Discussion
We studied ruminative thinking and its associated factors among nurses working in a busy tertiary hospital in China. We collected scores on ruminative thinking, empathy, social support and feedback thinking. All scores had a high Cronbach’s alpha value (0.70 or above) (online supplemental table 1), suggesting that the instruments used in this study are reliable and likely to produce consistent results across different administrations under similar conditions. We found that nurse ruminative thinking was significantly associated with working place (nursing units), length (years) of nursing practice, level of education and income. There was a positive association between rumination and empathy except for the empathic concern dimension. There were negative associations between rumination and social support or supervisor observational feedback-seeking behaviours.
Ruminative thinking has been linked to increased levels of stress, anxiety, emotional exhaustion, depression, memory issues5 and suicidal ideation.6 Nurses who ruminate excessively may experience difficulties focusing on their tasks and may struggle to detach from work-related stressors, leading to reduced job satisfaction and increased burnout.7 Several risk factors have been identified in relation to nurse ruminative thinking behaviour. Workload factors, such as high patient acuity and long working hours, have been associated with increased rumination.8 Organisational factors, including lack of support from supervisors or colleagues and inadequate communication, can also contribute to rumination.9 Additionally, personal characteristics, such as high levels of perfectionism, self-criticism and neuroticism, have been linked to higher levels of rumination.10 In this study, we sought to further identify sociodemographic and psychological factors that are related to rumination in nurses. We found that nurse ruminative thinking is significantly related to the place of work (nursing units), length of practice (years working as a clinical nurse), level of education and income, and to some extent, the personal relationship (marital status). Nurses working at intensive care units or emergency rooms showed significantly higher risk of rumination. These findings are consistent with other studies demonstrating that longer working hours, increased stressors and greater burnout were associated with depression and risk of psychiatric morbidity in intensive care unit nurses.8 The coronavirus disease 2019 pandemic has caused extra stresses to healthcare providers.11 We also found that nurses with working experience of 11–20 years appeared to be more likely to have rumination thinking. This may be due to increased personal and professional responsibilities during this career stage. A recent study of 335 Korean nurses found that the length of service is a significant contributor to anger rumination, though it did not specify which stage of practice was most significant.12 Levels of education and income were also significant risk factors we found. Surprisingly, nurses with higher education (master’s degree) showed a higher level of ruminative thinking. To the best of our knowledge, this is the first report on the association between education level and risk of rumination in nurses. Some may argue that individuals with higher levels of education are less prone to rumination due to improved problem-solving skills, better understanding of mental health and more adaptive coping strategies. However, the increased pressures and stress associated with higher-level job expectations and the cognitive capacity to engage in complex thought processes, including rumination, may explain the higher levels of rumination among highly educated nurses. Income level also showed a significant association with ruminative thinking. Nurses with lower incomes (less than CN¥3000, roughly US$400) were more likely to ruminate, with the RRS decreasing as income increased. This aligns with studies indicating that financial status impacts cognitive thinking, with lower-income individuals tending to ruminate more.13
In addition to sociodemographic factors, we found that all dimensions of ruminative thinking were positively associated with the IRI dimensions except empathic concern. The connection between empathy (as measured by the IRI) and rumination is complex. A study found that rumination had significant moderate effects on the relationship between emotional empathy and depression.14 Another study demonstrated that self-reflectiveness has an almost linear relationship with anxiety and guilt feelings.15 We found that higher perspective taking scores were associated with high ruminative thinking scores. Interestingly, we found a negative correlation between empathic concern and ruminative thinking. While concern for others is generally positive, it can also lead to increased rumination if the individual frequently worries about others’ problems or internalises their distress. Correlation analysis revealed negative associations between ruminative thinking (all dimensions) and social support (all dimensions) among survey participants. High-quality social support can help buffer against stress, a common trigger for rumination. Social support can help individuals feel connected and understood, which can reduce the intensity and frequency of rumination. Finally, we found that nursing ruminative thinking (total score and all dimensions) was negatively associated with feedback seeking (all dimensions). We found supervisor observational feedback seeking was significantly related to RRS total score and reflection, suggesting its critical role in nursing rumination. The impact of feedback seeking on rumination can depend on the style of feedback seeking. Individuals who approach feedback seeking as a learning opportunity and are receptive to criticism may be less prone to ruminate compared with those who seek feedback due to high levels of anxiety or insecurity. Therefore, while feedback seeking can facilitate learning and growth, potentially mitigating uncertainty and rumination, it can also exacerbate rumination if not managed effectively, particularly in response to negative feedback.
There are several limitations of this study. First, this study was conducted on a single site, which could introduce bias as many participants may know the lead investigators. However, single-site studies can still offer valuable insights, particularly in preliminary research, specific case studies or when resources are limited. In our study, all investigators were blinded to the data entered, and the data analysis was performed by someone external to the hospital, reducing potential bias. Second, there might be limitations for generalising the findings here to other hospitals of different sizes. However, the relatively large sample size in this study may compensate for such limitations. Lastly, the vast majority of the participants in this study were females, which could introduce potential bias as women are generally more prone to ruminate than men. Nevertheless, the findings in our study provide valuable insights into the major risk factors related to rumination in nurses.
In summary, we identified several sociodemographic risk factors for ruminative thinking in nurses, including their working unit, years of nursing practice, education level and income. We also found that nursing ruminative thinking was positively associated with empathy and negatively related to social support and feedback seeking. Understanding these relationships is crucial given nurses’ crucial role in healthcare. Identifying risk factors is an essential step to develop interventions. Effective interventions such as targeting nurses in high-stress units (such as intensive care unit or emergency room), those in mid-career stages or those with lower levels of education or income can help manage negative rumination. Providing training in empathetic strategies, fostering effective social support and promoting positive feedback seeking may help nurses manage their negative rumination. Further research is needed to better understand the underlying mechanisms, to identify additional risk factors and to evaluate the effectiveness of interventions.
