Effects of a work stress coping program based on social support theory for nurses returning to work after childbirth: A quasi-experimental study

Effects of a work stress coping program based on social support theory for nurses returning to work after childbirth: A quasi-experimental study | 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 Effects of a work stress coping program based on social support theory for nurses returning to work after childbirth: A quasi-experimental study Suya Li, Minfeng Yu, Yu Liu, Tieying Zeng, Jianrong Yue, Wenyan Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6509772/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Social support theory has been useful in stress management. The number of nurses returning to work after childbirth is increasing. However, return to work is often accompanied by substantial stress and return discomfort. Therefore, it is necessary to develop and implement coping measures based on social support theory. Objective To construct a work stress coping program based on social support theory and evaluate its effectiveness in reducing negative emotions and promoting return adaptation among nurses returning to work after childbirth. Design A two-armed, quasi-experimental study design. Methods Participants were assigned to either the intervention or control group depending on different hospital campuses. The control group received routine return management. The intervention group additionally received a 6-month stress coping program. Data at T0 (pre-intervention), T1 (one month post-intervention), T2 (three months post-intervention), and T3 (six months post-intervention) were collected. Intra- and inter-group differences were assessed using t-tests and repeated measures analysis of variance. Results No significant differences were found in baseline comparisons. After the intervention, the intervention group was more effective in improving work stress, postnatal depression, social support, and return adaptation compared to the control group. Significant group × time interactions were observed for work pressure, postpartum depression, and return adaptation. Conclusion The work stress coping program based on social support theory effectively alleviated the work stress and depression of nurses returning to work after childbirth and achieved a good return adaptation. Nurse Return to work Stress Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Nurses are an integral and growing component of the healthcare system. According to the "State of the World's Nursing 2020", the global nursing workforce reached 27.9 million. Among them, 38% were under the age of 35 and were in the childbearing age [ 1 ]. Over the past decade, China has experienced an annual average increase of 8% in its nursing workforce. By the end of 2021, the registered nurses in China surpassed 5 million, with 67% of them being under the age of 35 [ 2 ]. In 2021, China adjusted its national fertility policy, raising the limit on the number of children per couple from two to three [ 3 , 4 ]. Consequently, nurses, dominated by women of childbearing age, entered another peak of second childbirth, and the number of nurses who return to work (RTW) after childbirth continued to grow. Nursing is a high-pressure profession, exposed to numerous stressors, such as heavy workloads, irregular shift work, and complex medical environments [ 5 ]. To make matters worse, nurses returning to work after a prolonged period of maternity leave face the additional challenges of physical recovery, breastfeeding and childcare, and work adaptation [ 6 , 7 ]. Previous surveys have indicated that nurses returning to work after childbirth commonly exhibit high work stress and poor readjustment to RTW, which affects the quality of nursing care [ 8 – 10 ]. In addition, high levels of job stress are associated with negative physical and mental health among nurses, as well as high turnover rates [ 5 , 11 , 12 ]. Therefore, the high-stress levels of nurses deserve more attention. Currently, research on stress management for nurses has yielded favorable results. Lim demonstrated that stress management courses based on acceptance and commitment therapy significantly reduced perceived stress and fatigue among nursing students [ 11 ]. Hersch confirmed the effectiveness of a web-based stress management program in preventing the development of work stress among clinical nurses [ 5 ]. Alkhawaldeh also emphasized the feasibility of an interactive stress management program in public health nurses [ 13 ]. However, few experimental studies have focused on nurses returning to work after childbirth. Therefore, there is a lack of effective and safe interventions to address the specific stressors faced by nurses returning to work after maternity leave. Social support theory posits that social support can alleviate negative stress, and the stronger the social support, the better individuals can cope with stress [ 14 ]. The primary role of social support is to protect the physical and mental health of those under stress [ 15 , 16 ]. Numerous studies have shown that social support significantly improves stress and depression, and facilitates RTW adaptation after giving birth [ 17 – 19 ]. The need for social support for postnatal nurses returning to work is strong [ 4 ]. Therefore, this study aims to construct a work stress coping program based on social support theory and evaluate its effectiveness in reducing negative emotions and promoting RTW adaptation among nurses returning to work after childbirth. 2. Methods 2.1. Study design This study was a two-armed, quasi-experimental study performed from December 2022 to November 2023. Data were gathered at baseline, after one month, after three months, and after six months in an academic, medical, and teaching hospital in central China. This study met the ethical standards of medical research involving human subjects stipulated in the Declaration of Helsinki and was approved by the ethics committee of Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology (TJ-IRB20220968). Informed consent was obtained from all individual participants included in the study. In November 2022, it was registered in the Chinese Clinical Trial Registry at www.chictr.org.cn (registration number: ChiCTR2200065423). 2.2. Participants Participants were recruited from three campuses of a tertiary hospital in Hubei, Mainland China. Inclusion criteria were as follows: (1) nurses returning to work after childbirth; (2) nurses who can understand Chinese and speak Putonghua; and (3) nurses who can complete the questionnaire independently. Exclusion criteria were: (1) having depressive symptoms (undergoing psychotherapy or ≥ 13 points on the Edinburgh Postnatal Depression Scale); and (2) participation in other relevant studies. Informed consent was obtained from all participants during the recruitment phase. 2.3. Sample size G*Power software was used to calculate the sample size [ 20 ]. Since there were insufficient previous studies to calculate the effect size, this study used a medium effect size of 0.25 considering the available resources. Using a power of 0.8 and an alpha of 0.05, the study required a minimum sample size of 24 (each group). Considering a 15% attrition rate, the final sample size for each group was 28. Sample sizes for future large-scale intervention studies will be determined according to the results of this study. 2.4. Allocation procedures Different hospital campuses are generally separated by tens of kilometers, which helps to reduce the chance of contamination. For this reason, this study was conducted in three campuses of the same hospital. We determined the intervention site (Hankou campus) and the control sites (Guanggu and Zhongfa campuses) by drawing lots. Participants returned to either hospital campus according to departmental arrangements and were assessed for compliance with enrollment criteria upon return. 2.5. Intervention 2.5.1. Phase 1: Development of a work stress coping program based on social support theory We designed a work stress coping program based on social support theory. The theory suggests that social support mitigates negative stress and that the stronger the social support a person has, the better they can cope with challenges. Social support can be functionally categorized as emotional support (e.g., providing comfort or encouragement), instrumental support (e.g., providing practical assistance or resources), informational support (e.g., providing guidance or advice), and appraisal support (e.g., providing affirmation or praise). A questionnaire on stressors and support needs of nurses returning to work after childbirth was designed based on four types of support (emotional, instrumental, informational, and appraisal) and a literature review. Based on the results of 117 surveys of nurses returning to work after childbirth within one year, two supports were excluded as low need (telephone assistance line and clinical instructor). A multi-component intervention was initially developed, including text messaging, positive thinking exercises, website learning, and more. In addition, eight experts (two in nursing management, one in mother and child care, two in psychological care, and three in nursing education) with more than 10 years of experience were invited to discuss the form, content, and feasibility of the intervention, which ultimately resulted in a work stress coping program for nurses returning to work after childbirth, as shown in Table 1 . Table 1 The work stress coping program. Section Intervention type Intervention timing Intervention strategy Emotional support 1. Peer support As needed Form a WeChat group and invite well-adjusted nurses to share their experiences of returning to work. 2. SMS support Two per week Send 48 text messages for emotional inspiration. Instrumental support 1. Material support Day of return to work Provide gifts for returning to work (disposable breast pads, breast milk storage bags, parenting books, etc.). 2. Environmental rehabilitation As needed Set up a private space for breastfeeding or pumping. 3. Flexible scheduling Weekly Add a "scheduling preference form" to collect weekly scheduling requirements. Informational support 1. Expert consultation As needed Invite doctors and nurses from obstetrics and pediatrics to answer specialist questions within 24 hours. 2. Learning platform As needed Self-directed learning resources are provided through an education network ( https://www.512ks.cn/#/login ), including specialist training, mother and child care, stress management and more. Appraisal support 1. Welcome ceremony Day of return to work Invite returning nurses and their families to a welcome ceremony and give them letters of appreciation, encouragement, and support. 2. Award ceremony End of program Presentation of the "Amazing Nurse Mom" certificate. 2.5.2. Phase 2: Implementation of the developed intervention The intervention team consisted of a director of nursing, an obstetrician, a neonatal nurse specialist, a psychological counselor, and three registered nurses. The director of nursing was responsible for the supervision and promotion of the project; the obstetrician and the neonatal nurse specialist were responsible for the professional consultation on maternal and child care and the development of specialist courseware; the psychological counselor was responsible for developing motivational text messages and stress management courseware; and the three registered nurses were responsible for the implementation of the activities, management of the courses, data collection, and other assisting work. All researchers were trained in the work stress coping program, which consisted of (1) providing equipment training, (2) assisting with return-to-work administration, and (3) guiding participants in self-directed learning. We used a structured protocol to maintain intervention fidelity and held monthly meetings to discuss troubleshooting during the intervention. The intervention lasted six months, during which, if participants exhibited symptoms of depression, they were referred to a psychiatric clinic for treatment (≥ 13 points on the Edinburgh Postnatal Depression Scale). 2.6. Control group During the intervention, participants in the control group received routine RTW management, with relevant training initiated by the head nurse of each unit. The participants and their nurse practitioners did not know which allocation group they belonged to, but the researchers did. At the end of the study, participants in the control group were provided the opportunity to use the intervention program. 2.7. Measures Included participants completed assessments of the primary outcome (work stress) and secondary outcomes (social support, return adaptation, and postnatal depression) at T0 (pre-intervention), T1 (one month post-intervention), T2 (three months post-intervention), and T3 (six months post-intervention). The general characteristics questionnaire was completed only once at T0. 2.7.1. Participant characteristics Eligible participants were invited to complete the general characteristics questionnaire, which included information on demographics (age, work experience, education, etc.) and return to work after childbirth (maternity leave, weekly working hours, feeding, etc.). 2.7.2. Primary outcome measures The primary outcome (work pressure) was measured by the Mandarin Chinese version of the work stress scale [ 8 ]. The scale is a 30-item scale based on cognitive phenomenological transactional theory. All items are scored on a 5-point scale from 1 (never) to 5 (always). The total score fluctuates between 30 and 150 points. The higher the score, the greater the work stress. The scale proved to be reliable and valid when applied to nurses returning to work after childbirth, with a total Cronbach's α coefficient of 0.94 and Cronbach's α coefficients ranging from 0.73 to 0.8 for each dimension [ 8 ]. In the present study, Cronbach’s α coefficient for the total score was 0.95. 2.7.3. Secondary outcome measures 2.7.3.1. Social support ENRICHD Social Support Instrument (ESSI) was used to rate the frequency of receiving various forms of support, which consisted of 7 items [ 21 ]. Items 1 to 6 are scored on a 5-point Likert scale from 1 (none of the time) to 5 (all the time), and item 7 (living with spouse) is scored 4 for "yes" and 2 for "no." The total score ranges from 8 to 34, whereby the higher score indicates higher levels of social support. Cronbach's α coefficient for the total score was 0.86 in the previous study [ 21 ] and 0.74 in the present study. 2.7.3.2. Postnatal depression The Edinburgh Postnatal Depression Scale (EPDS) was a self-report scale with 10 items [ 22 ]. The scale is rated on a 4-point Likert scale (0–3), with higher scores indicating higher levels of depression. The cut-off value of 13 or higher is more conducive to identifying women who may be depressed [ 23 , 24 ]. The EPDS has been translated into more than 60 languages, and the Chinese version has demonstrated validity and reliability in previous studies [ 25 , 26 ]. In the present study, Cronbach’s α coefficient for the total score was 0.61. 2.7.3.3. Return adaptation A questionnaire with return adaptation for postpartum nurses was developed by Chen [ 9 ]. The questionnaire consists of 23 items: 4 items represent role behavior, 6 items for nursing coping, 4 items for nursing professional development, 5 items for interpersonal relationships, and 4 items for unit management. All items are rated via a 5-point Likert-type scale (1 = very unadapted, 5 = very adapted). The overall Cronbach's α coefficient was 0.92, and the CVI (content validity index) was 0.83. To increase the objectivity of the results, the questionnaire was assessed by the nurse manager. In the present study, Cronbach’s α coefficient for the total score was 0.70. 2.8. Data analysis Baseline data (T0) were compared between groups using independent t-test, Mann-Whitney U -test, chi-square test, or Fisher exact test, as well as differences between groups. Repeated-measures models with two levels of variables (intervention group, control group) and four time points (T0, T1, T2, T3) were used to explore the efficacy of the intervention in decreasing work stress, postnatal depression, and improving social support, and return adaptation. We analyzed data with the Intention-to-Treat (ITT) principle and replaced missing values with mean value imputation. Statistical significance was expressed as p < 0.05 (two-tailed). 3. Results Based on the eligibility criteria, 72 of the 75 nurses who returned to work after childbirth were ultimately included. Among them, 37 nurses were assigned to the intervention group, while 35 nurses were assigned to the control group. In the intervention group, one participant dropped out due to resignation and one participant missed. Meanwhile, in the control group, one participant dropped out due to referral. Figure 1 shows the recruitment and dropout of participants at each stage of the study. 3.1. Participant baseline characteristics There were no significant differences between the two groups in terms of demographic characteristics, maternity leave, workweek, and feeding, except for the department. At baseline, participants in the two groups did not differ significantly in work pressure, social support, postnatal depression, and return adaptation. More detailed characteristics of the participants are described in Table 2 . Table 2 Baseline characteristics. Variables Intervention group ( n = 37) Control group ( n = 35) t/χ 2 /z p Age (years), mean ± SD 30.84 ± 2.49 30.37 ± 2.52 0.790 a 0.432 Work experience (years), mean ± SD 7.49 ± 2.81 7.23 ± 2.51 -0.651 c 0.515 Degree, n (%) -1.515 c 0.130 Junior college and below 1 (2.7) 1 (2.9) Undergraduate course 29 (78.4) 32 (91.4) Master’s degree or above 7 (18.9) 2 (5.7) Job title, n (%) -1.767 c 0.077 Staff nurse 1 (2.7) 0 (0.0) Senior nurse 23 (62.2) 30 (85.7) Supervisor nurse or above 13 (35.1) 5 (14.3) Monthly household income (RMB), n (%) -0.785 c 0.433 30000 5 (13.5) 1 (2.9) Department, n (%) 13.790 d 0.012 Internal Medicine 5 (13.5) 5 (14.3) Surgery 13 (35.1) 2 (5.7) Obstetrics and Gynecology 3 (8.1) 2 (5.7) Pediatrics 1 (2.7) 5 (14.3) Emergency/ICU 2 (5.4) 7 (20.0) Other 13 (35.1) 14 (40.0) Number of pregnancies, n (%) -0.877 c 0.380 First 21 (56.8) 24 (68.6) Second 15 (40.5) 9 (25.7) Third and above 1 (2.7) 2 (5.7) Maternity leave (days), mean ± SD 184.68 ± 38.58 189.23 ± 39.30 -0.408 c 0.683 A planned pregnancy, n (%) 1.137 b 0.286 Yes 22 (59.5) 25 (71.4) No 15 (40.5) 10 (28.6) Workweek (hours), n (%) -0.542 c 0.588 ≤ 35 17 (45.9) 18 (51.4) 36~ 18 (48.6) 16 (45.7) > 40 2 (5.4) 1 (2.9) Feeding, n (%) 0.066 b 0.968 Breastfeeding only 14 (37.8) 14 (40.0) Formula feeding only 6 (16.2) 5 (14.3) Both breast and formula feeding 17 (45.9) 16 (45.7) Work pressure, mean ± SD 70.00 ± 16.68 67.54 ± 20.25 0.563 a 0.575 Social support, mean ± SD 27.41 ± 3.31 26.20 ± 2.53 1.728 a 0.088 Postnatal depression, mean ± SD 8.27 ± 2.48 7.54 ± 2.47 -1.260 c 0.208 Return adaptation, mean ± SD 87.22 ± 6.34 87.83 ± 7.98 -0.361 a 0.719 Note: SD (Standard deviation); a (Independent t-test); b (χ 2 test); c (Mann-Whitney U-test); d (Fisher's exact test). 3.2. Outcome evaluation 3.2.1. Work pressure After one month of intervention (T1), the intervention group scored significantly lower on the work pressure scale than the control group (t = -2.201, p = 0.031). However, there was no significant change in work pressure between the two groups at T2 and T3 (p = 0.090 and 0.191, respectively), as indicated in Table 2 . In addition, the repeated measures ANOVA showed a significant interaction of time and group on work pressure (F = 3.998, p = 0.009), indicating that the intervention group had a significantly greater improvement in work pressure than the control group (Table 3 ). In the intervention group, the average work pressure level decreased by 10.76 ± 2.06 (p < 0.001) from T0 to T1. The average work stress levels in the control group did not exhibit a significant decrease until T3 (mean difference = 7.39 ± 2.69, p = 0.046). Figure 2 enhances the interpretability of the interaction between time and group on the effect of work pressure. Table 3 Comparison of all outcome measures over time between groups. Outcome measure Time Intervention group Control group t/z p Mean ± SD Mean ± SD Work pressure T0 70.00 ± 16.68 67.54 ± 20.25 0.563 a 0.575 T1 59.24 ± 13.69 67.29 ± 17.20 -2.201 a 0.031 T2 54.93 ± 13.64 63.84 ± 21.90 -1.697 b 0.090 T3 54.95 ± 16.98 60.16 ± 16.51 -1.319 a 0.191 Social support T0 27.41 ± 3.31 26.20 ± 2.53 1.728 a 0.088 T1 30.54 ± 2.49 28.20 ± 3.31 3.405 a 0.001 T2 31.63 ± 1.68 29.10 ± 2.94 -3.914 b < 0.001 T3 32.64 ± 1.38 30.88 ± 2.49 -3.200 b 0.001 Postnatal depression T0 8.27 ± 2.48 7.54 ± 2.47 -1.260 b 0.208 T1 8.68 ± 1.92 10.00 ± 1.73 -3.071 a 0.003 T2 8.09 ± 1.59 8.96 ± 1.92 -2.082 a 0.041 T3 7.81 ± 1.41 8.26 ± 1.75 -1.193 a 0.237 Return adaptation T0 87.22 ± 6.34 87.83 ± 7.98 -0.361 a 0.719 T1 105.38 ± 5.56 100.74 ± 7.47 2.996 a 0.004 T2 110.25 ± 2.97 108.03 ± 4.06 2.649 a 0.010 T3 112.75 ± 4.16 108.82 ± 4.54 3.825 a < 0.001 Note: SD (Standard deviation); a (Independent t-test); b (Mann-Whitney U-test); T0 (pre-intervention); T1 (one month post-intervention); T2 (three months post-intervention); T3 (six months post-intervention). Table 4 Results of repeated measures ANOVA. Outcome measure Within-times Between-groups Interaction F P F P F P Work pressure 14.733 < 0.001 2.101 0.151 3.998 0.009 Social support 55.652 < 0.001 17.319 < 0.001 1.647 0.187 Postnatal depression 12.156 < 0.001 3.093 0.083 3.433 0.022 Return adaptation 329.228 < 0.001 7.047 0.010 8.767 < 0.001 3.2.2. Social support After one month of intervention, the level of social support was significantly higher in the intervention group than in the control group (t = 3.405, p = 0.001), and the positive impact on social support extended from T1 to T3 (Table 3 ). As shown in Table 4 , the changes in social support between the two groups across the four measurement time points were statistically significant (F = 55.652, p < 0.001), and the change was significantly greater in the intervention group than in the control group (F = 17.319, p < 0.001). Figure 3 shows significant changes in social support over time between groups. 3.2.3. Postnatal depression Following one month (T1) and three months (T2) of the intervention, the intervention group demonstrated significantly lower scores on the postnatal depression scale compared to the control group (p = 0.003 and 0.041, respectively). Nevertheless, at the 6-month post-intervention (T3), no significant difference in postnatal depression was observed between the two groups (t = -1.193, p = 0.237), as indicated in Table 2 . The repeated measures ANOVA revealed a noteworthy interaction between time and group concerning postnatal depression (F = 3.433, p = 0.022). Figure 4 shows the interaction between time and group on the effect of postnatal depression between groups. 3.2.4. Return adaptation After one month of intervention, the intervention group exhibited a markedly elevated level of return adaptation compared to the control group (t = 2.996, p = 0.004). This favorable influence on return adaptation persisted from T1 to T3, as evidenced in Table 3 . Furthermore, a significant interaction between time and group on return adaptation was identified through the repeated measures ANOVA (F = 8.767, p < 0.001), as indicated in Table 4 . The interaction between time and group on the effect of return adaptation between groups is visually represented in Fig. 5 . 4. Discussion Nurses returning to work after childbirth often experience increased work pressure due to role conflict and maladaptation, significantly impacting their physical and mental health, and subsequently affecting the quality of nursing services [ 8 , 27 ]. Nurses returning to work after childbirth deserve more attention. This study evaluated a four-part intervention for nurses returning to work after childbirth and demonstrated the effectiveness of a work stress coping program based on social support theory in improving work stress as well as other secondary outcomes. Returning to work is a transitional process accompanied by stress [ 6 ]. Previous research focused on investigating the stress levels of nurses returning to work after childbirth and analyzing the influencing factors. To our knowledge, this is the first complex intervention for stress coping in nurses returning to work after childbirth. Previous investigations have revealed that the work stress levels of postpartum nurses are higher in the first three months after returning to work and tend to decrease with a longer duration of return [ 8 , 28 ]. Consistent with our findings, the stress levels in the intervention group showed a significant decrease after one month, while the stress levels in the control group did not exhibit a significant decrease until the sixth month. Therefore, it is essential to assist postpartum returning nurses in stress coping to expedite the stressful transition. Work stressors for postpartum nurses returning to work include time allocation, nurse work, and interpersonal relationships [ 28 ]. Our study provided participants with flexible scheduling, a learning platform, and peer support to achieve targeted management of stressors, partially explaining the effective alleviation of work stress. Furthermore, research has demonstrated that the presence of breastfeeding support in the workplace is effective in alleviating stress [ 6 , 29 ]. This study adds to the evidence of clinical practice regarding work stress coping for postpartum returning nurses. Social support is an important determinant of the postpartum woman's RTW. Research has shown that nurses returning to work after childbirth cannot achieve role change without a large support system of the family, workplace, and community [ 30 ]. Our study provided rich and varied social support through four dimensions: emotional support, instrumental support, informational support, and appraisal support. The social support of the intervention group was significantly enhanced. Studies have shown that postpartum nurses who perceive higher levels of social support tend to experience lower levels of stress [ 19 ]. Moreover, it has been demonstrated that social support is a crucial predictor of the development of postpartum depression [ 31 ]. Social support for postpartum mothers in previous studies focused on emotional, instrumental, and informational support [ 32 ]. The present study filled in the lack of appraisal support through the welcome ceremony and award ceremony. In addition, we also designed 48 text messages that were sent regularly each week for inspiration. For example, "Believe in yourself, you're doing great". The research findings on postnatal depression were also encouraging. Postnatal depression increased after returning to work in both groups of participants, but the increase was significantly less in the intervention group. More measures to help alleviate postpartum depression will be incorporated in future studies. Finally, return adaptation is a key outcome for postnatal nurses. After a long period of maternity leave, the unfamiliarity resulting from the interruption of job continuity, coupled with the occupational characteristics of rapid updates in nursing knowledge, made postnatal nurses susceptible to barriers in RTW adaptation [ 33 ]. According to reports, the early period of return to work was a high-incidence period for nursing adverse events [ 34 ]. Nursing managers should prioritize the return-to-work adaptation of postnatal nurses, as it impacts patient safety. The strong evidence indicating that time of return training was a crucial factor in the postpartum RTW adaptation of nurses [ 9 ]. Our study produced similar evidence. The return adaptation in the intervention group steadily increased over the intervention period, with the most pronounced increase observed in the first month of the intervention. Also, at one month, three months, and six months of intervention, the return adaptation of participants in the intervention group was significantly higher than that of the control group, demonstrating the enduring effectiveness of the intervention. These favorable outcomes could be attributed to peer support, learning platforms, breastfeeding support, or their combined effects. However, it was difficult to determine which component was most effective, which was a limitation of this complex intervention. Another limitation was that to avoid contamination bias, a quasi-experimental design was used in this study. The allocation of volunteers depended on the hospital unit in which they returned to work. This method of allocation was not truly random, but the baseline data for both groups were roughly comparable. Therefore, we believed its impact on the study results was minimal. 5. Conclusion This study confirmed the applicability of a work stress coping program based on social support theory to nurses returning to work after childbirth. Multidimensional social support effectively alleviated work stress and depression in the early stages of return to work, leading to a successful return adaptation. We recommend hospital administrators develop a standardized stress coping program tailored to stressors and support needs within their institution, which may be crucial and sustainable in facilitating the role transition of postpartum returning nurses. Abbreviations RTW return to work ESSI ENRICHD Social Support Instrument EPDS Edinburgh Postnatal Depression Scale CVI content validity index ITT Intention-to-Treat Declarations Ethics approval and consent to participate This study was approved by the ethics committee of Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology (TJ-IRB20220968). Informed consent was obtained from all individual participants included in the study. Consent for publication Not applicable. Competing Interests None declared. Funding This study was supported by grants from National Natural Science Foundation of China (71974061) and Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology (2022C05). Author Contribution All authors contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript, as described below:1.SY L: Methodology, Investigation, Data curation, Writing-Original draft preparation.2.Y L: Supervision, Writing- Reviewing and Editing. 3.MF Y: Supervision, Writing- Reviewing and Editing. 4.TY Z: Validation. 5.JR Y: Methodology.6.WY Z: Software. Acknowledgements Not applicable. Data Availability The data that support the findings of this study are available from the corresponding author. References World Health Organization. State of the World’s Nursing Report – 2020. 2020. https://fctc.who.int/publications/i/item/9789240003279 . Accessed 28 Dec 2023. National Health Commission of the People’s Republic of China. China Health Statistics Yearbook. 2022. 2023. http://www.nhc.gov.cn/mohwsbwstjxxzx/tjtjnj/202305/6ef68aac6bd14c1eb9375e01a0faa1fb.shtml . Accessed 28 Dec 2023. The State Council of the People’s Republic of China. China releases decision on third-child policy, supporting measures. 2021. https://english.www.gov.cn/policies/latestreleases/202107/20/content_WS60f6c308c6d0df57f98dd491.html . Accessed 28 Dec 2023. Ye H, Zou P, D’Souza D, Xu W, Shen X, Zhang ZP et al. Experiences of nurses returning to work after the second/third childbirth and organizational support in Southeastern China: A qualitative exploration. J Nurs Educ Pract. 2023. Hersch RK, Cook RF, Deitz DK, Kaplan S, Hughes D, Friesen MA, et al. Reducing nurses’ stress: A randomized controlled trial of a web-based stress management program for nurses. Appl Nurs Res. 2016;32:18–25. Hill EK, Bimbi OM, Crooks N, Brown R, Maeder AB. Uncovering the Experience: Return to Work of Nurses After Parental Leave. J Emerg Nurs. 2023;49:210–21. Powell DN, Karraker K. Expectations, experiences, and desires: Mothers’ perceptions of the division of caregiving and their postnatal adaptation. J Fam Psychol. 2019;33:401–11. Chen K, Wei L, Zhang Y, Jiang W, Wang J, Pan Y. Work stress in nurses returning to tertiary a general hospitals in China after the delivery of their second child: a cross-sectional study. BMC Health Serv Res. 2022;22:492. Chen W, Liu J, Chen X, Lou F. Work adaptation and its related factors among returning postpartum nurses. Chin J Nurs. 2016;51:1434–8. Wu Q, Farley T, Cui M. Breastfeeding, maternal psychopathological symptoms, and infant problem behaviors among low-income mothers returning to work. Soc Sci Med. 2021;285:114288. Lim J-Y, Kim G-M, Kim E-J. Factors Associated with Job Stress among Hospital Nurses: A Meta-Correlation Analysis. Int J Environ Res Public Health. 2022;19. McCardel RE, Loedding EH, Padilla HM. Examining the Relationship Between Return to Work After Giving Birth and Maternal Mental Health: A Systematic Review. Matern Child Health J. 2022;26:1917–43. Alkhawaldeh JM, Soh KL, Mukhtar F, Peng OC, Alkhawaldeh HM, Al-Amer R, et al. Stress management training program for stress reduction and coping improvement in public health nurses: A randomized controlled trial. J Adv Nurs. 2020;76:3123–35. House JS. Work stress and social support. Addison Wesley Publishing Company; 1981. Ali H, Fatemi Y, Ali D, Hamasha MM, Hamasha S. Investigating Frontline Nurse Stress: Perceptions of Job Demands, Organizational Support, and Social Support During the Current COVID-19 Pandemic. Front Public Health. 2022;10:839600. De Sousa Machado T, Chur-Hansen A, Due C. First-time mothers’ perceptions of social support: Recommendations for best practice. Health Psychol Open. 2020;7:2055102919898611. Killien MG. The Role of Social Support in Facilitating Postpartum Women’s Return to Employment. J Obstetric Gynecologic Neonatal Nurs. 2005;34:639–46. Seiger CP, Wiese BS. Social Support, Unfulfilled Expectations, and Affective Well-being on Return to Employment. J Marriage Family. 2011;73:446–58. Wang Y, Gu J, Zhang F, Xu X. The effect of perceived social support on postpartum stress: the mediating roles of marital satisfaction and maternal postnatal attachment. BMC Women’s Health. 2023;23:482. Feng S, Wang S, Chen C-C, Lan L. GWAPower: a statistical power calculation software for genome-wide association studies with quantitative traits. BMC Genet. 2011;12:12. Mitchell PH, Powell L, Blumenthal J, Norten J, Ironson G, Pitula CR, et al. A short social support measure for patients recovering from myocardial infarction: the ENRICHD Social Support Inventory. J Cardiopulm Rehabil. 2003;23:398–403. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–6. Cox J. Thirty years with the Edinburgh Postnatal Depression Scale: voices from the past and recommendations for the future. Br J Psychiatry. 2019;214:127–9. Levis B, Negeri Z, Sun Y, Benedetti A, Thombs BD. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. BMJ. 2020;371:m4022. Heh SS. Validation of the Chinese version of the Edinburgh Postnatal Depression Scale: detecting postnatal depression in Taiwanese women. Nurs Res. 2001;9:105–13. Lee DTS, Yip SK, Chiu HFK, Leung TYS, Chan KPM, Chau IOL, et al. Detecting postnatal depression in Chinese women: Validation of the Chinese version of the Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1998;172:433–7. Shen J, Gao X, Xiong G, Yan L, Zuo M, Xia T. Work engagement, job stress and relationship among postpartum nurses with the second-child returning to work in operating room. J Nurs Sci. 2019;34:39–4044. Lin J, Lin Y, Chen C, Wang Q, Wu M, Hu R. Work stress of nurses returning to work after the second childbirth and its influencing factors. Chin Nurs Manage. 2020;20:1523–7. Riaz S, Condon L. The experiences of breastfeeding mothers returning to work as hospital nurses in Pakistan: A qualitative study. Women Birth. 2019;32:e252–8. Costantini A, Warasin R, Sartori R, Mantovan F. Return to work after prolonged maternity leave. An interpretative description. Women’s Stud Int Forum. 2022;90:102562. Corrigan CP, Kwasky AN, Groh CJ. Social Support, Postpartum Depression, and Professional Assistance: A Survey of Mothers in the Midwestern United States. J Perinat Educ. 2015;24:48–60. Sharifipour F, Javadnoori M, Behboodi Moghadam Z, Najafian M, Cheraghian B, Abbaspoor Z. Interventions to improve social support among postpartum mothers: A systematic review. Health Promotion Perspect. 2022;12:141–50. Cheng Y, Liu J, Zhu L. Return-to-work Adaptability of 245 Nurses after Second Childbirth and Its Influence Factors. J Nurs. 2018;25:43–6. Dai L, Hou D. Research progress on the work adaptation of postpartum returning nurses. J Nurs Adm. 2019;19:125–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 05 Feb, 2026 Reviewers agreed at journal 28 Jan, 2026 Reviewers agreed at journal 20 Nov, 2025 Reviewers invited by journal 07 Jul, 2025 Editor assigned by journal 31 May, 2025 Editor invited by journal 20 May, 2025 Submission checks completed at journal 20 May, 2025 First submitted to journal 19 May, 2025 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-6509772","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":481689530,"identity":"1711f62d-45ad-4fdb-911e-a9ee72bb5498","order_by":0,"name":"Suya Li","email":"","orcid":"","institution":"Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Suya","middleName":"","lastName":"Li","suffix":""},{"id":481689531,"identity":"9771875f-ab30-41a7-9db9-34e248ab1551","order_by":1,"name":"Minfeng Yu","email":"","orcid":"","institution":"Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Minfeng","middleName":"","lastName":"Yu","suffix":""},{"id":481689532,"identity":"19a086ee-ece8-4df2-a313-e4f2d6bda83a","order_by":2,"name":"Yu Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYDACdsYGhg8MbAlAJggzALmEADNjA+OMBKAWNuK1ABFPAgNICwNxWgwOM7dJ2/7gy2OQb3i6mYfBRnbDAeZnD/BrYWyTzklgKwbaknabhyHNeMMBNnMDYrQkNkC0HE7ccICHTYKgFguElv9EamFAaDlAWIvkYcZmy540tsQ2toS0m3MMko1nHmYzw6uF73j7wxs/bI4l9jOfSbvxpsJOtu948zO8WhQOgKljwAADxg4DKKiY8akHAvkGMFUDxOwHCKgdBaNgFIyCkQoAQYRFRN26nk0AAAAASUVORK5CYII=","orcid":"","institution":"Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Yu","middleName":"","lastName":"Liu","suffix":""},{"id":481689533,"identity":"0eb29774-c58d-4f10-bce6-4de204ecce27","order_by":3,"name":"Tieying Zeng","email":"","orcid":"","institution":"Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Tieying","middleName":"","lastName":"Zeng","suffix":""},{"id":481689534,"identity":"03ea415e-a138-49b9-b36e-65d899da137c","order_by":4,"name":"Jianrong Yue","email":"","orcid":"","institution":"Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Jianrong","middleName":"","lastName":"Yue","suffix":""},{"id":481689538,"identity":"e1398e84-cf95-4e6e-8fd4-93990b40a4ae","order_by":5,"name":"Wenyan Zhang","email":"","orcid":"","institution":"Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Wenyan","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2025-04-23 07:08:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6509772/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6509772/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86387881,"identity":"6a6e7e30-5dd3-43c4-bf65-70a901649153","added_by":"auto","created_at":"2025-07-10 06:14:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":183027,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of this study.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6509772/v1/0b530639ae21b26edd0d4a59.png"},{"id":86387115,"identity":"24949cde-4272-4ee5-8149-7c7077e18834","added_by":"auto","created_at":"2025-07-10 06:06:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":17222,"visible":true,"origin":"","legend":"\u003cp\u003eThe changes in work pressure between groups.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6509772/v1/4f4b8e2621dce8ae7100f786.png"},{"id":86387117,"identity":"bbadf18d-cbfe-402b-8854-1f4aeeb2977c","added_by":"auto","created_at":"2025-07-10 06:06:16","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":16633,"visible":true,"origin":"","legend":"\u003cp\u003eThe changes in social support between groups.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6509772/v1/0d4983849d0506567c7b226d.png"},{"id":86387880,"identity":"cdd356a1-2c43-44cc-95b8-79ceb44da24e","added_by":"auto","created_at":"2025-07-10 06:14:16","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":20104,"visible":true,"origin":"","legend":"\u003cp\u003eThe changes in postnatal depression between groups.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6509772/v1/09d1bfd043411292291d3dd9.png"},{"id":86387118,"identity":"a37de61c-fd01-4037-96ed-6343863444c3","added_by":"auto","created_at":"2025-07-10 06:06:16","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":15996,"visible":true,"origin":"","legend":"\u003cp\u003eThe changes of return adaptation between groups.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-6509772/v1/caf045239e215cd7a1449d81.png"},{"id":86389199,"identity":"bd131e8c-b933-4688-934e-4391612a3931","added_by":"auto","created_at":"2025-07-10 06:30:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1352238,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6509772/v1/5627792e-356f-4861-8f43-b303d24ba789.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of a work stress coping program based on social support theory for nurses returning to work after childbirth: A quasi-experimental study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eNurses are an integral and growing component of the healthcare system. According to the \"State of the World's Nursing 2020\", the global nursing workforce reached 27.9\u0026nbsp;million. Among them, 38% were under the age of 35 and were in the childbearing age [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Over the past decade, China has experienced an annual average increase of 8% in its nursing workforce. By the end of 2021, the registered nurses in China surpassed 5\u0026nbsp;million, with 67% of them being under the age of 35 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In 2021, China adjusted its national fertility policy, raising the limit on the number of children per couple from two to three [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, nurses, dominated by women of childbearing age, entered another peak of second childbirth, and the number of nurses who return to work (RTW) after childbirth continued to grow.\u003c/p\u003e\u003cp\u003eNursing is a high-pressure profession, exposed to numerous stressors, such as heavy workloads, irregular shift work, and complex medical environments [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. To make matters worse, nurses returning to work after a prolonged period of maternity leave face the additional challenges of physical recovery, breastfeeding and childcare, and work adaptation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Previous surveys have indicated that nurses returning to work after childbirth commonly exhibit high work stress and poor readjustment to RTW, which affects the quality of nursing care [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In addition, high levels of job stress are associated with negative physical and mental health among nurses, as well as high turnover rates [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, the high-stress levels of nurses deserve more attention.\u003c/p\u003e\u003cp\u003eCurrently, research on stress management for nurses has yielded favorable results. Lim demonstrated that stress management courses based on acceptance and commitment therapy significantly reduced perceived stress and fatigue among nursing students [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Hersch confirmed the effectiveness of a web-based stress management program in preventing the development of work stress among clinical nurses [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Alkhawaldeh also emphasized the feasibility of an interactive stress management program in public health nurses [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, few experimental studies have focused on nurses returning to work after childbirth. Therefore, there is a lack of effective and safe interventions to address the specific stressors faced by nurses returning to work after maternity leave.\u003c/p\u003e\u003cp\u003eSocial support theory posits that social support can alleviate negative stress, and the stronger the social support, the better individuals can cope with stress [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The primary role of social support is to protect the physical and mental health of those under stress [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Numerous studies have shown that social support significantly improves stress and depression, and facilitates RTW adaptation after giving birth [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The need for social support for postnatal nurses returning to work is strong [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Therefore, this study aims to construct a work stress coping program based on social support theory and evaluate its effectiveness in reducing negative emotions and promoting RTW adaptation among nurses returning to work after childbirth.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003e2.1. Study design\u003c/h2\u003e\n\u003cp\u003eThis study was a two-armed, quasi-experimental study performed from December 2022 to November 2023. Data were gathered at baseline, after one month, after three months, and after six months in an academic, medical, and teaching hospital in central China. This study met the ethical standards of medical research involving human subjects stipulated in the Declaration of Helsinki and was approved by the ethics committee of Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology (TJ-IRB20220968). Informed consent was obtained from all individual participants included in the study. In November 2022, it was registered in the Chinese Clinical Trial Registry at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.chictr.org.cn\u003c/span\u003e\u003c/span\u003e (registration number: ChiCTR2200065423).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003e2.2. Participants\u003c/h2\u003e\n\u003cp\u003eParticipants were recruited from three campuses of a tertiary hospital in Hubei, Mainland China. Inclusion criteria were as follows: (1) nurses returning to work after childbirth; (2) nurses who can understand Chinese and speak Putonghua; and (3) nurses who can complete the questionnaire independently. Exclusion criteria were: (1) having depressive symptoms (undergoing psychotherapy or \u0026ge;\u0026thinsp;13 points on the Edinburgh Postnatal Depression Scale); and (2) participation in other relevant studies. Informed consent was obtained from all participants during the recruitment phase.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003e2.3. Sample size\u003c/h2\u003e\n\u003cp\u003eG*Power software was used to calculate the sample size [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Since there were insufficient previous studies to calculate the effect size, this study used a medium effect size of 0.25 considering the available resources. Using a power of 0.8 and an alpha of 0.05, the study required a minimum sample size of 24 (each group). Considering a 15% attrition rate, the final sample size for each group was 28. Sample sizes for future large-scale intervention studies will be determined according to the results of this study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003e2.4. Allocation procedures\u003c/h2\u003e\n\u003cp\u003eDifferent hospital campuses are generally separated by tens of kilometers, which helps to reduce the chance of contamination. For this reason, this study was conducted in three campuses of the same hospital. We determined the intervention site (Hankou campus) and the control sites (Guanggu and Zhongfa campuses) by drawing lots. Participants returned to either hospital campus according to departmental arrangements and were assessed for compliance with enrollment criteria upon return.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003e2.5. Intervention\u003c/h2\u003e\n\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\n\u003ch2\u003e2.5.1. Phase 1: Development of a work stress coping program based on social support theory\u003c/h2\u003e\n\u003cp\u003eWe designed a work stress coping program based on social support theory. The theory suggests that social support mitigates negative stress and that the stronger the social support a person has, the better they can cope with challenges. Social support can be functionally categorized as emotional support (e.g., providing comfort or encouragement), instrumental support (e.g., providing practical assistance or resources), informational support (e.g., providing guidance or advice), and appraisal support (e.g., providing affirmation or praise). A questionnaire on stressors and support needs of nurses returning to work after childbirth was designed based on four types of support (emotional, instrumental, informational, and appraisal) and a literature review.\u003c/p\u003e\n\u003cp\u003eBased on the results of 117 surveys of nurses returning to work after childbirth within one year, two supports were excluded as low need (telephone assistance line and clinical instructor). A multi-component intervention was initially developed, including text messaging, positive thinking exercises, website learning, and more. In addition, eight experts (two in nursing management, one in mother and child care, two in psychological care, and three in nursing education) with more than 10 years of experience were invited to discuss the form, content, and feasibility of the intervention, which ultimately resulted in a work stress coping program for nurses returning to work after childbirth, as shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe work stress coping program.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSection\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIntervention type\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIntervention timing\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIntervention strategy\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEmotional support\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Peer support\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAs needed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eForm a WeChat group and invite well-adjusted nurses to share their experiences of returning to work.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2. SMS support\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTwo per week\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSend 48 text messages for emotional inspiration.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eInstrumental support\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Material support\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDay of return to work\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eProvide gifts for returning to work (disposable breast pads, breast milk storage bags, parenting books, etc.).\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2. Environmental rehabilitation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAs needed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSet up a private space for breastfeeding or pumping.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3. Flexible scheduling\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWeekly\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAdd a \"scheduling preference form\" to collect weekly scheduling requirements.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eInformational support\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Expert consultation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAs needed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInvite doctors and nurses from obstetrics and pediatrics to answer specialist questions within 24 hours.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2. Learning platform\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAs needed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSelf-directed learning resources are provided through an education network (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.512ks.cn/#/login\u003c/span\u003e\u003c/span\u003e), including specialist training, mother and child care, stress management and more.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAppraisal support\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1. Welcome ceremony\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDay of return to work\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInvite returning nurses and their families to a welcome ceremony and give them letters of appreciation, encouragement, and support.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2. Award ceremony\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEnd of program\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePresentation of the \"Amazing Nurse Mom\" certificate.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\n\u003ch2\u003e2.5.2. Phase 2: Implementation of the developed intervention\u003c/h2\u003e\n\u003cp\u003eThe intervention team consisted of a director of nursing, an obstetrician, a neonatal nurse specialist, a psychological counselor, and three registered nurses. The director of nursing was responsible for the supervision and promotion of the project; the obstetrician and the neonatal nurse specialist were responsible for the professional consultation on maternal and child care and the development of specialist courseware; the psychological counselor was responsible for developing motivational text messages and stress management courseware; and the three registered nurses were responsible for the implementation of the activities, management of the courses, data collection, and other assisting work. All researchers were trained in the work stress coping program, which consisted of (1) providing equipment training, (2) assisting with return-to-work administration, and (3) guiding participants in self-directed learning. We used a structured protocol to maintain intervention fidelity and held monthly meetings to discuss troubleshooting during the intervention. The intervention lasted six months, during which, if participants exhibited symptoms of depression, they were referred to a psychiatric clinic for treatment (\u0026ge;\u0026thinsp;13 points on the Edinburgh Postnatal Depression Scale).\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003e2.6. Control group\u003c/h2\u003e\n\u003cp\u003eDuring the intervention, participants in the control group received routine RTW management, with relevant training initiated by the head nurse of each unit. The participants and their nurse practitioners did not know which allocation group they belonged to, but the researchers did. At the end of the study, participants in the control group were provided the opportunity to use the intervention program.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003e2.7. Measures\u003c/h2\u003e\n\u003cp\u003eIncluded participants completed assessments of the primary outcome (work stress) and secondary outcomes (social support, return adaptation, and postnatal depression) at T0 (pre-intervention), T1 (one month post-intervention), T2 (three months post-intervention), and T3 (six months post-intervention). The general characteristics questionnaire was completed only once at T0.\u003c/p\u003e\n\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\n\u003ch2\u003e2.7.1. Participant characteristics\u003c/h2\u003e\n\u003cp\u003eEligible participants were invited to complete the general characteristics questionnaire, which included information on demographics (age, work experience, education, etc.) and return to work after childbirth (maternity leave, weekly working hours, feeding, etc.).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\n\u003ch2\u003e2.7.2. Primary outcome measures\u003c/h2\u003e\n\u003cp\u003eThe primary outcome (work pressure) was measured by the Mandarin Chinese version of the work stress scale [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]. The scale is a 30-item scale based on cognitive phenomenological transactional theory. All items are scored on a 5-point scale from 1 (never) to 5 (always). The total score fluctuates between 30 and 150 points. The higher the score, the greater the work stress. The scale proved to be reliable and valid when applied to nurses returning to work after childbirth, with a total Cronbach's \u0026alpha; coefficient of 0.94 and Cronbach's \u0026alpha; coefficients ranging from 0.73 to 0.8 for each dimension [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]. In the present study, Cronbach\u0026rsquo;s \u0026alpha; coefficient for the total score was 0.95.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\n\u003ch2\u003e2.7.3. Secondary outcome measures\u003c/h2\u003e\n\u003cdiv id=\"Sec15\" class=\"Section4\"\u003e\n\u003ch2\u003e2.7.3.1. Social support\u003c/h2\u003e\n\u003cp\u003eENRICHD Social Support Instrument (ESSI) was used to rate the frequency of receiving various forms of support, which consisted of 7 items [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Items 1 to 6 are scored on a 5-point Likert scale from 1 (none of the time) to 5 (all the time), and item 7 (living with spouse) is scored 4 for \"yes\" and 2 for \"no.\" The total score ranges from 8 to 34, whereby the higher score indicates higher levels of social support. Cronbach's \u0026alpha; coefficient for the total score was 0.86 in the previous study [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e] and 0.74 in the present study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section4\"\u003e\n\u003ch2\u003e2.7.3.2. Postnatal depression\u003c/h2\u003e\n\u003cp\u003eThe Edinburgh Postnatal Depression Scale (EPDS) was a self-report scale with 10 items [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. The scale is rated on a 4-point Likert scale (0\u0026ndash;3), with higher scores indicating higher levels of depression. The cut-off value of 13 or higher is more conducive to identifying women who may be depressed [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. The EPDS has been translated into more than 60 languages, and the Chinese version has demonstrated validity and reliability in previous studies [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. In the present study, Cronbach\u0026rsquo;s \u0026alpha; coefficient for the total score was 0.61.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section4\"\u003e\n\u003ch2\u003e2.7.3.3. Return adaptation\u003c/h2\u003e\n\u003cp\u003eA questionnaire with return adaptation for postpartum nurses was developed by Chen [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. The questionnaire consists of 23 items: 4 items represent role behavior, 6 items for nursing coping, 4 items for nursing professional development, 5 items for interpersonal relationships, and 4 items for unit management. All items are rated via a 5-point Likert-type scale (1\u0026thinsp;=\u0026thinsp;very unadapted, 5\u0026thinsp;=\u0026thinsp;very adapted). The overall Cronbach's \u0026alpha; coefficient was 0.92, and the CVI (content validity index) was 0.83. To increase the objectivity of the results, the questionnaire was assessed by the nurse manager. In the present study, Cronbach\u0026rsquo;s \u0026alpha; coefficient for the total score was 0.70.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n\u003ch2\u003e2.8. Data analysis\u003c/h2\u003e\n\u003cp\u003eBaseline data (T0) were compared between groups using independent t-test, Mann-Whitney \u003cem\u003eU\u003c/em\u003e-test, chi-square test, or Fisher exact test, as well as differences between groups. Repeated-measures models with two levels of variables (intervention group, control group) and four time points (T0, T1, T2, T3) were used to explore the efficacy of the intervention in decreasing work stress, postnatal depression, and improving social support, and return adaptation. We analyzed data with the Intention-to-Treat (ITT) principle and replaced missing values with mean value imputation. Statistical significance was expressed as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (two-tailed).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eBased on the eligibility criteria, 72 of the 75 nurses who returned to work after childbirth were ultimately included. Among them, 37 nurses were assigned to the intervention group, while 35 nurses were assigned to the control group. In the intervention group, one participant dropped out due to resignation and one participant missed. Meanwhile, in the control group, one participant dropped out due to referral. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the recruitment and dropout of participants at each stage of the study.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e3.1. Participant baseline characteristics\u003c/h2\u003e\u003cp\u003eThere were no significant differences between the two groups in terms of demographic characteristics, maternity leave, workweek, and feeding, except for the department. At baseline, participants in the two groups did not differ significantly in work pressure, social support, postnatal depression, and return adaptation. More detailed characteristics of the participants are described in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\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\u003eBaseline characteristics.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et/χ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e/z\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ep\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 (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30.84\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.37\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.790\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.432\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWork experience (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.49\u0026thinsp;\u0026plusmn;\u0026thinsp;2.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.23\u0026thinsp;\u0026plusmn;\u0026thinsp;2.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.651\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.515\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDegree, n (%)\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=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1.515\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.130\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJunior college and below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.9)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUndergraduate course\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (78.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (91.4)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaster\u0026rsquo;s degree or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (18.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (5.7)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJob title, n (%)\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=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1.767\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.077\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStaff nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSenior nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (62.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (85.7)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupervisor nurse or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (35.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (14.3)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonthly household income (RMB), n (%)\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=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.785\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.433\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;10000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (5.7)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10000~\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (59.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (65.7)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20000~\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (21.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (25.7)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;30000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (13.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.9)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepartment, n (%)\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=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.790\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.012\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\u003e5 (13.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (14.3)\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\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\u003e13 (35.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (5.7)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObstetrics and Gynecology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (8.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (5.7)\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\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\u003e1 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (14.3)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmergency/ICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (20.0)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (35.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (40.0)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of pregnancies, n (%)\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=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.877\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.380\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFirst\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21 (56.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (68.6)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecond\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (40.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (25.7)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThird and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (5.7)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaternity leave (days), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e184.68\u0026thinsp;\u0026plusmn;\u0026thinsp;38.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e189.23\u0026thinsp;\u0026plusmn;\u0026thinsp;39.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.408\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.683\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA planned pregnancy, n (%)\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=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.137\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.286\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (59.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (71.4)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (40.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (28.6)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorkweek (hours), n (%)\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=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.542\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.588\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (45.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (51.4)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e36~\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (48.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (45.7)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.9)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeeding, n (%)\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=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.066\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.968\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBreastfeeding only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (37.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (40.0)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFormula feeding only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (16.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (14.3)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth breast and formula feeding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (45.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (45.7)\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWork pressure, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70.00\u0026thinsp;\u0026plusmn;\u0026thinsp;16.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67.54\u0026thinsp;\u0026plusmn;\u0026thinsp;20.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.563\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.575\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial support, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.41\u0026thinsp;\u0026plusmn;\u0026thinsp;3.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.728\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.088\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostnatal depression, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.27\u0026thinsp;\u0026plusmn;\u0026thinsp;2.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.54\u0026thinsp;\u0026plusmn;\u0026thinsp;2.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1.260\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.208\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReturn adaptation, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87.22\u0026thinsp;\u0026plusmn;\u0026thinsp;6.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87.83\u0026thinsp;\u0026plusmn;\u0026thinsp;7.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.361\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.719\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: SD (Standard deviation); \u003csup\u003ea\u003c/sup\u003e (Independent t-test); \u003csup\u003eb\u003c/sup\u003e (χ\u003csup\u003e2\u003c/sup\u003e test); \u003csup\u003ec\u003c/sup\u003e (Mann-Whitney U-test); \u003csup\u003ed\u003c/sup\u003e (Fisher's exact test).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e3.2. Outcome evaluation\u003c/h2\u003e\u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1. Work pressure\u003c/h2\u003e\u003cp\u003eAfter one month of intervention (T1), the intervention group scored significantly lower on the work pressure scale than the control group (t = -2.201, p\u0026thinsp;=\u0026thinsp;0.031). However, there was no significant change in work pressure between the two groups at T2 and T3 (p\u0026thinsp;=\u0026thinsp;0.090 and 0.191, respectively), as indicated in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. In addition, the repeated measures ANOVA showed a significant interaction of time and group on work pressure (F\u0026thinsp;=\u0026thinsp;3.998, p\u0026thinsp;=\u0026thinsp;0.009), indicating that the intervention group had a significantly greater improvement in work pressure than the control group (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In the intervention group, the average work pressure level decreased by 10.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) from T0 to T1. The average work stress levels in the control group did not exhibit a significant decrease until T3 (mean difference\u0026thinsp;=\u0026thinsp;7.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.69, p\u0026thinsp;=\u0026thinsp;0.046). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e enhances the interpretability of the interaction between time and group on the effect of work pressure.\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\u003eComparison of all outcome measures over time between groups.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOutcome measure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTime\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntervention group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003et/z\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eWork pressure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70.00\u0026thinsp;\u0026plusmn;\u0026thinsp;16.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67.54\u0026thinsp;\u0026plusmn;\u0026thinsp;20.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.563\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.575\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59.24\u0026thinsp;\u0026plusmn;\u0026thinsp;13.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67.29\u0026thinsp;\u0026plusmn;\u0026thinsp;17.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-2.201\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.93\u0026thinsp;\u0026plusmn;\u0026thinsp;13.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63.84\u0026thinsp;\u0026plusmn;\u0026thinsp;21.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.697\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.090\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.95\u0026thinsp;\u0026plusmn;\u0026thinsp;16.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60.16\u0026thinsp;\u0026plusmn;\u0026thinsp;16.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.319\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.191\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eSocial support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.41\u0026thinsp;\u0026plusmn;\u0026thinsp;3.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.728\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.088\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.54\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.20\u0026thinsp;\u0026plusmn;\u0026thinsp;3.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.405\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.63\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-3.914\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30.88\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-3.200\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003ePostnatal depression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.27\u0026thinsp;\u0026plusmn;\u0026thinsp;2.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.54\u0026thinsp;\u0026plusmn;\u0026thinsp;2.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.260\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.208\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-3.071\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-2.082\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.041\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.193\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.237\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eReturn adaptation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87.22\u0026thinsp;\u0026plusmn;\u0026thinsp;6.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87.83\u0026thinsp;\u0026plusmn;\u0026thinsp;7.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.361\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.719\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e105.38\u0026thinsp;\u0026plusmn;\u0026thinsp;5.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100.74\u0026thinsp;\u0026plusmn;\u0026thinsp;7.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.996\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e110.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e108.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.649\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e112.75\u0026thinsp;\u0026plusmn;\u0026thinsp;4.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e108.82\u0026thinsp;\u0026plusmn;\u0026thinsp;4.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.825\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: SD (Standard deviation); \u003csup\u003ea\u003c/sup\u003e(Independent t-test); \u003csup\u003eb\u003c/sup\u003e(Mann-Whitney U-test); T0 (pre-intervention); T1 (one month post-intervention); T2 (three months post-intervention); T3 (six months post-intervention).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResults of repeated measures ANOVA.\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\u003eOutcome measure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eWithin-times\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eBetween-groups\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eInteraction\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eP\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\u003eWork pressure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.733\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.151\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.998\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e55.652\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17.319\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.647\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.187\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostnatal depression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.156\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.093\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.083\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.433\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.022\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReturn adaptation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e329.228\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.047\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8.767\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\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2. Social support\u003c/h2\u003e\u003cp\u003eAfter one month of intervention, the level of social support was significantly higher in the intervention group than in the control group (t\u0026thinsp;=\u0026thinsp;3.405, p\u0026thinsp;=\u0026thinsp;0.001), and the positive impact on social support extended from T1 to T3 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). As shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the changes in social support between the two groups across the four measurement time points were statistically significant (F\u0026thinsp;=\u0026thinsp;55.652, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the change was significantly greater in the intervention group than in the control group (F\u0026thinsp;=\u0026thinsp;17.319, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows significant changes in social support over time between groups.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section3\"\u003e\u003ch2\u003e3.2.3. Postnatal depression\u003c/h2\u003e\u003cp\u003eFollowing one month (T1) and three months (T2) of the intervention, the intervention group demonstrated significantly lower scores on the postnatal depression scale compared to the control group (p\u0026thinsp;=\u0026thinsp;0.003 and 0.041, respectively). Nevertheless, at the 6-month post-intervention (T3), no significant difference in postnatal depression was observed between the two groups (t = -1.193, p\u0026thinsp;=\u0026thinsp;0.237), as indicated in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The repeated measures ANOVA revealed a noteworthy interaction between time and group concerning postnatal depression (F\u0026thinsp;=\u0026thinsp;3.433, p\u0026thinsp;=\u0026thinsp;0.022). Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the interaction between time and group on the effect of postnatal depression between groups.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003e3.2.4. Return adaptation\u003c/h2\u003e\u003cp\u003eAfter one month of intervention, the intervention group exhibited a markedly elevated level of return adaptation compared to the control group (t\u0026thinsp;=\u0026thinsp;2.996, p\u0026thinsp;=\u0026thinsp;0.004). This favorable influence on return adaptation persisted from T1 to T3, as evidenced in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Furthermore, a significant interaction between time and group on return adaptation was identified through the repeated measures ANOVA (F\u0026thinsp;=\u0026thinsp;8.767, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as indicated in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The interaction between time and group on the effect of return adaptation between groups is visually represented in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eNurses returning to work after childbirth often experience increased work pressure due to role conflict and maladaptation, significantly impacting their physical and mental health, and subsequently affecting the quality of nursing services [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Nurses returning to work after childbirth deserve more attention. This study evaluated a four-part intervention for nurses returning to work after childbirth and demonstrated the effectiveness of a work stress coping program based on social support theory in improving work stress as well as other secondary outcomes.\u003c/p\u003e\u003cp\u003eReturning to work is a transitional process accompanied by stress [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Previous research focused on investigating the stress levels of nurses returning to work after childbirth and analyzing the influencing factors. To our knowledge, this is the first complex intervention for stress coping in nurses returning to work after childbirth. Previous investigations have revealed that the work stress levels of postpartum nurses are higher in the first three months after returning to work and tend to decrease with a longer duration of return [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Consistent with our findings, the stress levels in the intervention group showed a significant decrease after one month, while the stress levels in the control group did not exhibit a significant decrease until the sixth month. Therefore, it is essential to assist postpartum returning nurses in stress coping to expedite the stressful transition. Work stressors for postpartum nurses returning to work include time allocation, nurse work, and interpersonal relationships [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Our study provided participants with flexible scheduling, a learning platform, and peer support to achieve targeted management of stressors, partially explaining the effective alleviation of work stress. Furthermore, research has demonstrated that the presence of breastfeeding support in the workplace is effective in alleviating stress [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This study adds to the evidence of clinical practice regarding work stress coping for postpartum returning nurses.\u003c/p\u003e\u003cp\u003eSocial support is an important determinant of the postpartum woman's RTW. Research has shown that nurses returning to work after childbirth cannot achieve role change without a large support system of the family, workplace, and community [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Our study provided rich and varied social support through four dimensions: emotional support, instrumental support, informational support, and appraisal support. The social support of the intervention group was significantly enhanced. Studies have shown that postpartum nurses who perceive higher levels of social support tend to experience lower levels of stress [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Moreover, it has been demonstrated that social support is a crucial predictor of the development of postpartum depression [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Social support for postpartum mothers in previous studies focused on emotional, instrumental, and informational support [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The present study filled in the lack of appraisal support through the welcome ceremony and award ceremony. In addition, we also designed 48 text messages that were sent regularly each week for inspiration. For example, \"Believe in yourself, you're doing great\". The research findings on postnatal depression were also encouraging. Postnatal depression increased after returning to work in both groups of participants, but the increase was significantly less in the intervention group. More measures to help alleviate postpartum depression will be incorporated in future studies.\u003c/p\u003e\u003cp\u003eFinally, return adaptation is a key outcome for postnatal nurses. After a long period of maternity leave, the unfamiliarity resulting from the interruption of job continuity, coupled with the occupational characteristics of rapid updates in nursing knowledge, made postnatal nurses susceptible to barriers in RTW adaptation [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. According to reports, the early period of return to work was a high-incidence period for nursing adverse events [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Nursing managers should prioritize the return-to-work adaptation of postnatal nurses, as it impacts patient safety. The strong evidence indicating that time of return training was a crucial factor in the postpartum RTW adaptation of nurses [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Our study produced similar evidence. The return adaptation in the intervention group steadily increased over the intervention period, with the most pronounced increase observed in the first month of the intervention. Also, at one month, three months, and six months of intervention, the return adaptation of participants in the intervention group was significantly higher than that of the control group, demonstrating the enduring effectiveness of the intervention. These favorable outcomes could be attributed to peer support, learning platforms, breastfeeding support, or their combined effects. However, it was difficult to determine which component was most effective, which was a limitation of this complex intervention.\u003c/p\u003e\u003cp\u003eAnother limitation was that to avoid contamination bias, a quasi-experimental design was used in this study. The allocation of volunteers depended on the hospital unit in which they returned to work. This method of allocation was not truly random, but the baseline data for both groups were roughly comparable. Therefore, we believed its impact on the study results was minimal.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study confirmed the applicability of a work stress coping program based on social support theory to nurses returning to work after childbirth. Multidimensional social support effectively alleviated work stress and depression in the early stages of return to work, leading to a successful return adaptation. We recommend hospital administrators develop a standardized stress coping program tailored to stressors and support needs within their institution, which may be crucial and sustainable in facilitating the role transition of postpartum returning nurses.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRTW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ereturn to work\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eESSI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eENRICHD Social Support Instrument\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEPDS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEdinburgh Postnatal Depression Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCVI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003econtent validity index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eITT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntention-to-Treat\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\u003cp\u003e This study was approved by the ethics committee of Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology (TJ-IRB20220968). Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eNone declared.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis study was supported by grants from National Natural Science Foundation of China (71974061) and Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology (2022C05).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript, as described below:1.SY L: Methodology, Investigation, Data curation, Writing-Original draft preparation.2.Y L: Supervision, Writing- Reviewing and Editing. 3.MF Y: Supervision, Writing- Reviewing and Editing. 4.TY Z: Validation. 5.JR Y: Methodology.6.WY Z: Software.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. State of the World\u0026rsquo;s Nursing Report \u0026ndash;\u0026thinsp;2020. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://fctc.who.int/publications/i/item/9789240003279\u003c/span\u003e\u003cspan address=\"https://fctc.who.int/publications/i/item/9789240003279\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 28 Dec 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Health Commission of the People\u0026rsquo;s Republic of China. China Health Statistics Yearbook. 2022. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.nhc.gov.cn/mohwsbwstjxxzx/tjtjnj/202305/6ef68aac6bd14c1eb9375e01a0faa1fb.shtml\u003c/span\u003e\u003cspan address=\"http://www.nhc.gov.cn/mohwsbwstjxxzx/tjtjnj/202305/6ef68aac6bd14c1eb9375e01a0faa1fb.shtml\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 28 Dec 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe State Council of the People\u0026rsquo;s Republic of China. China releases decision on third-child policy, supporting measures. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://english.www.gov.cn/policies/latestreleases/202107/20/content_WS60f6c308c6d0df57f98dd491.html\u003c/span\u003e\u003cspan address=\"https://english.www.gov.cn/policies/latestreleases/202107/20/content_WS60f6c308c6d0df57f98dd491.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 28 Dec 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYe H, Zou P, D\u0026rsquo;Souza D, Xu W, Shen X, Zhang ZP et al. Experiences of nurses returning to work after the second/third childbirth and organizational support in Southeastern China: A qualitative exploration. J Nurs Educ Pract. 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHersch RK, Cook RF, Deitz DK, Kaplan S, Hughes D, Friesen MA, et al. Reducing nurses\u0026rsquo; stress: A randomized controlled trial of a web-based stress management program for nurses. Appl Nurs Res. 2016;32:18\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHill EK, Bimbi OM, Crooks N, Brown R, Maeder AB. Uncovering the Experience: Return to Work of Nurses After Parental Leave. J Emerg Nurs. 2023;49:210\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePowell DN, Karraker K. Expectations, experiences, and desires: Mothers\u0026rsquo; perceptions of the division of caregiving and their postnatal adaptation. J Fam Psychol. 2019;33:401\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen K, Wei L, Zhang Y, Jiang W, Wang J, Pan Y. Work stress in nurses returning to tertiary a general hospitals in China after the delivery of their second child: a cross-sectional study. BMC Health Serv Res. 2022;22:492.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen W, Liu J, Chen X, Lou F. Work adaptation and its related factors among returning postpartum nurses. Chin J Nurs. 2016;51:1434\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu Q, Farley T, Cui M. Breastfeeding, maternal psychopathological symptoms, and infant problem behaviors among low-income mothers returning to work. Soc Sci Med. 2021;285:114288.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLim J-Y, Kim G-M, Kim E-J. Factors Associated with Job Stress among Hospital Nurses: A Meta-Correlation Analysis. Int J Environ Res Public Health. 2022;19.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCardel RE, Loedding EH, Padilla HM. Examining the Relationship Between Return to Work After Giving Birth and Maternal Mental Health: A Systematic Review. Matern Child Health J. 2022;26:1917\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlkhawaldeh JM, Soh KL, Mukhtar F, Peng OC, Alkhawaldeh HM, Al-Amer R, et al. Stress management training program for stress reduction and coping improvement in public health nurses: A randomized controlled trial. J Adv Nurs. 2020;76:3123\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHouse JS. Work stress and social support. Addison Wesley Publishing Company; 1981.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAli H, Fatemi Y, Ali D, Hamasha MM, Hamasha S. Investigating Frontline Nurse Stress: Perceptions of Job Demands, Organizational Support, and Social Support During the Current COVID-19 Pandemic. Front Public Health. 2022;10:839600.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe Sousa Machado T, Chur-Hansen A, Due C. First-time mothers\u0026rsquo; perceptions of social support: Recommendations for best practice. Health Psychol Open. 2020;7:2055102919898611.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKillien MG. The Role of Social Support in Facilitating Postpartum Women\u0026rsquo;s Return to Employment. J Obstetric Gynecologic Neonatal Nurs. 2005;34:639\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSeiger CP, Wiese BS. Social Support, Unfulfilled Expectations, and Affective Well-being on Return to Employment. J Marriage Family. 2011;73:446\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang Y, Gu J, Zhang F, Xu X. The effect of perceived social support on postpartum stress: the mediating roles of marital satisfaction and maternal postnatal attachment. BMC Women\u0026rsquo;s Health. 2023;23:482.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFeng S, Wang S, Chen C-C, Lan L. GWAPower: a statistical power calculation software for genome-wide association studies with quantitative traits. BMC Genet. 2011;12:12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMitchell PH, Powell L, Blumenthal J, Norten J, Ironson G, Pitula CR, et al. A short social support measure for patients recovering from myocardial infarction: the ENRICHD Social Support Inventory. J Cardiopulm Rehabil. 2003;23:398\u0026ndash;403.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCox J. Thirty years with the Edinburgh Postnatal Depression Scale: voices from the past and recommendations for the future. Br J Psychiatry. 2019;214:127\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLevis B, Negeri Z, Sun Y, Benedetti A, Thombs BD. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. BMJ. 2020;371:m4022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeh SS. Validation of the Chinese version of the Edinburgh Postnatal Depression Scale: detecting postnatal depression in Taiwanese women. Nurs Res. 2001;9:105\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee DTS, Yip SK, Chiu HFK, Leung TYS, Chan KPM, Chau IOL, et al. Detecting postnatal depression in Chinese women: Validation of the Chinese version of the Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1998;172:433\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShen J, Gao X, Xiong G, Yan L, Zuo M, Xia T. Work engagement, job stress and relationship among postpartum nurses with the second-child returning to work in operating room. J Nurs Sci. 2019;34:39\u0026ndash;4044.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLin J, Lin Y, Chen C, Wang Q, Wu M, Hu R. Work stress of nurses returning to work after the second childbirth and its influencing factors. Chin Nurs Manage. 2020;20:1523\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRiaz S, Condon L. The experiences of breastfeeding mothers returning to work as hospital nurses in Pakistan: A qualitative study. Women Birth. 2019;32:e252\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCostantini A, Warasin R, Sartori R, Mantovan F. Return to work after prolonged maternity leave. An interpretative description. Women\u0026rsquo;s Stud Int Forum. 2022;90:102562.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCorrigan CP, Kwasky AN, Groh CJ. Social Support, Postpartum Depression, and Professional Assistance: A Survey of Mothers in the Midwestern United States. J Perinat Educ. 2015;24:48\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSharifipour F, Javadnoori M, Behboodi Moghadam Z, Najafian M, Cheraghian B, Abbaspoor Z. Interventions to improve social support among postpartum mothers: A systematic review. Health Promotion Perspect. 2022;12:141\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheng Y, Liu J, Zhu L. Return-to-work Adaptability of 245 Nurses after Second Childbirth and Its Influence Factors. J Nurs. 2018;25:43\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDai L, Hou D. Research progress on the work adaptation of postpartum returning nurses. J Nurs Adm. 2019;19:125\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Nurse, Return to work, Stress","lastPublishedDoi":"10.21203/rs.3.rs-6509772/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6509772/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eSocial support theory has been useful in stress management. The number of nurses returning to work after childbirth is increasing. However, return to work is often accompanied by substantial stress and return discomfort. Therefore, it is necessary to develop and implement coping measures based on social support theory.\u003c/p\u003e\n\u003cp\u003eObjective\u003c/p\u003e\n\u003cp\u003eTo construct a work stress coping program based on social support theory and evaluate its effectiveness in reducing negative emotions and promoting return adaptation among nurses returning to work after childbirth.\u003c/p\u003e\n\u003cp\u003eDesign\u003c/p\u003e\n\u003cp\u003eA two-armed, quasi-experimental study design.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eParticipants were assigned to either the intervention or control group depending on different hospital campuses. The control group received routine return management. The intervention group additionally received a 6-month stress coping program. Data at T0 (pre-intervention), T1 (one month post-intervention), T2 (three months post-intervention), and T3 (six months post-intervention) were collected. Intra- and inter-group differences were assessed using t-tests and repeated measures analysis of variance.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eNo significant differences were found in baseline comparisons. After the intervention, the intervention group was more effective in improving work stress, postnatal depression, social support, and return adaptation compared to the control group. Significant group × time interactions were observed for work pressure, postpartum depression, and return adaptation.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eThe work stress coping program based on social support theory effectively alleviated the work stress and depression of nurses returning to work after childbirth and achieved a good return adaptation.\u003c/p\u003e","manuscriptTitle":"Effects of a work stress coping program based on social support theory for nurses returning to work after childbirth: A quasi-experimental study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-10 06:06:11","doi":"10.21203/rs.3.rs-6509772/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-05T17:25:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120593788362972555654190083783059465791","date":"2026-01-28T14:25:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295353013339666032787687822293822953056","date":"2025-11-20T13:46:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-07T10:20:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-31T04:06:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-20T13:18:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-20T04:00:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-05-20T03:59:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"990844da-aa48-41f6-9852-cea7c8866264","owner":[],"postedDate":"July 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-10T06:06:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-10 06:06:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6509772","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6509772","identity":"rs-6509772","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}