Mental health service use and its associated factors among nurses in China: a cross-sectional survey

Introduction

Mental health problems are a significant global problem and cause a severe burden on both patients and society according to the Global Burden of Disease Study 2017 (Kyu et al., 2018). A recent study conducted in China reported that the lifetime prevalence of mental health disorders was 16.6% (Huang et al., 2019). Research suggests that nurses are one of the highest-risk groups for developing mental health problems due to their stressful and demanding work (Drury et al., 2014). Previous studies have reported depression, anxiety and insomnia as the most common mental health problems experienced by nurses, and that the prevalence of depression in nurses has shown an increasing trend (Pappa et al., 2020). Nurses suffer from depression at almost twice the rate of individuals working in other professions (Brandford & Reed 2016; Ren et al., 2019; Saeedi Shahri et al., 2017). According to a meta-analysis of 102 studies, the overall prevalence of depressive symptoms in Chinese nurses was 43.8% (Xie et al., 2020). The pooled prevalence of poor sleep quality among nurses was 61.0% according to a meta-analysis of 53 studies (Zeng et al., 2020). Several studies have also examined the prevalence of burnout among nurses. The pooled prevalence of high burnout symptoms among global nurses was 11.2% according to a meta-analysis of 61 studies (Woo et al., 2020). Burnout has negative consequences on the mental health of nurses through the association with fatigue, anxiety, sleep disorders as well as impaired concentration and memory (Woo et al., 2020). Mental health problems and burnout may lead to reduced job satisfaction and performance among nurses (Adriaenssens, De Gucht & Maes, 2015; Liu et al., 2018b), threatening the safety of patients (Garcia et al., 2019; Garrouste-Orgeas et al., 2015; Zhou et al., 2016). For example, the frequency of medication errors has been significantly associated with mental health problems among nurses (Di Simone et al., 2020a; Garrouste-Orgeas et al., 2015). Therefore, preventing and managing mental health problems among nurses is highly important, not only for their health but also for the delivery of good-quality healthcare services.

Several studies have reported on mental health service use (MHSU) and its correlates among medical staff (Adams et al., 2010; Jones, Whybrow & Coetzee, 2018; Sullivan, Camic & Brown, 2015). In a study conducted among 678 military doctors in the United Kingdom, 46.1% of them reported stress-related, mental health or emotional problems during the past three years. Among the military doctors in that study who had experienced these problems, 35.6% reported having sought help from formal sources, including mental health specialists and doctors as well as online and telephone therapists (Jones, Whybrow & Coetzee, 2018). The MHSU rate in that professional group was slightly lower than in the general population, which has been reported to be 38.9% in New Zealand (Foliaki et al., 2006). Some sociodemographic factors, such as single status, male gender and lower level of education, have been identified as factors associated with MHSU (Harris et al., 2016). In addition, mental health problems such as depression and sleep problems have been shown to be significant predictors of MHSU (Liu et al., 2018a; Yin et al., 2019). Burnout has been shown to be prevalent among nurses and to be associated with mental illness (Maslach & Leiter, 2016). It may also be a predictor of MHSU; however, few study has been done to explore the associations among them.

Therefore, to facilitate mental health service planning for nurses, data on the patterns of MHSU among nurses are needed. Several studies have been conducted among Chinese nurses and nursing students to explore their attitudes towards MHSU (Halter, 2004; Mitchell, 2018). However, to the best of our knowledge, no study has reported on MHSU and its associated factors among Chinese nurses. Therefore, this study aimed to explore the rate of MHSU among Chinese nurses, to identify the sociodemographic and occupational variables that are significantly associated with MHSU and to investigate the associations among sleep quality, burnout, depressive symptoms and MHSU.

Materials & Methods

Results

A total of 2768 nurses from 23 provinces of mainland China responded to the questionnaire. The responses of 18 nurses were excluded due to incomplete data. Among the 2750 respondents, 64.36% were married (35.64% were unmarried), 94.22% were female, 69.67% worked in tertiary-level hospitals, 66.15% held a junior professional title and 75.2% were shift workers. The respondents were aged 18 to 57, and 52.95% of them were below the age of 30. Their mean age was 30.58 ± 6.94 years (Table 1).

The rate of lifetime MHSU among the responding nurses was 10.94% (301/2750). The nurses with mid-level professional titles were more likely to use mental health services (13.77% χ² = 8.682, p = 0.013) than those with different professional titles. Sleep quality (χ² = 131.389, p < 0.001) was significantly associated with MHSU among the nurses, and 40.45% (36/89) of the nurses who had very poor sleep quality used mental health services. Burnout (χ² = 18.478, p < 0.001) and depressive symptoms (χ² = 56.558, p < 0.001) were significant factors associated with MHSU. Among the nurses with extremely serious level of burnout, 14.71% (55/374) used mental health services, and 20.15% (106/526) of the nurses with depressive symptoms used mental health services. Among the nurses who had experienced depressive symptoms, burnout and poor sleep, 26.95% (76/282) reported MHSU.

As shown in Table 2, the multivariate logistic regression analyses showed that very poor sleep quality (p < 0.001), mid-level professional title ( p = 0.004) and depressive symptoms (p < 0.001) were significant factors associated with MHSU, with odds ratios of 9.358 (95% CI [5.377–16.285]), 1.479 (95% CI [1.131–1.934]) and 1.655 (95% CI [1.283–2.133]), respectively.

Discussion

To the best of our knowledge, this study of MHSU and its associated factors is the first to be conducted among Chinese nurses. Only 10.94% of the respondents reported MHSU, and the nurses who had very poor sleep quality were approximately ten times more likely to seek mental health services than nurses who had very good sleep quality. Mid-level professional title and depressive symptoms were also independent factors associated with MHSU among the nurses.

The rate of MHSU among the nurses with depressive symptoms, poor sleep quality or burnout was low in this study. This study showed that among the nurses who experienced extremely serious burnout, only 14.71% reported MHSU. Among nurses who experienced burnout, depressive symptoms and poor sleep quality, 26.95% reported MHSU. This rate was lower than the MHSU rate (35.6%) among military doctors who reported experiencing stress, mental health or emotional problems in a survey conducted in the United Kingdom (Jones, Whybrow & Coetzee, 2018). Of the responding nurses in this study, 3.2% reported very poor sleep quality, and their MHSU rate was only 40.4%. A previous study revealed that nurses were more likely to seek medical help for sleep problems than for anxiety or depression (Huang et al., 2018). Poor sleep quality has serious negative consequences on physical and mental health and quality of life, such as fatigue, burnout, hypertension and depression (Furihata et al., 2020; Kim et al., 2018; Togo, Yoshizaki & Komatsu, 2017). Additionally, some studies have found that poor sleep to be highly associated with impaired cognitive performance, such as impaired concentration and memory, which may lead to poor work performance and even affect patient safety (Di Simone et al., 2020b). In addition, approximately half of the nurses who used sleep medication more than three times a week reported no MHSU. The use of hypnotics has beneficial effects in relieving insomnia symptoms. However, hypnotics have side effects which include muscle relaxation and “hangover” that may influence daytime function, resulting in negative effects on work efficiency and safety (Futenma et al., 2015; Lader, 2014) and leading to the risk of dependence addiction (Licata & Rowlett 2008). There are several possible reasons why nurses with poor sleep quality take sleep medicine frequently without consulting a psychiatrist, including self-prescribing and seeking help from other healthcare professionals. Medical staff have often been reported to attempt to conceal their health problems from other people by self-prescribing (Adams et al., 2010). Nurses have easy access to sleep medications such as benzodiazepines, which are not available over the counter due to government policies. In addition, some supplements for improving sleep quality, such as melatonin, are available in pharmacies and are widely used (Pereira et al., 2020). Some nurses may visit a general physician or a neurologist due to stigma or a lack of mental health knowledge. Mental health services include pharmacological and non-pharmacological therapies for sleep disorders. Psychiatrists can prescribe sleep medications that have few side effects and that are less likely to lead to dependence. Some non-pharmacological therapies, such as cognitive-based therapy for insomnia, sleep hygiene education and aromatherapy, have been proven to be effective and have no side effects (Booker et al., 2020; Fang & Li, 2015; Sun et al., 2019).

Mid-level professional title was revealed to be a significant factor associated with MHSU in both the univariate and multivariate analyses. The nurses with mid-level professional titles were most likely to use mental health services, followed by the nurses with junior professional titles and nurses with senior professional titles. In China, nurses with mid-level professional titles are the backbone of the nursing workforce. These nurses are responsible for not only patient care in their wards but also clinical teaching and administration work, such as quality control. They have more responsibility and work under higher pressure than nurses with different professional titles, which places them at a greater risk of mental health problems. Therefore, they are more likely to use mental health services. Nurses with senior professional titles in China are mostly nursing teachers working in nursing schools or administrators in nursing departments in hospitals who have a lighter workload than clinical nurses and tend to lead a regular lifestyle without night shifts. In addition, as a “face-saving approach,” they are more likely to underreport their MHSU.

Many studies have reported the barriers and facilitators of MHSU among medical staff, which were not examined in this study. A systematic review revealed that personal beliefs about mental health and mental health treatment, especially concerns about public stigma, were a significant factor related to the reluctance of medical staff to seek mental health services when needed (Vogt DJPs, 2011). Barriers such as concerns about confidentiality, career progression as well as the opinions of patients and colleagues were also reported (Adams et al., 2010). For nurses, the most highly rated barriers to seeking assistance for mental health problems were fear of embarrassment and concerns about losing their licence (Cares et al., 2015). In addition, mental health resources are scarce and distributed disproportionately in China, and there are only 28 thousand psychiatrists nationwide according to the 2018 national health yearbook (Commission, 2018). Therefore, it is difficult for nurses to access mental health services.

Conclusions

The mental health status of nurses remains a serious problem. Most of the nurses in this study experienced burnout, depressive symptoms or poor sleep quality. The MHSU rate among the nurses in this study was low, and many associated factors were identified. Nurses with depressive symptoms or poor sleep quality and those with a mid-level professional title were more likely to seek mental health services. Interventions to improve the mental health status of nurses and to promote the use of mental health services are urgently needed.

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