Relationships Between Perceived Organizational Support, Psychological Capital and Work Engagement Among Chinese Infection Control Nurses

Introduction

Nosocomial infection is the most common adverse event in global health services. It is reported that hundreds of millions of patients worldwide become infected in hospitals each year, leading to high mortality and financial losses for health systems.¹ In China, there are about 5 million cases of nosocomial infections annually, and the economic loss is as high as 10–15 billion yuan.² With the progress in medical techniques, novel diagnoses, and treatments have been gradually employed, and traumatic and invasive interventions have been introduced in hospitals in recent years. As a result, the source, transmission path, and susceptible population of nosocomial infection have been thoroughly changed. Furthermore, the generation of multidrug-resistant bacteria has enhanced the rate of refractory infections.³ To maximize the rational use of medical resources, medical institutions should attach importance to practical and effective measures for the prevention and control of nosocomial infection. Infection control nurses (ICNs), as an important part of hospital infection management, refer to registered nurses specialized in nosocomial infection control monitoring, supervision, guidance, training, and management. Clinically, ICNs are also responsible for monitoring risk factors associated with nosocomial infections in medical activities, implementing safety precautions (disinfection and isolation measures), and disposing and managing medical waste in medical institutions.^4,5 Besides, ICNs also propose scientific advice, support and guide the medical staff in the management of nosocomial infection.^6,7

Work engagement refers to an active, fulfilling, affective-motivational state in the working, and it is symbolized by vitality, devotion, and concentration.⁸ As a positive work attitude, work engagement is a vital assessment index of the individual work potential and work effect optimization.⁹ Halbesleben and Wheeler have indicated that the higher the employee’s engagement and energy level, the stronger the employee’s sense of participation in work activities.¹⁰ Conversely, the low work engagement of dominant practitioners results in a negative work attitude.¹¹ At present, ICNs are the main full-time personnel of hospital infection management in China, accounting for about 70%; the remaining 30% are professional staff with other backgrounds such as clinical medicine and laboratory medicine.¹² It can be seen that ICNs play a crucial role in Chinese hospital infection management, and the work engagement of ICNs determines the implementation and quality of nosocomial infection management in China to some extent.

In the previous study, the job demands-resources (JD-R) model was used to predict work engagement.¹³ The health-impairment process and the motivational process are integrated with the JD-R theory.¹⁴ Specifically, the health-impairment process is a response to the demands of the job, which can lead to negative outcomes such as burnout. When job and personal resources increase work engagement, the motivational process concerned in this study occurs.¹⁴ Job resources are considered to be the most important predictors of work engagement, contributing to both daily and long-term work engagement.^15,16 Perceived organizational support (POS), is a type of job resource that reflects employees’ perception of the organization’s support and concern for their contributions, interests, or benefits.^17,18 The existing studies have shown that POS has a good predictive effect on work engagement.^19,20 As a personal resource, psychological capital (PsyCap) is a measurable and exploitable positive mental state formed by an individual in their growth and development. The PsyCap mainly includes four dimensions: self-efficacy, optimism, hope, and resiliency.²¹ Individuals with higher PsyCap have higher work engagement as they are better equipped to deal with adverse factors and have a positive attitude towards work.^22,23

The JD-R model suggests that both job resources and personal resources have important effects on work engagement. The conservation of resources (COR) theory claims that resources, or resource shortages, tend to exist in clusters, rather than in isolation. For instance, individuals with high self-esteem also have a greater sense of self-control ability and receive better social support.²⁴ Therefore, POS and PsyCap might have comprehensive influences, contributing to the work engagement of the individuals. Previous studies have confirmed that POS can indirectly affect nurses’ work engagement through the intermediary role of PsyCap.^25,26

However, to the best of our knowledge, the correlations among POS, PsyCap, and work engagement of ICNs have not yet been confirmed. Accordingly, based on the JD-R model and COR theory, job and personal resources were focused on, the status quo of the POS, PsyCap, and work engagement of Chinese ICNs was explored, and their correlations were analyzed, especially the mediating effect of PsyCap between POS and work engagement. In addition, the three hypotheses were proposed as follows (Figure 1): (1) POS is positively associated with work engagement; (2) PsyCap is positively associated with work engagement; (3) The effects of POS on work engagement are partially mediated by PsyCap.

Figure 1 Theoretical model of the mediating role of PsyCap on the association between POS and work engagement.

Method

Participants and Sampling

A national cross-sectional survey was conducted by convenient sampling. The ICNs (> 18 years old) in China were taken as the research subjects. The criteria for inclusion of ICNs were as follows: (1) Registered nurse; (2) Full-time staff of the infection control department in the hospitals; (3) Voluntarily participated in the survey with informed consent. These ICNs who were not on the job for sick leave, maternity leave, or other reasons were not included. Finally, a total of 7479 ICNs from 3144 hospitals in 20 provinces were involved in the survey, and a total of 7382 (98.70%) valid questionnaires were obtained. When all answers in the questionnaire were identical, or the response time of the whole questionnaire was less than 3 minutes, this questionnaire was invalid and eliminated.

Measurements

Demographic data were collected. Data included age, gender, marital status, highest education, post category, years of working in the department, work part-time in other departments, average working hours per week, average monthly income, the number of beds in a hospital, hospital level, hospital nature, and hospital location (the specific economic region).

Work engagement was assessed by the Chinese version of the Utrecht Work Engagement Scale (UWES), which was developed by Schaufeli et al and adapted by Li et al. The version was composed of 16 items and 3 dimensions, namely vigor, dedication, and absorption.^27,28 A 6-point Likert scale was assigned to each item, and the total score range was 16–96 points; the higher total score suggested a higher degree of work engagement. This scale has been verified by Chinese medical staff with good reliability, and its overall and various dimensions Cronbach’s α range from 0.890 to 0.957.²⁹ In our research, the Cronbach’s α of the total scale and three dimensions (vigor, absorption, and dedication) were 0.943, 0.851, 0.917 and 0.883, respectively.

The psychological capital questionnaire (PCQ) was developed by Luthans to evaluate psychological capital in 2007.³⁰ In the Chinese version of the PCQ, there were 4 dimensions (ie, self-efficacy, hope, optimism, and resilience) and 24 items.³¹ The Likert 5-point scoring was assigned to each item of the scale, and the total score ranged from 24–120 points; a higher total score indicated a higher level of PsyCap. Research has shown that Cronbach’s α of the total scale is 0.879, and the range of Cronbach’s α of the dimensions is 0.768–0.814, which has good reliability among medical staff.³¹ In our research, Cronbach’s α of the total scale and four dimensions (self-efficacy, hope, optimism, and resilience) were 0.903, 0.874, 0.607, 0.865, and 0.685, respectively.

The 24-item perceived organizational support scale developed by Ling et al was used to measure the POS of employees.³² Meng modified the original scale to obtain the perceived organizational support scale for medical staff, which contained 12 items and 3 dimensions, namely support for work, concerns for interests, and value identity.³¹ The Likert 5-point scoring was assigned to each item of the scale, and the total score ranged from 12 to 60 points; the higher the total score, the higher level of POS. The previous study has shown that this scale was suitable for the Chinese medical staff with excellent reliability (Cronbach’s α ranging from 0.828 to 0.951).³¹ In our research, the overall Cronbach’s α for the scale was 0.923, and the Cronbach’s α was 0.879 in support for work, 0.869 in concern for interests, and 0.688 in value identity.

Data Collection

The electronic questionnaire was published on the “Questionnaire Star” online survey platform which is a professional questionnaire survey tool in China. The purpose, content, significance, filling instructions, and confidentiality of the survey were clearly stated. With the assistance of the National Hospital Infection Monitoring and Management Training Base and the Platform of the Hospital Infection Control Branch of the Chinese Preventive Medicine Association, the network link of questionnaires was delivered to the directors of hospital infection control departments, and then distributed to ICNs from March 27, 2020 to April 8, 2020. The ICNs answered the questions online by using a computer or mobile phone and submitted the questionnaires only if they completed all the options. To prevent repeated filling, the same IP address, computer or mobile phone was allowed to submit the questionnaire once.

Ethical Considerations

The study was authorized by the Ethic Committee of the Xiangya Hospital of Central South University (Certificate: IRB202002011). Meanwhile, the information on confidentiality was attached to the electronic questionnaire on the homepage of the questionnaire. Before filling out the questionnaire, the respondent was provided with an electronic informed consent form with two choices (yes/no). Respondents who selected “yes” can start to answer the questionnaire, and they can exit and give up answering at any time during the survey period. All procedures complied with the Declaration of Helsinki.

Statistical Analysis

All statistical analysis was performed by the SPSS 20.0 and Amos 22.0 statistical software. And the P-P plot and Q-Q plot were employed to reveal the data distribution. The continuous variables were represented by means (standard deviations) or medians (P25, P75), and the counting variables were represented by frequency (percentage). In the univariate analysis of work engagement of ICNs, for dichotomous data, a t-test was used if the variance was homogeneous, and the Mann–Whitney U-test was used if the variance was heterogeneous; for multiple classified data, ANOVA was used if the variance was homogeneous, and Kruskal–Wallis H-test was used if the variance was heterogeneous. Multiple comparisons were completed using the Bonferroni corrections if a relevant test result was significant. Pearson or Spearman correlation was performed to analyze the correlation among POS, PsyCap and work engagement. The mediating effect test proposed by Baron and Kenny was used to analyze whether PsyCap can mediate the correlation between POS and work engagement of ICNs.³³ To further verify the mediating effect, AMOS 22.0 was used to establish a structural equation model; POS, PsyCap and work engagement were taken as the independent variable, mediating variable, and dependent variable, respectively; the maximum likelihood method was used to test the mediating effect. In this study, two-tailed P <0.05 was considered statistically significant.

Results

Demographic Information

The majority of respondents were female (99.38%) and married (92.51%). Most had a bachelor’s degree (61.31%) and were in professional and technical posts (55.08%). In terms of work experience, the largest group (41.57%) had worked for 1–5 years, and over half (51.44%) worked part-time in other departments. The average working time per week for the majority of respondents (57.14%) was 35–45 hours, and over half (54.50%) had an average monthly income of 3000–6000 yuan. Table 1 presents the basic information of 7382 ICNs in this study.

Table 1 Basic Information and Distribution of Work Engagement on ICNs (N=7382)

Statistical Description of POS, PsyCap, and Work Engagement

The scores of ICNs’ work engagement, POS, and PsyCap were approximately normal distribution. As shown in Table 2, the total scores of work engagement, POS and PsyCap were 80.87 ± 14.95, 41.45 ± 7.37, and 89.14 ± 9.06, and their items’ average scores were 5.05 ± 0.93, 3.45 ± 0.61 and 3.71 ± 0.38, respectively.

Table 2 Total Score and Items' Average Score of the Main Variables (N=7382)

Univariate Analysis on Work Engagement of ICNs

According to the results of the univariate analysis on work engagement of ICNs, the differences in age, highest education, average monthly income, post category, years of working in the department, average working hours per week, hospital nature, hospital level, hospital location (the specific economic region) and the number of beds in the hospital were compared between groups and were statistically significant (P < 0.05) (Table 1).

Correlation Analysis

The Pearson correlation analysis revealed significant correlations between POS, PsyCap, and work engagement. Specifically, the POS and its dimensions were positively correlated with work engagement and its dimensions (r=0.218–0.403, P<0.01), as well as PsyCap and its dimensions (r=0.297–0.520, P<0.01). The PsyCap and its dimensions were also positively correlated with work engagement and its dimensions (r=0.301–0.604, P<0.01), as shown in Table 3.

Table 3 Correlations (r) of the Main Variables (N=7382)

Mediating Effect Analysis

The correlations of POS, PsyCap and work engagement of ICNs satisfied the premise of the mediating effect analysis, and the results of mediating effect analysis were obtained, as shown in Table 4. On the premise of controlling for the influence of demographic data with statistically significant differences in univariate analysis, the following steps were performed: (1) Regression analysis was carried out with the work engagement as a dependent variable and the POS as an independent variable. The results showed that the POS had a positive predictive effect on the work engagement of ICNs (β′=0.402, P<0.05). (2) Regression analysis was conducted with PsyCap as a dependent variable and POS as an independent variable. The results showed that POS had a positive predictive effect on the PsyCap of ICNs (β′=0.529, P<0.05). (3) Regression analysis was carried out with work engagement as a dependent variable, POS and PsyCap as independent variables. The results showed that the predictive effect of POS on work engagement of ICNs decreased from 0.402 to 0.118. Therefore, PsyCap plays a certain mediating effect between POS and work engagement of ICNs.

Table 4 Mediating Effect Analysis in the POS-PsyCap-Work Engagement Relationships on ICNs (N=7382)

To further verify the mediating effect, AMOS 22.0 statistical software was used to establish a structural equation model, in which POS, PsyCap and work engagement were taken as the independent variable, mediating variable and dependent variable, respectively. The mediating effect test was carried out by the maximum likelihood method. The model-fitting results showed that χ2 / df = 40.572, RMSEA = 0.073, GFI = 0.966, AGFI = 0.942, NFI = 0.969, CFI = 0.970, IFI = 0.970, as shown in Figure 2. The direct effect of POS on work engagement was 0.049. The mediating effect of PsyCap on the correlation between POS and work engagement was 0.394, the total effect was 0.443, and the ratio of mediating effect to the total effect was 88.94% (Table 5).

Table 5 Mediating Effect of PsyCap on the Association Between POS and Work Engagement on ICNs (N=7382)

Figure 2 Model of the mediating effect of PsyCap on the association between POS and work engagement on ICNs.

Discussion

Through the cross-sectional survey on the current status of work engagement of ICNs in China, we found that the ICNs’ work engagement is at a relatively high level, which is higher than that of other nurse groups.^34,35 In other words, most Chinese ICNs are energetic, enthusiastic and willing to contribute to work, and they can persevere in the face of difficulties. The reasons are explained as follows. Firstly, the status of ICNs is significant among specialist nursing in our country.¹² Since the ICNs’ professional duty meets the clinical needs for nosocomial infection prevention and control, the importance of ICNs is gradually emphasized by hospital administrators.³⁶ As a result, the ICNs’ professional identity is enhanced, and their work engagement is increased. Secondly, the effective implementation of the scientific performance appraisal and salary distribution policies formulated at the national level in recent years has mobilized the enthusiasm of the ICNs. Finally, our data collection was performed during the domestic COVID-19 outbreak, and ICNs have received much attention during this period. The Chinese government has strengthened the prevention and control of hospital infections and raised the management of nosocomial infections to an unprecedented height. In other words, in the context of the COVID-19 outbreak and the national call, the ICNs are more fully engaged in this anti-epidemic work as the core force to ensure the smooth and efficient implementation and completion of hospital infection management.

As hypothesized, there is a significant positive correlation between POS and work engagement, and it has a direct predictive effect on the work engagement of ICNs. Namely, ICNs with a higher POS have a higher level of work engagement, which is consistent with the research results of other nurse groups.^25,35,37,38 Based on the JD-R model, adequate job resources (such as organizational support) stimulate the workers’ motivation and leads to engagement.¹⁵ The results of this study are consistent with the predictions of the COR theory. Specifically, organizations can inspire employees to be motivated and keep good working conditions, to decrease the physical and mental drain of employees on resources and burnout at work. In this way, workers are more concentrated on their tasks and concentrated and strive for their goals. Moreover, the social exchange theory has pointed out that when employees perceive the organization’s support for themselves, employees will have a sense of obligation to pay for the organization, so employees are willing to work hard and contribute their strength to achieve organizational goals.³⁹ The ICNs who feel the support of the organization will feel that they are valuable, affirmed and accepted, and thus will be more enthusiastic about their work. It is reminded that nursing managers can take active measures to intervene in the POS to influence and improve the work engagement of ICNs. Rohades reported that organizational fairness, superior support, rewards from the organization and good working conditions are important variables that affect the POS.¹⁸ In addition, the results of semi-structured in-depth interviews show that the POS of clinical nurses is mainly reflected in four themes, namely personal value, welfare benefits, career development and work-related support.⁴⁰ The above research results suggest that nursing managers need to pay attention to their personal growth and provide more emotional support while providing material support to the ICNs to improve the POS.

PsyCap is the driving force for nurses to work efficiently and can keep nurses with a lasting enthusiasm for work.⁴¹ In this study, it is found that PsyCap is positively correlated with work engagement, and PsyCap is significantly positively predicted work engagement, indicating that the higher the PsyCap, the higher the level of work engagement of ICNs, which is consistent with the research results of other nurse groups.²⁵ Based on the correlation between PsyCap and work engagement, the following speculations are made for the ICNs: (1) ICNs with a high sense of self-efficacy believe that they can achieve their work goals after investing a certain amount of time and effort. Therefore, they will be energetic in their work and perseverant in the face of difficulties; (2) Hopeful ICNs have a positive expectation for their work. This motivation for success will motivate them to devote themselves to the work; (3) Resilience can help ICNs actively cope with difficulties and not give up easily; (4) Optimism can protect ICNs’ physical and mental health in coping with stress. For instance, when a positive event occurs, optimistic ICNs attribute it to their own, persistent and universal reasons, which is a good self-motivation for themselves; when a negative event occurs, they attribute it to external, temporary and situation-related reasons and are less likely to feel pessimistic and helpless.

Furthermore, PsyCap has a partial mediating effect on the impact of POS on ICNs’ work engagement, that is, personal resources can strengthen the positive role between job resources and work engagement. This finding is consistent with the results of other nurse and medical staff groups.^25,42 PsyCap can be effective in helping the ICNs deal with negative emotions resulting from inadequate organizational support. Therefore, when the ICNs with a high level of PsyCap perceive the low organizational support for their work, their emotional regulation ability can buffer (or reduce) the impact of organizational support on job engagement. Conversely, even if the ICNs believe that the organization provides strong support for their work, the work engagement can be reduced by their poor PsyCap. Considering the direct predictive effect of PsyCap on work engagement and the mediating effect of PsyCap between POS and work engagement, nursing managers should pay more attention to developing the PsyCap of ICNs, so as to encourage individuals to work more intently. Based on PsyCap intervention theory,⁴³ the following methods can be used, including the short-term Vipassana therapy,⁴⁴ focused solution mode,⁴⁵ mindfulness reduction,⁴⁶ the introduction of employee assistance program,⁴⁷ Satya transformational group therapy.⁴⁸

Therefore, nursing managers should take a series of measures to improve the work engagement of ICNs. For instance, nursing managers can provide organizational support for ICNs from different aspects (such as humanistic environment, working system and process, salary and welfare) and create a relatively comfortable and convenient working environment to ensure that ICNs can devote themselves to their work. At the same time, nursing managers should also strengthen ICNs psychological assessment, psychological training and other measures to improve their psychological capital. In this way, the confidence to complete the work and the psychological resilience in the face of work pressure of ICNs will be stimulated, and positive emotions of hope and optimism are also mobilized, thus generating a higher level of work engagement.

Study Limitations

Although these findings are notable, there are still several limitations. Firstly, the cross-sectional research is designed to explore the mechanism of ICNs’ work engagement based on the JD-R model and COR theory, however, it is not clear whether there is a causal relationship between POS, PsyCap and work engagement of ICNs. The relationship between different variables (in Figure 2) is not a direct causal relationship, but an association with a certain causal sequence, which needs to be confirmed in future longitudinal studies. Secondly, a convenient sampling method is adopted in the study, leading to the uneven distribution of demographic variables. For gender variables, male ICNs only account for 0.62%, which affects the sample representativeness of the study population. In future research, a variety of demographic variables and random probability sampling methods should be used, and the scope of research objects should be enlarged to improve the applicability and reliability of research results. Besides, although a comprehensive statistical data analysis method is used to increase the reliability of research results, the data collected by self-report and self-assessment of the research subjects may be exaggerated or reduced, resulting in inaccurate results. Finally, our data are collected during the fight against COVID-19 in China. As an individual characteristic of a state type, PsyCap has a large degree of malleability and changes under different circumstances, varying with the change of the work situation.⁴⁹ Hence, it is reasonable to wonder whether PsyCap levels in China’s ICNs have changed in response to COVID-19 compared to other non-challenging environments. If so, does the PsyCap level further affect their work engagement during the epidemic prevention period? Due to the impact of special circumstances, we have to consider the current situation of the POS, PsyCap and work engagement of ICNs in other situations. In the future, research on the group of ICNs under other situations should be conducted.

Conclusion

In summary, the work engagement of Chinese ICNs is at a relatively high level, and the POS and PsyCap are at the upper-middle level. The POS and PsyCap are positively correlated with work engagement, and both directly affect work engagement. PsyCap can mediate the correlation between POS and work engagement to a certain extent. Therefore, nursing managers should take a series of measures to make ICNs perceive that the organization attaches importance to their work. The higher the POS value, the higher the level of organizational care, recognition and attention experienced by the ICNs. Finally, the ICNs will have a strong sense of professional self-identity and self-worth, and be more loyal to the organization, and be more active, devoted and energetic to work. Moreover, nursing managers should also help enhance ICNs’ PsyCap, which can inhibit the negative influence of adverse factors on individuals, and the individual’s attitude and investment in work are changed.