Şiddete Karşı Güvenlik Algısı ve Psikolojik Sağlamlığın Duygusal Tükenme Üzerine Etkisi

Year 2024, Volume: 11 Issue: 2, 425 - 445, 31.12.2024

İbrahim Türkmen , Emine Çetin

https://doi.org/10.47097/piar.1557988

Abstract

Türkiye’de ve dünyada sağlık çalışanlarına yönelik şiddet önemli bir sorun haline gelmiştir. Sağlık sektöründeki şiddet, sağlık çalışanlarını fiziksel, psikolojik ve sosyal açıdan zor duruma sokuyor ve duygusal tükenmişliğe yol açabiliyor. Bu çalışmanın amacı hemşirelerde, şiddete karşı güvenlik algısı ve psikolojik sağlamlığın duygusal tükenme üzerindeki etkisinin tespit edilmesidir. Araştırmada şiddete karşı güvenlik algısı, psikolojik sağlamlık ve duygusal tükenme ölçeği kullanılarak, kesitsel tipte nicel bir araştırma tasarımı kullanılmıştır. Araştırmanın evrenini Türkiye’de kamu hastanelerinde görev yapan hemşireler oluşturmaktadır. Araştırmaya gönüllü olarak katılmayı kabul eden hemşirelere Google Forms’ta oluşturulan çevrimiçi anket formu gönderilmiştir. Araştırma verileri 298 hemşireden elde edilmiştir. Araştırma hipotezleri yapısal eşitlik modellemesi kullanılarak test edilmiştir. Araştırma sonuçlarına göre, hemşirelerde şiddete karşı güvenlik algısı ve psikolojik sağlamlık, duygusal tükenme üzerinde istatistiksel olarak anlamlı ve negatif bir etkiye sahiptir. Sonuç olarak hemşirelerin duygusal olarak tükenmelerin önlenmesi ve azaltılması için şiddete karşı güvenlik algısı ve psikolojik sağlamlıkları geliştirilmelidir.

Keywords

Şiddete Karşı Güvenlik Algısı, Duygusal Tükenme, Psikolojik Sağlamlık, Hemşireler

The Effect of Perception of Safety Against Violence and Resilience on Emotional Exhaustion

Abstract

Abstract
Violence against healthcare workers has become a significant problem in Türkiye and around the world. Violence in the health sector puts healthcare professionals in a difficult situation physically, psychologically, and socially and can cause emotional burnout. The aim of this study was to determine the effect of perception of safety against violence and psychological resilience on emotional exhaustion in nurses. A cross-sectional quantitative research design was used in the study, using the perception of safety against violence, psychological resilience, and emotional exhaustion scales. The universe of the research consists of nurses working in public hospitals in Türkiye. An online survey form created in Google Forms was sent to nurses who agreed to participate in the study voluntarily. Research data were obtained from 298 nurses. Research hypotheses were tested using structural equation modelling. According to the research results, perception of safety against violence and psychological resilience among nurses have a statistically significant and negative effect on emotional exhaustion. As a result, nurses' perception of safety and psychological resilience against violence should be improved to prevent and reduce emotional exhaustion.

Keywords

Perception of Safety Against Violence, Emotional Exhaustion, Resilience, Nurses

References

• Al-Harrasi, S., Sabei, S. A., Omari, A. O., & Abrawi, U. A. (2024). Nurses' job burnout and resilience in neonatal intensive care units. The Journal of Perinatal & Neonatal Nursing, 38(2), 201-211. https://doi.org/10.1097/JPN.0000000000000817
• Alsaleem, S. A., Alsabaani, A., Alamri, R. S., Hadi, R. A., Alkhayri, M. H., Badawi, K. K., … & Al-Bishi, A. M. (2018). Violence towards healthcare workers: A study conducted in Abha City, Saudi Arabia. Journal of Family and Community Medicine, 25(3), 188-193.
• Arrogante, O., & Aparicio-Zaldivar, E. (2017). Burnout and health among critical care professionals: The mediational role of resilience. Intensive and Critical Care Nursing, 42, 110-115. https://doi.org/10.1016/j.iccn.2017.04.010
• Atan, M., & Tekingündüz, S. (2014). Ambulans çalışanlarının (112) tükenmişlik, algılanan iş stresi ve iş tatminlerinin kişisel özelliklere göre incelenmesi. NWSA-Social Sciences, 54-69. https://doi.org/10.12739/NWSA.2014.9.3.3C0121
• Atkinson, P. A., Martin, C. R., & Raknin, J. (2009). Resilience revisited. Journal of Psychiatric and Mental Health Nursing, 16, 137–145. https://doi.org/10.1111/j.1365-2850.2008.01341.x
• Ayrancı, Ü., Yenilmez, Ç., Balcı, Y., & Kaptanoğlu, C. (2006). Identification of violence in Turkish health care settings. Journal of Interpersonal Violence, 21(2), 276-296. https://doi.org/10.1177/0886260505282565
• Balay, R., Kaya, A., & Geçdoğan Yılmaz, R. (2014). Eğitim yöneticilerinin hizmetkar liderlik yeterlilikleri ile farklılıkları yönetme becerileri araındaki ilişki. Eğitim Bilimleri Araştırma Dergisi, 4(1), 229-249.
• Bazmi, E., Alipour, A., Yasamy, M. T., Kheradmand, A., Salehpour, S., Khodakarim, S., & Soori, H. (2019). Job burnout and related factors among health sector employees. Iranian Journal of Psychiatry, 14(4), 309–316. https://doi.org/10.18502/ijps.v14i4.1982
• Bardoel, E., Pettit, T. M., De Cieri, H., & McMillan, L. (2014). Employee resilience: An emerging challenge for HRM. Asia Pacific Journal of Human Resources, 279-297. https://doi.org/10.1111/1744-7941.12033
• Berlanda, S., Pedrazza, M., Fraizzoli, M., & Cordova, F. (2019). Addressing risks of violence against healthcare staff in emergency departments: The effects of job satisfaction and attachment style. Hindawi BioMed Research International, 1-12. https://doi.org/10.1155/2019/5430870
• Blando, J. D., O'Hagan, E., Castel, C., Nocera, M. A., & Peek-Asa, C. (2012). Impact of hospital security programmes and workplace aggression on nurse perceptions of safety. Journal of Nursing Management, 21(3), 491-498. https://doi.org/10.1111/j.1365-2834.2012.01416.x
• Bonanno, G. A. (2004). Loss, trauma, and human resilience: We underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59(1), 20-28. https://doi.org/10.1037/0003-066X.59.1.20
• Brill, P. L. (1984). The Need for an operational definition of burnout. Family & Community Health, 6(4), 12-24. https://doi.org/10.1097/00003727-198402000-00005
• Buzzanell, P. M. (2010). Resilience: Talking, resisting, and imagining new normalcies into being. Journal of Communication, 60(1), 1-14. https://doi.org/10.1111/j.1460-2466.2009.01469.x
• Catlette, M. (2005). A descriptive study of the perceptions of workplace violence and safety strategies of nurses working in level I trauma centers. Journal of Emergency Nursing, 31(6), 519-525. https://doi.org/10.1016/j.jen.2005.07.008
• Charney, D. S. (2004). Psychobiological mechanisms of resilience and vulnerability: Implications for successful adaption to extreme stress. The American Journal of Psychiatry, 195-216. https://doi.org/10.1176/appi.ajp.161.2.195
• Copeland, D., & Henry, M. (2018). The relationship between workplace violence, perceptions of safety, and professional quality of life among emergency department staff members in a level I trauma centre. International Emergency Nursing, 39, 26-32. https://doi.org/10.1016/j.ienj.2018.01.006
• Dahlberg, L. L., & Krug, E. G. (2002). Violence - A global public health problem. World Health Organization. Deans, C. (2007). The effectiveness of a training program for emergency department nurses in managing violent situations. The Australian Journal of Advanced Nursing, 21(4), 17-22.
• Deng, J., Guo, Y., Ma, T., Yang, T., & Tian, X. (2019). How job stress influences job performance among Chinese healthcare workers: A cross-sectional study. Environmental Health and Preventive Medicine, 24, 1-11. https://doi.org/10.1186/s12199-018-0758-4
• Doğan, T. (2015). Kısa psikolojik sağlamlık ölçeği'nin Türkçe uyarlaması: Geçerlik ve güvenilirlik çalışması. The Journal of Happiness & Well-Being, 3(1), 93-102.
• Elliott, P. P. (1997). Violence in health care. What nurse managers need to know. Nursing Management, 28(12), 38-41.
• Ergin, C. (1992). Doktor ve hemşirelerde tükenmişlik ve Maslach tükenmişlik ölçeğinin uyarlanması. VII. Ulusal Psikoloji Kongresi Bilimsel Çalışmaları, 22-25 Eylül 1992, Hacettepe Üniversitesi, Ankara: VII. Ulusal Psikoloji Kongresi Düzenleme Kurulu ve Türk Psikologlar Derneği Yayını, 143-154
• Freudenberger, H. J. (1974). Staff burn-out. Journal of Social Issues, 30(1), 159-165. https://doi.org/10.1111/j.1540-4560.1974.tb00706.x
• Gillespie, B. M., Chaboyer, W., & Wallis, M. (2009). The influence of personal characteristics on the resilience of operating room nurses: A predictor study. International Journal of Nursing Studies, 46(7), 968-976. https://doi.org/10.1016/j.ijnurstu.2007.08.006
• Gillespie, G. L., Gates, D. M., Miller, M., & Howard, P. K. (2012). Emergency department workers' perceptions of security officers' effectiveness during violent events. Work, 42(1), 21-27. https://doi.org/10.3233/WOR-2012-1327
• Guo, Y.-F., Luo, Y.-H., Lam, L., Cross, W., Plummer, V., & Zhang, J.-P. (2018). Burnout and its association with resilience in nurses: A cross-sectional study. Journal of Clinical Nursing, 27(1-2), 441-449. https://doi.org/10.1111/jocn.13952
• Hair, J. J., Black, W. C., Babin, B. J., & Anderson, R. E. (2014). Multivariate Data Analysis Seventh Edition. Pearson Education Limited.
• Jun, J., Ojemeni, M. M., Kalamani, R., Tong, J., & Crecelius, M. L. (2021). Relationship between nurse burnout, patient and organizational outcomes: Systematic review. International Journal of Nursing Studies, 119, 1-11. https://doi.org/10.1016/j.ijnurstu.2021.103933
• Kim, S., Mayer, C., & Jones, C. B. (2021). Relationships between nurses’ experiences of workplace violence, emotional exhaustion and patient safety. Journal of Research in Nursing, 26(1–2), 35–46. https://doi.org/10.1177/1744987120960200
• Kingma, M. (2001). Workplace violence in the health sector: A problem of epidemic proportion. International Nursing Review, 48, 129-130. https://doi.org/10.1046/j.1466-7657.2001.00094.x
• Kızıl, M., Üstünkarlı, N., Erginer, D., & Şemin, M. İ. (2016). İzmir 112 ambulanslarında çalışan paramedik ve acil tıp teknisyenlerinin anksiyete düzeyleri ve iş stresörleri. Hastane Öncesi Dergisi, 1(1), 4354.
• Koolhaas, J. M., Bartolomucci, A., Buwalda, B., de Boer, S. F., Flügge, G., Korte, S. M., … & Fuchs, E. (2011). Stress revisited: A critical evaluation of the stress concept. Neuroscience & Biobehavioral Reviews, 35(5), 1291-1301. https://doi.org/10.1016/j.neubiorev.2011.02.003
• Kowalenko, T., Gates, D., Gillespie, G. L., Succop, P., & Mentzel, T. K. (2013). Prospective study of violence against ED workers. American Journal of Emergency Medicine, 31, 197-205. https://doi.org/10.1016/j.ajem.2012.07.01
• Lafta, R. K., & Falah, N. (2019). Violence Against health-care workers in a conflict affected city. Medicine, Conflict and Survival 35(1), 65-79. https://doi.org/10.1080/13623699.2018.1540095
• Lanctot, N., & Guay, S. (2014). The aftermath of workplace violence among healthcare workers: A systematic literature review of the consequences. Aggression and Violent Behavior, 19, 492-501. https://doi.org/10.1016/j.avb.2014.07.010
• Lee, H. L., Han, C. Y., Redley, B., Lin, C. C., Lee, M. Y., & Chang, W. (2020). Workplace violence against emergency nurses in Taiwan: A cross-sectional study. Journal of Emergency Nursing, 46(1), 66-71.e4. https://doi.org/10.1016/j.jen.2019.09.004
• Lee, J. H., Nam, S. K., Kim, A.-R., Kim, B., Lee, M. Y., & Lee, S. M. (2013). Resilience: A meta-analytic approach. Journal of Counseling & Development, 269-279. https://doi.org/10.1002/j.1556-6676.2013.00095.x
• Lee, J., Resick, C. J., Allen, J. A., Davis, A. L., & Taylor, J. A. (2024). Interplay between safety climate and emotional exhaustion: Effects on first responders’ safety behavior and wellbeing over time. Journal of Business and Psychology, 39, 209-231. https://doi.org/10.1007/s10869-022-09869-1
• Li, M., Liu, J., Zheng, J., liu, K., Wang, J., Ross, A. M., … & You, L. (2020). The relationship of workplace violence and nurse outcomes: Gender difference study on a propensity score matched sample. Journal of Advanced Nursing, 76(2), 600-610. https://doi.org/10.1111/jan.14268
• Liu, J., Zheng, J., Liu, K., Liu, X., Wu, Y., Wang, J., & You, L. (2019). Workplace violence against nurses, job satisfaction, burnout, and patient safety in Chinese hospitals. Nursing Outlook, 67(5), 558–566. https://doi.org/10.1016/j.outlook.2019.04.006
• López-Cabarcos, M. Á., López-Carballeira, A., & Ferro-Soto, C. (2021). Is public healthcare healthy? The role of emotional exhaustion. Baltic Journal of Management, 16(3), 386–406. https://doi.org/10.1108/BJM-04-2020-0136
• Lu, D. W., Zhan, T., Bilimoria, K. Y., Reisdorff, E. J., Barton, M. A., Nelson, L. S., Beeson, M. S., & Lall, M. D. (2023). Workplace mistreatment, career choice regret, and burnout in emergency medicine residency training in the United States. Annals of Emergency Medicine, 81(6), 706–714. https://doi.org/10.1016/j.annemergmed.2022.10.015
• Mahoney, B. S. (1991). The extent, nature, and response to victimization of emergency nurses in Pennsylvania. Journal of Emergency Nursing, 17(5), 282-291
• Maslach, C. (2003). Job burnout: New directions in research and intervention. Current Directions in Psychological Science, 12(5), 189-192. https://doi.org/10.1111/1467-8721.01258.
• Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Occupational Behaviour, 2, 99-113. https://doi.org/10.1002/job.4030020205
• Maslach, C., Jackson, S. E., & Leiter, M. (1997). The Maslach burnout inventory manual. In C. P. Zalaquett, & R. J. Wood, Evaluating Stress: A Book of Resources (pp. 191-218). The Scarecrow Press.
• Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52, 397–422. https://doi.org/10.1146/annurev.psych.52.1.397
• Masten, A. S. (2001). Masten, ordinary magic: Resilience processes in development. American Psychologist, 56(3), 227-238. https://doi.org/10.1037/0003-066X.56.3.227
• Mattei, A., Fiasca, F., Mazzei, M., Necozione, S., & Bianchini, V. (2017). Stress and burnout in health-care workers after the 2009 L’Aquila Earthquake: A cross-sectional observational study. Frontiers in Psychiatry, 8, 1-8. https://doi.org/10.3389/fpsyt.2017.00098
• Mattox, E., Wright, S., & Bracikowski, A. (2000). Metal detectors in the pediatric emergency department: Patron attitudes and national prevalence. Pediatric Emergency Care, 16(3), 163-165. https://doi.org/10.1097/00006565-200006000-00006
• McNamara, R., Yu, D. K., & Kelly, J. J. (1997). Public perception of safety and metal detectors in an urban emergency department. The American Journal of Emergency Medicine, 15(1), 40-42. https://doi.org/10.1016/S0735-6757(97)90045-0
• Mealer, M., Conrad, D., Evans, J., Jooste, K., Solyntjes, J., Rothbaum, B., & Moss, M. (2014). Feasibility and acceptability of a resilience training program for intensive care unit nurses. American Journal of Critical Care, 23(6), e97-e105. https://doi.org/10.4037/ajcc2014747
• Murden, F., Bailey, D., Mackenzie, F., Oeppen, R. S., & Brennan, P. A. (2018). The impact and effect of emotional resilience on performance: an overview for surgeons and other healthcare professionals. British Journal of Oral and Maxillofacial Surgery, 56(9), 786-790. https://doi.org/10.1016/j.bjoms.2018.08.012
• Najafi, F., Fallahi-Khoshknab, M., Ahmadi, F., Dalvandi, A., & Rahgozar, M. (2018). Antecedents and consequences of workplace violence against nurses: A qualitative study. Journal of Clinical Nursing, 27(1-2), e116-e128. https://doi.org/10.1111/jocn.13884
• Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric Theory (Third Edition). McGraw-Hill.
• Özel, M., Balsak, H., & Yıldız, T. (2024). Healthcare workers’ safety and emotional exhaustion: Exploring the impact of violence and trust in emergency departments. Journal of Patient Safety and Risk Management, 29(2), 106-114. https://doi.org/10.1177/25160435241240517
• Partridge, B., & Affleck, J. (2017). Verbal abuse and physical assault in the emergency department: Rates of violence, perceptions of safety, and attitudes towards security. Australasian Emergency Nursing Journal, 20(3), 139-145. https://doi.org/10.1016/j.aenj.2017.05.001
• Pınar, T., & Pınar, G. (2013). Sağlık çalışanları ve işyerinde şiddet. TAF Preventive Medicine Bulletin, 12(3), 315-326. https://doi.org/10.5455/pmb.1-1368188150
• Piko, B. F. (2006). Burnout, role conflict, job satisfaction and psychosocial health among hungarian health care staff: A questionnaire survey. International Journal of Nursing Studies, 43(3), 311-318. https://doi.org/10.1016/j.ijnurstu.2005.05.003
• Portoghese, I., Galletta, M., Leitter, M. P., Cocco, P., A'Aloja, E., & Compagna, M. (2017). Fear of future violence at work and job burnout: A diary study on the role of psychological violence and job control. Burnout Research, 7, 36-46. https://doi.org/10.1016/j.burn.2017.11.003
• Rees, C., Wirihana, L., Eley, R., Ossieran-Moisson, R., & Hegney, D. (2018). The effects of occupational violence on the well-being and resilience of nurses. The Journal of Nursing Administration, 48(9), 452-458. https://doi.org/10.1097/NNA.0000000000000648
• Richardson, G. (2002). The metatheory of resilience and resiliency. Journal of Clinical Psychology, 307-321. https://doi.org/10.1002/jclp.10020
• Ruotsalainen, J. H., Verbeek, J. H., Mariné, A., & Serra, C. (2014). Preventing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews, 1-115. https://doi.org/10.1002/14651858.CD002892.pub3
• Saines, J. C. (1999). Violence and aggression in A&E: Recommendations for action. Accident & Emergency Nursing, 7(1), 8-12. https://doi.org/10.1016/s0965-2302(99)80094-0
• Saravanabavan, L., Sivakumar, S. M., & Hisham, M. (2019). Stress and burnout among intensive care unit healthcare professionals in an Indian Tertiary Care Hospital. Indian Journal of Critical Care Medicine, 23(10), 462-466. https://doi.org/10.5005/jp-journals-10071-23265
• Schaufeli, W. B., & Buunk, B. P. (2003). Burnout: An overview of 25 years of research and theorizing. In M. J. Schabracq, J. A. Winnubst, & C. L. Cooper, The Handbook of Work and Health Psychology, Second Edition (pp. 383-425). John Wiley & Sons.
• Schermelleh-Engel, K., Moosbrugger, H., & Müller, H. (2003 8(2)). Evaluating the fit of structural equation models: Tests of significance and descriptive goodness-of-fit measures. Methods of Psychological Research Online, 23-74.
• Shin, J., Taylor, M. S., & Seo, M.-G. (2012). Resources for change: The relationships of organizational inducements and psychological resilience to employees' attitudes and behaviors toward organizational change. Academy of Management Journual, 55(3), 727-748. https://doi.org/10.5465/amj.2010.0325
• Smith, B. W., Dalen, J., Wiggins, K., Tooley, E., Christopher, P., & Bernard, J. (2008). The brief resilience scale: Assessing the ability to bounce back. International Journal of Behavioral Medicine, 15(3), 194-200. https://doi.org/10.1080/10705500802222972
• Şengül, H., Bulut, A., & Özgüleş, B. (2019). Testing the validity and reliability of the Turkish version of the health and safety scale against violence with the structural equation model. The Journal of International Social Research, 12(67), 973-979. http://dx.doi.org/10.17719/jisr.2019.3785
• Tabachnick, B. G., & Fidell, L. (2013). Using multivariate statistics (6th ed.). Pearson.
• Türkmen, İ., & Doğan, H. Y. (2020). 112 Acil Sağlık hizmetleri çalışanlarının şiddete maruz kalma durumu ile iş doyumu arasındaki ilişki. 18. Uluslararası Türk Dünyası Sosyal Bilimler Kongresi, (s. 845-851). Sakarya, Türkiye.
• Vrablik, M. C., Chipman, A. K., Rosenman, E. D., Simcox, N. J., Huynh, L., Moore, M., & Fernandez, R. (2019).
• Identification of processes that mediate the impact of workplace violence on emergency department healthcare workers in the USA: Results from a Qualitative Study. BMJ Open, 9, e031781. https://doi.org/10.1136/bmjopen-2019-031781
• Wang, C., Grassau, P., Lawlor, P. G., Webber, C., Bush, S. H., Gagnon , B., … & Spilg, E. G. (2020). Burnout and resilience among Canadian palliative care physicians. BMC Palliative Care, 19(1), 169. https://doi.org/10.1186/s12904-020-00677-z
• Wheaton, B., Muthén, B., Alwin, D. F., & Summers, G. F. (1977). Assessing reliability and stability in panel models. Sociological Methodology, 8, 84-136. https://doi.org/10.2307/270754
• WHO. (2020). World Health Organization: Violence and injury prevention, violence against health workers. World Health Organization: https://www.who.int/violence_injury_prevention/violence/workplace/en/ (Access Date: 08.10.2024).
• Wu, Y., Wang, J., Liu, J., Zheng, J., Liu, K., Judith, G. B., … & You, L. (2020). The impact of work environment on workplace violence, burnout and work attitudes for hospital nurses: A structural equation modelling analysis. Journal of Nursing Management, 28(3), 495-503. https://doi.org/10.1111/jonm.12947
• Yang, G., Liu, J., Liu, L., Wu, X., Ding, S., & Xie, J. (2018). Burnout and resilience among transplant nurses in 22 hospitals in China. Transplantation proceedings, 50(10), 2905-2910. https://doi.org/10.1016/j.transproceed.2018.04.033
• Yang, S., Meredith, P., & Khan, A. (2015). Stress and burnout among healthcare professionals working in a mental health setting in Singapore. Asian Journal of Psychiatry, 15, 15-20. https://doi.org/10.1016/j.ajp.2015.04.005
• Yural, B., Acuner, D., & Çevik Akkuş, G. (2024). Sağlık çalışanlarının şiddete karşı güvenlik ve güven algılarının incelenmesi. Sağlık ve Hemşirelik Yönetim Dergisi, 11(1), 82-90. https://doi.org/10.54304/SHYD.2024.02438
• Zadow, A. J., Dollard, M. F., Mclinton, S. S., Lawrence, P., & Tuckey, M. R. (2017). Psychosocial safety climate, emotional exhaustion, and work injuries in healthcare workplaces. Stress and Health, 33(5), 558-569. https://doi.org/10.1002/smi.2740
• Zanatta, F., Maffoni, M., & Giardini, A. (2020). Resilience in palliative healthcare professionals: a systematic review. Supportive Care in Cancer, 28, 971-978. https://doi.org/10.1007/s00520-019-05194-1
• Zautra, A. J., Hall, J. S., & Murray, K. E. (2010). Resilience: A new definition of health for people and communities. J. R. Reich, A. J. Zautra, & J. S. Hall içinde, Handbook of Adult Resilience (pp. 3-30). The Guilford Press.
• Zhao, S., Liu, H., Ma, H., Jiao, M., Li, Y., Hao, Y., … & Qiao, H. (2015). Coping with workplace violence in healthcare settings: Social support and strategies. International Journal of Environmental Research and Public Health, 12, 14429-14444. https://doi.org/10.3390/ijerph121114429