Iran Journal of Nursing

Introduction
The emergence of a novel coronavirus disease in 2019 and its global spread caused a lot of fear and panic in people [1]. In addition to physical problems, this disease caused psychological problems such as anxiety due to the unknown cause of this disease and the its transmission rate [2-4]. Anxiety can disturb the physiologic balance of the body and weaken the immune system [5]. Therefore, it is necessary to understand the psychological changes caused by the COVID-19 pandemic [1]. During the pandemic nurses were more prone to higher level of anxiety due to subject to risk factors such death cases, heavy workload, lack of protective equipment, lack of support, exposure to various chemicals [6, 7, 8]. Therefore, psychological approaches that can help maintain or promote mental health of nurses in these conditions are important [9]. Cognitive flexibility is one of these approaches that makes a person adapt to the changing conditions [10]. This study aims to investigate the relationship between cognitive flexibility and COVID-19-related anxiety in Iranian nurses.

Methods
This is a descriptive-analytical study with a cross-sectional design that was conducted on 120 male and female nurses working in one of the hospitals affiliated to Arak University of Medical Sciences. Sampling was done using a stratified and random sampling method from each department of the selected hospital in 2021. The inclusion criteria were working in the hospital, having at least six months of work experience as a nurse, and having a signed informed consent. The exclusion criteria were the use of psychiatric medications, and unwillingness to continue participation in the study. The cognitive flexibility inventory (CFI) and the Corona disease anxiety scale (CDAS) were used to collect data. Normal distribution was maintained for both anxiety and flexibility variables (p>0.05). Therefore, independent t-test, analysis of variance (ANOVA), and Pearson correlation test were used for data analysis.

Results
Participants were 41 (2.34%) male and 79 (8.65%) female nurses with a mean age of 30.5 years, and their average physical activity per week was 3.2 hours. Their work experience ranged from 1 to 19 years. Moreover, 82% had a bachelor’s degree in nursing and the rest had a master’s degree. Furthermore, 90% reported a history of COVID-19 infection, 93.3% had an experience of working in the coronavirus wards, 82.5% had permanent employment , and 5.8% reported a history of chronic disease. Most of nurses were from surgical and internal medicine departments and 61.7% were married. 
Based on the Pearson correlation test results, the CDAS score of nurses had no significant relationship with the CFI score (p>0.05). The mean scores of CFI and CDAS were not significantly different based on age, number of children, work experience, physical activity level, educational level; however, the mean CFI score of male nurses was lower than that of female nurses, and the mean CDAS score was significantly different based on marital status. 

Conclusion
The findings of the present study showed that COVID-19-related anxiety had no statistically significant relationship with cognitive flexibility of nurses. It is recommended that factors such as perceived social support, personality type, and social interactions of nurses should be taken into account in future studies. Additionally, further studies with larger sample size are recommended on nurses from others hospitals and cities.

Ethical Considerations
Compliance with ethical guidelines
All participants signed a written informed consent form. Ethical approval was obtained from the Ethics Committee of Arak University of Medical Sciences (Code: IR.ARAKMU.REC.1400.068).

Funding
This research was funded by Research Committee of Arak University of Medical Sciences (Grant No. 3807).

Authors' contributions
Conceptualization and project management: Mahsa Hosseini and Mahsa Rezaei; Investigation: Mahsa Hosseini, Data analysis: Azam Muslimi; Editing and review: Mahbobeh Sajadi.

Conflict of interest
The authors declared no conflict of interest.

Refrences

1. Haghbin M, Abbasi A, Rafei E, Kheradmand A, Javdani F, Hatami N, et al. Anxiety caused by new coronavirus (Covid-19) in breast cancer patients during the coronavirus pandemic. Iran J Obstet Gynecol Infertil. 2020; 23(8):8-17. [DOI:10.22038/ijogi.2020.17286]
2. Choi EPH, Hui BPH, Wan EYF. Depression and anxiety in hong kong during COVID-19. Int J Environ Res Public Health. 2020; 17(10):3740. [DOI:10.3390/ijerph17103740] [PMID] [PMCID]
3. Dong L, Bouey J. Public Mental Health Crisis during COVID-19 Pandemic, China. Emerg Infect Dis. 2020; 26(7):1616-8.[DOI:10.3201/eid2607.202407] [PMID] [PMCID]
4. Al Turki YA. Can we increase public awareness without creating anxiety about corona viruses? Patient Educ Couns. 2014; 94(2):286-7. [DOI:10.1016/j.pec.2013.10.023] [PMID] [PMCID]
5. Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R. Emotions, morbidity, and mortality: New perspectives from psychoneuroimmunology. Annu Rev Psychol. 2002; 53:83-107. [DOI:10.1146/annurev.psych.53.100901.135217] [PMID]
6. Talebi M. [The role of psychological resilience and spiritual health in predicting covid 19 anxiety in nurses (Persian)]. Iran J Rehabil Res Nurs. 2022; 8(2):12-20. [DOI:10.22034/IJRN.8.2.2]
7. Darbani S, Mirzaei A. Consequences of the COVID-19 pandemic on mental health: A review study. J Assess Res Appl Couns. 2022; 4(2):22-7. [DOI:10.52547/jarac.4.2.48]
8. Kawano Y. Association of job-related stress factors with psychological and somatic symptoms among Japanese hospital nurses: Effect of departmental environment in acute care hospitals. J Occup Health. 2008; 50(1):79-85. [DOI:10.1539/joh.50.79] [PMID]
9. Shrestha GS. COVID-19 pandemic: Shortage of personal protective equipment, use of improvised surrogates, and the safety of health care workers. J Nepal Health Res Counc. 2020; 18(1):150. [DOI:10.33314/jnhrc.v18i1.2593] [PMID]
10. Nogee D, Tomassoni AJ. Covid-19 and the N95 respirator shortage: Closing the gap. Infect Control Hosp Epidemiol. 2020; 41(8):958. [DOI:10.1017/ice.2020.124] [PMID] [PMCID]
11. Sher L. COVID-19, anxiety, sleep disturbances and suicide. Sleep Med. 2020; 70:124. [DOI:10.1016/j.sleep.2020.04.019] [PMID] [PMCID]
12. Kashdan TB, Rottenberg J. Psychological flexibility as a fundamental aspect of health. Clin Psychol Rev. 2010; 30(7):865-78. [DOI:10.1016/j.cpr.2010.03.001] [PMID] [PMCID]
13. Richardson CME, Jost SA. Psychological flexibility as a mediator of the association between early life trauma and psychological symptoms. Pers Individ Diff. 2019; 141:101-6. [DOI:10.1016/j.paid.2018.12.029]
14. Darby KP, Castro L, Wasserman EA, Sloutsky VM. Cognitive flexibility and memory in pigeons, human children, and adults. Cognition. 2018; 177:30-40. [DOI:10.1016/j.cognition.2018.03.015] [PMID] [PMCID]
15. Dawson DL, Golijani-Moghaddam N. COVID-19: Psychological flexibility, coping, mental health, and wellbeing in the UK during the pandemic. J Contextual Behav Sci. 2020; 17:126-34. [DOI:10.1016/j.jcbs.2020.07.010] [PMID] [PMCID]
16. Kroska EB, Roche AI, Adamowicz JL, Stegall MS. Psychological flexibility in the context of COVID-19 adversity: Associations with distress. J Contextual Behav Sci. 2020; 18:28-33. [DOI:10.1016/j.jcbs.2020.07.011] [PMID] [PMCID]
17. Hoseini Zarvijani SA, Fatah Moghadam L, Parche Bafieh S. [Correlation of perceived stress and psychological flexibility in razi psychiatric nurses in Tehran (Persian)]. J Health Promot Manage. 2019; 8(6):11-7. [Link]
18. Dennis JP, Vander Wal JS. The cognitive flexibility inventory: Instrument development and estimates of reliability and validity. Cogn Ther Res. 2010; 34:241-53. [DOI:10.1007/s10608-009-9276-4]
19. Saadati N, Yousefi Z, Golparvar M. [Effectiveness of systematic training of effective parenting (STEP) on parenting stress, emotion regulation, and cognitive flexibility on mothers of male adolescents (Persian)]. Appl Psychol. 2020; 14(2):100-77. [DOI:10.52547/apsy.14.2.77]
20. Fazeli M, Ehteshamzadeh P, Hashemi SE. [The effectiveness of cognitive behavior therapy on cognitive flexibility of depressed people (Persian)]. Thoughts Behav Clin Psychol. 2015; 9(34):27-36. [Link]
21. Alipour A, Ghadami A, Farsham A, Dorri N. A new self-reported assessment measure for COVID-19 anxiety scale (CDAS) in Iran: A web-based study. Iran J Public Health. 2020; 49(7):1316-23. [DOI:10.18502/ijph.v49i7.3585] [PMID] [PMCID]
22. Alipour A, Ghadami A, Alipour Z, Abdollahzadeh H. [Preliminary validation of the corona disease anxiety scale (CDAS) in the Iranian sample (Persian)]. Health Psychol. 2020; 8(32):163-75. [DOI:10.30473/hpj.2020.52023.4756]
23. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet. 2020; 395(10227):912-20. [DOI:10.1016/S0140-6736(20)30460-8] [PMID] [PMCID]
24. Kamody RC, Berlin KS, Rybak TM, Klages KL, Banks GG, Ali JS, et al. Psychological flexibility among youth with type 1 diabetes: Relating patterns of acceptance, adherence, and stress to adaptation. Behav Med. 2018; 44(4):271-9. [DOI:10.1080/08964289.2017.1297290] [PMID]
25. Shams S. [Predicting Covid Disease -19 anxiety based on perceived stress and anxiety sensitivity in nurses: The mediating role of cognitive flexibility (Persian)]. J Health Promot Manage. 2022; 11(3):1-14. [DOI:10.22034/JHPM.11.3.1]
26. Wielgus B, Urban W, Patriak A, Cichocki Ł. Examining the associations between psychological flexibility, mindfulness, psychosomatic functioning, and anxiety during the COVID-19 pandemic: A path analysis. Int J Environ Res Public Health. 2020; 17(23):8764. [DOI:10.3390/ijerph17238764] [PMID] [PMCID]

27. Fallah Madvari R, Zare Sakhvidi MJ, Sefidkar R, Jafari Nodoushan M. [Investigating corona disease anxiety in nurses and its relationship with cognitive flexibility: A case study (Persian)]. Arch Occup Health. 2022; 6(2):1243-9. [DOI:10.18502/aoh.v6i2.9488]
28. Asadi N, Salmani F, Pourkhajooyi S, Mahdavifar M, Royani Z, Salmani M. [Investigating the relationship between corona anxiety and nursing care behaviors working in corona’s referral hospitals (Persian)]. Iran J Psychiatr Clin Psychol. 2020; 26(3):306-19. [DOI:10.32598/ijpcp.26.3476.1]
29. Eyni S, Ebadi M, Hashemi Z. [Corona anxiety in nurses: The predictive role of perceived social support and sense of coherence (Persian)]. Iran J Psychiatr Clin Psychol. 2020; 26(3):320-31. [DOI:10.32598/ijpcp.26.3436.1]
30. Rahmanian M, Mosalanezhad H, Rahmanian E, Kalani N, Hatami N, Rayat Dost E, et al. [Anxiety and stress of new coronavirus (COVID-19) in medical personnel (Persian)]. Horizon Med Educ Dev. 2021; 12(2):80-70. [DOI:10.22038/hmed.2020.51423.1076]