job stress had a significant relationship with age, gender, employment status, and nurse’s department. In this respect, it was found that the mean scores of job stress were higher in women than in men (2.95 vs. 2.49) and in permanent nurses than in casual ones (2.86 vs. 2.63). Also, the participants who work in ICU and emergency departments have a high level of stress compared to the others. Among the demographic characteristics, only gender had a significant relationship with the quality of life, and the total mean score of quality of life was higher in men than in women (62.18 vs. 53.21). The relationship between demographic characteristics and caring behaviors showed that the total score of caring behaviors was significantly higher in men than in women (41.64 vs. 36.11) and in single cases than in married ones (40.30 vs. 36.45) (Table  1 ).

Mean values of study parameters

Correlation between ENSS with SF-12 and CDI-25

The data related to the relationship between the main variables of the study are summarized in Table  3 . It was revealed that the total score of quality of life was negatively correlated with all components of job stress, which was statistically significant and moderate. Furthermore, the psychological domain of quality of life had a negative correlation with all components of job stress. It was also found that there was a significant and negative relationship between the physical domain and most dimensions of job stress, except for problems with peers and death and dying stressors (Table  3 ).

Coloration between Job Stress with Quality of life and care behaviors

* P  < 0.05

** P  < 0.001

Based on the results of the study, the total score of caring behaviors had a negative correlation with the total and components scores of job stress. However, this correlation was significant merely with the total score, conflict with physicians, Problems with Supervision, and patients and their families, which was weak. In addition, a significant and negative relationship was found between most areas of caring behaviors and the dimensions of job stress. Nonetheless, this correlation was not statistically significant in between most aspects of both scale, and there was a positive relationship between most dimensions of job stress and inappropriate behaviors (Table  3 ).

The results of univariate linear regression analysis showed that job stress alone could explain 27.9% of the changes in the total score of quality of life (R 2 adj  = 0.279, P  < 0.001) and the negative relationship between these two variables indicated that an increase in the standard deviation of the total job stress score, could decrease the quality of life by 0.534 (β=-0.534, SE = 0.051, P  < 0.001). Moreover, according to the multivariate linear regression, job stress (β=- 0.514, P  < 0.001) and gender (β=-0.029, P  = 0.745) were predictive factors for quality of life, and the model 2 explained 27.4% changes in quality of life ( P  < 0.001) (Table  4 ).

Effect of ENSS and demographic characteristics on SF-12 based on univariate and multivariate linear regression

Based on the findings of Table  5 , job stress was able to predict 4.9% of the changes in the total score of caring behaviors (R 2 adj  = 0.049) and there was a negative relationship between these two variables; in other words, a 1 standard deviation increase in the total score of job stress led to the 0.098 decrease of caring behaviors rate (β=-0.098, P  < 0.001). The results of multivariate linear regression showed that independent variables could explain 9.2% of the dependent variable changes ( P  = 0.002), however job stress (β=-0.059, P  = 0.146), gender (β=-0.084, P  = 0.075), and marital status (β=-0.064, P  = 0.127) weren’t significant effect of caring behaviors.

Effect of ENSS and demographic characteristics on CBI based on univariate and multivariate linear regression

This study aimed to explore the status of job stress and examine its relationship with nurses’ quality of life and caring behavior. The results of the study indicated a negative relationship among the main components of the research. In this regard, the mean total score of job stress was higher than normal, which was slightly higher than that found in a study conducted in Greece. However, the findings of most studies have reported high levels of anxiety and stress among nursing staff. It was revealed that job stress was higher in females than in males, which could be attributed to their different roles in daily life. Nevertheless, in some studies, no significant difference was found between gender and job stress [ 27 , 28 ]. However, the lack of relationship between gender and stress levels in the mentioned studies may be due to a large number of female than men participants.

In the present study, no significant difference was found between marital status and the stress level, which was inconsistent with that of a study performed by Mehrabi et al. [ 29 ] the reason may be due to the fact that married individuals’ more involvement in life issues and the impact of other life matters that can affect job stress. In our study, an increase in stress level was also observed with aging, which may be due to the effect of job burnout in individuals. In the study of Abarghouei et al., there was no significant relationship between age and job stress, but there was a direct relationship between job stress and job history. Also, with increasing work experience, the rate of burnout was higher and there was relationship between job stress and job burnout [ 30 ]. Long-term job stress has been shown to lead to burnout which is often used by the health care personnel synonymously with occupational stress [ 31 , 32 ]. However, no relationship was found between age and stress in several studies [ 28 , 33 , 34 ], which can be attributed to the fact that, in our study, 50% of the participants were under 30 years old. In addition, the level of job stress was higher in permanent employees than in contract ones, which can be attributed to a higher sense of responsibility and more duties. Also, in the present study, no significant difference was found among different shifts. Data from Arkerstedt et al. support the idea that nighttime work is hazardous to a person’s wellbeing [ 35 ] and different work shifts are considered one of the sources of stress among nurses [ 36 ], however, the results of studies on this subject are different. So that in some studies, stress levels were reported to be high in night shift nurses [ 37 , 38 ] and in others, stress was reported to be high in morning shift nurses [ 36 , 39 ]. overall, it should be acknowledged that the sources of job stress and its level of effect are different according to the working conditions, working department, and culture of each society so nurses may have different levels of job stress and influencing factors due to different working conditions and the level of support provided.

According to the findings of our study, most occupational stressors were related to death and Death and Dying Stressors and insufficient emotional preparedness. The first occupational stressors were found to be death and suffering, which was consistent with the results of studies conducted in Greece [ 40 ] and the Philippines [ 41 ], reporting that such stress is probably rooted in the inability to prevent death. The second most important factor of job stress in the present study was found to be insufficient emotional preparedness, which in a study performed by Sarafis [ 5 ], this second cause of job stress was revealed to be the conflict with the patient and family. However, in our study, this factor was reported as the fifth cause of job stress. Insufficient emotional preparedness might have been created due to the sudden outbreak of COVID-19 at the time of performing the present study.

The third source of job stress was related to the problems with the supervisor, which was also reported as the third stressor in the study carried out by Sarafis et al. [ 5 ]. Based on the findings of a study conducted in Japan, poor support from the supervisor was associated with depression [ 42 ]. English researchers have also reported that the lack of adequate support from nursing managers leads to a significant increase in stress, whereas support with supervision causes a reduction in job stress [ 43 ]. The least stressful factor was revealed to be discrimination, which was in agreement with the results of other studies. Park and Haq introduced the lack of receiving rewards and encouragement as the main cause of stress among nurses, which can be attributed to the differences in the statistical population and used questionnaires between these two studies [ 44 , 45 ].

According to another finding of the present study, the total score of quality of life and its dimensions was obtained in the middle range, and the mean score of the psychological dimension was lower than the physical dimension. A review of the literature indicated that the mean values of the total score and dimensions of quality of life in our study were lower than those in other studies [ 7 , 46 , 47 ]. This discrepancy can be regarded as the time of performing the research, which coincided with the onset of coronavirus. Based on the findings of researchers, nurses are under various mental and physical pressures depending on their job status. The reason for such stress can be due to nurses’ workload during the day since they are responsible to take care of several patients simultaneously, the repetition of which on consecutive days causes physical and psychological damages, and ultimately, affects the quality of life [ 4 ]. There was a significant inverse relationship among all dimensions of job stress with total quality of life and psychological and physical dimensions, which was consistent with the results of other studies conducted in this domain [ 7 , 48 ]. The results revealed that job stress had a moderate and weak relationship with psychological and physical dimensions, respectively. Also, 27.9% of the changes in the total score of quality of life was related to job stress and this relation was negatively significant (β=-0.534, P  < 0.001). According to the previous report, job stress is associated with low self-esteem, depression, anxiety, and feelings of inadequacy, which is considered a major risk factor for mild psychiatric illness [ 49 ]. Moreover, it was revealed that heavy workload, long working hours, lack of support, and Inability to quit work and not having enough rest can cause physical harm to the nurses, reduce their quality of life, and increase stress and tension in the workplace [ 50 ]. Also, researchers shown that job stress was as an independent predictor of quality of life related to mental component (β=-4.98, P  < 0.001), and stress resulting from conflicts with supervisors was independently associated with mental health [ 5 ]. which is consistent with our study. According to researchers, good mental health increases trust and cooperation and control stressors [ 51 ]. Mental well-being and capacity to cope with stressful situation is important [ 52 ]. The psychological well-being is related to the higher using of the different coping strategies [ 53 ] and cultivating an environment of trust may provide organizations with a strategy to improve levels of mental health and satisfaction among their employees [ 54 ].

According to the results, nurses have paid more attention to such caring behaviors as writing reports, wearing clean and tidy uniforms, monitoring vital signs, and reporting the patient’s condition to the superior nurse, which is a technical-professional. However, assisting patients in daily activities, sitting at the patient’s bedside and talking to him/her, maintaining the patient’s privacy, maintaining professional competence, and listening to the patient were considered the least important. Overall, 4.9% of the changes in the total score of caring behaviors was related to occupational stress and the relation between to variables was negative (β=-0.098, P  < 0.001). The comparison of results of this study with those of similar studies performed in Spain and England indicated the existence of differences in the understanding of nurses’ caring behaviors [ 55 ]. However, this finding was consistent with that of studies conducted in Iran [ 56 , 57 ]. Factors influencing caring behaviors can be rooted in nursing education [ 57 ]. Paying too much attention to physical care during education, increasing the workload in the ward, a large number of patients per nurse in each shift have a great impact on the performance of nurses at the patient’s bedside [ 58 ]. Job stress were significant and independent predictors of total caring behaviors and its subscales.

Researchers have attributed these discrepancies to the cultural differences of societies [ 49 ]. The data analysis showed a weak inverse relationship between job stress and different dimensions of caring behaviors. It should be noted that the increase in scores in various dimensions of job stress had a significant negative relationship with the psychosocial domain, which was moderate. Apparently, psychosocial support of the patient decreases with an increase in such stressors as conflict with physicians, patient and family, and increased workload.

According to researchers, job stress is a physical-psychological syndrome accompanied by fatigue that leads to negative behaviors and attitudes toward oneself, work, family, and patients, and causes ineffective activity and absenteeism, immorality, and job dissatisfaction, seemingly stemming from nurses’ mental stress and lack of concentration [ 51 ]. Excessive job stress has negative impacts on nurses’ psychological well-being and reduces their work productivity. The results of the present study have been confirmed by the reports of other researchers; in this respect, the job stress of healthcare workers has a relationship with their low job satisfaction, negative attitude towards own job, and negative consequences on the quality of caregiving [ 59 , 60 ].

Limitations

One of the limitations of this study was related to the type of this research since it is not possible to correctly determine causal relationships in cross-sectional studies. Furthermore, the use of the availability sampling method can be one of the limitations of the study; however, the performance of this study in two teaching hospitals contributed to the effective generalization of the results. Moreover, the non-significant result especially between groups may be due to the low sample size and because of a small sample size, the number of predictive variables to be included in the regression models was limited. Since the present study was conducted at the time of the outbreak of COVID-19, it can be a confounding factor on the main variables of the study, namely job stress, quality of life, and caring behaviors, the effects of which have not been investigated. For future study in this area, these limitations described above have important implications for similar projects.

In general, the findings of this study showed that employed nurses had higher levels of perceived job stress that can have negative effects on their quality of life and caring behaviors. Job stress can endanger the physical and mental health of nurses, decrease energy and work efficiency, and fail to provide proper nursing care, which ultimately has a negative impact on patient outcomes. Therefore, it is required to investigate the stressors and effective planning to eliminate these factors. The provision of educational programs to the proper introduction of this profession to the community can increase awareness about the nurses’ problems and concerns, and ultimately, improve their quality of life. Nevertheless, it is recommended the initial management be performed at the organizational level. Purposeful education in university on nursing professional values is essential and hospital managers can improve nurses’ quality of life and caring behaviors by providing cognitive-behavioral intervention programs with the aim of identifying sources of stress in the workplace and providing soft skill programs such as team working, behavioral and communication skills and teaching effective coping strategies to reduce stressors.

Acknowledgements

We thank the women who participated in the study. We also appreciate the support from the Islamic Azad University of Medical Sciences.

Abbreviations

Authors’ contributions.

A. Fn-K developed the study concept and study design. Testing and data collection were performed by A.B and N.GM. Data analysis and interpretation were performed by A. Fn-K. Fn-K. and A.B drafted the manuscript, and A. Fn-K and GM. N provided critical revisions. All authors approved the final version of the manuscript for submission.

This study received no specific grant from any funding agency.

Availability of data and materials

Declarations.

Written informed consent was obtained from each participant before the completion of the survey. This study was approved by the Ethics Committee of the Azad Medical Sciences University, Iran (code number: IR.IAU.TABRIZ.REC.1399.122). All the methods were carried out in accordance with relevant guidelines and regulations.

Not applicable.

The authors declare that they have no competing interests.

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