Association Between Adverse Childhood Experiences and Mental Health among Nurses: A Propensity Score Matching Analysis

Association Between Adverse Childhood Experiences and Mental Health among Nurses: A Propensity Score Matching Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association Between Adverse Childhood Experiences and Mental Health among Nurses: A Propensity Score Matching Analysis Qing Wang, Chongmei Huang, Qiang Yu, Yusheng Tian, Jiaxin Yang, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7364698/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Nursing is a highly stressful profession with elevated risks of mental health issues. Although occupational stress is a well-established driver of poor mental health in nurses, the added impact of adverse childhood experiences (ACEs) on nurses’ mental health remains unclear. This study aims to examine the association between ACEs and mental health by using propensity score matching (PSM). Methods We conducted a cross-sectional analysis of baseline data from the Nurses’ Mental Health Study (NMHS), a nationwide multicenter prospective cohort study covers 67 tertiary hospitals across China’s 31 provincial-level regions. The Childhood Trauma Questionnaire (CTQ) was used to assess ACEs exposure. Outcomes included depressive symptoms (PHQ-9), anxiety (GAD-7), perceived stress (PSS-4), obsessive symptoms (SCL-90) and loneliness. We employed 1:1 nearest-neighbor propensity score matching with a caliper width of 0.02 to reduce selection bias, and regression analysis was applied to strengthen the robustness of the results. Results A total of 121,017 nurses participated, with 93.4% female and 68.2% married. ACEs were reported by 49.5%. After propensity score matching adjustment, nurses with ACEs exhibited substantially higher prevalence of loneliness (27.2% vs 15.7%, p < 0.001), more severe anxiety symptoms (GAD-7 scores: 11.03 ± 3.89 vs 9.74 ± 3.32, p < 0.001), depressive symptoms (PHQ-9 scores: 15.03 ± 4.53 vs 13.43 ± 3.92, p < 0.001), and obsessive symptoms (SCL-90 scores: 8.85 ± 3.57 vs 7.85 ± 3.09, p < 0.001) compared to counterparts, but paradoxically showing lower levels of perceived stress (PSS-4 scores: 11.44 ± 2.38 vs 11.77 ± 1.78, p < 0.001). Regression analyses confirmed that ACEs emerged as a strong independent predictor of mental health. Conclusions This study provides robust evidence that ACEs are strongly associated with poorer mental health among Chinese nurses, but the perceived stress is the opposite. The findings highlight the impact of ACEs on nurses’ psychological well-being and contribute to developing targeted interventions to reduce ACE-related psychological risks. Trial registration Registry Chinese Clinical Trail Registry, Registration Number ChiCTR2300072142, Registration date 5th June 2023. Adverse childhood experiences Nurse Mental health Propensity score matching Figures Figure 1 1 Introduction Nursing is a profession characterized by occupational stressors, including long shifts, heavy workloads, and continual exposure to patients’ suffering and death [ 1 , 2 ]. These occupational stressors increase the profession’s prevalence of mental health outcomes (e.g., depressive symptoms). These outcomes directly compromise care quality and patient safety, so identifying their risk factors is critical [ 3 ]. Although occupational stressor is a well-established driver of poor mental health outcomes in nurses, how the early-life risk factors shape these outcomes remains unclear [ 1 , 2 ]. Adverse Childhood Experiences (ACEs) are significant early-life risk factors for later mental health. ACEs are defined as a comprehensive array of negative events and experiences occurring during the vulnerable developmental phases of childhood and adolescence [ 4 ]. These experiences can cause persistent neurobiological changes, including brain structure/function alterations and hypothalamic-pituitary-adrenal axis dysregulation. These changes plays a key role in the occurrence and development of mental problems in adulthood [ 5 ]. Given the pivotal role of nurses in the healthcare system, an in-depth investigation of the impact mechanisms of ACEs on their mental health would contribute to the theoretical framework of occupational health. Moreover, such research could provide scientific evidence for developing targeted mental health interventions, ultimately improving healthcare service quality. The relationship between ACEs and mental health among nurses is multi-dimensional and influenced by a complex interplay of various confounders. Many studies show that individual-level factors may interact with occupational factors to influence nurses’ mental health [ 6 , 7 ]. Therefore, when examining the association between ACEs and mental health among nurses, it is essential to account for potential confounders to avoid biased estimates. However, existing research relies on conventional regression analysis that neither accounts for high-dimensional confounder interactions nor block selection biases. To address the aforementioned methodological limitations, a robust methodological approach is crucial to accurately delineate the true relationship between ACEs and mental health outcomes among nurses. PSM can estimate the probability of ACEs exposure and construct comparable exposed and unexposed groups [ 8 ]. By balancing potential confounders across groups, PSM reduces selection bias and enhances the internal validity of the study, allowing for a more accurate assessment of causal relationships [ 9 ]. In observational research, this approach effectively simulates a randomized controlled trial, thereby improving the accuracy of causal inferences regarding the impact of ACEs on nurses’ mental health. Therefore, propensity score matching analysis is used to quantify how ACEs shape nurses’ mental health. 2 Method 2.1 Participants This study utilized baseline data from the Nurses’ Mental Health Study (NMHS), a nationally representative, multicenter prospective cohort study designed to investigate mental health among registered nurses in China [ 10 ]. The NMHS employed a stratified cluster sampling approach to recruit participants from 62 tertiary hospitals across all 31 provincial-level administrative regions in mainland China, ensuring the demographic and geographic representativeness of nurses working in tertiary healthcare facilities. All participants gave written informed consent, and the research protocol was ethically approved by all involved institutions’ review boards, led by the primary institution (Approval number: E20230048). The protocol of NMHS was registered prospectively with the Chinese Clinical Trial Registry (Registration Number: ChiCTR2300072142). Baseline data were collected between December 2023 and January 2024. Of 147,832 invited nurses, 135,161 completed the online survey. After quality screening conducted by two investigators to exclude duplicates and inadequate responses, 132,910 participants were eligible for the NMHS baseline analysis (validity rate: 89.91%). We excluded: 1) individuals with physician-diagnosed psychiatric disorders, and 2) those with a family history of mental disorders. The sample selection process is shown in Fig. 1. A total of 121,017 nurses were included in this study. Figure 1 Study population flowchart 2.2 Measures Based on the study objectives and a comprehensive literature review, we selected ACEs as the exposure variable. The outcome variables comprised five mental health variables, including depressive symptoms, anxiety symptoms, loneliness, perceived stress, and obsessive symptoms. To account for potential confounding factors, we included three categories of covariates: 1) sociodemographic factors (age, gender, education, marital status, and religion), 2) occupational characteristics (employing hospital, years of working experience, weekly working hours, professional title, administrative position, and clinical department), and 3) health-related factors (exercise frequency and pain). 2.2.1 Exposure Variable: Adverse Childhood Experiences The Childhood Trauma Questionnaire (CTQ) has five dimensions [ 11 ]: 1) emotional neglect: I felt loved; 2) emotional abuse: someone in my family hated me; 3) physical abuse: people in my family hit me so hard that it left me with bruises or marks; 4) physical neglect: there was someone to take me to the doctor if I need it; and 5) sexual abuse: someone molested me (took advantage of me sexually). Responses were recorded using a 5-point Likert scale ranging from “never” to “very often”. Items assessing emotional neglect and physical neglect were scored in the reverse direction. Based on our analytical purposes and the classification of other research [ 12 ], we dichotomized the ACEs exposure variable, classifying participants as having ACEs if they 1) endorsed affirmative response (scores ≥ “sometimes”) on any of the dimensions of emotional abuse, physical abuse, or sexual abuse, or 2) reported negative responses (scoring ≤ “sometimes”) to the dimensions of emotional neglect or physical neglect. The Chinese version of the CTQ demonstrated good reliability and validity, with a Cronbach’s α coefficient of 0.79 [ 13 ]. 2.2.2 Outcome Variable: Mental Health 2.2.2.1 Depressive symptom The depressive symptoms were evaluated using the 9-item Patient Health Questionnaire (PHQ-9) [ 14 ], which is based on DSM-IV criteria for major depressive disorder. This instrument employs a 4-point Likert scale (0 = “not at all” to 3 = “nearly every day”), with total scores ranging from 0 to 27. Higher scores indicate greater severity of symptoms, with established clinical cutoffs: 5–9 (mild), 10–14 (moderate), 15–19 (moderately severe), and ≥ 20 (severe depression). The Chinese version of PHQ-9 has demonstrated good reliability in Chinese populations, with reported Cronbach’s α coefficients ranging from 0.765 to 0.938 in various validation studies [ 15 ]. 2.2.2.2 Anxiety symptoms Anxiety symptoms were measured through the 7-item Generalized Anxiety Disorder scale (GAD-7) [ 16 ], consistent with DSM-IV diagnostic parameters for generalized anxiety disorder. The scale utilizes a 4-point response format (0–3), with total scores ranging from 0 to 21; higher scores indicate increased severity of anxiety. The GAD-7 scale has been psychometrically validated in Chinese samples, demonstrating strong internal consistency with Cronbach’s α coefficient values exceeding 0.70 in both clinical and community populations [ 17 , 18 ]. 2.2.2.3 Loneliness Loneliness was screened by using the single-item dichotomous measure: “Do you frequently experience feelings of loneliness?” (Yes / No). This efficient screening tool demonstrates strong criterion validity ( r = 0.78) against established multi-item loneliness scales among healthcare populations [ 19 ]. The Mexican Health and Aging Study (MHAS), a nationwide longitudinal study in Mexico, used the same single-item question to assess loneliness among older Mexican adults [ 20 ]. 2.2.2.4 Perceived stress Perceived stress was assessed via the 4-item Perceived Stress Scale (PSS-4) [ 21 ], derived from the full 10-item PSS. This abbreviated version employs a 5-point Likert scale (0 = “never” to 4 = “very often”), with total scores from 0 to 16. Higher scores reflect a greater level of perceived stress. 2.2.2.5 Obsessive symptoms Obsessive symptoms were assessed using five Symptom Checklist-90 items (SCL-90) [ 22 ]: 1) Cognitive intrusions: Unwanted thoughts, words, or ideas that won’t leave your mind; 2) Appearance preoccupation: Worried about sloppiness or carelessness; 3) Perfectionistic behaviors: Having to do things very slowly to insure correctness; 4) Checking compulsions: Having to check and double-check what you do; 5) Ritualistic behaviors: Having to repeat the same actions such as touching, counting, washing. SCL-90 is widely used in the Chinese general population [ 23 ], and these items evaluate intrusive thoughts and compulsive behaviors through a 5-point severity scale (0 = “not at all” to 4 = “extremely”). 2.2.3 Covariates To comprehensively account for potential confounding factors, covariates were selected from factors associated with both ACEs and mental health outcomes. Sociodemographic covariates included age, gender, education, marital status, and religion. Occupational covariates comprised employing hospital, years of working experience, weekly working hours, professional title, administrative position, and clinical department. Health-related covariates incorporated exercise frequency and pain. 2.3 Statistical analysis Statistical analysis was performed using SPSS 26.0 and R 4.4.3 software. Continuous variables, including age and years of work experience, were reported as mean ± standard deviation ( x̄ ± s ). Categorical variables were reported as frequency ( n ) with corresponding percentages (%). Groups were compared with independent samples t-tests for normally distributed continuous variables and chi-square tests for categorical variables. The assumption of normality was verified using Shapiro-Wilk tests. To minimize potential confounding factors, we employed propensity score matching (PSM) with a 1:1 nearest-neighbor algorithm. The matching procedure incorporated multiple covariates: demographic characteristics (age, gender, education, marital status, religion), occupational factors (employing hospital, years of working experience, weekly working hours, professional title, administrative position, department), and health-related variables (exercise frequency, pain). A caliper width of 0.02 standard deviations of the propensity score logit was used to ensure matching quality while preserving adequate sample size. The balance of baseline characteristics between matched groups was evaluated using standardized mean differences (SMD), with an SMD < 0.1 considered indicative of satisfactory balance, suggesting minimal differences between the study groups. This study employed PSM followed by independent samples t-tests (for continuous variables) and chi-square tests (for categorical variables) to examine differences in mental health between nurses with and without ACEs. To strengthen the robustness of our findings, we further conducted both binary logistic regression and multivariable linear regression analysis to evaluate the association between ACEs and mental health among nurses. 3 Result 3.1 Participant Characteristics As shown in Table 1 , 49.5% ( n = 59,912) of 121,017 nurse participants reported ACEs. Their mean age is 33.34 years (SD = 7.302), with a predominance of female nurses (93.4%). The majority held bachelor’s degrees (87.2%) and were married (68.2%). 94.5% of the nurses held no administrative positions, and clinical nurses comprise 94.0% of the study population. Nurses worked a mean of 38.17 hours (SD = 13.169) per week, and their average working experience was 10.80 years (SD = 8.150). Table 1 Participant Characteristics Characteristics N = 121017 ( x̄ ± s ; %) Age 33.34 ± 7.302 Years of working experience 10.80 ± 8.150 Weekly working hours 38.17 ± 13.169 Religion (No) 113489 (93.8) Gender (Female) 112980 (93.4) Professional title RN-Level I (Junior Staff Nurse) 19237 (15.9) RN-Level II (Senior Staff Nurse) 44150 (36.5) RN-Level III (Nurse Manager) 51900 (42.9) RN-Level IV (Associate Director of Nursing) 5013 (4.1) RN-Level V (Director of Nursing) 717 (0.6) Administrative position None 114399 (94.5) Head Nurse / Unit Nursing Manager 6477 (5.4) Director of Nursing / Deputy Director of Nursing 141 (0.1) Education Secondary specialized education 433 (0.4) Associate degree 10059 (8.3) Bachelor’s degree 105482 (87.2) Master’s degree 4933 (4.1) Doctoral degree 110 (0.1) Marital status Single (Never married) 35474 (29.3) Married 82541 (68.2) Divorced 2522 (2.1) Remarried 233 (0.2) Widowed 247 (0.2) Nurse category Clinical Nursing 113729 (94.0) Non-Clinical Nursing 7288 (6.0) Department Internal Medicine 31463 (26.0) Surgery 26945 (22.3) Obstetrics & Gynecology 6104 (5.0) Ophthalmology & Otorhinolaryngology 3812 (3.1) Pediatrics 4062 (3.4) Psychiatry Department 871 (0.7) Infectious Diseases Department 1851 (1.5) Intensive Care Unit (ICU) 14107 (11.7) Outpatient Clinic 5594 (4.6) Emergency Department 7379 (6.1) Operating Room 9044 (7.5) Nursing Department 1357 (1.1) Others 8428 (7.0) Pain (No) 112311 (92.9) Exercise frequency Never 49826 (41.2) ≤ 1 time per week 52005 (43.0) 2–3 times per week 14741 (12.2) 4–5 times per week 3229 (2.7) Daily 1216 (1.0) ACEs (No) 61105 (50.5) Loneliness (No) 95205 (78.7) Anxiety symptoms 11.16 ± 2.104 Depressive symptoms 14.21 ± 4.340 Perceived stress 10.37 ± 3.686 Obsessive symptoms 8.34 ± 3.389 3.2 Participant Characteristics Before and After Propensity Score Matching As shown in Table 2 , baseline characteristics reduced from 59,912 controls and 61,105 ACE pre-matching to 53,115 matched pairs post-matching. Before PSM, significant group differences existed across multiple domains including demographic (age, p = 0.023; gender, p < 0.001; education, p = 0.001; marital status, p < 0.001; religion, p < 0.001), occupational (years of working experience, p = 0.001; department, p < 0.001; employing hospital, p < 0.001; weekly working hours, p < 0.001; professional title, p < 0.001; administrative position, p < 0.001), and health-related variables (pain, p < 0.001, exercise frequency, p < 0.001), with SMD ranging up to 0.234 for employing hospital. After implementing 1:1 nearest-neighbor matching with a 0.2 caliper width, all covariates achieved excellent balance as evidenced by SMD below 0.02 (range: 0.001–0.020) and non-significant p-values (all p > 0.18), indicating successful mitigation of selection bias. The matched cohorts established comparable groups for subsequent outcome analysis and maintained the study’s original sample representativeness. Table 2 Participant Characteristics Before and After Propensity Score Matching Variable Before PSM After PSM Control ( n = 59912) ACE ( n = 61105) P value SMD Control ( n = 53115) ACE ( n = 53115) P value SMD Age 33.39 ± 7.42 33.29 ± 7.18 0.023 0.013 33.32 ± 7.33 33.35 ± 7.23 0.540 0.004 Years of working experience 10.88 ± 8.27 10.72 ± 8.02 0.001 0.019 10.77 ± 8.19 10.80 ± 8.06 0.565 0.004 Weekly working hours 38.48 ± 12.71 37.85 ± 13.62 < 0.001 0.048 38.13 ± 12.87 38.13 ± 13.41 0.920 0.001 Gender (Male) 3340 (5.5) 4697 (7.8) < 0.001 0.095 3282 (6.2) 3354 (6.3) 0.368 0.006 Professional title < 0.001 0.031 0.996 0.003 RN-Level I 9791 (16.0) 9446 (15.8) 8363 (15.7) 8336 (15.7) RN-Level II 22191 (36.3) 21959 (36.7) 19410 (36.5) 19404 (36.5) RN-Level III 26042 (42.6) 25858 (43.2) 22880 (43.1) 22895 (43.1) RN-Level IV 2683 (4.4) 2330 (3.9) 2168 (4.1) 2178 (4.1) RN-Level V 398 (0.7) 319 (0.5) 294 (0.6) 302 (0.6) Administrative position < 0.001 0.042 0.967 0.002 None 57475 (94.1) 56924 (95.0) 50322 (94.7) 50307 (94.7) Head Nurse 3555 (5.8) 2922 (4.9) 2734 (5.1) 2747 (5.2) Director of Nursing 75 (0.1) 66 (0.1) 59 (0.1) 61 (0.1) Education 0.001 0.024 0.954 0.005 Secondary specialized education 194 (0.3) 239 (0.4) 182 (0.3) 189 (0.4) Associate degree 4935 (8.1) 5124 (8.6) 4414 ( 8.3) 4406 (8.3) Bachelor's degree 53479 (87.5) 52003 (86.8) 46307 (87.2) 46262 (87.1) Master's degree 2439 (4.0) 2494 (4.2) 2166 (4.1) 2209 (4.2) Doctoral degree 58 (0.1) 52 (0.1) 46 (0.1) 49 (0.1) Employing hospital < 0.001 0.234 1.000 0.020 Religion (No) 57808 (94.6) 55681 (92.9) < 0.001 0.069 49937 (94.0) 49877 (93.9) 0.646 0.006 Marital status < 0.001 0.060 0.966 0.005 Single 17654 (28.9) 17820 (29.7) 15554 (29.3) 15534 (29.2) Married 42178 (69.0) 40363 (67.4) 36334 (68.4) 36317 (68.4) Divorced 1037 (1.7) 1485 (2.5) 1020 (1.9) 1052 (2.0) Remarried 111 (0.2) 122 (0.2) 99 (0.2) 102 (0.2) Widowed 125 (0.2) 122 (0.2) 108 (0.2) 110 (0.2) Nurse category (Clinic) 57350 (93.9) 56379 (94.1) 0.070 0.010 49966 (94.1) 49957 (94.1) 0.917 0.001 Department < 0.001 0.059 0.999 0.009 Internal Medicine 16021 (26.2) 15442 (25.8) 13907 (26.2) 13865 (26.1) Surgery 13997 (22.9) 12948 (21.6) 11849 (22.3) 11777 (22.2) Obstetrics & Gynecology 3193 (5.2) 2911 (4.9) 2677 (5.0) 2666 (5.0) Ophthalmology&Otorhinolaryngology 1920 (3.1) 1892 (3.2) 1662 (3.1) 1707 (3.2) Pediatrics 2002 (3.3) 2060 (3.4) 1786 (3.4) 1788 (3.4) Psychiatry Department 451 (0.7) 420 (0.7) 376 (0.7) 387 (0.7) Infectious Diseases Department 953 (1.6) 898 (1.5) 819 (1.5) 816 (1.5) Intensive Care Unit (ICU) 6972 (11.4) 7135 (11.9) 6228 (11.7) 6174 (11.6) Outpatient Clinic 2721 (4.5) 2873 (4.8) 2446 (4.6) 2470 (4.7) Emergency Department 3472 (5.7) 3907 (6.5) 3202 (6.0) 3243 (6.1) Operating Room 4373 (7.2) 4671 (7.8) 3936 (7.4) 3934 (7.4) Nursing Department 680 (1.1) 677 (1.1) 589 (1.1) 601 (1.1) Others 4350 (7.1) 4078 (6.8) 3638 (6.8) 3687 (6.9) Pain (No) 57495 (94.1) 54916 (91.7) < 0.001 0.095 49580 (93.3) 49470 (93.1) 0.183 0.008 Exercise frequency < 0.001 0.097 0.989 0.003 Never 23716 (38.8) 26110 (43.6) 22027 (41.5) 22033 (41.5) ≤ 1 time per week 27348 (44.8) 24657 (41.2) 22739 (42.8) 22725 (42.8) 2–3 times per week 7694 (12.6) 7047 (11.8) 6431 (12.1) 6413 (12.1) 4–5 times per week 1715 (2.8) 1514 (2.5) 1375 (2.6) 1403 (2.6) Daily 632 (1.0) 584 (1.0) 543 (1.0) 541 (1.0) 3.3 Mental Health Outcomes Before and After Propensity Score Matching As shown in Table 3 , before PSM, significant differences in all measured mental health outcomes were observed between nurses with and without ACEs ( p < 0.001). After matching 53,115 pairs, nurses with ACEs had significantly higher rates of loneliness (27.2% vs 15.7%, p < 0.001), greater anxiety symptoms (GAD-7 scores: 11.03 ± 3.89 vs 9.74 ± 3.32, p < 0.001), depressive symptoms (PHQ-9 scores: 15.03 ± 4.53 vs 13.43 ± 3.92, p < 0.001), and obsessive symptoms (SCL-90 scores: 8.85 ± 3.57 vs 7.85 ± 3.09, p < 0.001) compared to nurses without ACEs. In contrast, nurses with ACEs reported lower levels of perceived stress (PSS-4 scores: 11.44 ± 2.38 vs 11.77 ± 1.78, p < 0.001) compared to nurses without ACEs. Table 3 Mental Health Outcomes Before and After Propensity Score Matching Variable Before PSM After PSM Control ( n = 59912) ACE ( n = 61105) P value Control ( n = 53115) ACE ( n = 53115) P value Loneliness < 0.001 < 0.001 No 51827 (84.8) 43378 (72.4) 44785 (84.3) 38686 (72.8) Yes 9278 (15.2) 16534 (27.6) 8330 (15.7) 14429 (27.2) Anxiety symptoms 9.68 ± 3.29 11.07 ± 3.93 < 0.001 9.74 ± 3.32 11.03 ± 3.89 < 0.001 Depressive symptoms 13.34 ± 3.88 15.09 ± 4.60 < 0.001 13.43 ± 3.92 15.03 ± 4.53 < 0.001 Perceived stress 11.77 ± 1.78 11.44 ± 2.38 < 0.001 11.76 ± 1.78 11.46 ± 2.35 < 0.001 Obsessive symptoms 7.80 ± 3.06 8.90 ± 3.61 < 0.001 7.85 ± 3.09 8.85 ± 3.57 < 0.001 3.4 Regression analysis of the mental health outcomes Fully-adjusted models show ACEs strongly predict worse nurse mental health: loneliness odds double( OR = 2.026, 95% CI : 1.965–2.089, p < 0.001), anxiety ( β = 0.175, t = 59.145, p < 0.001), depressive ( β = 0.186, t = 62.935, p < 0.001), and obsessive symptoms heightened (β = 0.148, t = 49.57, p < 0.001), while perceived stress declined ( β = -0.072, t = -23.721, p < 0.001) (Supplementary 1). 4 Discussion This study used PSM to investigate the association between ACEs and mental health among nurses. Our findings revealed that ACE were associated with higher level of anxiety, depressive and obsessive symptoms among Chinese nurses. Contrary to our hypothesis, ACEs were associated with lower levels of perceived stress among nurses. Our findings indicated that nurses with ACEs reported significantly higher levels of both anxiety and depressive symptoms compared to those without ACEs. Our findings are consistent with the findings of previous research [ 7 , 24 ]. A meta-analysis of the relationship between ACEs, anxiety, and chronic pain found that individuals with ACEs are at a higher risk of developing anxiety disorders compared to those without such experiences [ 24 ]. Similarly, a systematic review of ACEs and depression reported a strong association between them, highlighting the long-term impact of ACEs on mental health [ 7 ]. The positive association can be attributed to a combination of neurobiological, psychological, and occupational factors. Neurobiologically, ACEs dysregulate the HPA axis, heightening stress reactivity and altering amygdala-hippocampus-prefrontal circuits, thereby increasing vulnerability to anxiety and depression. Psychologically, ACEs can disrupt the development of healthy coping mechanisms and emotional regulation skills, leading to maladaptive behaviors and increased vulnerability to mental health disorders [ 25 ]. Additionally, ACEs can impact social and interpersonal functioning, leading to difficulties in forming supportive relationships, which are critical protective factors against mental health problems [ 6 ]. The high-stress work environment and demanding job requirements can exacerbate these symptoms [ 26 ]. The emotional and physical demands of patient care can lead to emotional exhaustion and burnout, particularly among those with a history of ACEs who may struggle with emotional regulation and stress management [ 2 ]. Interestingly, our study found that nurses with ACEs reported lower levels of stress compared to those without ACEs. Inconsistently, a previous study links ACEs to elevated perceived stress among North European university students [ 27 ]. The inconsistency may be attributed to the difference in the study populations and culture. North European university students often face academic and career-related stress. This stress may exacerbate their vulnerability when combined with ACEs [ 27 ]. In contrast, Chinese nurses, shaped by occupational training and workplace adaptation, tend to develop better coping strategies which can cushion the effects of ACEs on perceived stress [ 28 ]. The individualistic culture in Northern Europe tends to encourage open expression of stress and help-seeking behaviors, resulting in higher reported stress levels [ 27 ]. In contrast, collectivist cultures like China emphasize emotional resilience and stress reappraisal, leading to lower self-reported stress despite potentially similar underlying distress levels [ 29 ]. Our study found that nurses exposed to ACEs were more likely to experience loneliness compared to those without such exposure. Consistently, previous studies showed that ACEs are associated with increased feelings of loneliness in adulthood [ 30 – 32 ]. This can be attributed to the long-term effects of ACEs on social and emotional development. ACEs can disrupt early attachment processes, leading to difficulties in forming secure and supportive relationships in later life [ 33 ]. Additionally, the heightened sense of loneliness among nurses with ACEs may be amplified by their demanding and isolating work environments [ 34 ]. Our findings demonstrate that nurses with ACEs report significantly higher obsessive symptoms than their non-ACEs counterparts. This can be attributed to several interrelated mechanisms supported by existing literature [ 35 – 38 ]. Neurobiological sensitization from early-life stress leads to HPA axis dysregulation, amplifying stress reactivity in high-pressure nursing environments and manifesting as obsessive thoughts [ 39 ]. Furthermore, the nursing profession’s inherent requirements for precision and accountability may reinforce compulsive behaviors (e.g., repeated equipment checks), especially among those with ACEs who are predisposed to anxiety [ 40 ]. 5 Conclusion This study provides compelling evidence that ACEs are significantly associated with poorer mental health outcomes among nurses. These findings underscore the importance of addressing early-life adversities in the context of occupational mental health. Abbreviations ACEs Adverse childhood experiences PSM Propensity score matching NMHS The Nurses’ Mental Health Study CTQ The Childhood Trauma Questionnaire Declarations Funding This study was supported by the Chinese Nursing Association (grant number: ZHKY202306). Ethics and dissemination This study was approved by the Institute Review Board from the ethical committee of The Second Xiangya Hospital of Central South University (E20230048) and NMHS was performed in line with Helsinki Declarations. All participants gave written informed consent, and the research protocol was ethically approved by all involved institutions’ review boards, led by the primary institution. Conflicts of interest The authors declare no conflicts of interest. Authorship contribution statement All authors have participated in the study and have read and approved the submitted version of the manuscript. Qing Wang: Writing - Original draft, Writing - review & editing, Methodology, Data curation, Conceptualization, Formal analysis. Chongmei Huang: Investigation, Formal analysis, Methodology, Writing - review & editing. Qiang Yu: Investigation, Software, Writing-review. Yusheng Tian: Visualization, Validation, Project administration. Jiaxin Yang: Resources, Data curation. Xuting Li: Methodology, Data curation. Zengyu Chen: Investigation, Methodology, Data curation. Meng Ning: Investigation, Data curation, Software. Yiting Liu: Software, Resources. Dan Zhang: Investigation, Data curation. Chunhui Bin: Visualization, Methodology. Jianghao Yuan: Resources, Investigation. Yamin Li: Resources, Supervision, Funding acquisition, Conceptualization, Writing - review & editing. Data availability statement Research data are not shared References Havaei F, Ji XR, MacPhee M, Straight H. 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BMJ Open. 2025;15(2):e087507. Georgieva S, Tomas JM, Navarro-Pérez JJ. Systematic review and critical appraisal of Childhood Trauma Questionnaire - Short Form (CTQ-SF). Child Abuse Negl. 2021;120:105223. Houtepen LC, Heron J, Suderman MJ, Fraser A, Chittleborough CR, Howe LD. Associations of adverse childhood experiences with educational attainment and adolescent health and the role of family and socioeconomic factors: A prospective cohort study in the UK. PLoS Med. 2020;17(3):e1003031. He J, Zhong X, Gao Y, Xiong G, Yao S. Psychometric properties of the Chinese version of the Childhood Trauma Questionnaire-Short Form (CTQ-SF) among undergraduates and depressive patients. Child Abuse Negl. 2019;91:102–8. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. Yin L, Teklu S, Pham H, Li R, Tahir P, Garcia ME. Validity of the Chinese Language Patient Health Questionnaire 2 and 9: A Systematic Review. Health Equity. 2022;6(1):574–94. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. Sun J, Liang K, Chi X, Chen S. Psychometric Properties of the Generalized Anxiety Disorder Scale-7 Item (GAD-7) in a Large Sample of Chinese Adolescents. Healthc (Basel) 2021, 9(12). Shih YC, Chou CC, Lu YJ, Yu HY. Reliability and validity of the traditional Chinese version of the GAD-7 in Taiwanese patients with epilepsy. J Formos Med Assoc. 2022;121(11):2324–30. Hughes ME, Waite LJ, Hawkley LC, Cacioppo JT. A Short Scale for Measuring Loneliness in Large Surveys: Results From Two Population-Based Studies. Res Aging. 2004;26(6):655–72. Wong R, Michaels-Obregon A, Palloni A. Cohort Profile: The Mexican Health and Aging Study (MHAS). Int J Epidemiol. 2017;46(2):e2. Lee EH. Review of the psychometric evidence of the perceived stress scale. Asian Nurs Res (Korean Soc Nurs Sci). 2012;6(4):121–7. Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psychiatric rating scale–preliminary report. Psychopharmacol Bull. 1973;9(1):13–28. Yu Y, Wan C, Huebner ES, Zhao X, Zeng W, Shang L. Psychometric properties of the symptom check list 90 (SCL-90) for Chinese undergraduate students. J Ment Health. 2019;28(2):213–9. Dalechek DE, Caes L, McIntosh G, Whittaker AC. Anxiety, history of childhood adversity, and experiencing chronic pain in adulthood: A systematic literature review and meta-analysis. Eur J Pain. 2024;28(6):867–85. Jiang C, Jiang S. Effects of Adverse Childhood Experiences on Late-life Mental Health: Potential Mechanisms Based on a Nationally Representative Survey in China. Arch Gerontol Geriatr. 2022;100:104648. Cecere L, de Novellis S, Gravante A, Petrillo G, Pisani L, Terrenato I, Ivziku D, Latina R, Gravante F. Quality of life of critical care nurses and impact on anxiety, depression, stress, burnout and sleep quality: A cross-sectional study. Intensive Crit Care Nurs. 2023;79:103494. McLafferty M, Armour C, Bunting B, Ennis E, Lapsley C, Murray E, O'Neill S. Coping, stress, and negative childhood experiences: The link to psychopathology, self-harm, and suicidal behavior. Psych J. 2019;8(3):293–306. Yu-lian HU, Y-qZ. Effects of work stress, psychological resilience and perceived social support on compassion fatigue of nurses in assisted reproduction departments. J Shanghai Jiao Tong Univ (Medical Science). 2021;41(12):1565–71. Guo YF, Cross W, Plummer V, Lam L, Luo YH, Zhang JP. Exploring resilience in Chinese nurses: a cross-sectional study. J Nurs Manag. 2017;25(3):223–30. Sabaß L, Buchenrieder N, Rek SV, Nenov-Matt T, Lange J, Barton BB, Musil R, Jobst A, Padberg F, Reinhard MA. Attachment mediates the link between childhood maltreatment and loneliness in persistent depressive disorder. J Affect Disord. 2022;312:61–8. Issler TC, Ferreira de Sá D, Michael T, Schäfer SK. The relationship between childhood gender nonconformity, aversive childhood experiences, and mental health in heterosexual and non-heterosexual cisgender men: The buffering effect of sense of coherence. Stress Health. 2023;39(4):782–97. Curtis A, Kirwan EM, Luchetti M, Creaven AM, Turiano N, McGeehan M, Graham EK, O'Súilleabháin PS. Loneliness Links Adverse Childhood Experiences to Mortality Risk Across 26 Years. J Gerontol B Psychol Sci Soc Sci 2025, 80(6). Zhang T, Liu R, Li Y, Luo L, Shi W. Adverse childhood experiences with physical, depressive, and cognitive multimorbidity among Chinese adults and the mediating role of loneliness. J Affect Disord. 2025;381:190–9. Kohnen D, De Witte H, Schaufeli WB, Dello S, Bruyneel L, Sermeus W. What makes nurses flourish at work? How the perceived clinical work environment relates to nurse motivation and well-being: A cross-sectional study. Int J Nurs Stud. 2023;148:104567. Basting EJ, Medenblik AM, Eberwein JD, Garner AR, Shorey RC, Stuart GL. Adverse childhood experiences, posttraumatic stress disorder symptoms, and compulsive behaviors among adults in substance use treatment: A latent class analysis. J Trauma Stress. 2024;37(6):971–83. Vazquez M, Palo A, Schuyler M, Small BJ, McGuire JF, Wilhelm S, Goodman WK, Geller D, Storch EA. The Relationship Between Adverse Childhood Experiences, Symptom Severity, Negative Thinking, Comorbidity, and Treatment Response in Youth with Obsessive-Compulsive Disorder. Child Psychiatry Hum Dev. 2024;55(5):1201–10. Lafleur DL, Petty C, Mancuso E, McCarthy K, Biederman J, Faro A, Levy HC, Geller DA. Traumatic events and obsessive compulsive disorder in children and adolescents: is there a link? J Anxiety Disord. 2011;25(4):513–9. Destrée L, Brierley ME, Albertella L, Jobson L, Fontenelle LF. The effect of childhood trauma on the severity of obsessive-compulsive symptoms: A systematic review. J Psychiatr Res. 2021;142:345–60. Clemens V, Bürgin D, Eckert A, Kind N, Dölitzsch C, Fegert JM, Schmid M. Hypothalamic-pituitary-adrenal axis activation in a high-risk sample of children, adolescents and young adults in residential youth care - Associations with adverse childhood experiences and mental health problems. Psychiatry Res. 2020;284:112778. Kuzu Durmaz A, Çiçekoğlu Öztürk P, Çevik, Durmaz Y. Work stress and obsessive-compulsive symptoms in nurses and office workers: a comparative study. Int J Occup Saf Ergon 2024, 30(3):711–716. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7364698","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":515605760,"identity":"a65e8934-f029-408b-8163-07000d571e3e","order_by":0,"name":"Qing Wang","email":"","orcid":"","institution":"Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Qing","middleName":"","lastName":"Wang","suffix":""},{"id":515605761,"identity":"a98322d0-3069-4ad1-8cfc-abac322a7072","order_by":1,"name":"Chongmei Huang","email":"","orcid":"","institution":"Ningxia Medical 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(The First Affiliated Hospital of Hunan Normal University)","correspondingAuthor":true,"prefix":"","firstName":"Yamin","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2025-08-13 11:53:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7364698/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7364698/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91599737,"identity":"0f68aef2-4d9c-4b25-a5ae-726cc39707a3","added_by":"auto","created_at":"2025-09-18 08:24:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54162,"visible":true,"origin":"","legend":"\u003cp\u003eStudy population flowchart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7364698/v1/eed9fd2b2cc55de59e61d1ea.png"},{"id":108804179,"identity":"9bcee357-1ffd-4bbe-91ec-7f716d5cd1b7","added_by":"auto","created_at":"2026-05-08 15:17:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":704715,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7364698/v1/f4a6088f-b6eb-4c10-993e-3198479f80e7.pdf"},{"id":91600019,"identity":"2ec552bd-7f05-4715-9074-273694fa62f2","added_by":"auto","created_at":"2025-09-18 08:32:39","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":30457,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7364698/v1/5efbe7cae4e1e322293ab918.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association Between Adverse Childhood Experiences and Mental Health among Nurses: A Propensity Score Matching Analysis","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eNursing is a profession characterized by occupational stressors, including long shifts, heavy workloads, and continual exposure to patients\u0026rsquo; suffering and death [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These occupational stressors increase the profession\u0026rsquo;s prevalence of mental health outcomes (e.g., depressive symptoms). These outcomes directly compromise care quality and patient safety, so identifying their risk factors is critical [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although occupational stressor is a well-established driver of poor mental health outcomes in nurses, how the early-life risk factors shape these outcomes remains unclear [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdverse Childhood Experiences (ACEs) are significant early-life risk factors for later mental health. ACEs are defined as a comprehensive array of negative events and experiences occurring during the vulnerable developmental phases of childhood and adolescence [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These experiences can cause persistent neurobiological changes, including brain structure/function alterations and hypothalamic-pituitary-adrenal axis dysregulation. These changes plays a key role in the occurrence and development of mental problems in adulthood [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Given the pivotal role of nurses in the healthcare system, an in-depth investigation of the impact mechanisms of ACEs on their mental health would contribute to the theoretical framework of occupational health. Moreover, such research could provide scientific evidence for developing targeted mental health interventions, ultimately improving healthcare service quality.\u003c/p\u003e\u003cp\u003eThe relationship between ACEs and mental health among nurses is multi-dimensional and influenced by a complex interplay of various confounders. Many studies show that individual-level factors may interact with occupational factors to influence nurses\u0026rsquo; mental health [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, when examining the association between ACEs and mental health among nurses, it is essential to account for potential confounders to avoid biased estimates. However, existing research relies on conventional regression analysis that neither accounts for high-dimensional confounder interactions nor block selection biases.\u003c/p\u003e\u003cp\u003eTo address the aforementioned methodological limitations, a robust methodological approach is crucial to accurately delineate the true relationship between ACEs and mental health outcomes among nurses. PSM can estimate the probability of ACEs exposure and construct comparable exposed and unexposed groups [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. By balancing potential confounders across groups, PSM reduces selection bias and enhances the internal validity of the study, allowing for a more accurate assessment of causal relationships [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In observational research, this approach effectively simulates a randomized controlled trial, thereby improving the accuracy of causal inferences regarding the impact of ACEs on nurses\u0026rsquo; mental health.\u003c/p\u003e\u003cp\u003eTherefore, propensity score matching analysis is used to quantify how ACEs shape nurses\u0026rsquo; mental health.\u003c/p\u003e"},{"header":"2 Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Participants\u003c/h2\u003e\u003cp\u003eThis study utilized baseline data from the Nurses\u0026rsquo; Mental Health Study (NMHS), a nationally representative, multicenter prospective cohort study designed to investigate mental health among registered nurses in China [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The NMHS employed a stratified cluster sampling approach to recruit participants from 62 tertiary hospitals across all 31 provincial-level administrative regions in mainland China, ensuring the demographic and geographic representativeness of nurses working in tertiary healthcare facilities. All participants gave written informed consent, and the research protocol was ethically approved by all involved institutions\u0026rsquo; review boards, led by the primary institution (Approval number: E20230048). The protocol of NMHS was registered prospectively with the Chinese Clinical Trial Registry (Registration Number: ChiCTR2300072142). Baseline data were collected between December 2023 and January 2024.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eOf 147,832 invited nurses, 135,161 completed the online survey. After quality screening conducted by two investigators to exclude duplicates and inadequate responses, 132,910 participants were eligible for the NMHS baseline analysis (validity rate: 89.91%). We excluded: 1) individuals with physician-diagnosed psychiatric disorders, and 2) those with a family history of mental disorders. The sample selection process is shown in Fig.\u0026nbsp;1. A total of 121,017 nurses were included in this study.\u003c/p\u003e\u003cp\u003eFigure 1 Study population flowchart\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Measures\u003c/h2\u003e\u003cp\u003e Based on the study objectives and a comprehensive literature review, we selected ACEs as the exposure variable. The outcome variables comprised five mental health variables, including depressive symptoms, anxiety symptoms, loneliness, perceived stress, and obsessive symptoms. To account for potential confounding factors, we included three categories of covariates: 1) sociodemographic factors (age, gender, education, marital status, and religion), 2) occupational characteristics (employing hospital, years of working experience, weekly working hours, professional title, administrative position, and clinical department), and 3) health-related factors (exercise frequency and pain).\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\u003ch2\u003e2.2.1 Exposure Variable: Adverse Childhood Experiences\u003c/h2\u003e\u003cp\u003eThe Childhood Trauma Questionnaire (CTQ) has five dimensions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]: 1) emotional neglect: I felt loved; 2) emotional abuse: someone in my family hated me; 3) physical abuse: people in my family hit me so hard that it left me with bruises or marks; 4) physical neglect: there was someone to take me to the doctor if I need it; and 5) sexual abuse: someone molested me (took advantage of me sexually). Responses were recorded using a 5-point Likert scale ranging from \u0026ldquo;never\u0026rdquo; to \u0026ldquo;very often\u0026rdquo;. Items assessing emotional neglect and physical neglect were scored in the reverse direction. Based on our analytical purposes and the classification of other research [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], we dichotomized the ACEs exposure variable, classifying participants as having ACEs if they 1) endorsed affirmative response (scores \u0026ge; \u0026ldquo;sometimes\u0026rdquo;) on any of the dimensions of emotional abuse, physical abuse, or sexual abuse, or 2) reported negative responses (scoring \u0026le; \u0026ldquo;sometimes\u0026rdquo;) to the dimensions of emotional neglect or physical neglect. The Chinese version of the CTQ demonstrated good reliability and validity, with a Cronbach\u0026rsquo;s \u003cem\u003eα\u003c/em\u003e coefficient of 0.79 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e\u003cem\u003e2.2.2 Outcome Variable: Mental Health\u003c/em\u003e\u003c/h2\u003e\u003cdiv id=\"Sec7\" class=\"Section4\"\u003e\u003ch2\u003e2.2.2.1 Depressive symptom\u003c/h2\u003e\u003cp\u003eThe depressive symptoms were evaluated using the 9-item Patient Health Questionnaire (PHQ-9) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], which is based on DSM-IV criteria for major depressive disorder. This instrument employs a 4-point Likert scale (0 = \u0026ldquo;not at all\u0026rdquo; to 3 = \u0026ldquo;nearly every day\u0026rdquo;), with total scores ranging from 0 to 27. Higher scores indicate greater severity of symptoms, with established clinical cutoffs: 5\u0026ndash;9 (mild), 10\u0026ndash;14 (moderate), 15\u0026ndash;19 (moderately severe), and \u0026ge;\u0026thinsp;20 (severe depression). The Chinese version of PHQ-9 has demonstrated good reliability in Chinese populations, with reported Cronbach\u0026rsquo;s \u003cem\u003eα\u003c/em\u003e coefficients ranging from 0.765 to 0.938 in various validation studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section4\"\u003e\u003ch2\u003e2.2.2.2 Anxiety symptoms\u003c/h2\u003e\u003cp\u003eAnxiety symptoms were measured through the 7-item Generalized Anxiety Disorder scale (GAD-7) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], consistent with DSM-IV diagnostic parameters for generalized anxiety disorder. The scale utilizes a 4-point response format (0\u0026ndash;3), with total scores ranging from 0 to 21; higher scores indicate increased severity of anxiety. The GAD-7 scale has been psychometrically validated in Chinese samples, demonstrating strong internal consistency with Cronbach\u0026rsquo;s \u003cem\u003eα\u003c/em\u003e coefficient values exceeding 0.70 in both clinical and community populations [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section4\"\u003e\u003ch2\u003e2.2.2.3 Loneliness\u003c/h2\u003e\u003cp\u003eLoneliness was screened by using the single-item dichotomous measure: \u0026ldquo;Do you frequently experience feelings of loneliness?\u0026rdquo; (Yes / No). This efficient screening tool demonstrates strong criterion validity (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.78) against established multi-item loneliness scales among healthcare populations [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The Mexican Health and Aging Study (MHAS), a nationwide longitudinal study in Mexico, used the same single-item question to assess loneliness among older Mexican adults [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section4\"\u003e\u003ch2\u003e2.2.2.4 Perceived stress\u003c/h2\u003e\u003cp\u003ePerceived stress was assessed via the 4-item Perceived Stress Scale (PSS-4) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], derived from the full 10-item PSS. This abbreviated version employs a 5-point Likert scale (0 = \u0026ldquo;never\u0026rdquo; to 4 = \u0026ldquo;very often\u0026rdquo;), with total scores from 0 to 16. Higher scores reflect a greater level of perceived stress.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section4\"\u003e\u003ch2\u003e2.2.2.5 Obsessive symptoms\u003c/h2\u003e\u003cp\u003eObsessive symptoms were assessed using five Symptom Checklist-90 items (SCL-90) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]: 1) Cognitive intrusions: Unwanted thoughts, words, or ideas that won\u0026rsquo;t leave your mind; 2) Appearance preoccupation: Worried about sloppiness or carelessness; 3) Perfectionistic behaviors: Having to do things very slowly to insure correctness; 4) Checking compulsions: Having to check and double-check what you do; 5) Ritualistic behaviors: Having to repeat the same actions such as touching, counting, washing. SCL-90 is widely used in the Chinese general population [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and these items evaluate intrusive thoughts and compulsive behaviors through a 5-point severity scale (0 = \u0026ldquo;not at all\u0026rdquo; to 4 = \u0026ldquo;extremely\u0026rdquo;).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e2.2.3 Covariates\u003c/h2\u003e\u003cp\u003eTo comprehensively account for potential confounding factors, covariates were selected from factors associated with both ACEs and mental health outcomes. Sociodemographic covariates included age, gender, education, marital status, and religion. Occupational covariates comprised employing hospital, years of working experience, weekly working hours, professional title, administrative position, and clinical department. Health-related covariates incorporated exercise frequency and pain.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was performed using SPSS 26.0 and R 4.4.3 software. Continuous variables, including age and years of work experience, were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (\u003cem\u003ex̄\u003c/em\u003e \u0026plusmn; \u003cem\u003es\u003c/em\u003e). Categorical variables were reported as frequency (\u003cem\u003en\u003c/em\u003e) with corresponding percentages (%). Groups were compared with independent samples t-tests for normally distributed continuous variables and chi-square tests for categorical variables. The assumption of normality was verified using Shapiro-Wilk tests.\u003c/p\u003e\u003cp\u003eTo minimize potential confounding factors, we employed propensity score matching (PSM) with a 1:1 nearest-neighbor algorithm. The matching procedure incorporated multiple covariates: demographic characteristics (age, gender, education, marital status, religion), occupational factors (employing hospital, years of working experience, weekly working hours, professional title, administrative position, department), and health-related variables (exercise frequency, pain). A caliper width of 0.02 standard deviations of the propensity score logit was used to ensure matching quality while preserving adequate sample size. The balance of baseline characteristics between matched groups was evaluated using standardized mean differences (SMD), with an SMD\u0026thinsp;\u0026lt;\u0026thinsp;0.1 considered indicative of satisfactory balance, suggesting minimal differences between the study groups.\u003c/p\u003e\u003cp\u003e This study employed PSM followed by independent samples t-tests (for continuous variables) and chi-square tests (for categorical variables) to examine differences in mental health between nurses with and without ACEs. To strengthen the robustness of our findings, we further conducted both binary logistic regression and multivariable linear regression analysis to evaluate the association between ACEs and mental health among nurses.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Result","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Participant Characteristics\u003c/h2\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, 49.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;59,912) of 121,017 nurse participants reported ACEs. Their mean age is 33.34 years (SD\u0026thinsp;=\u0026thinsp;7.302), with a predominance of female nurses (93.4%). The majority held bachelor\u0026rsquo;s degrees (87.2%) and were married (68.2%). 94.5% of the nurses held no administrative positions, and clinical nurses comprise 94.0% of the study population. Nurses worked a mean of 38.17 hours (SD\u0026thinsp;=\u0026thinsp;13.169) per week, and their average working experience was 10.80 years (SD\u0026thinsp;=\u0026thinsp;8.150).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;121017 (\u003cem\u003ex̄\u003c/em\u003e \u0026plusmn; \u003cem\u003es\u003c/em\u003e; %)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.34\u0026thinsp;\u0026plusmn;\u0026thinsp;7.302\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYears of working experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.80\u0026thinsp;\u0026plusmn;\u0026thinsp;8.150\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeekly working hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38.17\u0026thinsp;\u0026plusmn;\u0026thinsp;13.169\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReligion (No)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e113489 (93.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (Female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e112980 (93.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional title\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRN-Level I\u0026nbsp;(Junior Staff Nurse)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19237 (15.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRN-Level II\u0026nbsp;(Senior Staff Nurse)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44150 (36.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRN-Level III\u0026nbsp;(Nurse Manager)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51900 (42.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRN-Level IV\u0026nbsp;(Associate Director of Nursing)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5013 (4.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRN-Level V\u0026nbsp;(Director of Nursing)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e717 (0.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdministrative position\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e114399 (94.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHead Nurse / Unit Nursing Manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6477 (5.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirector of Nursing / Deputy Director of Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e141 (0.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary specialized education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e433 (0.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAssociate degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10059 (8.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e105482 (87.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaster\u0026rsquo;s degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4933 (4.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDoctoral degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e110 (0.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle (Never married)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35474 (29.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82541 (68.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2522 (2.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRemarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e233 (0.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e247 (0.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse category\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e113729 (94.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-Clinical Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7288 (6.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepartment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInternal Medicine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31463 (26.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26945 (22.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObstetrics \u0026amp; Gynecology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6104 (5.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOphthalmology \u0026amp; Otorhinolaryngology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3812 (3.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePediatrics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4062 (3.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychiatry Department\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e871 (0.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfectious Diseases Department\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1851 (1.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntensive Care Unit (ICU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14107 (11.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutpatient Clinic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5594 (4.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmergency Department\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7379 (6.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating Room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9044 (7.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNursing Department\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1357 (1.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8428 (7.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain (No)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e112311 (92.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExercise frequency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49826 (41.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;1 time per week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52005 (43.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;3 times per week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14741 (12.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u0026ndash;5 times per week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3229 (2.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDaily\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1216 (1.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eACEs (No)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61105 (50.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLoneliness (No)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95205 (78.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.104\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepressive symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.21\u0026thinsp;\u0026plusmn;\u0026thinsp;4.340\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived stress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.686\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObsessive symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.389\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Participant Characteristics Before and After Propensity Score Matching\u003c/h2\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, baseline characteristics reduced from 59,912 controls and 61,105 ACE pre-matching to 53,115 matched pairs post-matching. Before PSM, significant group differences existed across multiple domains including demographic (age, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.023; gender, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; education, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001; marital status, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; religion, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), occupational (years of working experience, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001; department, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; employing hospital, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; weekly working hours, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; professional title, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; administrative position, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and health-related variables (pain, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, exercise frequency, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with SMD ranging up to 0.234 for employing hospital. After implementing 1:1 nearest-neighbor matching with a 0.2 caliper width, all covariates achieved excellent balance as evidenced by SMD below 0.02 (range: 0.001\u0026ndash;0.020) and non-significant p-values (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.18), indicating successful mitigation of selection bias. The matched cohorts established comparable groups for subsequent outcome analysis and maintained the study\u0026rsquo;s original sample representativeness.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Characteristics Before and After Propensity Score Matching\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eBefore PSM\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003eAfter PSM\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;59912)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eACE\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;61105)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eSMD\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53115)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eACE\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53115)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eSMD\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.39\u0026thinsp;\u0026plusmn;\u0026thinsp;7.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.29\u0026thinsp;\u0026plusmn;\u0026thinsp;7.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e33.32\u0026thinsp;\u0026plusmn;\u0026thinsp;7.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e33.35\u0026thinsp;\u0026plusmn;\u0026thinsp;7.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.540\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYears of working experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.88\u0026thinsp;\u0026plusmn;\u0026thinsp;8.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.72\u0026thinsp;\u0026plusmn;\u0026thinsp;8.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10.77\u0026thinsp;\u0026plusmn;\u0026thinsp;8.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e10.80\u0026thinsp;\u0026plusmn;\u0026thinsp;8.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.565\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeekly working hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38.48\u0026thinsp;\u0026plusmn;\u0026thinsp;12.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.85\u0026thinsp;\u0026plusmn;\u0026thinsp;13.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.048\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e38.13\u0026thinsp;\u0026plusmn;\u0026thinsp;12.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e38.13\u0026thinsp;\u0026plusmn;\u0026thinsp;13.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.920\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender (Male)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3340 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4697 (7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3282 (6.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3354 (6.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.368\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional title\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.996\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRN-Level I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9791 (16.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9446 (15.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8363 (15.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8336 (15.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRN-Level II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22191 (36.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21959 (36.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19410 (36.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19404 (36.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRN-Level III\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26042 (42.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25858 (43.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22880 (43.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22895 (43.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRN-Level IV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2683 (4.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2330 (3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2168 (4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2178 (4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRN-Level V\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e398 (0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e319 (0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e294 (0.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e302 (0.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdministrative position\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.042\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.967\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57475 (94.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56924 (95.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e50322 (94.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e50307 (94.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHead Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3555 (5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2922 (4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2734 (5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2747 (5.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirector of Nursing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75 (0.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66 (0.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e59 (0.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e61 (0.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.954\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary specialized education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e194 (0.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e239 (0.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e182 (0.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e189 (0.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAssociate degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4935 (8.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5124 (8.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4414 ( 8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4406 (8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBachelor's degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53479 (87.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52003 (86.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e46307 (87.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e46262 (87.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaster's degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2439 (4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2494 (4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2166 (4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2209 (4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDoctoral degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58 (0.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52 (0.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e46 (0.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e49 (0.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmploying hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.234\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.020\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReligion (No)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57808 (94.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55681 (92.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.069\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e49937 (94.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e49877 (93.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.646\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.060\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.966\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17654 (28.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17820 (29.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15554 (29.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e15534 (29.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42178 (69.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40363 (67.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36334 (68.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e36317 (68.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1037 (1.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1485 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1020 (1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1052 (2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRemarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e111 (0.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e122 (0.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e99 (0.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e102 (0.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e125 (0.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e122 (0.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e108 (0.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e110 (0.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse category (Clinic)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57350 (93.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56379 (94.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.070\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e49966 (94.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e49957 (94.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.917\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepartment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.059\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInternal Medicine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16021 (26.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15442 (25.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13907 (26.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e13865 (26.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13997 (22.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12948 (21.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11849 (22.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e11777 (22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObstetrics \u0026amp; Gynecology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3193 (5.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2911 (4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2677 (5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2666 (5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOphthalmology\u0026amp;Otorhinolaryngology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1920 (3.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1892 (3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1662 (3.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1707 (3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePediatrics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2002 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2060 (3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1786 (3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1788 (3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychiatry Department\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e451 (0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e420 (0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e376 (0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e387 (0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfectious Diseases Department\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e953 (1.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e898 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e819 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e816 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntensive Care Unit (ICU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6972 (11.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7135 (11.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6228 (11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6174 (11.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutpatient Clinic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2721 (4.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2873 (4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2446 (4.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2470 (4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmergency Department\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3472 (5.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3907 (6.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3202 (6.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3243 (6.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating Room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4373 (7.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4671 (7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3936 (7.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3934 (7.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNursing Department\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e680 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e677 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e589 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e601 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4350 (7.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4078 (6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3638 (6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3687 (6.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain (No)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57495 (94.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54916 (91.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e49580 (93.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e49470 (93.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExercise frequency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.097\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.989\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23716 (38.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26110 (43.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22027 (41.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22033 (41.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;1 time per week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27348 (44.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24657 (41.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22739 (42.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22725 (42.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;3 times per week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7694 (12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7047 (11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6431 (12.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6413 (12.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u0026ndash;5 times per week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1715 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1514 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1375 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1403 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDaily\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e632 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e584 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e543 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e541 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Mental Health Outcomes Before and After Propensity Score Matching\u003c/h2\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, before PSM, significant differences in all measured mental health outcomes were observed between nurses with and without ACEs (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). After matching 53,115 pairs, nurses with ACEs had significantly higher rates of loneliness (27.2% vs 15.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), greater anxiety symptoms (GAD-7 scores: 11.03\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89 vs 9.74\u0026thinsp;\u0026plusmn;\u0026thinsp;3.32, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), depressive symptoms (PHQ-9 scores: 15.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.53 vs 13.43\u0026thinsp;\u0026plusmn;\u0026thinsp;3.92, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and obsessive symptoms (SCL-90 scores: 8.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57 vs 7.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.09, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to nurses without ACEs. In contrast, nurses with ACEs reported lower levels of perceived stress (PSS-4 scores: 11.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.38 vs 11.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to nurses without ACEs.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMental Health Outcomes Before and After Propensity Score Matching\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eBefore PSM\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eAfter PSM\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;59912)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eACE\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;61105)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53115)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eACE\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53115)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLoneliness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e51827 (84.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43378 (72.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e44785 (84.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e38686 (72.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9278 (15.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16534 (27.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8330 (15.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e14429 (27.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.68\u0026thinsp;\u0026plusmn;\u0026thinsp;3.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.07\u0026thinsp;\u0026plusmn;\u0026thinsp;3.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.74\u0026thinsp;\u0026plusmn;\u0026thinsp;3.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e11.03\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepressive symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.09\u0026thinsp;\u0026plusmn;\u0026thinsp;4.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13.43\u0026thinsp;\u0026plusmn;\u0026thinsp;3.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e15.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived stress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e11.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObsessive symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.80\u0026thinsp;\u0026plusmn;\u0026thinsp;3.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.90\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Regression analysis of the mental health outcomes\u003c/h2\u003e\u003cp\u003eFully-adjusted models show ACEs strongly predict worse nurse mental health: loneliness odds double(\u003cem\u003eOR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.026, 95% \u003cem\u003eCI\u003c/em\u003e: 1.965\u0026ndash;2.089, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), anxiety (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.175, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;59.145, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), depressive (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.186, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;62.935, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and obsessive symptoms heightened (β\u0026thinsp;=\u0026thinsp;0.148, t\u0026thinsp;=\u0026thinsp;49.57, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while perceived stress declined (\u003cem\u003eβ\u003c/em\u003e = -0.072, \u003cem\u003et\u003c/em\u003e = -23.721, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Supplementary 1).\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis study used PSM to investigate the association between ACEs and mental health among nurses. Our findings revealed that ACE were associated with higher level of anxiety, depressive and obsessive symptoms among Chinese nurses. Contrary to our hypothesis, ACEs were associated with lower levels of perceived stress among nurses.\u003c/p\u003e\u003cp\u003eOur findings indicated that nurses with ACEs reported significantly higher levels of both anxiety and depressive symptoms compared to those without ACEs. Our findings are consistent with the findings of previous research [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A meta-analysis of the relationship between ACEs, anxiety, and chronic pain found that individuals with ACEs are at a higher risk of developing anxiety disorders compared to those without such experiences [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Similarly, a systematic review of ACEs and depression reported a strong association between them, highlighting the long-term impact of ACEs on mental health [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The positive association can be attributed to a combination of neurobiological, psychological, and occupational factors. Neurobiologically, ACEs dysregulate the HPA axis, heightening stress reactivity and altering amygdala-hippocampus-prefrontal circuits, thereby increasing vulnerability to anxiety and depression. Psychologically, ACEs can disrupt the development of healthy coping mechanisms and emotional regulation skills, leading to maladaptive behaviors and increased vulnerability to mental health disorders [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Additionally, ACEs can impact social and interpersonal functioning, leading to difficulties in forming supportive relationships, which are critical protective factors against mental health problems [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The high-stress work environment and demanding job requirements can exacerbate these symptoms [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The emotional and physical demands of patient care can lead to emotional exhaustion and burnout, particularly among those with a history of ACEs who may struggle with emotional regulation and stress management [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInterestingly, our study found that nurses with ACEs reported lower levels of stress compared to those without ACEs. Inconsistently, a previous study links ACEs to elevated perceived stress among North European university students [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The inconsistency may be attributed to the difference in the study populations and culture. North European university students often face academic and career-related stress. This stress may exacerbate their vulnerability when combined with ACEs [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In contrast, Chinese nurses, shaped by occupational training and workplace adaptation, tend to develop better coping strategies which can cushion the effects of ACEs on perceived stress [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The individualistic culture in Northern Europe tends to encourage open expression of stress and help-seeking behaviors, resulting in higher reported stress levels [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In contrast, collectivist cultures like China emphasize emotional resilience and stress reappraisal, leading to lower self-reported stress despite potentially similar underlying distress levels [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur study found that nurses exposed to ACEs were more likely to experience loneliness compared to those without such exposure. Consistently, previous studies showed that ACEs are associated with increased feelings of loneliness in adulthood [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This can be attributed to the long-term effects of ACEs on social and emotional development. ACEs can disrupt early attachment processes, leading to difficulties in forming secure and supportive relationships in later life [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Additionally, the heightened sense of loneliness among nurses with ACEs may be amplified by their demanding and isolating work environments [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur findings demonstrate that nurses with ACEs report significantly higher obsessive symptoms than their non-ACEs counterparts. This can be attributed to several interrelated mechanisms supported by existing literature [\u003cspan additionalcitationids=\"CR36 CR37\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Neurobiological sensitization from early-life stress leads to HPA axis dysregulation, amplifying stress reactivity in high-pressure nursing environments and manifesting as obsessive thoughts [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Furthermore, the nursing profession\u0026rsquo;s inherent requirements for precision and accountability may reinforce compulsive behaviors (e.g., repeated equipment checks), especially among those with ACEs who are predisposed to anxiety [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThis study provides compelling evidence that ACEs are significantly associated with poorer mental health outcomes among nurses. These findings underscore the importance of addressing early-life adversities in the context of occupational mental health.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eACEs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdverse childhood experiences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePSM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePropensity score matching\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNMHS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThe Nurses\u0026rsquo; Mental Health Study\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCTQ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThe Childhood Trauma Questionnaire\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Chinese Nursing Association (grant number: ZHKY202306).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics and dissemination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institute Review Board from the ethical committee of The Second Xiangya Hospital of Central South University (E20230048) and NMHS was performed in line with Helsinki Declarations. All participants gave written informed consent, and the research protocol was ethically approved by all involved institutions\u0026rsquo; review boards, led by the primary institution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have participated in the study and have read and approved the submitted version of the manuscript. \u003cstrong\u003eQing Wang:\u0026nbsp;\u003c/strong\u003eWriting - Original draft, Writing - review \u0026amp; editing, Methodology, Data curation, Conceptualization, Formal analysis. \u003cstrong\u003eChongmei Huang:\u003c/strong\u003e Investigation, Formal analysis, Methodology, Writing - review \u0026amp; editing. \u003cstrong\u003eQiang Yu:\u003c/strong\u003e Investigation, Software, Writing-review.\u003cstrong\u003e\u0026nbsp;Yusheng Tian:\u003c/strong\u003e Visualization, Validation, Project administration. \u003cstrong\u003eJiaxin Yang:\u003c/strong\u003e Resources, Data curation.\u003cstrong\u003e\u0026nbsp;Xuting Li:\u003c/strong\u003e Methodology, Data curation. \u003cstrong\u003eZengyu Chen:\u003c/strong\u003e Investigation, Methodology, Data curation. \u003cstrong\u003eMeng Ning:\u003c/strong\u003e Investigation, Data curation, Software. \u003cstrong\u003eYiting Liu:\u003c/strong\u003e Software, Resources.\u003cstrong\u003e\u0026nbsp;Dan Zhang:\u003c/strong\u003e Investigation, Data curation. \u003cstrong\u003eChunhui Bin:\u003c/strong\u003e Visualization, Methodology.\u003cstrong\u003e\u0026nbsp;Jianghao Yuan:\u003c/strong\u003e Resources, Investigation. \u003cstrong\u003eYamin Li:\u003c/strong\u003e Resources, Supervision, Funding acquisition, Conceptualization, Writing - review\u0026nbsp;\u0026amp;\u0026nbsp;editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch data are not shared\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHavaei F, Ji XR, MacPhee M, Straight H. Identifying the most important workplace factors in predicting nurse mental health using machine learning techniques. BMC Nurs. 2021;20(1):216.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYu Q, Huang C, Tian Y, Yang J, Li X, Ning M, Chen Z, Du J, He J, Li Y. Factors associated with clinical nurse's mental health: a qualitative study applying the social ecological model. BMC Nurs. 2024;23(1):330.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhao Y, Liu F, Lin P, Tu Z, Wu B. Sleep quality and mental health among Chinese nurses after the COVID-19 pandemic: A moderated model. PLoS ONE. 2024;19(5):e0295105.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFelitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. 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Loneliness Links Adverse Childhood Experiences to Mortality Risk Across 26 Years. J Gerontol B Psychol Sci Soc Sci 2025, 80(6).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang T, Liu R, Li Y, Luo L, Shi W. Adverse childhood experiences with physical, depressive, and cognitive multimorbidity among Chinese adults and the mediating role of loneliness. J Affect Disord. 2025;381:190\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKohnen D, De Witte H, Schaufeli WB, Dello S, Bruyneel L, Sermeus W. What makes nurses flourish at work? How the perceived clinical work environment relates to nurse motivation and well-being: A cross-sectional study. Int J Nurs Stud. 2023;148:104567.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBasting EJ, Medenblik AM, Eberwein JD, Garner AR, Shorey RC, Stuart GL. Adverse childhood experiences, posttraumatic stress disorder symptoms, and compulsive behaviors among adults in substance use treatment: A latent class analysis. J Trauma Stress. 2024;37(6):971\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVazquez M, Palo A, Schuyler M, Small BJ, McGuire JF, Wilhelm S, Goodman WK, Geller D, Storch EA. The Relationship Between Adverse Childhood Experiences, Symptom Severity, Negative Thinking, Comorbidity, and Treatment Response in Youth with Obsessive-Compulsive Disorder. Child Psychiatry Hum Dev. 2024;55(5):1201\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLafleur DL, Petty C, Mancuso E, McCarthy K, Biederman J, Faro A, Levy HC, Geller DA. Traumatic events and obsessive compulsive disorder in children and adolescents: is there a link? J Anxiety Disord. 2011;25(4):513\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDestr\u0026eacute;e L, Brierley ME, Albertella L, Jobson L, Fontenelle LF. The effect of childhood trauma on the severity of obsessive-compulsive symptoms: A systematic review. J Psychiatr Res. 2021;142:345\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eClemens V, B\u0026uuml;rgin D, Eckert A, Kind N, D\u0026ouml;litzsch C, Fegert JM, Schmid M. Hypothalamic-pituitary-adrenal axis activation in a high-risk sample of children, adolescents and young adults in residential youth care - Associations with adverse childhood experiences and mental health problems. Psychiatry Res. 2020;284:112778.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuzu Durmaz A, \u0026Ccedil;i\u0026ccedil;ekoğlu \u0026Ouml;zt\u0026uuml;rk P, \u0026Ccedil;evik, Durmaz Y. Work stress and obsessive-compulsive symptoms in nurses and office workers: a comparative study. \u003cem\u003eInt J Occup Saf Ergon\u003c/em\u003e 2024, 30(3):711\u0026ndash;716.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adverse childhood experiences, Nurse, Mental health, Propensity score matching","lastPublishedDoi":"10.21203/rs.3.rs-7364698/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7364698/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eNursing is a highly stressful profession with elevated risks of mental health issues. Although occupational stress is a well-established driver of poor mental health in nurses, the added impact of adverse childhood experiences (ACEs) on nurses\u0026rsquo; mental health remains unclear. This study aims to examine the association between ACEs and mental health by using propensity score matching (PSM).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a cross-sectional analysis of baseline data from the Nurses\u0026rsquo; Mental Health Study (NMHS), a nationwide multicenter prospective cohort study covers 67 tertiary hospitals across China\u0026rsquo;s 31 provincial-level regions. The Childhood Trauma Questionnaire (CTQ) was used to assess ACEs exposure. Outcomes included depressive symptoms (PHQ-9), anxiety (GAD-7), perceived stress (PSS-4), obsessive symptoms (SCL-90) and loneliness. We employed 1:1 nearest-neighbor propensity score matching with a caliper width of 0.02 to reduce selection bias, and regression analysis was applied to strengthen the robustness of the results.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 121,017 nurses participated, with 93.4% female and 68.2% married. ACEs were reported by 49.5%. After propensity score matching adjustment, nurses with ACEs exhibited substantially higher prevalence of loneliness (27.2% vs 15.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), more severe anxiety symptoms (GAD-7 scores: 11.03\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89 vs 9.74\u0026thinsp;\u0026plusmn;\u0026thinsp;3.32, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), depressive symptoms (PHQ-9 scores: 15.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.53 vs 13.43\u0026thinsp;\u0026plusmn;\u0026thinsp;3.92, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and obsessive symptoms (SCL-90 scores: 8.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57 vs 7.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.09, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to counterparts, but paradoxically showing lower levels of perceived stress (PSS-4 scores: 11.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.38 vs 11.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Regression analyses confirmed that ACEs emerged as a strong independent predictor of mental health.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThis study provides robust evidence that ACEs are strongly associated with poorer mental health among Chinese nurses, but the perceived stress is the opposite. The findings highlight the impact of ACEs on nurses\u0026rsquo; psychological well-being and contribute to developing targeted interventions to reduce ACE-related psychological risks.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e\u003cp\u003eRegistry Chinese Clinical Trail Registry, Registration Number ChiCTR2300072142, Registration date 5th June 2023.\u003c/p\u003e","manuscriptTitle":"Association Between Adverse Childhood Experiences and Mental Health among Nurses: A Propensity Score Matching Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-18 08:24:34","doi":"10.21203/rs.3.rs-7364698/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"542aa944-cede-49c3-865a-66c8a2f05112","owner":[],"postedDate":"September 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T05:25:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-18 08:24:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7364698","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7364698","identity":"rs-7364698","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}