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Associations of emotional burden and coping strategies with sick leave among healthcare professionals: A longitudinal observational

study

CHEVAL, Boris, et al .

Abstract

Objectives: To investigate 1) whether care-related regrets (regret intensity, number of recent regrets) are associated with sick leave, independently of personality traits, perceived safety climate, and physical activity; and 2) whether these associations were mediated or moderated by coping strategies. Methods : Using a longitudinal international observational study (ICARUS), data were collected by the means of a weekly web survey. Descriptive and generalized estimation equations were performed. Results : A total of 276 newly practicing healthcare professionals (nurses, physicians, others) from 11 countries were included in this study. The average proportion of weeks with at least one day of sick leave was 3.2%. Nurses' sick leave increased with number of care-related regrets (Relative Risk [RR]=1.52; 95%

Confidence Interval [CI]=[1.18; 1.95], p=.001), while physicians' sick leave increased with intensity of care-related regret (RR=1.21; 95%CI=[1.00; 1.21], p=.049). Coping was associated with lower risk of sick leave for nurses (RR problem-focused strategies = 0.53;

95%CI=[0.37; 0.74], p=.001, and RRphysical [...]

CHEVAL, Boris, et al . Associations of emotional burden and coping strategies with sick leave among healthcare professionals: A longitudinal observational study. International Journal of Nursing Studies , 2021, vol. 115, p. 103869

DOI : 10.1016/j.ijnurstu.2021.103869 PMID : 33517081

Available at:

http://archive-ouverte.unige.ch/unige:153694

Disclaimer: layout of this document may differ from the published version.

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International Journal of Nursing Studies 115 (2021) 103869

ContentslistsavailableatScienceDirect

International Journal of Nursing Studies

journal homepage:www.elsevier.com/ijns

Associations of emotional burden and coping strategies with sick leave among healthcare professionals: A longitudinal observational study

Boris Cheval

a,b,

, Denis Mongin

a

, Stéphane Cullati

a,c

, Adriana Uribe

a

, Jesper Pihl-Thingvad

d,e

, Pierre Chopard

a

, Delphine S. Courvoisier

a

aQuality of Care Service, Department of Readaptation and Geriatrics, University of Geneva, Switzerland

bSwiss NCCR “LIVES: Overcoming Vulnerability: Life Course Perspectives”, University of Geneva, Switzerland

cPopulation Health Laboratory, University of Fribourg, Switzerland

dDepartment of Occupational and Environmental Medicine, Odense University Hospital, Denmark

eNational Center of Psychotraumatology, University of Southern Denmark, Denmark

article info

Article history:

Received 1 July 2020

Received in revised form 21 December 2020 Accepted 2 January 2021

Keywords:

Emotional burden Regrets Sick leave Coping strategy

Newly healthcare professionals

abstract

Objectives:Toinvestigate1)whethercare-relatedregrets(regretintensity,numberofrecentregrets)are associatedwithsickleave,independentlyofpersonalitytraits,perceivedsafetyclimate,andphysicalac- tivity;and2)whethertheseassociationsweremediatedormoderatedbycopingstrategies.

Methods: Using a longitudinal international observational study (ICARUS), datawere collectedby the meansofaweeklywebsurvey.Descriptiveandgeneralizedestimationequationswereperformed.

Results:Atotalof276newlypracticinghealthcareprofessionals(nurses,physicians,others)from11coun- tries wereincludedinthisstudy.Theaverageproportionofweekswithatleast onedayofsickleave was3.2%.Nurses’sickleaveincreasedwithnumberofcare-relatedregrets(RelativeRisk[RR]=1.52;95%

Confidence Interval [CI]=[1.18; 1.95],p=.001), while physicians’ sickleave increased with intensityof care-relatedregret(RR=1.21;95%CI=[1.00;1.21],p=.049).Copingwasassociatedwithlowerriskofsick leave fornurses (RR problem-focusedstrategies = 0.53; 95%CI=[0.37; 0.74],p=.001,and RRphysicalactivity=0.68;

95%CI:[0.54;0.85],p<.001),butnotforphysicians.Nevertheless,theassociationofregretwithsickleave remainedsignificantevenwhenadjustingforcoping.Finally,thisstudydidnotfindevidenceofmoder- ationbythecopingstrategies.

Conclusion:Regretsareassociatedwithincreasedrisksofsickleave,eveninyounghealthcareprofession- als. Use ofcoping strategiespartially mediatedtheseassociations innurses. Theresults ofthisstudy should be used to inform interventions to reduce emotional burdens and enhance protectivecoping strategies.

© 2021TheAuthor(s).PublishedbyElsevierLtd.

ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/)

Whatisalreadyknownaboutthetopic?

• Healthcareprofessionals are athighrisk ofexperiencing vari- ouspsychologicalandphysicalhealthproblems,whichinturn increasethelikelihoodofsickleave.

• Previousstudies suggest that emotional burden, notably care- related regrets, might be associated with increased absen- teeism,though these studies relied oncross-sectional designs anddidnot adjustforother criticalfactors such assafetycli- mateorpersonalitytraits.

Corresponding author at: Quality of Care Division, Geneva University Hospitals, Chemin Thury 3, Geneva 1206, Switzerland.

E-mail address: boris.cheval@unige.ch (B. Cheval).

Whatthispaperadds

• Inthis1-yearintensivelongitudinaldatacollectionwithweekly measures, care-related regrets were associated with increased risksofsickleaveinbothnursesandphysicians.

• Coping strategies partially mediated these associations in nurses.

• The findingsstrengthenthe needtodevelop interventionsde- signedtoreduceemotionalburdenandenhancecopingoptions amonghealthcareprofessionals.

1. Introduction

The psychological and physical health problems likely to be encountered by healthcareprofessionals are well established and https://doi.org/10.1016/j.ijnurstu.2021.103869

0020-7489/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )

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extensive. Being a healthcare professional increases the risk of experiencing,back pain (Ibrahim etal., 2020), sleep problems (Chevaletal.,2018),burnout(DyrbyeandShanafelt,2016),andde- pression(Mataetal.,2015).Thesenegativehealthoutcomeshave animpactonworkefficiency(Melnyketal.,2018),jobsatisfaction (Cheval et al., 2019), turnover (Cheval et al., 2019, Addor et al., 2017), absenteeism and long spells of sick leave (Dewa et al., 2014). In turn,theseconsequences have adetrimental impact on the organization andquality of patient care (Letvaket al., 2012), and represents a considerable economic burden (Letvak et al., 2012), thereby jeopardizing the sustainability of the healthcare system(DyrbyeandShanafelt,2011).Abetterunderstandingofthe factors supporting retention and reducing absenteeism and sick leave isthus warranted.The currentstudyfocuson self-reported absenteeism(sickleave)becauseitisanimportantproblemcom- plicating unit management andquality ofcare, and is known to predictfuturejobquitting(Daouk-Öyryetal.,2014).

Multiple factors are likely to contribute to sick leave, such as healthcareprofessionals’work environment(high workload,night shifts,time pressure) orpsychosocialfactors (workconflicts, lack of perceived support and lack of an encouraging work culture) (Roelen et al., 2018). In addition, there have been an increasing growthofstudiesthatfocusontheemotionalburdenofhealthcare work(OhandGastmans, 2015).Emotional burdeninvolves various emotionalstatessuchasperceptionofinappropriatecareprovided topatients(Piersetal.,2011),moraldistress(Lamianietal.,2017), loss ofcontrol duringthe process of patient care (Shapiro et al., 2011),involvementinmedicalerrors(Sirriyehetal.,2010),aswell ascare-relatedregret.(Courvoisieretal.,2013).

Regret is a normal and frequently experienced emotion (Frijda,1994). Regret canbe definedastheemotion that individ- uals feel when they believe that the outcome would have been better if they had acted or decided differently (Zeelenberg and Pieters, 2007). Pertinent to sick leave, previous studies revealed that care-related regrets have a negative influence on self-rated health (Cullati et al., 2017), and sleep (Cheval et al., 2018; Schmidt et al., 2015) as well asjob satisfactionand turnoverin- tention(Chevaletal., 2019;von Arxetal., 2021). However,these associationsbetweenregretandoutcomesarelessstrongwhenac- countingforthecopingstrategiesusedbyhealthcareprofessionals (Cullatietal.,2017;CarverandConnor-Smith,2010).Whileadap- tivecopingstrategies,suchasproblemsolvingandacceptance,can bebeneficialbyhelpingmanagingstressfulsituations,maladaptive strategies,suchasrumination,can havedeleteriousconsequences (Courvoisier et al., 2014). Hence, coping strategies can partlyex- plainwhetherandhowaregrettedeventwillinfluencehealthand workoutcomes.

Tothebestofourknowledge,only onestudyhasinvestigated theassociationsbetweencare-related regrets(i.e.,regretintensity, numberofrecentregrets,andcopingstrategies)andself-reported absenteeism amonghealthcare professionals (Cullati etal., 2017).

In this study, care-related regret intensity was associated with more frequent sick leave in nurses, whereas adaptive emotion- focused strategies were associated with less frequent sick leave in physicians (Cullati et al., 2017). However, the study relied on cross-sectional data, and could not investigate the dynamics of theassociationsbetweenregrettedexperiences overtimeandsick leave. In addition, the associations were not adjusted for critical factors such as perceived safety climate (Quillivan et al., 2016), personality traits (Goldberg, 1993), or physical activity. For in- stance,ahealthcareprofessionalwithalackofemotionalstability mayexperience highernumberormoreintense regretscompared aprofessionalwithgreateremotionalstability(Allenetal.,2014).

Likewise, a lack of perceived safety climate likely reduces the possibility to report potential problems (Miller et al., 2019), the willingness to speak up about safety (Alingh et al., 2019), or to

discuss ones own mistakes in a context of benevolence. This,in turn,decreasesthequalityofcare(Boweretal.,2003;Hannetal., 2007), increases the risk of errors (Haynes et al., 2011), and reduces the healthcare professionals’ ability to effectively cope with them (Quillivan et al., 2016; Vifladt et al., 2016). Finally, physicalactivityhasbeenshowntohavea positiveeffectonsick leave(Properetal.,2006;Rongenetal.,2013)andtoprotectboth physical andmental health(Warburton etal., 2006; Rebar etal., 2015).Itislikelythatphysicalactivitycouldhelppeoplecopewith healthcare relatedstress situationsandmitigatetheir detrimental effects on health.Thus, in summary,evidence ofan independent associationbetweenregretsandsickleavearestilllacking.

The objective of the study was therefore to investigate the interplay ofsick leave withintensity andnumberof care-related regrets, accounting for critical confounding factors such as per- sonality traits, and perceived safety climate. A second objective was to examine the mediating or moderating effect of coping strategies. Based on previous literature that has shown associa- tions betweencare-relatedregretandvarious outcomesincluding absenteeism, we hypothesized that regret should be associated withan increasedrisk ofsickleave.Finally,wehypothesizedthat coping strategy should mediateand/or moderatethe associations betweenregretandsickleave.

2. Methods

2.1. Studydesignandparticipants

Our analyses used data from the Impact of CAre-related Re- gret Upon Sleep (ICARUS) cohort study (Cheval et al., 2018). In short,ICARUSisaninternationalcohortstudyofnewlypracticing healthcare professionalsworkinginacutecarehospitalsandclin- ics including52repeatedmeasurements over 1 year(i.e.,weekly assessment). The main goal is to examine the real-time associa- tions betweencare-relatedregretandmultiplehealth-relatedand psychological variables. Arandom sampleofhospitalsandclinics were selected from French, English, German, or Danish-speaking countries (e.g., Australia, Austria, Botswana, Canada, Denmark, France, Haiti, Ireland, Kenya, United Kingdom, United States of America). Participants fulfilling all the following criteria were eligibleforthestudy:1)newlypracticinghealthcareprofessionals, 2) speakFrench,English,German,orDanish,and3)completed at least one web survey.Participants who had not provided careto patientsinthelast 6monthswereexcluded.Asincentive, asmall donation to a charity (Theodora Foundation) of 0.5 Switzerland franc(SFr)foreachcompletedsurveywasmade.

2.2. Measures

2.2.1. Primaryoutcome

Sick leavewasmeasured by asking foreach ofthe seven days oftheweekifitwasa“daywork”,“nightwork”,“dayoff” or“sick leave”. Tofullypresenttheoccurrenceofsickleave, itisreported in threedifferent waysinthe study.First, on aweekly basis, we useda binaryvariableindicatingwhethertherewere atleastone day of sick leave on a given week (week with sick leave). This variable wasusedasoutcome of theinferential models,since its frequency of assessment corresponds to the frequency of regret assessment.Twoother waysofreportingsickleaveweredone for descriptive purposes. Specifically, we reported the proportion of participantswithatleastonesickleaveduringthestudyduration (atleast1sickleave).ThisvariablewasusedinourTable1.Finally, weusedtheproportionofsickleavedaysoutoftotalshiftsworked ina week toaccount forpart-time work(%sickleaveshifts). This variablewasreportedtoillustrateourdatainTable1andFig.1.

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B. Cheval, D. Mongin, S. Cullati et al. / International Journal of Nursing Studies 115 (2021) 103869 3 Table 1

Participant characteristics.

Nurses Physicians Other p Overall

Register characteristics

Number of individuals 146 80 50 276

Number of surveys 2008 988 499 3495

Duration of follow-up (mean, SD) 27.0 (31.3) 23.5 (27.0) 16.2 (26.2) 0.078 24.1 (29.4)

Participant characteristics

Age (years) 30.58 (8.58) 30.38 (5.62) 29.64 (7.68) 0.816 30.39 (7.64)

Sex (female, %) 135 (95.7) 54 (67.5) 46 (95.8) < 0.001 235 (87.4)

Personality (mean, SD)

Extraversion 3.56 (0.93) 3.05 (1.09) 3.09 (1.20) 0.014 3.38 (1.02)

Agreeableness 3.89 (0.68) 3.63 (0.80) 3.69 (0.88) 0.128 3.80 (0.74)

Conscientiousness 4.38 (0.61) 3.88 (0.83) 4.14 (0.59) < 0.001 4.23 (0.70)

Emotional stability 2.79 (0.99) 2.84 (1.10) 2.95 (1.16) 0.856 2.82 (1.03)

Openness to experience 3.26 (0.96) 3.57 (0.74) 3.43 (0.83) 0.179 3.36 (0.90)

Perceived safety climate (mean, SD) 3.52 (1.07) 3.62 (0.69) 3.57 (1.01) 0.922 3.55 (0.96)

Physical activity (mean n days, SD) 2.36 (1.76) 3.10 (1.85) 2.31 (1.59) 0.030 2.54 (1.78)

Regret experiences (mean, SD)

Number of regrets 1.61 (1.12) 1.63 (0.96) 1.91 (1.31) 0.005 1.66 (1.10)

Regret intensity (1 -10) 4.03 (2.32) 4.30 (2.05) 3.48 (1.67) < 0.001 4.05 (2.16)

Consequences for the patients of the regretted situation (1 -5) 0.12 (0.49) 0.30 (0.76) 0.15 (0.50) < 0.001 0.18 (0.59)

Perceived medical errors (number, %) 172 (29.5) 137 (35.8) 55 (33.7) 0.161 364 (32.0)

Regret coping strategies (mean, SD)

Problem-focused 2.30 (0.64) 2.47 (0.70) 2.54 (0.74) < 0.001 2.38 (0.68)

Adaptive 2.28 (0.67) 2.80 (0.72) 2.59 (0.63) < 0.001 2.48 (0.72)

Maladaptive 1.74 (0.63) 1.84 (0.76) 1.85 (0.64) < 0.001 1.78 (0.68)

Coper type (%) < 0.001

Adaptive 74 (51.0) 36 (45.0) 26 (52.0) 136 (49.5)

Maladaptive 47 (32.4) 15 (18.8) 5 (10.0) 67 (24.4)

Mixed 24 (16.6) 29 (36.2) 19 (38.0) < 0.001 72 (26.2)

Work schedule (mean, SD)

Number of shifts 4.04 (1.33) 4.56 (1.22) 3.74 (1.50) < 0.001 4.14 (1.35)

Proportion of night shifts worked 24.91 (35.00) 10.08 (22.59) 24.78 (39.02) < 0.001 20.67 (33.28) Proportion of day shifts worked 73.63 (35.68) 88.59 (23.51) 73.96 (39.20) < 0.001 77.93 (33.91)

Number of weeks with sick leave (%) 74 (3.7) 38 (3.8) 17 (3.4) 0.914 129 (3.7)

Proportion of sick leave 1.46 (8.29) 1.34 (7.54) 1.25 (7.71) 0.846 1.40 (8.00)

At least one sick leave (%) 43 (29.5%) 22 (27.8%) 12 (23.5%) 0.719 77 (27.9)

Number of days off 2.68 (1.52) 2.15 (1.39) 2.96 (1.58) < 0.001 2.57 (1.52)

Worked at least one night (%) 86 (58.9) 49 (61.3) 22 (44.0) 0.120 157 (56.9)

Note. The proportion of night shifts worked , day shifts worked, and sick leave were out of total shift worked.

2.2.2. Explanatoryvariables

Care-related regrets variables included the number of recent regrets, regret intensity, and care-related coping strategies. The numberofrecentregretswasassessedbyusingthefollowingsingle item: “During the last week, how many patient care situations havetherebeeninwhichyouexperiencedregret?”, withanopen (numerical) answer. The regret intensity was measured by using the following single item: “What would you say is the average level ofintensity ofyour feelings ofregret in the situations that happenedlastweek?”.Hereresponsewasgivenonavisualanalog scale (VAS), with response options ranging from 0 (null) to 10 (very high). If participants reported no regret over the last 7 days, the intensity question was not asked and an intensity of 0 wasimputed. Care-related coping strategies were assessed with theCare-relatedRegret Coping ScaleforHealth-careProfessionals (RCS-HCP). The scale is validated in French, German and Danish (Courvoisier et al., 2014; Pihl-Thingvad et al., 2018). The scale measures the frequency of use of different coping strategies in relation to regretted experiences in healthcare work. The RCS- HCP contains 15 items divided in 3 subscales: problem-focused strategies(e.g.,“Itry tofindconcretesolutions tothe situation”), emotion-focused adaptive strategies (e.g., “I try to see the posi- tive side ofthings”), and emotion-focused maladaptive strategies (e.g., “I turn these situations over in my mind all the time”).

Respondents answered each item on a four-point Likert scale ranging from 1 (never or almost never) to 4 (always or almost always).InoursampleCronbach’salphawere0.84,0.88,and0.88, for problem-focused adaptive, emotional focused adaptive, and emotionfocusedmaladaptivestrategyrespectively.

In linewithprevious studies(Chevalet al., 2018), we defined three types of healthcare professionals according to the coping strategiesthey typically reliedon.“Adaptivecopers” (i.e., lowuse of emotion-focused maladaptive strategies), “Maladaptive copers”

(i.e., high use of emotion-focused maladaptive strategies), and

“Mixedcopers” (high useofmaladaptiveandofadaptive/problem focused coping strategies). Specifically, we used the healthcare professionalmeanvalueofeach typeofcopingstrategyovertime to characterize the strategies each individual typically relied on during the whole study duration. “Adaptive copers” were char- acterized by a low use of emotion-focused maladaptive coping strategies (< 1.8 on average on the four-point Likert scale) and by thefrequentuseofemotion-focusedadaptiveand/or problem- focused coping strategies (≥ 2.2 on average of the two scales).

“Mixed copers” were characterized by a high use of emotion- focused maladaptive coping strategies and, concomitantly, by a high use of emotion-focused adaptive and/or problem-focused coping strategies. “Maladaptive copers” were characterized by a high use of emotion-focused maladaptive coping strategies and, concomitantly, by a low use of both emotion-focused adaptive andproblem-focusedcopingstrategies.Thesecut-offs werebased on themedianscoresofeachsubscalewithin thecurrentsample consistentwithpreviousstudies(Chevaletal.,2018).

Physicalactivityfocusedonmoderate-to-vigorousphysicalactiv- ity andwasassessed byusing two items:“During thelast week, how many days didyou domoderate (vigorous) physicalactivity foratleast10min”,withascalerangingfrom“noday” to“7days”.

Thenumberofdaysspentineithermoderateorvigorousphysical activitywereused.

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Fig. 1. Associations between care-related regrets and sick leave, according to coper types for nurses and physicians.

Illustration of the associations of emotional burden number (left panels) and intensity (right panels) with sick leave, according to coper types, for nurses (top panels) and physicians (bottom panels), with weeks observed indicated below each bar. For readability, bars at 0 on the Y axis are drawn at -1 to make their color visible. The width of the bars represents the frequency of each coping type.

Perceived safety climate was assessed using 3 scales from the SafetyAttitudes Questionnaire (SAQ) (Sexton etal., 2006):team- workclimate(e.g.,“Inthisareaitis difficulttospeakup ifIper- ceivea problemwithpatientcare”), safetyclimate(e.g.,“Medical errorsare handledappropriately inthisclinicalarea”),andwork- ing conditions (e.g.,“All the necessaryinformation fordiagnostic and therapeutic decisions is routinely available to me”). Respon- dentsansweredeachitemonafive-pointLikertscalerangingfrom 1(disagreestrongly) to5(agreestrongly).Apossibilitytoanswer

“notapplicable” wasalsoprovidedforeachitem.

Personalitytraitswereassessedby usingtheBig FiveInventory (BIF-10)(RammstedtandJohn,2007).TheBIF-10contains10items dived in 5 subscales to assess the 5 dimensions of personality:

extraversion (e.g., I see myself as: “Extraverted, enthusiastic”), agreeableness (e.g., I see myself as: “reserved, quiet”), conscien- tiousness (e.g., I see myself as: “dependable, self-disciplined”), emotional stability (e.g., I see myself as: “calm, emotionally sta- ble”),andopennesstoexperiences(e.g.,Iseemyselfas:“opento newexperiences, complex”). Respondents answered toeach item onafive-pointLikertscalerangingfrom1(disagreestrongly)to5 (agreestrongly).

2.2.3. Covariates

The following variables were assessed: gender, profession (physicians,nurses,otherhealthcareprofessions,e.g.,occupational therapists, midwife), night shifts, numberof days off,number of perceivedmedicalerrors(whethertheeventelicitingthemostim- portant regret in the week was related to an error or not),and consequencesforthepatientoftheregrettedsituation.

2.2.4. Missingdataimputation

Data on covariates were imputed using multiple imputation with thejointmodelling approach(Schafer andYucel, 2002), us- ing the R mitml package and the jomo R packages (Schafer and Zhao, 2014; Grund etal., 2016). The jomopackage allows to per- formimputationofcontinuousandcategoricalvariablesatthefirst and second levelof agiven multilevelstructure, whilethe mitml provides a userinterface tothe former.Toensure validinference of the statistical analysis(Black etal., 2011), the inherent multi- level structureofthelongitudinal datawastakenintoaccountin the imputationmodel. All variables with missing data were im- putedwithrandomintercepts,consideringtheindividualsasclus- tersandprofession,numberofsickleaves,numberofnightshifts and number ofdays off as the independent variables of the im- putation model. Withthese variables included in the imputation model,missingdatawasassumedto bemissingatrandom.Vari- ables being constant at the individual level, such as personality, were imputed at the second level of the multilevel imputation withadependenceontheprofession.

2.3. Statisticalanalyses

We first performed raw and adjusted generalized estimation equations(GEE)withaPoissonlog-link,theindividualasacluster, and an autoregressive correlation structure. These models were used to examine the associations of care-related regrets (i.e., numberofregrets,regretintensity,andcare-relatedcopingstrate- gies), perceived safety climate, personality traits, and physical activity withsick leave ina givenweek (having atleast one day

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B. Cheval, D. Mongin, S. Cullati et al. / International Journal of Nursing Studies 115 (2021) 103869 5

ofsickleaveonagivenweek).Whentestingbinaryoutcomes,the Poissonregressionwithrobuststandard erroris recommendedto accurately estimate the relative risk (Zou, 2004). The advantage of using this model is that relative risks are easier to interpret as a multiplicative coefficient of the baseline risk, compared to odds ratio. The autoregressive correlation structure allows taking intoaccount thelongitudinal natureofthe data,consideringthat observationsclosertogetherintime aremorecorrelatedthanob- servations furtherapart.Variables measuring care-related regrets, physicalactivityaswell ascovariatesmeasured onaweeklybasis were decomposedintoan intra-individualandan inter-individual component, to identify the contribution of both inter-individual differencesandintra-individualdynamics.Specifically,individuals’

meanvalue ofa particularvariable estimatesinter-individualdif- ferences.Forinstance,anindividualansweringthesurvey3weeks withvalues in numberof regrets of3, 6,and 0would receive a mean number of regrets of 3. In contrast, individual’s deviation from this mean value at each time point (i.e., week) estimates intra-individualchanges(yieldingintra-individualchangesof0,3, and-3forthesameindividualasabove).Forexample,healthcare professionals with, on average, lower number of regrets (e.g., 1 by week) may have lower risk of sick leave, compared to their counterparts who experienced, on average, higher number of regrets(e.g.,5byweek)(i.e.,inter-individualeffects).Likewise,for a given healthcare professional, having a lower level of number ofregrets than usual (e.g.,1 regretin agiven week relativeto 3 regrets on average) may be associated with a lower risk of sick leave(i.e.,intra-individualeffects).

To examine the role of coping strategies (i.e., maladaptive, mixed, adaptive), we performed three adjusted models. The ad- justed models include only the significant predictors of the raw models,withtheexceptionofprofessionwhichwasadjustedforin allmodels.Thisstrategywasusedfortworeasons.First,thenum- ber ofevents(in thiscasethe numberofweekswith sickleave) wasrelativelylow,andwecouldnotincludeallcovariatesbecause ofissuesintheestimation.Second, othercovariatescould becor- relatedtoacertain extent,potentiallyleadingtomulticollinearity issues. Incase ofnon-significance, we not only relied on the ar- bitrary cut-off of p<.05 whichdo not reflect the variableimpor- tance(Hayatetal.,2019).Wealsocarefullycheckedtheeffectsize to ensure that the strengths of non-significant associationswere closetothenulleffects.Notethatwedidnotincludebothnumber andintensityofregretalsotoavoidcollinearityproblems.Thefirst model(M1)includedeithernumberofregretsorregretintensity, aswellaspotentialconfoundersandprofession.Then,theselected predictorswereincluded.Inasecondadjustedmodel,copingstyle wasadded asindependent variableto assesspotential mediating processes(M2). Finally,ina thirdadjusted model,the threecop- ing styles and an interaction termbetween the copingstyle and regretswasaddedtoM1toassesspotentialmoderatingprocesses ofthe copingstyle (M3).All analyses were firstperformedwith- out stratifyingonprofessions. Then, adjusted modelswere strati- fiedon professions (i.e.,nurses, physicians, andother).Finally, to examine if respondent’s context (i.e., the country in which they work)influence the results observed, we performed a sensitivity analysiswherecountrywasincludedinthemodels.Werestricted theanalyticalsample(N=220)byincludingonlycountrieswithat leasttenparticipants(i.e.,Austria,Denmark,France,Germany,and Switzerland).

2.4. Ethicalapprovalandinformedconsent

Thisstudywasapprovedby allthe relevantlocalEthics Com- mittees, and all participants signed informed consent forms. See Chevaletal.(2018)formoredetailsontheICARUSprotocol.

3. Results

3.1. Descriptiveresults

We followed a total of276 healthcareprofessionals (87.4% fe- males; meanage=30.4±7.6years; 29.0%physicians, 52.9%nurses, 18.1%otherhealthcareprofessions,e.g.,physiotherapists,socialas- sistants) for 23 weeks on average. Physicians had a significantly lower conscientiousness than the other professions, while nurses hadasignificantlyhigherlevelofextraversion.Onaverage,partic- ipantsexperienced over1regretperweek andtheaverageregret intensitywhenexperiencingaregretwasaround4.Nursesusedall typesofcopingstrategieslessfrequently.Thiswasespeciallytrue for adaptive strategies(nurses: 2.3, physicians: 2.8, other health- care professions: 2.6, p<0.001). When characterizing participants asusingmostlyadaptive,mostlymaladaptiveormixedstrategies, the “copingtype” differed significantly betweenprofessions.Only 45% of physicians used mostly adaptive strategies, compared to more than 50% of nurses and other healthcare professionals. Of note, 32.4% ofnurses used mostly maladaptive coping strategies, comparedtolessthan20%ofphysiciansandotherhealthcarepro- fessionals(Table1).

Reportingthethreeestimatesofsickleave,theaveragepropor- tion ofweeks withatleastone dayofsick leave (weekwith sick leave),overthewholefollow-up,was3.7%,with3.8%inphysicians, 3.7% innurses, and3.4% inthe otherprofessions. Onaverage,the proportionofsickleavedaysout oftotalshiftsworkedinaweek (%sickleaveshifts)was1.4%.Overall,77(27.9%)participantshadat leastonesickleaveduringthestudyduration(atleast1sickleave), 22 (27.8%)physicians, 43(29.5%)innurses, and12(23.5%)inthe otherprofessions.

3.2. Associationsofcare-relatedregrets,perceivedsafetyclimate, personality,andphysicalactivity withsickleave

Fig. 1illustrates theassociation ofregret number(leftpanels) and intensity (right panels) with sick leave, according to coper types,fornurses(toppanels)andphysicians (bottompanels). For readability, barsat0ontheY axisare drawnat-1tomaketheir color visible. The width of the bars represents the frequency of each coping type. Maladaptive coping types were more frequent when reportingmore regretsormore intense regrets.The height ofthebarsrepresentsthefrequencyofsickleavedaysoutoftotal shifts worked(%sickleave shifts).The Fig. illustrates hownurses’

sickleaveincreasedespeciallywithnumberofregretsamongmal- adaptivecopersandphysicians’sickleaveincreasedespeciallywith intensityofregretsamongmaladaptivecopers.

Raw associations. Sick leave (having at least one day of sick leave on a givenweek: week with sick leave)was positively as- sociated with the individual mean number of regrets (Relative Risk (RR)=1.32; 95% confidenceinterval (CI)=[1.08;1.61], p=.007), and its intensity (RR=1.20; 95%CI=[1.07;1.56], p=.028). In other words, one extra regret on average was associated to an in- creased risk of sick leave of 32%. Also, one extra point on average on the 1-10 intensity scale was associated to an in- creased risk of sick leave of 20%. Emotion-focused maladaptive strategies were positively associated with sick leave (RR=1.27;

95%CI=[1.01;1.61],p=.042),whileemotion-focusedadaptivestrate- gies (RR=0.71; 95%CI=[0.57;0.88], p=.002) and problem-focused strategies(RR=0.77;95%CI=[0.59;1.0],p=.046)werenegativelyas- sociated withsick leave. Additionally,maladaptive copershad an increasedriskofsickleave of54%comparedwithadaptivecopers (RR=1.54;95%CI=[1.03;2.29],p=.034).

In contrast, conscientiousness was negatively associated with sick leave (RR=0.76;95%CI=[0.59;0.97], p=0.026).Also, the mean level and intra-individual variation in number of days off was

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Table 2

Generalized estimation equations testing the associations of mean level and intra-individual variation in number of regrets with sick leave and the mediating role of coping strategies in healthcare professionals.

Outcome: Sick leave Without coping strategies (M1) With coping strategies (M2) % of missing

Fixed effects RR (95%CI) P value RR (95%CI) P value

Care-related regrets

Individual mean number of regrets 1.26 (1.03;1.56) 0.028 1.20 (0.95;1.51) 0.120 0.2

Intra-individual variation in number of regrets 1.02 (0.85;1.22) 0.786 1.02 (0.86;1.21) 0.817 0.9 Physical activity

Individual mean level of physical activity 0.85 (0.75;0.96) 0.009 0.87 (0.77;0.99) 0.034 18.6 Intra-individual variation in the level of physical activity 0.78 (0.65; 0.94) 0.009 0.77 (0.64;0.93) 0.007 19.1 Personality

Conscientiousness 0.70 (0.54;0.92) 0.009 0.72 (0.55;0.94) 0.017 22.3

Coping strategies

Problem-focused 0.75 (0.57;1.0) 0.049 1.1

Adaptive 0.84 (0.64;1.11) 0.210 1.2

Maladaptive 1.14 (0.89;1.47) 0.300 1.1

Covariates Profession

Nurses ref ref

Physicians 0.67 (0.44;1.02) 0.061 0.76 (0.50;1.17) 0.209

Other professions 1.0 (0.59;1.71) 0.989 1.14 (0.67;1.94) 0.621

Number of days off

Individual mean number of days off 0.56 (0.47;0.66) < 0.001 0.55 (0.46;0.66) < 0.001 0 Intra-individual variation in number of days off 0.59 (0.50;0.69) < 0.001 0.58 (0.49;0.68) < 0.001 0

Note. The adjusted models were run separately for regret intensity and number of regrets. The adjusted model includes only the significant predictors of the raw models, with the exception of profession which was adjusted for. Of note, in case of non-significance, authors carefully checked the effect size to ensure that the strength of non-significant associations were close to the null effects. Gender, number of night shifts, medical errors, consequence for the patients, other personality dimensions, and perceived safety climate were tested in the raw models, but were not associated with sick leave. The generalized estimation equations used a Poisson log-link and an autoregressive correlation structure.

negativelyassociatedwithsickleave(RR=0.63;95%CI=[0.54;0.73], p<0.001andRR=0.62;95%CI=[0.54;0.71],p<0.001,formeanlevel and intra-individual variation respectively). Finally, physical ac- tivity was also negatively associated with sick leave (RR=0.86;

95%CI=[0.76;0.98],p=0.019;RR=0.80;95%CI=[0.67;0.95],p=0.009, formeanlevelandintra-individualvariation,respectively).Inother words,oneextrapointonconscientiousness onthe1-5scalewas associatedwith32%(i.e.,1/0.76)reductionintheriskofsickleave.

A higher number of days off on average (inter-individual differ- ences) orina givenweek (intra-individualchanges)were associ- atedwitha59%anda61%reductionoftherisk ofsickleave,re- spectively.Andahigherlevelofphysicalactivityonaverageorina givenweekwereassociatedwitha16%anda25%reductionofthe riskofsickleave,respectively.Nosignificantassociationsemerged withsafetyclimate,nor withtheparticipants-reportedcharacter- isticoftheevent(consideringtheregret-eliciting eventasamed- icalerror,consequencestothepatients,feelingresponsibleforthe event),norwithanyoftheothercovariates.

3.2.1. Adjustedmodels

3.2.1.1. Number ofregrets (Table 2). When adjusting only forcon- founders (M1) sick leave remained positively associated with thenumberofregrets (M1RR=1.26;95%CI=[1.03;1.56],p=0.028).

It also remained negatively associated with conscientiousness, and the mean level and intra-individual variation in days off in a week and in physical activity. The association between sick leave and number of regrets decreased and no longer re- mained significant after controlling for the style of coping (M2 RR=1.20; 95%CI=[0.95;1.51], p=0.120). Sick leave was negatively associated withproblem-focused coping strategies (M2 RR=0.75;

95%CI=[0.57;1.0], p=0.049).Noneofthetwootherscopingstrate- gies were significantly associated with sick leave. In the third model (M3), coping style did not moderate the association be- tweensickleaveandnumberofregrets(ps>0.160).

3.2.1.2.Regret intensity (Table 3). In M1, sick leave remained positively associated with regret intensity (M1 RR=1.13;

95%CI=[1.02;1.26], p=0.018), and this association remained

stable when adjusting for coping strategies (M2 RR=1.12;

95%CI=[1.00;1.26], although p=0.053). With respect to coping strategies, problem-focused strategies were associated with a decrease in sick leave (RR=0.74; 95%CI=[0.56;0.99], p=0.042).

Coping styledidnot moderatetheassociation betweensickleave andregretintensity(ps>0.562).

3.2.2. AdjustedmodelsM1andM2stratifyingonprofessions Duetothesmallsamplesize,stratifiedanalysesweredoneonly fornursesandphysicians,butnotforother healthcareprofession- als.

3.2.2.1. Number of regrets. In M1, sick leave wasassociated with themeannumberofregretsamongnurses(RR=1.51;95%CI=[1.15;

1.98], p=.003), but only marginally among physicians (RR=1.46;

95%CI=[0.93;2.3],p=.099).Amongnurses,theassociationbetween sick leave and number of regrets decreased after controlling for coping style and became marginal (RR=1.34; 95%CI=[0.99;

1.82], p=.061). Similarly to the analysis of all participants to- gether, problem-focused strategies were associated with a lower risk of sick leave among nurses (RR=0.50; 95%CI=[0.34; 0.74], p=.001).In contrast,thiscoping strategywasnot associatedwith lower risk ofsickleaveamongphysicians (RR=1.41;95%CI=[0.87;

2.28], p=.165). Finally,intra-individualvariation in physicalactiv- ity was associated with lower risk of sick leave among nurses (RR=0.68; 95%CI=[0.54;0.85], p<.001), but not among physicians (RR=0.93;95%IC=[0.71;1.22],p=.610).ModelsM3were nottested because the smaller sample size precludes accurate testing of interactions.

3.2.2.2. Regret intensity. The pattern of results for regret inten- sity was similar than for number of regrets, except that the associations were stronger for physicians instead of nurses. In M1, sickleave wasassociated withregret intensityamongphysi- cians(RR=1.24;95%CI=[1.08;1.42],p=.002),butnotamongnurses (RR=1.10;95%CI=[0.97;1.26],p=.136).

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B. Cheval, D. Mongin, S. Cullati et al. / International Journal of Nursing Studies 115 (2021) 103869 7 Table 3

Generalized estimation equations testing the associations of mean level and intra-individual variation in regret intensity with sick leave and the mediating role of coping strategies in healthcare professionals.

Outcome: Sick leave Without coping strategies With coping strategies % missing

Fixed effects RR (95%CI) P value RR (95%CI) P value

Care-related regrets

Individual mean in regret intensity 1.13 (1.02;1.26) 0.018 1.12 (1.0;1.26) 0.053 0.2

Intra-individual variation in regret intensity 0.97 (0.89;1.05) 0.400 0.97 (0.89;1.05) 0.398 0.2 Physical activity

Individual mean level of physical activity 0.86 (0.76;0.97) 0.013 0.88 (0.77;0.99) 0.041 18.6 Intra-individual variation in the level of physical activity 0.78 (0.65; 0.94) 0.009 0.77 (0.64;0.93) 0.007 19.1 Personality

Conscientiousness 0.70 (0.54;0.91) 0.008 0.72 (0.55;0.94) 0.016 22.3

Coping strategies

Problem-focused 0.74 (0.56;0.99) 0.042 1.1

Adaptive 0.85 (0.64;1.11) 0.224 1.2

Maladaptive 1.15 (0.89;1.48) 0.298 1.1

Covariates Profession

Nurses ref ref

Physicians 0.66 (0.43;0.99) 0.047 0.75 (0.49;1.14) 0.174

Other professions 1.05 (0.62;1.78) 0.853 1.18 (0.70;1.99) 0.524

Number of days off

Individual mean number of days off 0.57 (0.48;0.67) < 0.001 0.56 (0.47;0.67) < 0.001 0 Intra-individual variation in number of days off 0.59 (0.50;0.69) < 0.001 0.58 (0.49;0.68) < 0.001 0 Note. The adjusted models were run separately for regret intensity and number of regrets. The adjusted model includes only the significant predictors of the raw models, with the exception of profession which was adjusted for. Of note, in case of non-significance, authors carefully checked the effect size to ensure that the strength of non-significant associations were close to the null effects. Gender, number of night shifts, medical errors, consequence for the patients, other personality dimensions, and perceived safety climate were tested in the raw models, but were not associated with sick leave. The generalized estimation equations used a Poisson log-link and an autoregressive correlation structure.

3.2.3. Sensitivityanalysis

Overall,resultsofthesensitivityanalyseswereconsistentwith those ofthe main analysis.However, some differences shouldbe noted.First,themaineffectofthenumberofregretsonsickleave wasnolongersignificant. Yet,copingstylemoderatedthisassoci- ation,witha positiveassociation betweensickleave andnumber ofregrets significantly higherinmaladaptivecopers compared to adaptive copers (p=.028). Furthermore,conscientiousness was no longer associated with sick leave (ps>.285) andthe effect of re- gret intensity did not remain significant in the adjusted models (ps>.246). Finally, regarding coping strategies, the negativeasso- ciationbetweensickleaveandproblem-focusedstrategieswasno longersignificant ineither therawor adjustedmodels (ps>.101).

On the contrary, emotion-focused maladaptive strategies became marginallyassociatedwithsickleaveintheadjustedmodels.

4. Discussion 4.1. Mainfindings

Thisstudyexaminedtheassociationsbetweencare-related re- gretsandsickleaveinamulticenter,international,prospectiveco- hort studyof novice healthcareprofessionals. It also investigated whether coping strategies mediated or moderated these associa- tions.Overall,theprevalenceofsickleavewasrelativelylowcom- pared to other studies, as could be expected in this cohort of novicehealthcareprofessionals.Interestingly,sickleaveprevalence wassimilarfornurses,physicians,andotherhealthcareprofession- als.Yet,thisresultcanbe explainedby thefactthat we assessed sickleaveinnewlypracticinghealthcareprofessionalsthathadjust startedworkingwithpatients,withonaverage,afollow-updura- tion of24 weeks.Significant differences in absenteeismbetween professions aremorelikelyto beobservable inmoreexperienced healthcareprofessionals(RuglessandTaylor,2011).

Number (for nurses) and intensity (for physicians) of regrets were associated with an increased numberof sick leaves. In ad- dition, conscientiousness, as well as individuals’ differences and intra-individualchangesin physicalactivity,were associatedwith

adecreasednumberofsickleaves.Finally,theassociationbetween numberofregretsandsickleavewereslightlymediatedbycoping styles,withproblem-focusedstrategiesmarginallyassociatedwith adecreasednumberofsickleaves.Itisimportanttonotethatthe models stratified on professions (nurses and physicians) showed that theassociationbetweennumberofregrets andsick leave,as wellasthemediatingroleofproblem-focusedstrategies,wereonly observed among nurses. At leasttwo differences betweennurses and physicians can explain these differences in the results ob- served between professions. First, the clinical activity differs be- tween these two professions, with nurses spending more time in direct contactwithpatients. Because ofthis proximity, nurses maybe moreemotionallyimplicatedinthecareofpatientscom- paredtophysicians.Second,aqualitativestudyrevealedthat pro- fessionalsocializationalsodifferedbetweennursesandphysicians.

Unlikephysicians,nursesmassivelyusedsocialresources(i.e.,cope withtheirclosecolleagues)todealwithregrets(Courvoisieretal., 2011), andconsideredthesupportoftheircolleagues asessential.

Incontrast,physiciansreliedmoreonacceptance(Goldbergetal., 2002), acognitivecopingstrategywhichisrarelyobserved inthe generalpopulation(ZeidnerandEndler,1995).

4.2. Comparisonwithotherstudies

Our finding that care-related regret is associated withhigher levelsofsickleaveisinlinewithapreviouscross-sectionalstudy (Cullatietal., 2017).However, the previous studyfound an asso- ciationofsick leave withregretintensity,butnot withthenum- berofregretsamongnurses.Moreover,consistentwithourresults, this research found that adaptive coping strategies were associ- ated withlessfrequent sickleave amongnurses.However, unlike ourstudy,itdidnotfindevidenceofassociationsbetweencoping strategiesandsickleaveamongphysicians.Thisdiscrepancycould beexplainedbythefactthatourstudyinvolvedasampleofnovice healthcare professionals,whereas theprevious studyinvolved ex- perienced physicians andnurses, often with10 yearsor more of experience.Thislatterpopulationisthusmoreexposedtotherisk of experiencing difficult eventsrelated topatient care.Moreover,

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thispopulationismorelikelytoincludeindividualswhodealmore effectively withhealthcare-related difficult events and situations, andinparticularwhohavelearnedtouseproblem-focusedstrate- gies,suchastalkingtocolleaguesandsupervisortoavoidthesitu- ationre-occurring.Incontrast,novicehealthcareprofessionalsmay stillshow agradient ofknowing howtonavigate thehospitalin- stitutiontodealwithregret-inducingsituations.

Adjustmentforcopingstrategyonlypartlyexplainedtheasso- ciationbetween numberof regrets andsick leave among nurses.

Thesefindings are inlinewithprevious studies that haveshown amediatingrole ofcopingstrategiesbetweencare-related regrets and health outcomes, including for instance psychological well- being (Sirriyeh et al., 2010), and self-rated health (Cullati et al., 2017). However,the mediation waspartial,suggestingthat regret experience is still very relevant forsick leave. It is also possible that novicehealthcare professionals rely oncoping strategiesnot measured bythe copingscale usedinthe currentstudy.Ofnote, inthesensitivityanalyses,weobservedamoderatingeffectofcop- ing strategies on the association betweennumber ofregrets and sick leave. Here, the positive association betweensick leave and number of regrets was more pronounced in maladaptive copers compared to adaptive copers. These findings suggest that coping strategiescannot onlypartlyexplain theassociationbetweenre- gretsandsickleave(i.e.,mediation),butalsoexplaintheboundary conditionsin whichtheeffect ofregrets willbe particularlypro- nouncedvs.attenuated(i.e.,moderation).

Interestingly,thelowerlevelofconscientiousnessinphysicians, apersonalitydimensionplayingaprotectiveroleintheemergence ofsick leave, contrasts with theusually lower prevalenceof sick leaveobservedinthisprofession.Asaconsequence,thesefindings maysuggestthatprotectivepersonalitytraitscouldnotbeenough toeffectivelytempertheaversiveeffectofemotionalburdenafter several years ofwork. This effect must be interpreted with cau- tion becauseit didnot remain significant in thesensitivity anal- ysis. Likewise, the absence of association between the perceived safetyclimateandsickleavemayalsoreflectthestudytimeframe.

Thatis,theworkingconditionsrelatedtosafetymayrequiresome time to havea significant impact(either positive ornegative) on thehealthcareprofessionals,whichmaynotbereachedinthislon- gitudinal study lasting approximately 6 months. Future research should examine longer-term influence of coping strategies, per- sonalitydimensions, andworkingenvironment ontheemergence of sick leave. Finally, the protective influence of physical activ- ityonthe numberofsick leavesare inlinewithprevious litera- turedemonstratingthe numeroushealthbenefits associatedwith amorephysicallyactivelifestyle(Godlee,2019).Promotingphysi- calactivityamonghealthcareprofessionalmayrepresentapartic- ularlyeffectivewayto reducetheprevalenceofsick leaveamong healthcareprofessionals.

4.3. Strengthsandweaknessesofthestudy

Among the strengths of the present study are the use of an intensive longitudinal design (i.e., 1-year weekly assessment), to better explore associations over time. Likewise, the inclusion of differenthealthcareprofessions (i.e.,nurses,physicians,andother professions),theinternationalrecruitmentinarandomsampleof medical and nursing schools in multiple countries, and the se- lectionofnewly practicinghealthcareprofessionalsreducesselec- tionbias.In addition,thefocuson regret,anormalandcommon emotionratherthanabnormalandlessfrequentemotion,mayen- hancetheusefulnessofthisstudyforallhealthcare professionals and not only for people suffering fromburnout. Finally, the ad- justmentofindividuals’(i.e.,personality)andenvironmental’(i.e., perceivedsafetyclimate)characteristicshelpreducepotentialcon- founding.However,severallimitationsofthisstudyshouldbecon-

sidered. First, sick leave was measured using self-reportedretro- spectivedataandmaythereforebysubjecttorecallbiasorsocial desirability.However,recallbiaswasreducedthankstotheweekly data collectionand thesocial desirability biaswas minimizedby the useof an internet-basedsurvey,which allows participantsto feel morecomfortablereportingtheirsick leaveandtheir experi- ences(Sikorskiietal.,2009).Second,asparticipationisvoluntary, apotentialselectionbiascannotbeexcluded.Nevertheless,partic- ipants whohadatleastone time ofmeasurement wereincluded intheanalysisthankstothestatisticalapproachemployed,which limited selection bias due toattrition. Third, because ofa rather lowsamplesizewithineachcountry,wewereunabletoprovidea meaningfulassessmentofthedifferencesbetweencountriesinthe associationsobserved– althoughitshouldbenotedthatallpartic- ipantswereincludedintheanalysis,regardlesstheir numberina givencountry.Likewise, becausethestudydidnotrecruitenough participants within each gender and professions strata, we were unable toassesswhethergenderdifferencesbetweenprofessional groupsandexpressionofregretcouldbe observed.Futurestudies withlargersamplesizesforeachcountryshouldbe conductedin orderto investigateanycountryorgenderrelateddifferences. Fi- nally,toguaranteetheschoolsandparticipantsanonymity,wedid not captureanydataonsupportprograms.Thisfeaturelimitsthe abilityto evaluatehowthecontent ofthegraduate programscan impacttheassociationsbetweenregretsandsickleaveobservedin thisstudy.Forexample,wecanexpectthatasupportprogramem- phasizing notonly thatregret isan unavoidablecorollary ofpro- vidingcare,butalsohowtoeffectivelycopewithit,maybeuseful to prevent thefuture detrimentaleffects ofregrets onhealthcare professionalownhealth.

4.4. Conclusionandimplications

Accumulation ofcare-related regretswasassociatedwithmore sick leave among nurses, even after adjusting for individual and environmental factors.Theseassociationswere partiallymediated bycopingstrategies.Becausesickleavehasseriousimpactonunit management, quality of patient care, and the healthcare system sustainability, helping healthcare professionals, especially nurses, toeffectivelydealwithregrettedsituationsiswarranted.Integrat- ing trainingmodules in the curriculum aiming to preparefuture healthcareprofessionalstoeffectivelydealwithdifficulteventsand situations, especially by facilitating their use of problem-focused coping strategies, may lead to beneficial outcomes not only for healthcare professionals’ own health andwell-being, butalso for the quality of patient care. Of note, physical activity, which has been shown to protect both physical and mental health on var- ious context (Warburton et al., 2006; Rebar et al., 2015), seems also effective in reducing the risk of sick leave among young healthcareprofessionals.Interventionsthatpromotephysicalactiv- ity among healthcare professionals may be particularly suited to protectagainstpsychologicalandphysicalhealthproblems.

CRediTauthorshipcontributionstatement

Boris Cheval: Conceptualization, Formal analysis, Writing - originaldraft,Writing-review&editing.DenisMongin:Datacu- ration,Formalanalysis, Writing-review& editing.StéphaneCul- lati:Conceptualization,Writing-review&editing.AdrianaUribe:

Data curation, Writing - review & editing. Jesper Pihl-Thingvad:

Writing - review & editing. Pierre Chopard: Writing - review &

editing.DelphineS.Courvoisier:Conceptualization,Formal analy- sis,Writing-originaldraft,Writing-review&editing.

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