The relationships among nurses’ spiritual health, sleep quality, and stress and the factors influencing stress during the late global COVID-19 pandemic: A cross- sectional study

Abstract

Background

COVID-19 has had a significant impact on healthcare workers. Although several studies have looked at the pandemic’s physical and mental effects on nurses, little has been done to investigate their spiritual health and its relationship to stress and sleep quality during the late pandemic.

Purpose

This study sought to fill a knowledge gap in the literature about the relationships between nurses’ reported stress, sleep quality, and spiritual health during the late COVID-19 epidemic.

Methods

A cross-sectional study using purposive sampling was performed out in a medical center in Taiwan. A total of 376 nurses participated. The Perceived Stress Scale, Pittsburgh Sleep Quality Index, and Spiritual Health Scale-Short Form were used for assessing nurses’ stress levels, sleep quality, and spiritual health.

Results

The results showed that the mean perceived stress score was 1.80 ± 0.50 (out of 4), the sleep quality score was 8.17 ± 3.29 (out of 21), and the mean spiritual health score was 3.66 ± 0.59 points (out of 5). Although 77.1% of the nurses in this study experienced sleep disorders (PSQI > 5), they had better sleep quality during the COVID-19 pandemic than those in other countries. Perceived stress, sleep quality, and spiritual health were significantly correlated. Nurses with support from their friends and family and hospital during the COVID-19 pandemic had lower perceived stress and higher sleep quality and spiritual health scores than their peers (p < .05). Age, work experience, sleep quality, and spiritual health were predictors of perceived stress in nurses during the late COVID-19 pandemic (F = 20.19, p < .001) and could explain 30.6% of the variation.

Conclusions

Spiritual health is correlated with the nurses’ stress levels. Despite providing extrinsic support, we encourage nursing management to pay attention to nurses’ spiritual needs and implement psychological education programs to help frontline nurses navigate ever-changing and discerning healthcare environments.

Introduction

The 2019 novel coronavirus disease (COVID-19) pandemic has caused unprecedented mass panic among the global population and led to enormous challenges for clinical staff. Frontline nurses in clinical care have the most contact with patients. Although the COVID-19 pandemic has highlighted the special dedication of nurses, it has also had seriously physically and psychosocially impacted them.

During the pandemic, 48% of nursing professionals showed signs of depression, 52% exhibited anxiety, 52% displayed indications of stress, 75% had sleep disorders, and 68% reported insomnia [1]. Although the world has entered a post pandemic era, there has been an increase in nurses’ burnout and turnover [2], which has exacerbated nursing shortages and patient care. Medical institutions must learn about the pandemic and be prepared at all times to face the challenge of the next unknown major infectious disease. Therefore, looking back at the impacts on and needs of nurses during the pandemic may help provide better support for nurses and adequately prepare for the next challenge.

A large body of research has examined the effects of stress related to the COVID-19 pandemic on nurses. The literature shows that nurses experienced greater stress than other medical staff during the pandemic [3], and that stress is negatively correlated with clinical performance in nurses [4]. Many studies have revealed that nurses’ work stressors during the pandemic are mostly derived from heavy care burdens [3,5], inadequate personal protective equipment [5–7], fear of becoming infected [5,7] and isolation from society [6,8]. The impacts of the pandemic and the lack of support from family and society may also cause immense physical and mental stress in frontline nurses, resulting in a decline in sleep quality [9–11].

Although many studies have examined the impact of the COVID-19 pandemic on nurses’ sleep quality. There is no consensus on this aspect.. Approximately 75.0% of all nurses in Brazil had sleep disorders [1], with 73.3% in Japan [12], and 71.4% in Italy [13] reporting sleep issues. However, only 26.4% of nurses presented with sleep disorders in a Brazilian study [14] and 52.8% in Chinese study, respectively [15], and 82.4% of nurses reported no change in their sleep quality among Norwegian nurses [16]. Although there is no consensus regarding the number of nurses whose sleep quality was affected by the COVID-19 pandemic, it has been proven that the poor sleep quality during the pandemic is positively correlated with the degree of stress, anxiety, fatigue, and fear of COVID‐19 among nurses [12,15].

Spirituality is a dimension of well-being that should be included in holistic health and has attracted much attention in the health-related and nursing sciences. During an unknown pandemic, nurses often struggle with patient care and self-protection. Moral distress can lead to spiritual exhaustion [17]. However, few studies have examined nurse’s spiritual health during the COVID-19 pandemic. Spirituality refers to internal motives that give meaning and hope to an individual’s life and an essence that gives meaning and purpose to their individual’s existence [18]. People with high spiritual health have better emotional, social, physical, and mental resilience [19], and spiritual health has been shown to positively impact professional commitment and care among nurses [20,21]. It is evident that the spiritual well-being of advance practice nurses has been significantly impacted during the COVID-19 pandemic [22], and spirituality is a common strategy used by nurses when coping with stress and burnout [23]. However, relatively few studies have examined nurses’ spiritual health and its relationship with stress during the global pandemic. Accordingly, the current study aimed to examine the correlation between perceived stress, sleep quality, and spiritual health in nurses, as well as factors influencing stress during the late global pandemic.

Materials and methods

Study design and samples

This cross-sectional study was conducted at a medical center in northern Taiwan. A cross-sectional study design was selected because it is the best method to determine the prevalence of health outcomes, and examine the association between multiple exposures and outcomes [24]. We collected and analyzed data from frontline nurses at a single time point. Convenience sampling was employed, and frontline nurses were recruited to participate in this study from June 2022 to December 2022. Although COVID-19 was initially discovered in late 2019, the World Health Organization (WHO) did not declare COVID-19 a global health emergency until March 2020 and the public health emergency declarations ended in May 2023 [25], the period of data collection was identified as the late pandemic period.

The inclusion criteria were frontline nurses working full-time in general wards and intensive care units in the medical center during the pandemic and available at the time of data collection. Nurses with no previously reported characteristics were excluded from the study. G*Power 3.1.9.4 software was used for sample size estimation. Multiple regression was employed as the statistical method, with a significance level (α) of 0.05 and power of 0.8. An effect size of 0.15 was used as a reference[24], and the minimum sample size needed was 217. A total of 400 frontline nurses were invited to participate in this study, and 376 participants completed the survey. The response rate of valid questionnaires was 94.0%.

Ethical considerations

This study was approved by the Institutional Review Board of Chang Gung Memorial Hospital (approval no. 202101826A3C101) prior to data collection. The data collected in this study were used only for this research and all participants’ information was anonymized to ensure confidentiality. The nurses were informed of their right to refuse to participate in the study or withdraw at any time before completing the questionnaires and that there would be no consequences for doing so. During the case collection process, the interviewees can choose to participate voluntarily or not, and the rights and interests will not be affected.

Measurements/instruments

Demographic characteristics.

The demographic characteristics collected in this study included gender, age, marital status, education level, years of working experience, working unit, religion, experience of caring for COVID-19 patients, willingness to work in dedicated COVID-19 wards, whether the participants had children, support from friends and family, and support from the hospital during the COVID-19 pandemic.

Perceived Stress Scale (PSS).

The Perceived Stress Scale (PSS) [26] was used to determine the degree of stress perceived by nurses during the COVID-19 pandemic. The Taiwanese version of PSS was translated by Chu & Kao (2005). The scale has good internal consistency (Cronbach’s α = .84–.86) and test–retest reliability (r = .85) [27]. This 5-point Likert scale with 14 questions is a self-reported tool to measure an individual’s thoughts on lifestyle stress in the preceding month. The score for each question ranges from 0 to 4, with never = 0, occasionally = 1, sometimes = 2, often = 3 and always = 4. The total score ranges from 0 to 56 points with higher scores indicating greater perceived stress.

Pittsburgh Sleep Quality Index (PSQI).

The Pittsburgh Sleep Quality Index (PSQI) [28] was used to measure sleep quality. This self-rated questionnaire assesses sleep quality and disturbances over a 1-month time interval. The Taiwanese version was translated by Tsai et al. (2005). The scale’s sensitivity and specificity were 98% and 55%, respectively, and Cronbach’s α of.82–.83 [29]. The scale contains 19 questions, and its contents include subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, sleeping medication use, and daytime dysfunction. The score for each item ranges from 0 to 3 points (0 = no difficulty, 3 = severe difficulty), and the total score ranges from 0 to 21 points with higher scores denoting poorer sleep quality. A total PSQI score of 5 points was used as a cutoff [29–32]. in which a total score ≦ 5 indicated good sleep quality and a total score > 5 indicated poor sleep quality [28].

Spiritual Health Scale-Short Form (SHS-SF).

The Spiritual Health Scale-Short Form (SHS-SF) [33] was employed to assess spiritual health this study. This Taiwanese scale measures nurses’ spiritual health and is divided into five subscales: connection to others, meaning derived from living, transcendence, religious attachment, and self-understanding. Responses to the scale’s 24 questions are recorded on a Likert scale ranging from 1 to 5 points, with 1 representing “extremely disagree” and 5 representing “extremely agree.” The total score ranges from 24 to 120 points with higher scores indicating better spiritual health. The construct reliability of the original scale was between 0.86 and 0.90, and the average variance extracted ranged from 0.60 to 0.69, which shows good convergent validity [33]. The Cronbach’s α of the various subscales ranged from 0.86 to 0.92.

Data collection/procedure.

The data were collected from June 2022 to December 2022. As Taiwan has downgraded the legal status of COVID-19 to a less serious disease since May 2023, the duration of data collection can be identified as the late pandemic period. After the study was approved by the Institutional Review Board (IRB), the researcher went to the wards or intensive care units during a pre-shift meeting (i.e., a brief meeting held before the start of each work shift) to explain the study objectives to nurses and invited them to participate. Informed consent forms and questionnaires were left for nurses to read and complete. After completion, participants were asked to return the questionnaires by placing them in a sealed envelope left by the researcher. The advantage of this data collection method is that nurses can complete the questionnaire anonymously and have sufficient time to answer the questions without fear of prejudice.

Data analysis.

The IBM SPSS Statistics 26.0 program was used for data analysis. Means and standard deviations were used for the stress, sleep, and spiritual health scores of nurses during the COVID-19 outbreak. An independent t test and one-way ANOVA were used to compare the differences in stress, sleep, and spiritual health scores between groups with different characteristics, a Pearson correlation coefficient was employed to examine the relationship between stress, sleep, and spiritual health, and multiple linear regression analysis was used to analyze the influencing factors of stress among nurses during the COVID-19 pandemic.

Results

Demographic characteristics of participants

A total of 376 nurses completed the questionnaire, with a response rate of 94.0%. Table 1 lists the demographic characteristics of the frontline nurses in this study. The mean age of the participating nurses was 31.52 ± 7.97 years, with an average working experience of 8.70 ± 7.77 years. Approximately 96.0% of the nurses were women, 55.6% had religious beliefs, 85.9% had graduated from university, 72.1% were single, 78.5% did not have children, and 32.7% were the breadwinners of their families. A total of 20.2% of the nurses were concerned about their living arrangements during the late COVID-19 pandemic, 94.9% perceived that they received support from friends and family, and 89.9% felt that they received sufficient support from the hospital. Of the 376 nurses, 160 (42.6%) had experience caring for COVID-19 patients and 122 (76.3%) had volunteered to be deployed to dedicated COVID-19 wards.

[Figure omitted. See PDF.]

Perceived stress, sleep quality and spiritual health

Table 2 presents the results for perceived stress, sleep quality, and spiritual health of nurses during the late COVID-19 pandemic. The mean perceived stress score was 1.80 ± 0.50 (out of 4) with a total score of 25.16 ± 6.93 (out of 56 points), the sleep quality score was 8.17 ± 3.29 (out of 21), and the mean spiritual health score was 3.66 ± 0.59 points (out of 5 points). The mean daily sleep duration was 6.89 ± 1.32 hours, and 77.1% of nurses perceived sleep disorders (PSQI > 5 points).

[Figure omitted. See PDF.]

Table 3 shows the analysis of the differences in perceived stress, total sleep score, and spiritual health score. Nurses with religious beliefs showed better spiritual health than nurses without religious beliefs (p = .41). Nurses who were the family’s breadwinner had poorer sleep quality than those who were not the breadwinner (p = .010). Nurses who did not volunteer to be deployed in COVID-19 wards had poorer sleep quality than those who volunteered to be deployed in dedicated wards (p < .001). Nurses with COVID-19 care experience had lower perceived stress than nurses without COVID-19 care experience (p = .045). Furthermore, nurses who received support from friends and family during the COVID-19 pandemic had lower stress (p = .017), better sleep quality (p = .012), and better spiritual health (p < .001) than their counterparts. Similarly, nurses with sufficient perceived support from the hospital during the pandemic had lower stress (p = .006), better sleep quality (p = .010), and better spiritual health (p = 006). However, there were no significant differences in perceived stress, sleep quality, and spiritual health scores by education level, marital status, work unit, or concerns about living arrangements during the epidemic.

[Figure omitted. See PDF.]

Table 4 shows the results of Pearson’s correlation between spiritual health, perceived stress, sleep quality, and continuous demographic variables including age and working experience of nurses during the pandemic. The higher the perceived stress, the poorer the sleep quality (r = .384, p < .01), the higher the perceived stress, the lower the spiritual health (r = -.388, p < .01), and the poorer the sleep quality, the lower the spiritual health (r = -.217, p < .01). In addition, nurses with more years of work experience had lower perceived stress (r = -.165, p < .05) but had poorer sleep quality (r = .106, p < .05). There was no significant correlation between work experience and spiritual health (p > .05).

[Figure omitted. See PDF.]

Table 5 shows a multiple regression analysis of predictors of perceived stress in the nurses. The results showed that age (β = .331, p < .019), work experience (β = -.528, p < .001), sleep quality (β = .322, p < .001), and spiritual health (β = -.332, p < .001) were predictors of perceived stress in nurses (F = 20.19, p < .001) during the late COVID-19 pandemic. It could explain 30.6% of the variation (R²= .306).

[Figure omitted. See PDF.]

Discussion

Perceived stress

This study found that the mean perceived stress score of nurses during the COVID-19 pandemic was 25.16 ± 6.93 (out of 56 points). A study by Leng et al. [5] showed that the mean perceived stress score of nurses during the pandemic was 19.33 ± 7.21; thus, the nurses in our study had higher perceived stress. However, further analysis of the backgrounds of the participants in these two studies revealed that the participants in Leng et al. [5] were nurses who cared for COVID-19 patients in an intensive care unit, whereas our study recruited frontline nurses with and without experience in caring for COVID-19 confirmed cases. Nurses who cared for confirmed cases were experienced in the actual care process and the hospital provided comprehensive protective measures when they cared for confirmed patients. Consequently, their perceived stress levels were lower. This argument can be proven by the results of this study; that is, nurses who received sufficient support from the hospital had significantly lower perceived stress scores than those who reported no support (p < .01). Another reason could be that the actual care experience helps decrease uncertainty about COVID-19. The multiple linear regression analysis results also validated that work experience is an influencing factor that predicts perceived stress. According to a survey by Huang et al. [34] facing emerging and highly contagious diseases in Taiwan will increase the stress of medical staff. In the early stages, the stress of medical staff will be affected by the progress of the epidemic. The lack of supplies and information may put medical staff under greater pressure.

In addition, this study found that nurses who received support from friends, family, and the hospital reported lower perceived stress. Previous studies have shown that a shortage of protective equipment [5,7] and isolation from friends, family, and society [6,8] can result in stress for nurses during the COVID-19 pandemic. An integrative review [35] also concluded that loss of life and lack of supportive leadership contributed to symptoms of anxiety, stress, depression, and moral distress in nurses during the global pandemic. The ability to discuss their stress or work experiences with loved ones may help nurses reduce the psychological burden of suppressed emotions during the late pandemic.

Furthermore, support from the hospital that contributed to decreased stress included the provision of sufficient personal protective equipment and other supplies such as monetary pay. In response to the impact of the global pandemic, the Taiwanese government announced a special act for COVID-19 and provided frontline nurses who cared for COVID-19 patients with NT$10,000 (US$ 334.43) for each eight-hour shift worked [36]. For individual employees, pay is an important reward for their work. It has also been shown that nurses’ perceptions of organizational support and monetary pay satisfaction were positively related to their job satisfaction and negatively correlated with turnover intention during the COVID‐19 pandemic [37]. This indicates that nurses require both intrinsic and extrinsic support to combat the impacts of a pandemic. Sufficient extrinsic support from hospitals and intrinsic support from friends and family during the late pandemic have allowed nurses to devote themselves to clinical care with peace of mind. It was conducted in 2022, and medical staff were more affected than Leng et al. [5], Galehdar et al. [6], and Arnetz et al. [8] in the early stage of the epidemic in 2020.

Sleep quality

The results of this study showed that 77.1% of nurses had sleep disorders (PSQI > 5) with a mean score of 6.89 ± 1.32 during the late COVID-19 pandemic, and sleep quality was an influencing factor for perceived stress. Other studies conducted during the COVID-19 pandemic have shown that the prevalence of sleep disorders among nurses ranged from 26.4% to 75.0% [1,12–15]. Although there is no consensus regarding sleep disorders among nurses during the COVID-19 pandemic, our results are similar to those of studies conducted in Brazil [1], Japan [12] and Italy [13]. Our study also proved that nurses’ poor sleep quality during the late pandemic was significantly correlated with the degree of stress [12,15].

Compared with the average sleep quality score of 9.85 ± 2.72 in the United States [9] and 8.48 ± 3.63 in China [11], the nurses in this study had a lower mean PSQI score (6.89 ± 1.32), indicating better sleep quality during the COVID-19 pandemic. However, this may be due to the different survey periods used in the studies. Studies in the United States and China were conducted during the early COVID-19 pandemic, whereas this study’s data were collected during the late global pandemic in 2022. Notably, nurses during the late pandemic may have learned how to react to and cope with the pandemic. Consequently, the sleep quality of the nurses in this study was relatively less affected by the COVID-19 pandemic. In addition, the nurses in this study had a similar prevalence of sleep disorders compared to a Korean study conducted before the COVID-19 pandemic in which 79.8% of nurses reported sleep disorders [38]. This might also indicate that nurses’ sleep quality is always a concern and that nurse leaders and executives should consider measures to improve it.

Spiritual health

Regarding spiritual health, our study found that the mean spiritual health score of nurses during the COVID-19 pandemic was 3.66 ± 0.59. Lee et al. [39] investigated the physical and mental status of nurses who served as frontline caregivers during the COVID-19 epidemic in Taiwan. The average spiritual health was 3.79 ± 0.58, which was not much different from this study, but it was proposed that spiritual health provides the meaning of life. Since few studies have examined the spiritual health of nurses during the late pandemic, there are no available study results for comparison. Among the few studies that examined spiritual health in nurses, Chiang et al. [20] showed that the spiritual health subscale scores of connections to others, meaning derived from living, transcendence, religious attachment, and self-understanding were 4.35, 4.09, 3.78, 3.75, and 3.82, respectively, which were higher than the scores revealed in this study (4.01, 3.80, 3.60, 3.18, and 3.66, respectively). Hence, nurses’ spiritual health decreased during the COVID-19 pandemic, indicating that the pandemic negatively impacted nurses’ spiritual health.

Furthermore, this study showed that spiritual health was an influencing factor for perceived stress among nurses during the COVID-19 pandemic. Consistently ignoring professional caregivers’ needs can seriously affect their emotional and spiritual health. Therefore, in addition to providing equipment and mental support from friends and family, satisfying the spiritual needs of nurses helped decrease perceived stress during the late pandemic. As previously noted, nurses commonly use spirituality to cope with stress and burnout [23]. A systematic review also revealed that spiritual education significantly decreases nurses overall stress of nurses [40]. It has been suggested [17] that the first step toward spiritual and moral resilience is self-awareness. Nurses can be trained to identify symptoms of spiritual fatigue and adopt adaptive coping strategies to reconnect with the self and meaning of life. Working in a rapidly changing healthcare environment is always stressful, and frontline nurses must be prepared to cope with this ever-changing and stressful environment. We recommend that nursing managers provide spiritual health education to nurses, especially when they face enormous challenges such as an epidemic. This will help frontline nurses cope with the challenges posed by major infectious diseases.

Limitations

This study has several limitations. First, the long-term impact of spiritual health on stress could not be determined because this study used a cross-sectional methodology. Second, this study only collected data from a single medical center; thus, the generalizability of the results is limited. Furthermore, the survey period of this study was 2022, a period in which many countries experienced several peaks in outbreaks during the late pandemic. Therefore, the results of this study may only reflect the stress, sleep quality, and spiritual health of nurses during the “late pandemic era.” Further studies are required to determine how spiritual health affects nurses’ stress levels and health outcomes. Third, the purposive sampling technique may introduce selection bias, which may affect the generalizability of the research results. In addition, factors such as shift patterns, working hours, and direct contact with COVID-19 patients that may affect stress and sleep quality were not collected. It is recommended that further discussion be conducted in the future.

Conclusions

In the late stages of COVID-19 pandemic, nurses still experienced higher levels of sleep disturbances. Those were the breadwinners of their families, volunteered to be deployed to COVID-19 wards, and more supported from family, friends, and the hospital had better sleep quality. Additionally, individuals with religious beliefs and who received support from family, friends, and the hospital demonstrated better spiritual health. It is noteworthy that working experience, sleep quality, and spiritual health influenced perceived stress factors in the late of the pandemic. In addition, this is a cross-sectional design inference that limits the ability to track the impact of changes in stress. Suggesting future longitudinal research to establish causality would enhance the discussion.

Although the world has entered a post-pandemic era, humankind has experienced a range of epidemics—from the 2002 severe acute respiratory syndrome (SARS) outbreak to the COVID-19 pandemic in 2019. Accordingly, medical staff must be prepared to face the challenges of the next major unknown infectious disease. The results of this study showed that protective equipment support from the hospital and mental support from friends and family enabled nurses to devote themselves to clinical care with peace of mind during the COVID-19 pandemic and that nurses’ spiritual needs affected their perceived stress during the late pandemic. In addition, there is a need to establish a mental health support system that can address the need of the general population. The education on coping strategies and stress management may be helpful[41]. It is recommended that medical institutions set up consultation centers for medical personnel to provide necessary psychological consultation and assistance. High-quality sleep and positive coping methods are also factors that affect stress [42], and we suggest that mindfulness is effective in improving levels of stress, sleep quality, and resilience[43]. We recommend that clinical managers use the existing experience as a reference to formulate response measures and assist frontline medical staff in facing the enormous challenges posed by infectious disease outbreaks. We also suggest that more attention be paid to the spiritual health of nurses and spiritual education programs to help frontline nurses prepare for changing and challenging clinical environments.

Acknowledgments

We would like to thank all participants from the Linkou Chang Gung Memorial Hospital for their assistance and the Chang Gung Medical Foundation for supporting us with a grant (No: CORPG3M0131).

References

1. 1. do Rocio Maier M, Kanunfre CC. Impact on nursing personnel’s mental health and sleep quality during the COVID- 19 pandemic. Rev Bras Enferm. 2021;29:1–8.

* View Article

* Google Scholar

2. 2. Woodward KF, Willgerodt M. A systematic review of registered nurse turnover and retention in the United States. Nurs Outlook. 2022;70(4):664–78. pmid:35798584

* View Article

* PubMed/NCBI

* Google Scholar

3. 3. Croghan IT, Chesak SS, Adusumalli J, Fischer KM, Beck EW, Patel SR, et al. Stress, resilience, and coping of healthcare workers during the COVID-19 pandemic. J Prim Care Community Health. 2021;12:21501327211008448. pmid:33834900

* View Article

* PubMed/NCBI

* Google Scholar

4. 4. Ardıç M, Ünal Ö, Türktemiz H. The effect of stress levels of nurses on performance during the COVID-19 pandemic: the mediating role of motivation. J Res Nurs. 2022;27(4):330–40. pmid:35837263

* View Article

* PubMed/NCBI

* Google Scholar

5. 5. Leng M, Wei L, Shi X, Cao G, Wei Y, Xu H, et al. Mental distress and influencing factors in nurses caring for patients with COVID-19. Nurs Crit Care. 2021;26(2):94–101. pmid:33448567

* View Article

* PubMed/NCBI

* Google Scholar

6. 6. Galehdar N, Kamran A, Toulabi T, Heydari H. Exploring nurses’ experiences of psychological distress during care of patients with COVID-19: a qualitative study. BMC Psychiatry. 2020;20(1):489. pmid:33023535

* View Article

* PubMed/NCBI

* Google Scholar

7. 7. García-Martín M, Roman P, Rodriguez-Arrastia M, Diaz-Cortes MDM, Soriano-Martin PJ, Ropero-Padilla C. Novice nurse’s transitioning to emergency nurse during COVID-19 pandemic: A qualitative study. J Nurs Manag. 2021;29(2):258–67. pmid:32881134

* View Article

* PubMed/NCBI

* Google Scholar

8. 8. Arnetz JE, Goetz CM, Arnetz BB, Arble E. nurse reports of stressful situations during the COVID-19 pandemic: qualitative analysis of survey responses. Int J Environ Res Public Health. 2020;17(21):8126. pmid:33153198

* View Article

* PubMed/NCBI

* Google Scholar

9. 9. Kim-Godwin YS, Lee MH, Logan JG, Liu X. Factors influencing sleep quality among female staff nurses during the early COVID-19 pandemic in the United States. Int J Environ Res Public Health. 2021;18(9):4827. pmid:33946606

* View Article

* PubMed/NCBI

* Google Scholar

10. 10. Targa ADS, Benítez ID, Moncusí-Moix A, Arguimbau M, de Batlle J, Dalmases M, et al. Decrease in sleep quality during COVID-19 outbreak. Sleep Breath. 2021;25(2):1055–61. pmid:32989674

* View Article

* PubMed/NCBI

* Google Scholar

11. 11. Tu Z-H, He J-W, Zhou N. Sleep quality and mood symptoms in conscripted frontline nurse in Wuhan, China during COVID-19 outbreak: A cross-sectional study. Medicine (Baltimore). 2020;99(26):e20769. pmid:32590755

* View Article

* PubMed/NCBI

* Google Scholar

12. 12. Al Maqbali M, Al Khadhuri J. Psychological impact of the coronavirus 2019 (COVID-19) pandemic on nurses. Jpn J Nurs Sci. 2021;18(3):e12417. pmid:33749144

* View Article

* PubMed/NCBI

* Google Scholar

13. 13. Simonetti V, Durante A, Ambrosca R, Arcadi P, Graziano G, Pucciarelli G, et al. Anxiety, sleep disorders and self-efficacy among nurses during COVID-19 pandemic: A large cross-sectional study. J Clin Nurs. 2021;30(9–10):1360–71. pmid:33534934

* View Article

* PubMed/NCBI

* Google Scholar

14. 14. Dos Santos MA, Pereira FH, DE Souza Caliari J, Oliveira HC, Ceolim MF, Andrechuk CRS. Sleep and professional burnout in nurses, nursing technicians, and nursing assistants during the COVID-19 pandemic. J Nurs Res. 2022;30(4):e218. pmid:35674665

* View Article

* PubMed/NCBI

* Google Scholar

15. 15. Zhan Y, Liu Y, Liu H, Li M, Shen Y, Gui L, et al. Factors associated with insomnia among Chinese front-line nurses fighting against COVID-19 in Wuhan: A cross-sectional survey. J Nurs Manag. 2020;28(7):1525–35. pmid:32657449

* View Article

* PubMed/NCBI

* Google Scholar

16. 16. Waage S, Pallesen S, Vedaa Ø, Buchvold H, Blytt KM, Harris A, et al. Sleep patterns among Norwegian nurses between the first and second wave of the COVID-19 pandemic. BMC Nurs. 2021;20(1):105. pmid:34154585

* View Article

* PubMed/NCBI

* Google Scholar

17. 17. Sawyer AT, Bailey AK. Beyond clinical competence: prioritizing and supporting nurses’ mental and spiritual health. J Psychosoc Nurs Ment Health Serv. 2022;60(8):3–5. pmid:35917245

* View Article

* PubMed/NCBI

* Google Scholar

18. 18. Linda NS, Phetlhu DR, Klopper HC. Nurse educators’ understanding of spirituality and spiritual care in nursing: A South African perspective (Part 1). Int. J. Afr. Nurs. Sci. 2020;12:100187.

* View Article

* Google Scholar

19. 19. Koenig HG. Maintaining health and well-being by putting faith into action during the COVID-19 pandemic. J Relig Health. 2020;59(5):2205–14. pmid:32409989

* View Article

* PubMed/NCBI

* Google Scholar

20. 20. Chiang Y, Lee H, Chu T, Han C, Hsiao Y. The impact of nurses’ spiritual health on their attitudes toward spiritual care, professional commitment, and caring. Nurs Outlook. 2016; 64(3): 215–24.

* View Article

* Google Scholar

21. 21. Fradelos E, Alexandropoulou CA, Kontopoulou L, Papathanasiou IV, Tzavella F. Factors affecting Greek nurses’ caring behaviors: The role of nurses’ spirituality and the spiritual climate of hospitals. J Relig Health. 2022;61(3):1816–30.

* View Article

* Google Scholar

22. 22. Rogers M, Lamarche K, Miller M, Moore KS, Spies LA, Taylor J, Staempfli S. Global emotional and spiritual well-being and resilience of advanced practice nurses during the COVID-19 pandemic: A cross-sectional study. J Adv Nurs. 2022;78(5):1483–92.

* View Article

* Google Scholar

23. 23. De Diego-Cordero R, Iglesias-Romo M, Badanta B, Lucchetti G, Vega-Escaño J. Burnout and spirituality among nurses: A scoping review. Explore (NY). 2022;18(5):612–20. pmid:34429263

* View Article

* PubMed/NCBI

* Google Scholar

24. 24. Wang X, Cheng Z. Cross-sectional studies: strengths, weaknesses, and recommendations. Chest. 2020;158(1S):S65–71. pmid:32658654

* View Article

* PubMed/NCBI

* Google Scholar

25. 25. Northwestern Medicine. COVID-19 Pandemic Timeline: COVID-19 Milestones around the World and at Northwestern Medicine. 2023. [cited 2023 April 3. ]. https://www.nm.org/healthbeat/medical-advances/new-therapies-and-drug-trials/covid-19-pandemic-timeline

* View Article

* Google Scholar

26. 26. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385.

* View Article

* Google Scholar

27. 27. Chu L, Kao HSR. The moderation of meditation experience and emotional intelligence on the relationship between perceived stress and negative mental health. Chin J Psych 2005;47(2):157–79.

* View Article

* Google Scholar

28. 28. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213. pmid:2748771

* View Article

* PubMed/NCBI

* Google Scholar

29. 29. Tsai P-S, Wang S-Y, Wang M-Y, Su C-T, Yang T-T, Huang C-J, et al. Psychometric evaluation of the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) in primary insomnia and control subjects. Qual Life Res. 2005;14(8):1943–52. pmid:16155782

* View Article

* PubMed/NCBI

* Google Scholar

30. 30. Tai Y-M, Tsai C-W, Yang S-N. suicidal ideation, quality of life, and psychometric outcomes in Taiwanese military personnel with subjective hypersomnia or insomnia. Taiwan J Psychiatry. 2020;34(4):162.

* View Article

* Google Scholar

31. 31. Chou H-Y, Chu H-T, Tai Y-M, Yang S-N. Comparison of sleep problems and posttraumatic stress disorder associated psychiatric states in military active-duty army and navy personnel in Taiwan. Taiwan J. Psychiatry. 2022;36(3):111–7.

* View Article

* Google Scholar

32. 32. Yang HM, Tai Y-M, Yang S-N. Mental health states of soldiers with histories of corona virus disease 2019 infection in Taiwan. Taiwan J. Psychiatry. 2022;36(4):164–9.

* View Article

* Google Scholar

33. 33. Hsiao Y-C, Chiang Y-C, Lee H-C, Han C-Y. Psychometric testing of the properties of the spiritual health scale short form. J Clin Nurs. 2013;22(21–22):2981–90. pmid:24118517

* View Article

* PubMed/NCBI

* Google Scholar

34. 34. Huang YL, Lee YM, Huang WT, Wei FC. Stress perception of medical professionals during the COVID-19 pandemic. Health Promot. Res Pract. 2022;5(2):33-43.

* View Article

* Google Scholar

35. 35. Boone LD, Rodgers MM, Baur A, Vitek E, Epstein C. An integrative review of factors and interventions affecting the well-being and safety of nurses during a global pandemic. Worldviews Evid Based Nurs. 2023;20(2):107–15. pmid:36811445

* View Article

* PubMed/NCBI

* Google Scholar

36. 36. Ministry of Health and Welfare. A subsidy program for healthcare professionals and facilities that treated people linked to a COVID-19 cluster infection. [cited 2022 June 24] Available at https://covid19.mohw.gov.tw/ch/cp-4847-52289-205.html

37. 37. Pahlevan Sharif S, She L, Liu L, Naghavi N, Lola GK, Sharif Nia H, et al. Retaining nurses via organizational support and pay during COVID-19 pandemic: The moderating effect between intrinsic and extrinsic incentives. Nurs Open. 2023;10(1):123–34. pmid:35906871

* View Article

* PubMed/NCBI

* Google Scholar

38. 38. Park E, Lee HY, Park CS-Y. Association between sleep quality and nurse productivity among Korean clinical nurses. J Nurs Manag. 2018;26(8):1051–8. pmid:29855101

* View Article

* PubMed/NCBI

* Google Scholar

39. 39. Lee HC, Chiang YC, Lin CH, Chu TL, Hsiao YC. A study of the relationships among spirituality, mindfulness, and self-compassion in nurses during the coronavirus epidemic. Formosa J Ment Health. 2023;36(3):235–60.

* View Article

* Google Scholar

40. 40. Sharifnia AM, Fernandez R, Green H, Alananzeh I. The effectiveness of spiritual intelligence educational interventions for nurses and nursing students: A systematic review and meta-analysis. Nurse Educ Pract. 2022;63:103380. pmid:35714561

* View Article

* PubMed/NCBI

* Google Scholar

41. 41. Kar N, Kar B, Kar S. Stress and coping during COVID-19 pandemic: Result of an online survey. Psychiatry Res. 2021;295:113598. pmid:33264677

* View Article

* PubMed/NCBI

* Google Scholar

42. 42. Peng Y, Lv SB, Low SR, Bono SA. The impact of employment stress on college students: psychological well-being during COVID-19 pandemic in China. Curr Psychol. 2023:1–12. pmid:37359658

* View Article

* PubMed/NCBI

* Google Scholar

43. 43. Benavides-Gil G, Martínez-Zaragoza F, Fernández-Castro J, Sánchez-Pérez A, García-Sierra R. Mindfulness-based interventions for improving mental health of frontline healthcare professionals during the COVID-19 pandemic: a systematic review. Syst Rev. 2024;13(1):160. pmid:38902795

* View Article

* PubMed/NCBI

* Google Scholar

Citation: Lin Y-E, Chien L-Y, Hu M-L (2025) The relationships among nurses’ spiritual health, sleep quality, and stress and the factors influencing stress during the late global COVID-19 pandemic: A cross- sectional study. PLoS One 20(5): e0323164. https://doi.org/10.1371/journal.pone.0323164

About the Authors:

Yueh-E. Lin

Roles: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Writing – original draft

Affiliations: Department of Nursing, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan

Li-Yu Chien

Roles: Conceptualization, Data curation, Formal analysis, Methodology, Software, Supervision, Writing – original draft, Writing – review & editing

Affiliations: Department of Nursing, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan

Mei-Lien Hu

Roles: Conceptualization, Data curation, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

E-mail: [email protected]

Affiliation: Department of Nursing, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan

ORICD: https://orcid.org/0000-0002-8867-8216

[/RAW_REF_TEXT]

References

1. do Rocio Maier M, Kanunfre CC. Impact on nursing personnel’s mental health and sleep quality during the COVID- 19 pandemic. Rev Bras Enferm. 2021;29:1–8.

2. Woodward KF, Willgerodt M. A systematic review of registered nurse turnover and retention in the United States. Nurs Outlook. 2022;70(4):664–78. pmid:35798584

3. Croghan IT, Chesak SS, Adusumalli J, Fischer KM, Beck EW, Patel SR, et al. Stress, resilience, and coping of healthcare workers during the COVID-19 pandemic. J Prim Care Community Health. 2021;12:21501327211008448. pmid:33834900

4. Ardıç M, Ünal Ö, Türktemiz H. The effect of stress levels of nurses on performance during the COVID-19 pandemic: the mediating role of motivation. J Res Nurs. 2022;27(4):330–40. pmid:35837263

5. Leng M, Wei L, Shi X, Cao G, Wei Y, Xu H, et al. Mental distress and influencing factors in nurses caring for patients with COVID-19. Nurs Crit Care. 2021;26(2):94–101. pmid:33448567

6. Galehdar N, Kamran A, Toulabi T, Heydari H. Exploring nurses’ experiences of psychological distress during care of patients with COVID-19: a qualitative study. BMC Psychiatry. 2020;20(1):489. pmid:33023535

7. García-Martín M, Roman P, Rodriguez-Arrastia M, Diaz-Cortes MDM, Soriano-Martin PJ, Ropero-Padilla C. Novice nurse’s transitioning to emergency nurse during COVID-19 pandemic: A qualitative study. J Nurs Manag. 2021;29(2):258–67. pmid:32881134

8. Arnetz JE, Goetz CM, Arnetz BB, Arble E. nurse reports of stressful situations during the COVID-19 pandemic: qualitative analysis of survey responses. Int J Environ Res Public Health. 2020;17(21):8126. pmid:33153198

9. Kim-Godwin YS, Lee MH, Logan JG, Liu X. Factors influencing sleep quality among female staff nurses during the early COVID-19 pandemic in the United States. Int J Environ Res Public Health. 2021;18(9):4827. pmid:33946606

10. Targa ADS, Benítez ID, Moncusí-Moix A, Arguimbau M, de Batlle J, Dalmases M, et al. Decrease in sleep quality during COVID-19 outbreak. Sleep Breath. 2021;25(2):1055–61. pmid:32989674

11. Tu Z-H, He J-W, Zhou N. Sleep quality and mood symptoms in conscripted frontline nurse in Wuhan, China during COVID-19 outbreak: A cross-sectional study. Medicine (Baltimore). 2020;99(26):e20769. pmid:32590755

12. Al Maqbali M, Al Khadhuri J. Psychological impact of the coronavirus 2019 (COVID-19) pandemic on nurses. Jpn J Nurs Sci. 2021;18(3):e12417. pmid:33749144

13. Simonetti V, Durante A, Ambrosca R, Arcadi P, Graziano G, Pucciarelli G, et al. Anxiety, sleep disorders and self-efficacy among nurses during COVID-19 pandemic: A large cross-sectional study. J Clin Nurs. 2021;30(9–10):1360–71. pmid:33534934

14. Dos Santos MA, Pereira FH, DE Souza Caliari J, Oliveira HC, Ceolim MF, Andrechuk CRS. Sleep and professional burnout in nurses, nursing technicians, and nursing assistants during the COVID-19 pandemic. J Nurs Res. 2022;30(4):e218. pmid:35674665

15. Zhan Y, Liu Y, Liu H, Li M, Shen Y, Gui L, et al. Factors associated with insomnia among Chinese front-line nurses fighting against COVID-19 in Wuhan: A cross-sectional survey. J Nurs Manag. 2020;28(7):1525–35. pmid:32657449

16. Waage S, Pallesen S, Vedaa Ø, Buchvold H, Blytt KM, Harris A, et al. Sleep patterns among Norwegian nurses between the first and second wave of the COVID-19 pandemic. BMC Nurs. 2021;20(1):105. pmid:34154585

17. Sawyer AT, Bailey AK. Beyond clinical competence: prioritizing and supporting nurses’ mental and spiritual health. J Psychosoc Nurs Ment Health Serv. 2022;60(8):3–5. pmid:35917245

18. Linda NS, Phetlhu DR, Klopper HC. Nurse educators’ understanding of spirituality and spiritual care in nursing: A South African perspective (Part 1). Int. J. Afr. Nurs. Sci. 2020;12:100187.

19. Koenig HG. Maintaining health and well-being by putting faith into action during the COVID-19 pandemic. J Relig Health. 2020;59(5):2205–14. pmid:32409989

20. Chiang Y, Lee H, Chu T, Han C, Hsiao Y. The impact of nurses’ spiritual health on their attitudes toward spiritual care, professional commitment, and caring. Nurs Outlook. 2016; 64(3): 215–24.

21. Fradelos E, Alexandropoulou CA, Kontopoulou L, Papathanasiou IV, Tzavella F. Factors affecting Greek nurses’ caring behaviors: The role of nurses’ spirituality and the spiritual climate of hospitals. J Relig Health. 2022;61(3):1816–30.

22. Rogers M, Lamarche K, Miller M, Moore KS, Spies LA, Taylor J, Staempfli S. Global emotional and spiritual well-being and resilience of advanced practice nurses during the COVID-19 pandemic: A cross-sectional study. J Adv Nurs. 2022;78(5):1483–92.

23. De Diego-Cordero R, Iglesias-Romo M, Badanta B, Lucchetti G, Vega-Escaño J. Burnout and spirituality among nurses: A scoping review. Explore (NY). 2022;18(5):612–20. pmid:34429263

24. Wang X, Cheng Z. Cross-sectional studies: strengths, weaknesses, and recommendations. Chest. 2020;158(1S):S65–71. pmid:32658654

25. Northwestern Medicine. COVID-19 Pandemic Timeline: COVID-19 Milestones around the World and at Northwestern Medicine. 2023. [cited 2023 April 3. ]. https://www.nm.org/healthbeat/medical-advances/new-therapies-and-drug-trials/covid-19-pandemic-timeline

26. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385.

27. Chu L, Kao HSR. The moderation of meditation experience and emotional intelligence on the relationship between perceived stress and negative mental health. Chin J Psych 2005;47(2):157–79.

28. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213. pmid:2748771

29. Tsai P-S, Wang S-Y, Wang M-Y, Su C-T, Yang T-T, Huang C-J, et al. Psychometric evaluation of the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) in primary insomnia and control subjects. Qual Life Res. 2005;14(8):1943–52. pmid:16155782

30. Tai Y-M, Tsai C-W, Yang S-N. suicidal ideation, quality of life, and psychometric outcomes in Taiwanese military personnel with subjective hypersomnia or insomnia. Taiwan J Psychiatry. 2020;34(4):162.

31. Chou H-Y, Chu H-T, Tai Y-M, Yang S-N. Comparison of sleep problems and posttraumatic stress disorder associated psychiatric states in military active-duty army and navy personnel in Taiwan. Taiwan J. Psychiatry. 2022;36(3):111–7.

32. Yang HM, Tai Y-M, Yang S-N. Mental health states of soldiers with histories of corona virus disease 2019 infection in Taiwan. Taiwan J. Psychiatry. 2022;36(4):164–9.

33. Hsiao Y-C, Chiang Y-C, Lee H-C, Han C-Y. Psychometric testing of the properties of the spiritual health scale short form. J Clin Nurs. 2013;22(21–22):2981–90. pmid:24118517

34. Huang YL, Lee YM, Huang WT, Wei FC. Stress perception of medical professionals during the COVID-19 pandemic. Health Promot. Res Pract. 2022;5(2):33-43.

35. Boone LD, Rodgers MM, Baur A, Vitek E, Epstein C. An integrative review of factors and interventions affecting the well-being and safety of nurses during a global pandemic. Worldviews Evid Based Nurs. 2023;20(2):107–15. pmid:36811445

36. Ministry of Health and Welfare. A subsidy program for healthcare professionals and facilities that treated people linked to a COVID-19 cluster infection. [cited 2022 June 24] Available at https://covid19.mohw.gov.tw/ch/cp-4847-52289-205.html

37. Pahlevan Sharif S, She L, Liu L, Naghavi N, Lola GK, Sharif Nia H, et al. Retaining nurses via organizational support and pay during COVID-19 pandemic: The moderating effect between intrinsic and extrinsic incentives. Nurs Open. 2023;10(1):123–34. pmid:35906871

38. Park E, Lee HY, Park CS-Y. Association between sleep quality and nurse productivity among Korean clinical nurses. J Nurs Manag. 2018;26(8):1051–8. pmid:29855101

39. Lee HC, Chiang YC, Lin CH, Chu TL, Hsiao YC. A study of the relationships among spirituality, mindfulness, and self-compassion in nurses during the coronavirus epidemic. Formosa J Ment Health. 2023;36(3):235–60.

40. Sharifnia AM, Fernandez R, Green H, Alananzeh I. The effectiveness of spiritual intelligence educational interventions for nurses and nursing students: A systematic review and meta-analysis. Nurse Educ Pract. 2022;63:103380. pmid:35714561

41. Kar N, Kar B, Kar S. Stress and coping during COVID-19 pandemic: Result of an online survey. Psychiatry Res. 2021;295:113598. pmid:33264677

42. Peng Y, Lv SB, Low SR, Bono SA. The impact of employment stress on college students: psychological well-being during COVID-19 pandemic in China. Curr Psychol. 2023:1–12. pmid:37359658

43. Benavides-Gil G, Martínez-Zaragoza F, Fernández-Castro J, Sánchez-Pérez A, García-Sierra R. Mindfulness-based interventions for improving mental health of frontline healthcare professionals during the COVID-19 pandemic: a systematic review. Syst Rev. 2024;13(1):160. pmid:38902795