The impact of negative affects on the high prevalence of anxiety,depression and stress in healthcare professionals

Abstract

BACKGROUND:

Psychiatric disorders are the conditions that most contribute to incapacity worldwide. While many healthcare professionals adapt in dealing with various demands, others do not. How much of these conditions is associated with affective experience needs to be studied.

OBJECTIVE:

Assess the prevalence of anxiety, depression, and stress while investigating the relationship between the presence of positive and negative affect in healthcare professionals.

METHODS:

This study’s convenience sample consisted of 975 providers (including nursing, physicians, and multidisciplinary team) and administrative professionals (service and supervision teams) working at a general private hospital in Brazil. Data were collected in 2019 through a socio-demographic questionnaire, the Depression Anxiety and Stress Scale (DASS-21), and the Positive and Negative Affect Schedule (PANAS-X). The results are shown through multinomial regression with odds ratio, 95% confidence interval, and P-value.

RESULTS:

The prevalence of depression, anxiety, and stress was 49.4%, 46.1%, and 49.8%, respectively, showing high prevalence. It was observed that a high presence of negative affect is associated with a greater likelihood of developing anxiety, depression, and stress, while a high presence of positive affect is associated with a lower likelihood of depression and stress prevalence.

CONCLUSIONS:

The high prevalence of anxiety, depression and stress in healthcare professionals is associated with the presence of negative affects. Mental disorders should be measured, and practices adopted to ensure well-being and job performance.

Keywords

Anxiety depression stress psychological affect health personnel dyssomnia musculoskeletal pain headache

1 Background

Depressive and anxiety disorders are ranked among the top 25 leading causes of burden and health-related incapacity [1]. The impacts of excessive stress may increase the risks for health hazards, including physical and psychiatric health, such as depression, anxiety, and burnout, caused by an imbalanced model of demands, resources, and individuals’ abilities to deal with such demands [2].

Hospitals are dynamic and complex institutions, and studies suggest a connection between healthcare professionals’ health and patient care safety. The association between medical errors and mental health in healthcare professionals shows that the safety of patient care correlates to the presence of burnout in healthcare professionals [3, 4]. Healthcare professionals must be engaged and satisfied with their quality of life to provide safe care [5]. This setting involves care for pain, anxiety, stress, fear, fatigue, and these issues are not regularly considered as factors that can interfere with both their mental health and their ability to make clinical decisions and the quality of care provided [6]. Positive and negative emotions or affects are associated with the presence and absence of well-being, as well as how the individual will respond to different demands [7].

In a healthcare setting, it is necessary for professionals to have psychological resilience (the ability to recover) in the face of daily circumstances that can potentially be stressful. This capacity for adaptation and overcoming helps prevent psychiatric disorders [8].

Psychiatric disorders linked to the professional environment have been thoroughly investigated within healthcare institutions. Nevertheless, apart from the established correlations with factors such as workload, working hours, complex environments, and interpersonal interactions, limited attention has been directed towards comprehending how the emotional state of professionals impacts their adaptation to the prevalent demands. The aim of the study was to evaluate the prevalence of anxiety, depression, and stress while exploring the correlation between the presence of positive and negative affect and psychiatric disorders among healthcare professionals.

2 Methods

This analytical cross-sectional study was conducted during May and June 2019, involving healthcare professionals at a private hospital (referred to as “the institution”) in São Paulo, Brazil. A total of 1011 professionals participated in the study. Inclusion criteria comprised professionals with a formal agreement with the organization, while exclusion criteria included professionals operating without a formal work agreement. Data collection was conducted on a voluntary and anonymous basis using REDCap.

The study was submitted to and approved by the Hospital’s Institutional Review Board under identification number CAAE 98464718.5.0000.0071. All subjects signed an informed consent form prior to study enrollment. The study was conducted according to the requirements of the Declaration of Helsinki.

An institutional email was sent to 10.323 eligible professionals, from which respondents formed our convenience sample. Subjects completed a questionnaire with the following questions: age, sex, marital status, level of education, occupation, presence of chronic conditions and chronic pain, timing working at Institution. The Depression Anxiety and Stress Scale (DASS-21), and the Positive and Negative Affect Schedule (PANAS-X), were applied.

2.1 Depression anxiety and stress scale

The Depression Anxiety and Stress Scale (DASS-21) was used to measure depressive, anxiety, and stress disorders. The DASS-21 consists of 21 statements that can be rated on a Likert scale (0 –Did not apply to me at all, 1 –Applied to me to some degree, or some of the time, 2 –Applied to me to a considerable degree or a good part of time, and 3 –Applied to me very much or most of the time) [9]. The depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/involvement, anhedonia, and inertia. It is assessed by items 3, 5, 10, 13, 16, 17, and 21. The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. It is assessed by items 2, 4, 6, 9, 13, 19, and 20. The stress scale is sensitive to levels of chronic nonspecific arousal. It assesses difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive, and impatient. It is assessed with items 1, 6, 8, 11, 12, 14, and 18. Items in each subscale are summed and multiplied by 2 to calculate the final score [10].

The psychometric properties of the Brazilian Portuguese version of the DASS-21 (Depression, Anxiety, and Stress Scale) demonstrate strong reliability, as indicated by internal consistencies. The Cronbach’s alpha (α) coefficients were found to be.88 for the Depression scale,.86 for the Anxiety scale,.90 for the Stress scale, and.95 for the Total scale. Moreover, the DASS-21 exhibited strong correlations with the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI), as well as with the Lipp’s Stress Symptoms Inventory (ISSL). These findings underscore the DASS-21’s substantial convergent and discriminant validity when compared with other well-validated measures of depression and anxiety [9].

2.2 Positive and negative affect schedule

Positive and Negative Affect Schedule (PANAS-X) is a psychometric scale that elucidates the interaction between positive and negative emotions, in conjunction with statistical and personality characteristics. The study on the PANAS conducted in 1988, reliability coefficients, Cronbach’s alpha (α), were reported to range between 0.86 and 0.90 in all situations, also demonstrate that the PANAS scale exhibits high internal consistency and strong correlations with other scales measuring distress and psychological disorders, such as the Hopkins Symptom Checklist –HSCL, the Beck Depression Inventory –BDI, and the State-Trait Anxiety Inventory –STAI [11].

The questionnaire is self-administered, aiming to assess the individual’s emotional state at a given moment. This brief scale measures the two dominant dimensions of emotional experience (positive and negative affect) and it is used to understand subjective well-being and general adaptability. It consists of a list with 20 adjectives, 10 positive and 10 negative were respondents were asked to rate, on a 5-point Likert scale (very slightly or not at all to very much), the extent to which they experienced each particular emotion within a past week including past day [12].

Positive affect experiences are assessed by the following terms: active, alert, attentive, determined, enthusiastic, excited, inspired, interested, strong. A set of 10 more terms define negative affect experiences: afraid, scared, nervous, jittery, irritable, hostile, guilty, ashamed, upset, distressed. During the validation process of the Brazilian Portuguese version, the adjective “proud” and its corresponding term in Brazilian Portuguese were omitted due to their inherent dual connotations. In the study Cronbach’s alpha (α) was reported as 0.84 for the positive affect scale and 0.90 for the negative affect scale [13, 14].

3 Statistical analysis

Quantitative variables were analyzed with the following concepts: mean, standard deviation, median, interquartile interval, and extreme values. Distribution was also assessed with quantile plots, a histogram, and a boxplot, in addition to the Shapiro-Wilk test for cases where distribution of the data as a whole deviated from normal. Linear regression models were used for numerical response variables; results are shown with 95% CIs and p-values. Qualitative variables were analyzed with absolute frequency and percentage values [15]. The three outcomes —depression, anxiety, and stress —were assessed in light of the collected variables using the PANAS-X. The overall outcome of the simple model was adjusted, and variables were selected for a final model, which contained only variables with a Wald test p-value <0.05. For adjusting the multivariate regression model, the first step was considering predictor variables of interest, including those with p-value <0.20 in simple regression. Multinomial regression models were utilized to analyze categorical response variables [16]. The findings were elucidated through odds ratios, accompanied by 95% confidence intervals (CIs), and corresponding p-values, maintaining a significance threshold of 0.05. Following this, a conclusive model was constructed for each of the three categories (normal, mild to moderate, severe to extremely severe) based on the DASS-21 depression, anxiety, and stress scales [17].

4 Results

Final sample consisted of 1011 healthcare professionals, 975 of which were considered valid and included in the analysis, corresponding to 9.4% of the population eligible to participate in the study. Of total subjects, 36 healthcare professionals were excluded from the analysis due to incomplete data. The resulting sample comprised 797 (81.7%) female subjects with a mean age of 36.3±9.2 years. Pain was reported by 61.7% of the respondents. The median length of employment at the institution was found to be 6 years. The percentage of professional’s occupation who constituted the sample, the educational level, and the frequency of pain are presented in Table 1.

Table 1
Socio-demographic distribution of study subjects

Variables N (%)

Sex 975

Female 797 (81.7)

Male 178 (18.3)

Marital status 975

Single 323 (33.1)

Married or in marriage-like relationship 581 (59.6)

Widower or divorced 71 (7.3)

Level of education 975

Completed high school 181 (18.6)

Completed undergraduate school 203 (20.8)

Graduate school 424 (43.5)

Vocation school 167 (17.2)

Time working at the institution (years)

Median [IIQ] 6 [3; 11]

Min –Max (n) 0–45 (970)

Occupation 966

Nursing technician or aid 232 [24]

Nurse 203 [21]

Multiprofessional team 93 (9.6)

Physician 57 (5.9)

Administrative team 381 (39.4)

Comorbid diseases 1011

Hypertension 85 (8.4)

Diabetes mellitus 17 (1.7)

Heart failure 3 (0.3)

Coronary disease 4 (0.4)

Rheumatic conditions 12 (1.2)

Insomnia 120 (11.9)

COPD 3 (0.3)

Cancer 7 (0.69)

Headache 225 (22.3)

Other 214 (21.2)

At least 1 comorbid disease 499 (49.4)

Pains and aches 972

Do you experience pains and aches anywhere in your body? 600 (61.7)

Frequency of pains and aches 956

Daily 208 (34.9)

Triweekly 185 [31]

Once a week 152 (25.5)

Rarely 51 (8.6)

Variables	N (%)
Sex	975
Female	797 (81.7)
Male	178 (18.3)
Marital status	975
Single	323 (33.1)
Married or in marriage-like relationship	581 (59.6)
Widower or divorced	71 (7.3)
Level of education	975
Completed high school	181 (18.6)
Completed undergraduate school	203 (20.8)
Graduate school	424 (43.5)
Vocation school	167 (17.2)
Time working at the institution (years)
Median [IIQ]	6 [3; 11]
Min –Max (n)	0–45 (970)
Occupation	966
Nursing technician or aid	232 [24]
Nurse	203 [21]
Multiprofessional team	93 (9.6)
Physician	57 (5.9)
Administrative team	381 (39.4)
Comorbid diseases	1011
Hypertension	85 (8.4)
Diabetes mellitus	17 (1.7)
Heart failure	3 (0.3)
Coronary disease	4 (0.4)
Rheumatic conditions	12 (1.2)
Insomnia	120 (11.9)
COPD	3 (0.3)
Cancer	7 (0.69)
Headache	225 (22.3)
Other	214 (21.2)
At least 1 comorbid disease	499 (49.4)
Pains and aches	972
Do you experience pains and aches anywhere in your body?	600 (61.7)
Frequency of pains and aches	956
Daily	208 (34.9)
Triweekly	185 [31]
Once a week	152 (25.5)
Rarely	51 (8.6)

N: sample size; IQR: interquartile range. ^*Multiprofessional team: social workers, physiotherapists, speech therapists, psychologists, and occupational therapists.

4.1 Analysis of the depression anxiety and stress scale (DASS-21)

The DASS-21 scale generates the scores for depression, anxiety, and stress. For analysis purposes, it was pooled into three categories: normal, mild, or moderate, severe, or extremely severe.

The data obtained from the assessment scale reveals that, in the context of depression, 50.6% of the studied population falls within the ‘normal’ category, indicating an absence of depressive symptoms; 29.1% exhibit mild to moderate symptoms, while 20.2% manifest severe to extremely severe symptoms. Regarding anxiety, 53.9% of the population remains symptom-free, 22.9% demonstrate mild to moderate symptoms, and 23.2% exhibit severe to extremely severe symptoms. In the case of stress, 50.2% of the population is devoid of stress-related symptoms, whereas 29.3% experience mild to moderate symptoms, and 20.6% present severe to extremely severe symptoms (Table 2).

Table 2
Scores calculated for scales applied in the study

DASS-21 Scores Total and %

DASS-21 —Anxiety score 956 (100)

Normal 515 (53.9)

Mild or moderate 219 (22.9)

Severe or extremely severe 222 (23.2)

DASS-21 —Depression score 944 (100)

Normal 478 (50.6)

Mild or moderate 275 (29.1)

Severe or extremely severe 191 (20.2)

DASS-21 —Stress score 943 (100)

Normal 473 (50.2)

Mild or moderate 276 (29.3)

Severe or extremely severe 194 (20.6)

DASS-21 Scores	Total and %
DASS-21 —Anxiety score	956 (100)
Normal	515 (53.9)
Mild or moderate	219 (22.9)
Severe or extremely severe	222 (23.2)
DASS-21 —Depression score	944 (100)
Normal	478 (50.6)
Mild or moderate	275 (29.1)
Severe or extremely severe	191 (20.2)
DASS-21 —Stress score	943 (100)
Normal	473 (50.2)
Mild or moderate	276 (29.3)
Severe or extremely severe	194 (20.6)

For assessing outcomes, the “Normal” category was selected as the standard response; odds ratio was calculated by comparing odds between each category and the standard response. A correlation between anxiety and study variables was found.

4.2 Assessment of the anxiety scale and its related factors

Our findings indicate a 12.8% rise in the likelihood of experiencing mild or moderate anxiety (MMA) for every unit increase in negative affect (p < 0.001). When comparing healthcare professionals presenting with pains and aches to those who don’t, a 67.5% increase in MMA likelihood was seen (p = 0.008). Furthermore, an estimated 98.3% increase in MMA likelihood was associated with healthcare professionals presenting with headache symptoms (p = 0.001).

When compared to subjects not presenting with anxiety, every additional negative affect unit, increase 25.1% in severe or extremely severe anxiety (SEA) (p < 0.001) likelihood was seen.

As an additional finding, for each year worked in the institution, there is a reduction in the likelihood of experiencing MMA and SEA (p < 0.001).

There is an increased chance of experiencing SEA when factors such as insomnia (p = 0.010), body aches (p = 0.001), and headaches (p = 0.030) are present. On the contrary, the presence of positive affect did not prove to be a contributing factor to anxiety after the development of the multiple regression model. Additionally, it’s noteworthy that anxiety does not demonstrate a statistically significant association with MMA anxiety (p = 0.849) (Table 3).

Table 3
Anxiety score associated with affect and physical symptoms

DASS-21 —Anxiety score (3 categories) Odds ratio [95% CI], Mild or moderate×Normal P value Odds ratio [95% CI], Severe or extremely severe×Normal P value

PANAS-X Negative Affect Schedule 1.128 [1.095, 1.161] <0.001 1.251 [1.209, 1.295] <0.001

Insomnia = No Reference Reference

Insomnia = Yes 1.062 [0.573, 1.969] 0.849 2.304 [1.222, 4.343] 0.010

Body Pain = No Reference Reference

Reference = Yes 1.675 [1.144, 2.452] 0.008 2.228 [1.380, 3.598] 0.001

Headache = No Reference Reference

Headache = Yes 1.983 [1.301, 3.021] 0.001 1.742 [1.056, 2.874] 0.030

DASS-21 —Anxiety score (3 categories)	Odds ratio [95% CI], Mild or moderate×Normal	P value	Odds ratio [95% CI], Severe or extremely severe×Normal	P value
PANAS-X Negative Affect Schedule	1.128 [1.095, 1.161]	<0.001	1.251 [1.209, 1.295]	<0.001
Insomnia = No	Reference		Reference
Insomnia = Yes	1.062 [0.573, 1.969]	0.849	2.304 [1.222, 4.343]	0.010
Body Pain = No	Reference		Reference
Reference = Yes	1.675 [1.144, 2.452]	0.008	2.228 [1.380, 3.598]	0.001
Headache = No	Reference		Reference
Headache = Yes	1.983 [1.301, 3.021]	0.001	1.742 [1.056, 2.874]	0.030

CI = confidential interval.

4.3 Assessment of the depression scale and its related factors

For every additional positive affect unit decrease 8.6% in the mild or moderate depression (MMD) (p < 0.001) likelihood was seen; and in the presence of negative affect, a 14.5% increase in MMD is estimated (p < 0.001).

We observed a 51.9% increase in MMD likelihood is estimated for subjects reporting global pains and aches when compared to those who rarely feel any pains and aches (p < 0.037).

The presence of positive affect shows a 13.4% decrease (p < 0.001), and the presence of negative affect shows a 24.4% increase in severe or extremely severe depression (SED) likelihood (p < 0.001).

When comparing healthcare professionals presenting with pains and aches to those who don’t, an increase in SED was observed (p = 0.032). Regarding the length of employment at the institution, for each additional year of work, a decrease in the likelihood of experiencing MMD (p = 0.003) and SED is estimated (p < 0.001) (Table 4).

Table 4
Depression score associated with affects and physical symptoms

DASS-21 —Depression score (3 categories) Odds ratio [95% CI], Mild or moderate×Normal P value Odds ratio [95% CI], Severe or extremely severe×Normal P value

PANAS-X Positive Affect Schedule 0.914 [0.887, 0.942] <0.001 0.866 [0.830, 0.903] <0.001

PANAS-X Negative Affect Schedule 1.145 [1.110, 1.181] <0.001 1.244 [1.198, 1.292] <0.001

Body Pain = No Reference Reference

Body Pain = Yes 1.519 [1.026; 2.247] 0,037 1,799 [1.051; 3.077] 0,032

Working at another Institution = No Reference Reference

Working at another Institution = Yes 0,606 [0,348; 1,054] 0,076 0,314 [0,136; 0,729] 0,007

DASS-21 —Depression score (3 categories)	Odds ratio [95% CI], Mild or moderate×Normal	P value	Odds ratio [95% CI], Severe or extremely severe×Normal	P value
PANAS-X Positive Affect Schedule	0.914 [0.887, 0.942]	<0.001	0.866 [0.830, 0.903]	<0.001
PANAS-X Negative Affect Schedule	1.145 [1.110, 1.181]	<0.001	1.244 [1.198, 1.292]	<0.001
Body Pain = No	Reference		Reference
Body Pain = Yes	1.519 [1.026; 2.247]	0,037	1,799 [1.051; 3.077]	0,032
Working at another Institution = No	Reference		Reference
Working at another Institution = Yes	0,606 [0,348; 1,054]	0,076	0,314 [0,136; 0,729]	0,007

CI = confidential interval.

When examining professionals who work at another institution besides ours with those who work solely within our institution, there is a positive association in the likelihood of developing SED (p = 0.007). Conversely, for MMD, no statistically significant association was observed (p = 0.076).

4.4 Assessment of the stress scale and its related factors

We observed a 15.8% increase in the likelihood of mild or moderate stress (MMS) for every additional negative affect unit (p < 0.001). Conversely, for every additional positive affect unit, there was a 6.2% decrease in the likelihood of severe or extremely severe stress (SES) (p < 0.001). Conversely, an estimated 32.2% increase in the likelihood of experiencing SES was observed for every unit of negative affect (p < 0.001).

Regarding the frequency of pain and aches, comparing groups experiencing daily pain with those experiencing pain rarely revealed a potential increase in the likelihood of experiencing MMS (p = 0.003) and SES (p = 0.035). Similarly, individuals experiencing pain once a week, compared to those experiencing pain rarely, showed a potential increase in the likelihood of experiencing MMS (p = 0.013), while no statistically significant association was found with SES (p = 0.372). Likewise, when contrasting individuals experiencing pain three times a week with those experiencing pain rarely, an increase in the likelihood of experiencing MMS (p = 0.021) was observed, although there was no statistically significant association for SES (p = 0.294) (Table 5).

Table 5
Stress score associated with affects and physical symptoms

DASS-21 —Stress score (3 categories) Odds ratio [95% CI], Mild or moderate×Normal P value Odds ratio [95% CI], Severe or extremely severe×Normal P value

PANAS-X Negative Affect Schedule 1.158 [1.111, 1.206] <0.001 1.322 [1.256, 1.392] <0.001

Frequency of pains and aches = Rarely Reference Reference

Frequency of pains and aches = Daily 4.475 [1.674, 11.964] 0.003 4.074 [1.102, 15.052] 0.035

Frequency of pains and aches = 3 times weekly 3.166 [1.191, 8.413] 0.021 2.022 [0.542, 7.542] 0.294

Frequency of pains and aches = once weekly 3.468 [1.300, 9.257] 0.013 1.867 [0.475, 7.344] 0.372

DASS-21 —Stress score (3 categories)	Odds ratio [95% CI], Mild or moderate×Normal	P value	Odds ratio [95% CI], Severe or extremely severe×Normal	P value
PANAS-X Negative Affect Schedule	1.158 [1.111, 1.206]	<0.001	1.322 [1.256, 1.392]	<0.001
Frequency of pains and aches = Rarely	Reference		Reference
Frequency of pains and aches = Daily	4.475 [1.674, 11.964]	0.003	4.074 [1.102, 15.052]	0.035
Frequency of pains and aches = 3 times weekly	3.166 [1.191, 8.413]	0.021	2.022 [0.542, 7.542]	0.294
Frequency of pains and aches = once weekly	3.468 [1.300, 9.257]	0.013	1.867 [0.475, 7.344]	0.372

CI = confidential interval.

4.5 Analysis of PANAS-X

When applied to the overall sample, the PANAS-X positive affect scale ranging from 9–45 showed median score of 25. The negative affect scale ranging from 10–50 showed median score of 20, i.e., positive affect was more present.

5 Discussion

Our study has unveiled a substantial prevalence of anxiety, depression, and stress with rates of 46.2%, 49.4%, and 49.9% observed in the studied population. The relationship between psychological disorders and the presence of positive and negative affect, we observed that positive affect was linked to a reduced risk of developing depression and stress. Conversely, the presence of negative affect was associated with an increased likelihood of experiencing anxiety, depression, and stress. Additionally, we found that insomnia was positively correlated with anxiety, and the presence of physical discomfort, such as pains and aches, was positively associated with anxiety, depression, and stress.

The findings regarding the prevalence of psychiatric disorders are not new. Other studies, using the same instrument (DASS-21), a high prevalence of these disorders was also seen. A study with Australian nurses found 32.4% subjects with depressive disorder and 41.2% with anxiety and stress [18]. A Hong Kong study with nurses showed a 35.8% prevalence for depression, 37.3% for anxiety, and 41.1% for stress [19]. The presence of anxiety in nurses (38.7%) was also seen in a Taiwan study, which corroborates our findings [20].

In a 2020 study carried out within our hospital’s adult ICU, which included physicians, nurses, and physiotherapists, and utilized the DASS-21 scale, the prevalence of anxiety, depression, and stress was notably lower at 12.9%, 11.4%, and 10.4%, respectively [21]. The contrast between the findings in this study and our own can be attributed to the differences in the studied populations. In our study, we included professionals from diverse job categories and educational backgrounds (support and administrative staff), wherein various factors, such as socioeconomic vulnerability, may play a significant role in the development of psychological disorders [22, 23]. Furthermore, it is crucial to acknowledge the dynamic nature of the ICU environment, which continually demands a high level of professional resilience in the performance of their duties [24].

According to our Hospital’s occupational health service, among the causes of leaves taken by employees, psychiatric disorders (ICD F codes) rank second, only behind diseases of the musculoskeletal system (ICD M codes).

Regarding the association of psychiatric disorders and the presence of positive and negative affect, our findings revealed a notably high level of statistical significance. This underscores the pivotal role of affective states. Other studies also suggest a connection between positive affect and subject well-being, feelings of competence, high satisfaction with social relationships, influencing mental health outcomes. The capacity to experience positive emotions must be considered as a fundamental human strength that enhances people’s physical, social and psychological resources [25]. On the other hand, the absence of negative affect is associated with better perception of mental health than the actual presence of positive affect [13].

The emotional state of a healthcare professional can fluctuate in response to various situations within the healthcare context. When we examine the expression of positive and negative affects, differences in patient safety outcomes become evident. The presence of positive affect is associated with a reduced number of conflict reports in patient care, thereby contributing to teamwork. In contrast, the presence of negative affects is suggested to be linked to a decreased ability to cope with professional stress and is more strongly associated with adverse patient safety outcomes [6].

The profound impact of emotions on behavior is a well-established concept within psychological theory [26]. However, in the healthcare profession, there is a notable absence of comprehensive education on recognizing and proactively addressing the real-time influence of emotions on behavior, beyond limited coverage on attrition, burnout, and patient-centered care. Healthcare professionals are not adequately equipped to identify and anticipate the effects of emotions on their actions and engage in meaningful discussions about this aspect of their practice with peers [27].

According to the tripartite theory, the individual’s identity is composed of three components: one is individual, shaped by genetics and personal experiences; another pertains to the group to which the individual belongs, and there is also a universal component where all individuals share similarities with others. Consequently, we can comprehend that when we refer to affect, it can fluctuate depending on the situation to which an individual is exposed. Both positive and negative affect can be part of an individual’s characteristics, underscoring the uniqueness of the human being [28].

Other aspects assessed by our study were the existing relationship between the collected variables (pain, insomnia, working at another institution and length of working at the institution) and an association with anxiety, depression, and stress. We observed that the data obtained showed statistical significance except for the association of insomnia with mild and moderate anxiety and the frequency of pain (1× or 3× per week) in relation to severe stress. The lack of statistical significance for the presence of pain 1 or 3 times per week may be explained by the statistical significance observed in individuals experiencing severe stress and its association with the presence of daily pain.

Many studies with healthcare professionals point to an association between anxiety, depression and stress, and pain in different parts of the body [29 –32]. In addition, one of these studies reported that when professionals took time off work, stress improved, thus establishing a relationship between the disorder and professional activity [31].

The presence of insomnia was positively associated with the presence of anxiety, a 304% increase in the likelihood of developing severe and extremely severe anxiety is estimated. The studies conducted in the United States, Switzerland, and Hong Kong showed a strong relationship between stress, depression, anxiety and sleep disorders [20 , 34].

A literature review demonstrates the association between the presence of positive and negative emotions with sleep quality and emotional responses. The function of sleep is linked to a mechanism for coping with everyday stressors. In situations of sleep deprivation for two consecutive days, the chances of developing depression, anxiety, and stress increase [35].

Another salient finding in our study relates to the length of service at the institution. We observed that for each year worked at the institution, the probability of developing anxiety or depression decreases. This observation suggests that professionals with more extensive time at the institution tend to demonstrate emotional maturity acquired through their cumulative learning experiences.

A 2009 OMS report points out that mental health influences a wide range of life aspects, including healthier lifestyles; fewer limitations in daily living; better physical health; greater productivity; better social relationships. These outcomes are not just or necessarily a consequence of good mental health but are associated with the presence of positive mental health, sometimes referred to as “well-being”. Positive mental health is a resilience-promoting asset that enables people to cope with adversity, reaching their full potential [36].

In organizations dedicated to enhancing patient safety, prioritizing the well-being of their healthcare providers is imperative. Implementing innovative and cost-effective, or even zero-cost solutions is essential to foster personal well-being, happiness, and mitigate stress, anxiety, depression, and burnout symptoms. These measures aim to enhance the overall quality of life [37 –40]. Nonetheless, instigating a significant behavioral shift towards adopting new mental health practices, such as meditation, kindness, self-compassion, and gratitude, remains a crucial challenge [41]. These practices not only enhance individual mental health but also foster stronger social relationships among healthcare professionals [42].

Furthermore, studies demonstrate that resilient professionals are less prone to experiencing mental health issues, and when they do encounter such issues, they tend to experience less psychological distress and achieve a quicker return to a sense of well-being [41]. Given this study’s findings, we recommend healthcare institutions assess the prevalence of psychiatric disorders and consider offering their collaborators mental health and well-being promotion strategies for the consequent benefit of patient safety.

6 Conclusion

High prevalence of anxiety, depression, and stress in healthcare professionals are strongly associated with negative affects. Positive affects reduce the likelihood of depression and stress but show no association with the likelihood of developing anxiety. Additionally, we noted a strong correlation between pain, insomnia, and psychiatric disorders. Years worked at the institution are linked to reduced likelihood of anxiety and depression.

It is important to consider offering mental health support and well-being promotion strategies for the healthcare professionals.

7 Study limitations

Our study presents a few limitations. The sample was a convenience sample; thus, we cannot know whether the population studied is representative of the institution’s professionals. Furthermore, it should be noted that the statistical population was not homogeneous in terms of both occupation and educational background. This, however, does not invalidate data obtained from the study. Data were collected from healthcare professionals of the caregiving and administrative settings, which present different characteristics in the performance of their professional activities, despite sharing common healthcare ground. There was no assessment of socio-economic level, which can be inferred from the level of education, but socio-economic data would further subsidize the correlation between psychiatric disorders and social and economic vulnerability.

Conflict of interest

There is no conflict of interest to declare.

Footnotes

Acknowledgments

Authors are grateful to Elivane da Silva Victor for statistical analysis; Marcelo Katz for assisting in the preparation of the study project; Ary Serpa Neto for assistance with data collection for the study project; Miriam Branco, Claudia Regina Laselva, Miguel Cendoroglo Neto, for facilitating data collection and to all the professionals from the Hospital Israelita Albert Einstein who took part in the study.

The study was approved by the Ethic Committee of the Hospital Israelita Albert Einstein under the number CAAE: 98464718.5.0000.0071 and all participants completed an informed consent document.

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