Mediating Effect of Social Support on the Relationship between Occupational Stress during the COVID-19-Related Respiratory Disease Pandemic and Professional Quality of Life of Clinical Nurses: A Descriptive Study

Article information

J Korean Acad Fundam Nurs. 2025;32(3):364-375

Publication date (electronic) : 2025 August 31

doi : https://doi.org/10.7739/jkafn.2025.32.3.364

Eunhee Jo ¹⁾

, Rahyeon Hwang ²⁾^,

, Ju-Hee Lee ³⁾

, Yoon-Ji Lee ⁴⁾

¹⁾Associate Professor, Department of Nursing, Kunsan College, Gunsan, Korea

²⁾Associate Professor, Department of Nursing, VISION College of Jeonju, Jeonju, Korea

³⁾Assistant Professor, Department of Nursing, Wonkwang Health Science University, Iksan, Korea

⁴⁾Assistant Professor, Department of Nursing, VISION College of Jeonju, Jeonju, Korea

Corresponding author: Hwang, Rahyeon Department of Nursing, VISION College of Jeonju 235 Cheonjam-ro, Wansan-gu, Jeonju 55069, Korea Tel: +82-63-220-3813, Fax: +82-63-220-2419, E-mail: hoang12@naver.com

Received 2025 May 2; Revised 2025 August 7; Accepted 2025 August 19.

Abstract

Purpose

To identify the relationship between COVID-19 related respiratory disease occupational stress and professional quality of life among clinical nurses and investigate the mediating effect of social support on the relationship between occupational stress and professional quality of life.

Methods

Data were collected from 135 nurses who had experience caring for patients with COVID-19 related respiratory disease in a general hospital with 300 or more beds from December 26, 2021 to January 30, 2022. Hayes' PROCESS macro(version 3.5) was used to test the significance of the indirect effects of the parameters.

Results

Occupational stress had a significant negative effect on professional quality of life (empathy satisfaction; β=-.75, p<.001), and the mediator social support had a significant positive effect on professional quality of life (empathy satisfaction; β=.19, p=.010). Occupational stress had a significant positive effect on professional quality of life (burnout; β=.40, p=.005) and the mediator social support had a significant negative effect on professional quality of life (burnout; β=-.28, p<.001). Occupational stress had no significant effect on professional quality of life (secondary traumatic stress; β=.21, p=.219), and the mediator social support had a significant negative effect on professional quality of life (secondary traumatic stress; β=-.27, p<.001).

Conclusion

To reduce occupational stress associated with COVID-19 related respiratory disease and improve the professional quality of life among clinical nurses, administrative backing of active social support is needed. In addition, psychological counseling programs should be provided regularly, and systematic infectious disease management education programs should be established.

Keywords: Disease; Nurses; Occupational stress; Quality of life; Social support

INTRODUCTION

In December 2019, coronavirus disease, a novel infectious disease of uncertain cause, was discovered in a cluster of patients with pneumonia hospitalized in Wuhan, China, and subsequently spread worldwide [1]. This medical health crisis induced a high degree of stress among clinical nurses, who are pivotal in preventing the rapid spread of infection [2]. The ongoing COVID-19 pandemic has had physical, mental, economic, and social impacts, and nurses providing direct patient care have experienced extreme stress, including discomfort from wearing Level D protective Equipment and anxiety about the risk of infection [3]. In particular, clinical nurses who provide direct patient care at the frontline of an outbreak experience significant occupational stress due to exposure to infectious environments and anxiety about the risk of infection, even though they practice infection control according to guidelines [4].

Occupational stress is a negative response that occurs when occupational-related demands exceed an individual's capabilities or when occupational-related resources and the environment do not improve [5]. Nurses who care for patients with COVID-19 related respiratory disease in the clinical setting experience psychological distress due to patients' deaths and infection, and the fear that they may transmit the infection acts as negative stress and reduces the quality of care [6]. To provide continuous nursing care for patients with COVID-19 related respiratory disease, nurses wear level D protective Equipment and provide nursing care in isolation in patients' rooms for a certain period. The scope of nursing care ranges from direct nursing care to non-nursing tasks such as environmental organization and cleaning [7]. The increase in occupational stress of nurses caring for COVID-19 patients is due to the increase in nursing workload and burden due to the increase in infected patients and strengthening of infection control, but also due to the shortage of nursing staff.[8]. High levels of occupational stress among nurses can increase turnover intentions, leading to a decrease in the quality of nursing care and affecting patient safety [9]. Occupational stress increases empathy fatigue, which negatively affects the professional quality of life (ProQoL)[10]. Professional quality of life (ProQoL) is the quality of life that professionals perceive in relation to their work and has been defined as the positive dimensions of empathy satisfaction and the negative dimensions of burnout and secondary traumatic stress [11]

A study of clinical nurses revealed that the higher the occupational stress, the more they experienced burnout and secondary traumatic stress, which are subdomains of empathy fatigue in ProQoL [12]. Especially, burnout needs to be managed because unaddressed burnout can lead to poor nursing performance, including psychological losses such as feelings of failure, guilt, and regret, which can increase occupational stress, which in turn affects the nursing organization, not just one individual [13,14]. Furthermore, occupational stress and burnout experienced by clinical nurses caring for patients with COVID-19 related respiratory diseases were correlated [15]. Increased occupational stress is associated with decreased ProQoL; therefore, social attention and active support are needed to reduce it [12].

Social support makes individuals feel valued, loved and cared for [16]. Social support from supervisors and coworkers significantly impacts nursing practice, and good support from supervisors and coworkers reduces nurses' depression and increases their psychological well-being [17]. It can help clinical nurses adjust to their occupations and mitigate negative experiences, including occupational stress. It has been shown that the higher the social support, the higher the ProQoL [18]. ProQoL is the perceived quality of life of workers in professions that help others, including healthcare professionals [11]. Since there is a relationship between occupational stress and ProQoL among clinical nurses, it is necessary to establish a social support system to reduce it.

Therefore, it is important to identify the relationship between occupational stress and the ProQoL of clinical nurses who care for patients with COVID-19 related respiratory disease, as well as the mediating effect of social support on the relationship between occupational stress and ProQoL, and to introduce measures to improve the ProQoL of clinical nurses who care for patients with emerging infectious diseases. In this study, we aimed to identify the effects of social support on occupational stress and ProQoL of clinical nurses who care for patients with COVID-19 related respiratory disease, and use this as a basis for policy development.

METHODS

1. Study Design

This descriptive survey study aimed to determine the mediating effect of social support on the relationship between COVID-19 related respiratory disease-derived occupational stress and ProQoL among clinical nurses.

2. Sample and Setting

The research participants were selected from nurses who cared for patients with pandemic respiratory disease at a general hospital with ≥300 beds located in Jeolla-buk-do, Korea. Nurses with experience caring for patients with pandemic respiratory disease, who understood the purpose and method of the study, and who agreed to participate were included. The researchers included nurses working in hospitals with ≥300 beds who provided treatment for patients with pandemic respiratory disease. The researchers excluded nurses with no experience in nursing patients with pandemic respiratory disease and managers whose main occupational function was administrative work. The required sample size was calculated using G* Power version 3.1. for multiple regression analysis, 10 independent variables were calculated with a median effect size of 0.15, significance level of .05, and power of .85 [19]. The calculated number of participants required was 131. The sample was not stratified according to the hospital level. Considering a dropout rate of 10%, 144 participants were selected for the study, but nine participants dropped out, resulting in 135 questionnaires being analyzed.

3. Research Instruments

1) Occupational stress

Occupational stress was measured using the Korean Occupational Stress Scale-Short Form after obtaining permission from the tool's developer [5]. The Occupational stress tool consists of 7 areas, with a total of 24 questions: 4 questions on occupational demands, 4 questions on lack of occupational autonomy, 3 questions on relationship conflicts, 2 questions on occupational instability, 4 questions on organizational structure, 3 questions on inadequate compensation, and 4 questions on workplace culture. In-verse questions were reverse scored, with each response scored on a Likert scale ranging from 1 (not at all) to 4(strongly agree). At the time of development, the Cronbach's ⍺ of the tool was .79, and it was .84 in this study.

2) ProQoL

After obtaining permission for use from the tool's developer, we measured ProQoL using the Korean version of the ProQoL5 questionnaire of the ProQoL scale, which was modified and supplemented by Stamm [11] in the Compassion Satisfaction and Fatigue Self-test for Helpers developed by Figley in the late 1980s. ProQoL consists of a total of 30 questions, including 10 questions on empathy satisfaction, 10 questions on burnout, and 10 questions on secondary traumatic stress. Each item is rated on a 5-point Likert scale ranging from 1 (not at all) to 5 (very much so). 10 items scores ranged from a minimum of 10 points to a maximum of 50 points. At the time of development, the Cronbach's ⍺ of the tool was .88 for empathy satisfaction, .75 for burnout, and .81 for secondary traumatic stress. In this study, the Cronbach's ⍺ was .92 for empathy satisfaction, .74 for burnout, and .83 for secondary traumatic stress.

3) Social support

For social support, the Multidimensional Scale of Perceived Social Support developed by Zimet et al.[20] was modified and supplemented by Shin and Lee [21]. The social support tool comprises 12 items across three areas. It consists of 4 questions about family support, 4 questions about friend support, and 4 questions about meaningful other support. Each item was rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). At the time of development, the Cronbach's ⍺ of the tool was 0.85; it was 0.89 in the study by Shin and Lee [21] and 0.96 in this study.

4) General characteristics

Age, marital status, religion, work department, clinical experience, occupational satisfaction, and duration of COVID-19 patient care were identified by referring to previous studies [6,15].

4. Data Collection

Data collection for this study was conducted from December 26, 2021, to January 30, 2022.

The researcher explained the purpose and survey methods of the study to the hospital director and department head in charge prior to data collection and obtained permission to collect data.

The researcher posted recruitment notices in hospitals where clinical nurses meeting the selection criteria were employed. Interested applicants were encouraged to apply voluntarily.

The researcher explained the purpose of the study, research methods, research schedule, personal information protection, and the time required for the survey to the participants in the consultation room of their department.

The researcher explained that participants could withdraw from the study at any time if they wished. The researcher explained that the collected data would be used solely for the purpose of the study, that the participants' names would be kept confidential, and that all research questionnaires would be destroyed after submission to the academic journal. Participants understood the purpose of the study and voluntarily decided to participate. The researcher obtained informed consent from participants who agreed to participate in the study. After completing the questionnaire, participants sealed it in an envelope, which the researcher collected and stored directly. The questionnaire took approximately 10∼15 minutes to complete, and participants received a token of appreciation for their participation in the study.

5. Ethical Considerations

This study was conducted according to The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans. This study was approved by the Korea National Institute for Bio-ethics Policy (No: P01-202112-21-006). In accordance with ethical requirements, the researcher explained the purpose and methods of the study directly to the participant. The researcher explained to the participants that they can refuse to participate at any time after voluntarily agreeing to participate in the study and that they will not be penalized for refusing. The researcher explained to the participants that the data collected will not be used for any purpose other than the research and that anonymity and confidentiality will be guaranteed. Participants were informed that the research questionnaires will be kept for three years and then destroyed.

6. Data Analysis

Data analysis was performed using SPSS version 23.0(IBM Corp., Armonk, NY, USA). General participant characteristics were analyzed using descriptive statistics. Occupational stress, ProQoL, and social support were analyzed using means and standard deviations. Differences in occupational stress, ProQoL, and social support according to the participants' general characteristics were analyzed using an independent t-test and one-way analysis of variance. The Scheffé test was used as a post hoc test. The correlations between occupational stress, ProQoL, and social support were calculated using Pearson's correlation coefficient. To determine the mediating effects of occupational stress, ProQoL, and social support, the significance of the indirect effects of the parameters was analyzed using Model 4 of Hayes' PROCESS macro (version 3.5). The statistical significance of the indirect effects of the parameters was tested using the bootstrapping approach with bias-corrected 95% confidence intervals (CIs) and 10,000 resampling.

RESULTS

1. Differences in Occupational Stress, Social Support, and ProQoL by General Characteristics of the Participants and General Characteristics of the Participants

The mean age of the participants was 28.24±4.03 years. In total, 111 participants (82.2%) were single, and 86 (63.7%) were not religious. Regarding work department, 94 (69.6%) nurses worked in general wards. Clinical experience was less than 61 months in 86 (63.7 %) participants. Regarding occupational satisfaction, 83 (61.5%) participants were moderately satisfied. Seventy-three (54.1%) had spent less than 6 months caring for patients with pandemic respiratory disease (Table 1).

Table 1.

Differences in Professional Quality of Life by General Characteristics of Participants (N=135)

In the analysis of occupational stress according to general characteristics, occupational satisfaction was statistically significant (F=30.88, p<.001), and post hoc analyses revealed that dissatisfied was higher than moderate, and moderate was higher than satisfied. In terms of social support, there were statistically significant differences in marital status (t=-2.73, p=.007) and work department (t=1.99, p=.049), with social support being higher among married than among single individuals and among those working in general wards than among those working in specialized departments. Regarding differences in ProQoL by general characteristics, empathy satisfaction significantly differed according to work department (t=-2.00, p=.048), clinical experience (F=3.73, p=.027), and occupational satisfaction (F=27.07, p<.001). Empathy satisfaction was higher in nurses working in specialty departments than in those working in general wards, and in terms of clinical experience, it was higher in those with more than 121 months of experience than in those with 61∼120 months of experience. In terms of occupational satisfaction, the post hoc analysis revealed that satisfied was higher than moderate, and moderate was higher than dissatisfied. Regarding ProQoL differences, burnout significantly differed according to clinical experience (F=4.56, p=.012), occupational satisfaction (F=23.85, p<.001), and duration of care for patients with COVID-19-related respiratory diseases (F=3.23, p =.043). The post hoc analysis revealed that burnout was higher in nurses with less than 61 months and those with 61∼120 months of clinical experience than in those with more than 121 months of experience. It was also higher in those who were dissatisfied than in those who were moderately satisfied with their occupationals, as well as higher in those who were moderately satisfied than in those who were satisfied. The length of care for patients with COVID-19-related respiratory disease was the same in both the groups. There was a statistically significant difference in secondary traumatic stress according to the length of care for patients with COVID-19-related respiratory disease (F=6.62, p=.002), and the post hoc analysis revealed that it was higher for those with a length of care of less than six months than for those with a length of care of 12 months or more (Table 1).

2. Occupational Stress, Social Support, and ProQoL

The average occupational stress score was 2.39±0.30 out of 4, and the average social support score was 4.16 ±0.65 out of 5. Empathy satisfaction averaged 3.21±0.66 out of 5, burnout averaged 2.74±0.53 out of 5, and secondary traumatic stress averaged 2.43±0.61 (Table 2).

Table 2.

Level of Occupational Stress, Social Support, and Professional Quality of Life Correlation among the Variables (N=135)

3. Correlation among the Variables

The results of the correlations between occupational stress, social support, and ProQoL showed that occupational stress had a statistically significant inverse correlation with social support (r=-.27, p=.002) and empathy satisfaction (r=-.57, p<.001), and a statistically significant positive correlation with burnout (r=.51, p<.001) and secondary traumatic stress (r=.19, p =.027). Social support was significantly positively correlated with empathy satisfaction (r=.31, p<.001) and significantly negatively correlated with burnout (r=-.46, p<.001) and secondary traumatic stress (r=-.31, p <.001). Within ProQoL, empathy satisfaction was inversely correlated with burnout (r=-.62, p<.001) but not with secondary traumatic stress (r=.08, p =.382). Burnout was positively correlated with secondary traumatic stress (r=.49, p<.001) (Table 2).

4. Mediating Effect of Social Support on the Relationship between Occupational Stress and Pro-QoL

Herein, we confirmed the mediating effect of social support on the relationship between occupational stress and ProQoL scores. Before the regression analysis, the variance expansion index to check for multicollinearity among the independent variables ranged from 1.00 to 4.36, which was less than 10, and the tolerance limits ranged from 0.24 to 1.10, which were all above 0.1. This indicates that there is no problem with multicollinearity. In addition, the Dubin-Watson index ranged from 1.99 to 2.06, which was close to the standard value of 2.00, indicating that auto-correlation was not a problem, and the p-p chart for normality verification showed a normal distribution of error terms, as the points were close to a 45° straight line. The standardized residual viscosity results did not reveal any tendency, trend, or cycle around the mean of 0 and were irregularly distributed, confirming the equidispersity of the residuals and, therefore, the validity of multiple regression analysis.

1) Mediating effect of social support on the relationship between occupational stress and ProQoL (empathy satisfaction)

The mediating effect of social support on the relationship between occupational stress and ProQoL (empathy satisfaction) was tested using the PROCESS macro, controlling for clinical experience, work department, occupational satisfaction, and duration of care for patients with pandemic respiratory diseases. The results revealed significant differences in empathy satisfaction. Occupational stress had a significant negative effect on social support (β=-.55, p<.001), and the explanatory power of the model was 7%. Occupational stress had a significant negative effect on ProQoL (empathy satisfaction)(β=-.75, p<.001), and social support had a significant positive effect on ProQoL (empathy satisfaction)(β=.19, p =.010), with an explanatory power of 47% (Table 3).

Table 3.

Mediating Effects of Social Support in the Relationship between Occupational Stress and Professional Quality of Life (N=135)

To test the significance of the mediating effect of social support on the relationship between occupational stress and ProQoL (empathy satisfaction), the magnitude of the total effect was estimated to be −0.86 with a 95% bootstrap confidence interval (−1.2 to −0.50), and the magnitude of the direct effect was −0.75 with a 95% bootstrap confidence interval (−1.11 to −0.40), which was statistically significant as it did not include zero (Table 4).

Table 4.

Verification of Total, Direct, and Individual Indirect Effects Through Bootstrapping (N=135)

2) Mediating effect of social support on the relationship between occupational stress and ProQoL(burnout)

We used the PROCESS macro to test the mediating effect of social support on the relationship between occupational stress and ProQoL (burnout), controlling for clinical experience, occupational satisfaction, and duration of care for patients with pandemic respiratory disease, which showed significant differences in burnout. Occupational stress had a significant negative effect on social support (β=-.57, p=.013), and the explanatory power of the model was 7%. Occupational stress had a significant positive effect on ProQoL (burnout) (β=.40, p=.005), and the mediator social support had a significant negative effect on ProQoL (burnout) (β=-.28, p<.001), with an explanatory power of 49% (Table 3). To test the significance of the mediating effect of social support on the relationship between occupational stress and ProQoL (burnout), the total effect size was 0.56 with a 95% bootstrap confidence interval (0.26∼0.86), and the direct effect size was 0.40 with a 95% bootstrap confidence interval (0.12∼0.68), which was statistically significant because it did not include zero (Table 4).

3) Mediating effect of social support on the relationship between occupational stress and ProQoL (secondary traumatic stress)

Occupational stress had a significant negative effect on social support (β=-.59, p<.001), and the model had an explanatory power of 7%. Occupational stress had no significant effect on ProQoL (secondary traumatic stress) (β=.21, p=.219), and social support had a significant negative effect on ProQoL (secondary traumatic stress) (β=-.27, p<.001), with an explanatory power of 20% (Table 3). To test the significance of the mediating effect of social support on the relationship between occupational stress and ProQoL (secondary traumatic stress), the size of the total effect was estimated to be 0.37 with a 95% bootstrap confidence interval (0.04∼0.70), and the size of the direct effect was 0.21 with a 95% bootstrap confidence interval (-0.12 to 0.54), which included zero and was not statistically significant (Table 4).

DISCUSSION

We attempted to determine the extent of occupational stress related to COVID-19-related respiratory disease, social support, and ProQoL among clinical nurses and to characterize the effect of social support on the relationship between occupational stress and ProQoL. The results revealed an average occupational stress score of 2.39 out of 4. Using the same instrument, the score was similar to the 2.47 found in Park, Cha, & Lee's [22] study of nurses in hospitals with nationally designated isolation beds and higher than the 2.19 found in Shin and Joung's [23] study of nurses directly caring for confirmed cases in a dedicated COVID-19 hospital. These results may have been influenced by differences in circumstances, such as the timing of data collection and the presence of designated hospitals.

In hospitals with dedicated COVID-19 hospitals or nationally designated isolation beds, nurses were initially exposed to emotionally stressful situations while providing care for COVID-19 patients due to complex procedures and constantly changing guidelines. However, over time, they gradually adapted to their work by standardizing the guidelines and redefining their roles. However, if the medical institution where the subjects of this study work is not a dedicated COVID-19 hospital like the medical institution where the subjects of this study work, various subjects can be hospitalized, so the stress of quarantine and infection control of the subjects is bound to be continuous, and if a confirmed case occurs among the hospitalized subjects, additional nursing tasks such as isolation of the confirmed case may be overwhelming, so the occupational stress may be higher than previous studies [23].

The social support score in this study averaged 4.16 out of 5, which is similar to the results reported by Lee [24] on nurses working in a hospital dedicated to patients and Park and Ha's [25] study of nurses at a national infectious disease center with COVID-19-related respiratory disease.

It is thought that nurses actively cope with the situation through mutual cooperation and support among the medical staff, even in a difficult environment. In situations where nurses are assigned excessive duties, social support has been shown to mitigate negative psychological factors by promoting adaptive coping behaviors [26]. Therefore, it is necessary to establish a cooperative social support system that can continuously promote mutually cooperative relationships among healthcare workers in stressful occupational situations.

The average professional quality of life in this study was 3.21 for empathy satisfaction, 2.74 for burnout, and 2.43 for secondary traumatic stress on a 5-point scale, which was different from the previous study of nurses in the ICU of a university hospital [27] and the study of nurses in a dedicated COVID-19 hospital [23], where empathy satisfaction was at the same level, but burnout and secondary traumatic stress scores were higher. Moon & Jang's [27] study was due to the high severity of patients hospitalized in the ICU with COVID-19 infection, and Shin and Joung's [23] study was also in a dedicated COVID-19 hospital, which may be due to frequent changes in COVID-19 healthcare policies and increased nursing workload to care for patients with COVID-19. Therefore, to reduce burnout and secondary traumatic stress in clinical nurses caring for patients with infectious diseases, accurate work guidelines are needed from the initial stage, and a social support system should be established through regular infection education and support of human and material resources so that infection prevention and control tasks can be carried out smoothly.

In the present study, the differences in general characteristics showed that occupational stress varied according to occupational satisfaction. This is in line with the findings of a study on hospital nurses [28], in which the researchers reported that they would change occupations if they had the opportunity, as well as a study on nurses at the beginning of their career [29], who were dissatisfied with their nursing occupations. In both cases, this was associated with high levels of occupational stress. These results suggest that dissatisfaction with the occupation leads to increased occupational stress, which in turn contributes to nurse turnover [28]. Therefore, it is important to identify the extent and causes of occupational stress and provide administrative support to take measures for each cause, improve working conditions, and establish customized welfare policies.

In this study, social support differed according to marital status and work department; however, no such differences were found in the study by Kim [30], which focused on psychiatric nurses. We attribute this result to the fact that married individuals have a support system in the form of a family that can relieve occupational stress and anxiety. Other studies have found higher levels of social support among those working in specialized departments [31]. As previously suggested by Lee and Ko [31], the levels of social support offered by different departments should be investigated. As important differences were found in previous studies, it is necessary to repeat the study to verify the social support offered by each department.

In this study, ProQoL (empathy satisfaction) differed according to work department, clinical experience, and occupational satisfaction, with nurses working in specialty units having higher empathy satisfaction than those working in general units. This contrasts with the findings of studies conducted among general hospital nurses [32], which revealed no significant effect of the work unit on empathy satisfaction. The participants in this study were nurses who were caring for or had cared for patients with COVID-19. In the case of nurses who work in specialty units and care for patients with pandemic respiratory disease, empathy is thought to be a result of intrinsic motivation due to a sense of responsibility as a professional nurse and professional pride [33] amidst the challenges of frequent patient contact, frequent use of protective Equipment, and the experience of sudden death.

Clinical experience and occupational satisfaction affected burnout levels. Clinical experience was associated with higher levels of empathy satisfaction in those with more than 121 months of experience, while burnout was higher in those with ≤61 months and 61∼120 months of experience. The results of higher empathy satisfaction with more experience were similar to those reported by Lim and Kim [32], and those of higher burnout with less experience were similar to those reported by Lee and Lee [34]. It is thought that nurses with more clinical experience have higher empathy satisfaction to overcome difficult situations by relying on previous experiences and accumulated knowledge, and they are more prone to helping colleagues [35]. In contrast, nurses with less clinical experience and physical and psychological pressures of problem solving have lower occupational satisfaction and higher burnout due to occupational stress [9].

Furthermore, the results of this study are in agreement with those of a previous study [32], which revealed that higher levels of occupational satisfaction were associated with higher levels of empathy satisfaction, and higher levels of burnout were associated with higher levels of dissatisfaction. This is thought to be due to the enhancement of empathy and positive satisfaction as professional nurses work with a sense of mission. Therefore, it is necessary to increase self-efficacy as a professional to increase occupational satisfaction and reduce burnout in the management of human resources in the nursing field. This is important not only for self-efficacy but also for the management of human resources in clinical settings.

In general characteristics, duration of care for COVID-19 patients was associated with significant differences in both burnout and secondary traumatic stress, with "less than 6 months" having higher secondary traumatic stress than "12 months or more." This differs from the study by Lee et al. [35], who found that a longer duration of care for COVID-19 patients was associated with higher secondary traumatic stress. These results may be due to the fact that although there have been epidemics of infectious diseases such as MERS and novel influenza in the past, the amount of work increased due to lack of experience in infection prevention and control and lack of experience in a global pandemic situation such as COVID-19 or a prolonged situation lasting for approximately three years. In addition, the lack of guidelines and frequent changes in the early stages of the COVID-19 pandemic may have caused nurses to experience high stress levels, leading to burnout.

In this study, occupational stress was negatively correlated with social support, which was similar to the results of a study of nurses in COVID-19 dedicated hospitals [23]. In addition, occupational stress was negatively correlated with empathy satisfaction among professional quality of life and positively correlated with burnout and secondary traumatic stress, which was similar to the results of Shin and Joung [23]. However, this differs from the results of a study of nurses in a national infectious disease hospital [25], which showed that occupational stress was positively correlated with burnout but not with social support. Because of these differences in findings depending on the subjects and circumstances of the study, follow-up studies are needed for nurses who have experience caring for COVID-19 patients.

In this study, social support was positively related to empathy satisfaction and negatively related to burnout and secondary traumatic stress among professional quality of life, which was the same as in Shin and Joung [23]. This may be due to the encouragement of supportive relationships at the coworker, organizational, and hospital levels to positively cope with the fearful pandemic situation of caring for COVID-19 patients and the formation of a positive atmosphere of social interest and encouragement for medical staff. Therefore, it is important to establish a social support system, as nurses can reduce burnout and stress by communicating and creating a supportive system.

In the present study, empathy satisfaction in professional quality of life was inversely correlated with burnout, but not statistically significant with secondary traumatic stress, and burnout was positively correlated with it. This is consistent with the findings of Lim and Kim [32] and Moon & Jang [27]. Although there was no direct correlation between empathy satisfaction and secondary traumatic stress, burnout was correlated with both empathy satisfaction and secondary traumatic stress. Therefore, it is recommended that clinical nurses have adequate rest, staffing, and rewarding activities to reduce burnout when caring for patients with infectious diseases such as COVID-19.

The mediating effect of social support on the relationship between job stress and professional quality of life (empathy satisfaction) in this study revealed that job stress had a negative effect on professional quality of life (empathy satisfaction), and the mediating variable, social support, had a significant positive effect on professional quality of life (empathy satisfaction). In addition, the relationship between job stress and professional quality of life (burnout) revealed that job stress had a positive effect on professional quality of life (burnout), and the mediating variable, social support, had a negative effect on professional quality of life (burnout). This suggests that even if nurses caring for COVID-19 patients experience occupational stress due to their demanding work, social support can improve their empathy satisfaction with their professional quality of life and reduce burnout. However, the effect of occupational stress was greater than that of social support on professional quality of life (empathy satisfaction) and professional quality of life (burnout), suggesting that the effect of social support may be ineffective if occupational stress is too high.

Therefore, it is necessary to provide active social support and reduce occupational stress so that they can fulfill their roles as professionals, improve their professional quality of life (empathy satisfaction), and reduce their professional quality of life (burnout). Social support [21] can be divided into three main areas: support from family, support from friends, and support from meaningful others. While family and friends can provide support at home and through friendships, support from coworkers in the workplace may not always be possible. However, having the support of coworkers, the people you care for, and the patients and caregivers who receive your care is one of the greatest sources of professional satisfaction and the best quality of professional life for a nurse.

In testing the significance of the mediating effect of social support in the relationship between occupational stress and professional quality of life (secondary traumatic stress), the magnitude of the total effect was significant, but the magnitude of the direct effect was not. i.e. Occupational stress does not have a direct effect on professional quality of life (secondary traumatic stress); however, the presence of social support in situations exposed to occupational stress decreases professional quality of life (secondary traumatic stress).

The findings of this study suggest that social support is an important factor for nurses to improve empathy satisfaction with their professional quality of life and reduce burnout and secondary traumatic stress in the face of increased occupational stress from caring for COVID-19 patients. In addition, to reduce nurses' occupational stress, it is necessary to identify the interpersonal environment with coworkers, family members, and acquaintances in the nursing field to provide a favorable support system. Caring for patients with infectious diseases such as COVID-19 increases nurses' occupational stress and burnout, leading to a decrease in their professional quality of life. This decrease in the professional quality of life may be a cause of turnover among Generation MZ nurses, who prioritize quality of life more than previous generations, leading to loss of human resources and decrease in the quality of nursing care in the medical field. Therefore, social support is important for reducing turnover and improving the professional quality of life.

The significance of this study is that it confirmed the relationship between each variable and the mediating effect of social support in the relationship between occupational stress and the nurses' professional quality of life of nurses with COVID-19 patients, given the lack of previous research on the mediating effect of social support. Therefore, it is necessary to provide administrative support for active social support systems to reduce COVID-19 occupational stress and improve the professional quality of life of clinical nurses.

CONCLUSION

The results of this study confirmed the mediating effect of social support on ProQoL (empathy satisfaction, burnout, and secondary traumatic stress) in clinical nurses caring for patients with pandemic respiratory disease.

Based on the findings of this study, we make the following suggestions. First, based on the experience of the COVID-19 pandemic, social support must be improved to enhance the occupational stress and quality of life of clinical nurses. Therefore, it is necessary to establish the type and target of social support and positive social support. Second, it is necessary to investigate the psychological and emotional status of clinical nurses caring for various infectious diseases on the frontline. Thus, a systematic and regular counseling program is needed to manage the occupational stress that clinical nurses experience while caring for patients with infectious diseases. Third, measures are needed to reduce occupational stress caused by caring for patients with infectious diseases and improve professional quality of life to reduce turnover.

This requires careful policy design and implementation by the government, medical institutions, and nursing organizations to increase the number of on-site nursing staff, control work intensity, clearly delineate duties, adequately reward nurses for their efforts, and improve their working conditions. As this study was conducted at a single institution, the results may not be generalizable to other hospitals, regions, or healthcare organizations.

Notes

CONFLICTS OF INTEREST

The authors declared no conflict of interest.

AUTHORSHIP

Conceptualization; methodology; formal analysis; writing - review and editing (lead) - Jo E; Formal analysis; writing - original draft; writing - review and editing - Hwang R; Formal analysis; writing - original draft - Lee J; Data curation; writing - original draft - Lee Y; All authors approved the final version for submission.

DATA AVAILABILITY

Please contact the corresponding author for data availability.

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Characteristics	Categories	M± SD or n (%)	Occupational stress		Social support		Professional quality of life
			Occupational stress		Social support		Empathy satisfaction		Burn		Secondary traumatic stress
			M± SD	t or F (p)	M± SD t	t or F (p)	M± SD t	t or F (p)	M± SD	t or F (p)	M± SD	t or F (p)
Age (year)		28.24±4.03(22∼43)
Marital status	Single	111 (82.2)	2.41±0.89	1.23	4.10±0.67	-2.73	3.19±0.63	-0.87	2.79±0.51	1.72	2.47±0.63	1.60
Marital status	Married	24 (17.8)	2.32±0.33	(.221)	4.49±0.46	(.007)	3.32±0.80	(.387)	2.58±0.61	(.088)	2.25±0.52	(.112)
Religion	Yes	49 (36.3)	2.42±0.31	0.86	4.16±0.57	-0.07	3.31±0.69	1.32	2.72±0.53	-0.45	2.54±0.67	1.63
Religion	No	86 (63.7)	2.37±0.29	(.391)	4.47±0.69	(.947)	3.15±0.65	(.187)	2.77±0.83	(.652)	2.37±0.57	(.106)
Work department	General ward	94 (69.6)	2.41±0.32	1.14	4.24±0.58	1.99	3.14±0.70	-2.00	2.78±0.52	0.93	2.39±0.59	-1.23
Work department	Special department	41 (30.4)	2.33±0.28	(.257)	4.00±0.77	(.049)	3.38±0.54	(.048)	2.69±0.53	(.351)	2.53±0.66	(.222)
Clinical experience^†(month)	＜61^a	86 (63.7)	2.39±0.31	1.53	4.16±0.65	0.91	3.23±0.68	3.73	2.81±0.50	4.56	2.51±0.64	2.99
	∼61–120^b	33 (24.4)	2.44±0.30	(.220)	4.10±0.73	(.405)	3.01±0.63	(.027)	2.78±0.58	(.012)	2.40±0.56	(.054)
	≥121^c	16 (11.9)	2.28±0.23		4.36±0.46		3.54±0.52	b＜ c	2.39±0.43	a, b＞ c	2.11±0.47
Occupational satisfaction^†	Satisfactory^a	39 (28.9)	2.17±0.29	30.88	4.29±0.65	1.77	3.72±0.44	27.07	2.41±0.46	23.85	2.29±0.67	2.03
	Usual^b	83 (61.5)	2.44±0.26	(＜.001)	4.14±0.65	(.175)	3.08±0.58	(＜.001)	2.82±0.46	(＜.001)	2.47±0.54	(.135)
	Unsatisfactory^c	13 (9.6)	2.76±0.20	a＜ b＜ c	3.92±0.63		2.55±0.75	a＞ b＞ c	3.36±0.37	a＜ b＜ c	2.65±0.82
Nursing period during pandemic respiratory disease^† (month)	＜6^a	73 (54.1)	2.40±0.32	0.13	4.16±0.76	0.12	3.27±0.67	1.24	2.82±0.50	3.23	2.59±0.65	6.62
	6∼＜11^b	22 (16.3)	2.40±0.29	(.882)	4.22±0.56	(.888)	3.02±0.63	(.294)	2.83±0.47	(.043)	2.38±0.60	(.002)
	≥12^c	40 (29.6)	2.37±0.27		4.14±0.46				2.58±0.57		2.18±0.45	a＞ c

Variables		M± SD	Range	Occupational stress	Social support	Professional quality of life
				Occupational stress	Social support	Empathy satisfaction	Burnout	Secondary traumatic stress
				r (p)	r (p)	r (p)	r (p)	r (p)
Occupational stress		2.39±0.30	1∼4	1
Social support		4.16±0.65	1∼5	-.27(.002)	1
Professional quality of life	Empathy satisfaction	3.21±0.66	1∼5	-.57(＜.001)	.31(＜.001)	1
	Burnout	2.74±0.53	1∼5	.51(＜.001)	-.46(＜.001)	-.62(＜.001)	1
	Secondary traumatic stress	2.43±0.61	1∼5	.19(.027)	-.31(＜.001)	.08(.382)	.49(＜.001)	1

Direct effect	β	SE	t	p	95% CI
Direct effect	β	SE	t	p	LLCI	ULCI
1. Occupational stress → Social support R=.27; R²=.07; F (p)=10.49 (.002)	-.55	0.22	7.92	＜.001	3.99	6.65
2. Occupational stress → Professional quality of life (empathy satisfaction)	-.75	0.18	-4.17	＜.001	-1.11	-0.40
3. Social support → Professional quality of life (empathy satisfaction) R=.68; R²=.47; F (p)=12.21 (＜.001)	.19	0.07	2.62	.010	0.05	0.33
1. Occupational stress → Social support R=.27; R²=.07; F (p)=10.49 (.002)	-.57	0.23	-2.52	.013	-1.02	-0.12
2. Occupational stress → Professional quality of life (burnout)	.40	0.14	2.86	.005	0.12	0.68
3. Social support → Professional quality of life (burnout) R=.70; R²=.49; F (p)=15.20 (＜.001)	-.28	0.05	-5.16	＜.001	-0.38	-0.17
1. Occupational stress → Social support R=.27; R²=.07; F (p)=10.49 (.002)	-.59	0.18	12.44	＜.001	4.66	6.43
2. Occupational stress → Professional quality of life (secondary traumatic stress)	.21	0.17	1.24	.219	-0.12	0.54
3. Social support → Professional quality of life (secondary traumatic stress) R=.45; R²=.20; F (p)=8.18 (＜.001)	-.27	0.08	-3.56	＜.001	-0.42	-0.12

Variables	Effect	SE	95% CI
Variables	Effect	SE	Boot LLCI	Boot ULCI
1. Total effect	-0.86	0.18	-1.21	-0.50
2. Direct effect Occupational stress → Professional quality of life (empathy satisfaction)	-0.75	0.18	-1.11	-0.40
3. Indirect effect Occupational stress → Social support → Professional quality of life (empathy satisfaction)	-0.10	0.07	-0.26	-0.01
1. Total effect	0.56	0.15	0.26	0.86
2. Direct effect Occupational stress → Professional quality of life (burnout)	0.40	0.14	0.12	0.68
3. Indirect effect Occupational stress → Social support → Professional quality of life (burnout)	0.16	0.08	0.01	0.33
1. Total effect	0.37	0.17	0.04	0.70
2. Direct effect Occupational stress → Professional quality of life (secondary traumatic stress)	0.21	0.17	-0.12	0.54
3. Indirect effect Occupational stress → Social support → Professional quality of life (secondary traumatic stress)	0.16	0.08	0.03	0.36