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Mindow in crisis: the mediating role of psychological
capital and coping competence between mindfulness and
ow during COVID-19.
Nargess Rahnama
Ferdowsi University of Mashhad
Gholamreza Malekzadeh ( malekzadeh@um.ac.ir )
Ferdowsi University of Mashhad
Mohammad Moshtari
Tampere University
Research Article
Keywords: Flow, Mindfulness, Psychological capital, Coping competence, Emergency staff
Posted Date: August 8th, 2023
DOI: https://doi.org/10.21203/rs.3.rs-3209999/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License
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Abstract
Background
The present study aims to investigate whether and how mindfulness leads to the ow experience in high-pressure
situations during the coronavirus pandemic peak, especially in high-risk, challenging contexts such as emergencies.
therefore, the authors aim to expand existing knowledge about experiencing ow at work, specically in the crisis context
of the COVID-19 period, when challenges convert to hindrance demands. Before examining the possible processes and
mechanisms in this relationship, we examined the mediating role of two variables: psychological capital and coping
competence.
Method
The statistical population of this study consists of all employees of emergency centers in Mashhad, Iran; there were 550
at the time of the study. Using a simple random sampling method and the Morgan table, a sample of 220 people was
considered. A structural equation model, AMOS, and SPSS software were used to analyze the collected data.
Result
The results emphasize that among employees who experienced mindfulness, an optimal experience did not necessarily
occur, specically in those situations in which challenge stressors become hindrance stressors. Although the association
of mindfulness and coping competence was veried, its association with ow through coping competence was rejected.
It is veried that mindfulness would be associated with ow through psychological capital.
Conclusion
The study extends our understanding of occurring ow at high-risk work environments in which challenges are not
motivational. The authors studied the experience of ow in a work context with challenges that appear in the form of
hindrance demands, different from the previous ones that have studied ow experience in challenging and motivating
contexts such as sports contexts, including mountain climbing, surng, and similar cases. In addition, there was no
consensus in different past studies about associating mindfulness with ow experience. Therefore, in this case, further
study had been left to future studies. Moreover, the process of this relationship through the mediating role of
psychological capital and coping competence has not been investigated in previous studies.
Background
In today’s business world, whispers of “I work for my own sake” are seldom uttered by employees or by managers. Those
who work for their own sakes will enjoy work to the fullest and concentrate all their energy on their work, without any
expectation of external rewards. Is it possible that people who are deeply absorbed in an activity are not worried about
something? They are full of enthusiasm and passion and walk along the path without concern. They become one with
their work; they may not know how, but they become immersed in what they create. Even if we all acknowledge knowing
people like this, we still need to know how this phenomenon occurs. This is a question that can be answered with the help
of positive psychology. The state described above results from a feeling of enjoyment, which is distinct from pleasure.
Seligman and Csikszentmihalyi(1), the co-founders of positive psychology, describe the difference as follows. Pleasure
refers to the desirable feeling that comes from satisfying homeostatic needs such as hunger and sexual desire, while
enjoyment refers to the desirable feeling that people experience when going beyond the limitations of homeostasis while
doing what they want. This transcendental experience can lead to ow in individuals when engaging in an activity. In this
case, people use all their energy and skills to do the job better. Csikszentmihalyi(2) describes this phenomenon as an
“optimal experience”, conceptualizing it as engaging in activities with intrinsic motivators. Seligman & Csikszentmihalyi
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(1) state that people sometimes pay more attention to activities and continue to work even when hungry and tired; the
motive for this signicant investment and systematic awareness is called optimal experience or ow(3, 4). A closely
related concept to ow is mindfulness, which has been suggested as a precursor to ow.
In the state of optimal experience, individuals demonstrate a total focus on their work, requiring them to be aware of the
experience here and now of both internal and external events. This state of awareness and full attention in the present
moment without evaluation, interpretation, or judgment is dened as mindfulness by Kabat-Zinn(5); the focus of that
concept is attention, a scarce resource whose absence has made responding to the turmoil of today’s business
environment and the full range of environmental demands vastly more dicult. The scarcity of attention and its
importance has given rise to a scientic eld called the economics of attention. Mindfulness has other signicant
consequences, including developing psychological capital and coping competence. These two factors contribute in turn
to the experience of ow at work. In the contemporary context, organizations seek high-performing employees who can
function well in turmoil and actively learn and grow from adversity despite the obstacles they face. Average performance
no longer meets the increasing expectations of stakeholders and is insucient for the achievement of organizational
goals. Employees need to proudly and quickly come out of the challenging problems and uncertainty they face. The
phenomena of ow and mindfulness, regardless of the contexts in which they occur, are helpful in virtually all situations
and conditions, but they are simply crucial in business because they are among the most important strengths that
employees can have, due to their positive consequences. Experiencing an optimal state and mindfulness is especially
crucial in sensitive and high-risk positions. In such jobs, employees’ attention and their complete involvement at work
play a decisive role in the quality of their performance. The experiencing of ow through mindfulness leads to mindful
ow, or rather, as Cacioppe(6) put it, "mindow”. This state of mind which is described by Cacioppe (6) as a “type of
attention with a main focus yet is open and aware of other information and sensations”, would be valuable in dynamic
workplaces. In emergency healthcare organizations, the importance of ow at work and people’s awareness is more
apparent because of the challenging nature of the work. Performing emergency tasks requires sucient professional
skills and abilities. Because emergency personnel provide relief in cases of disasters, they are unlikely to perform well
without having all the professional knowledge and skills they need to master and overcome dangerous situations.
Without those assets, they cannot ensure their safety and focus on rescue operations. According to Csikszentmihalyi (2),
when people experience ow, undertake a particular activity, and become immersed in it, they become physically and
mentally fully engaged in their work, without any sense of time. Thus, people can do things that would not usually be
possible. This presence of mind of individuals as to all external and internal events and being in the here and now is
known as mindfulness, the positive consequences of which have been revealed in research conducted in the last two
decades(7). Those studies have identied positive associations between mindfulness and well-being, behavior regulation,
reduction of negative symptoms and emotional reactions (8), stress reduction and optimism (9), psychological well-
being(10), cognitive exibility, emotional transparency (11), self-esteem, satisfaction with life, positive emotions and
optimism (12), and ourishing and coping competence (13). Given the positive connections between mindfulness and
psychological capital and coping competence, it is reasonable to posit that mindfulness can also lead to the experience
of ow in individuals. The importance of investigating ow and its antecedents at work, especially mindfulness among
emergency personnel, is reinforced by the high sensitivity and signicant risks inherent in that kind of work. Despite the
importance of this issue, existing research has not focused on the study of this phenomenon in emergency personnel(14,
15). In addition, although some studies have examined the relationship between mindfulness and ow (4, 16–18), none
have concentrated on work-related ow. In the present study, the positive consequences of mindfulness such as coping
competence and psychological capital, are examined as mediators for the experience of work-related ow. Akin and Akin
(13) addressed the mediating role of coping competence in the relationship between mindfulness and student ourishing
while coping competence research is largely found in purely psychological studies, with coping competence at work and
in management less intensively examined. Roach et al. (19) studied the relationship between mindfulness and
psychological capital and their impact on the well-being of leaders. In the present study, an attempt is made to determine
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whether psychological capital and coping competence contribute to the impact of mindfulness on ow in crises such as
pre-hospital emergencies.
Hypothesis development
Mindfulness
Mindfulness, which originated in Buddhist philosophy, is described as the mere observation or non-argumentative
recording of events without reaction or mental evaluation. Kabat-Zin(20) denes mindfulness as being in the present
moment and focusing on the target without judgment. Weick and Robert(21) introduced the concept of mindfulness in
management literature. Their approach to the concept was unsurprisingly different from the original concepts in
Buddhism, largely by its focus on two concepts: attention and awareness. In Buddhist philosophy, mindfulness means
focused attention. However, the newer concept of mindfulness is a combination of attention and awareness; mindfulness
is thus not just a therapeutic method but a natural capacity that plays a crucial role in the cognitive process(22)
.Mindfulness has a wide range of positive effects on human performance(23). Research in disciplines such as
psychology, neuroscience, and medicine has shown a positive effect of mindfulness on attention, cognition, emotions,
behavior, and physiology(24). People who experience mindfulness have deep peace of mind and a signicant focus on
everyday tasks. When managers or employees put mindfulness on their agendas, they provide conscious, appropriate
responses to each situation throughout the day, rather than conditional and often inappropriate reactions. In times of
crisis, mindfulness can create a clear mind and deep calm that prevents fear and self-loathing. Mindfulness during a
crisis can bestow the power to change the situation. Stedham and Skaar’s (25)conceptual framework points to the
positive effect of mindfulness on characteristics such as empathy, resilience, and positivity, which increase trust and
management effectiveness. Many other studies have demonstrated the positive consequences of mindfulness, such as
increasing cognitive capacity, especially working memory capacity, emotion regulation(26, 27), behavioral regulation and
increased well-being (25, 28, 29), more exible and adaptive responses based on reduced automatic impulse responses
(25, 30, 31), individual and social awareness(30, 32), and prosperity and coping competence(13).
Psychological capital
Psychological capital traces its origin to positive psychology and positive organizational behavior, which focuses on the
strengths and capabilities of individuals. Psychological capital is the positive psychological state of an individual that
stems from his or her development and progress. It is characterized by having condence in one’s ability to complete a
task (self-ecacy), having positive thoughts about and expectations for the future (optimism), maintaining one’s path
toward a goal, and, if necessary, reorienting toward the goal (hope), and enduring hardships (resilience). According to
Luthans and colleagues (33), these psychological sources, in combination with one another, form a more orderly core
construct that has a higher predictive power over individuals’ attitudes and actions than each component does on its
own. Luthans and colleagues (33) conclude that psychological capital, by relying on positivist psychological variables
such as hope and self-ecacy, enhance the value of human capital (the skills and knowledge of individuals) and social
capital (the network of relationships between people) in an organization. Psychological capital has a strong positive
relationship with desirable behaviors, attitudes, and performance, along with the psychological well-being of employees
(34, 35). In other studies, positive relationships between psychological capital or its dimensions with factors such as life
satisfaction and indicators of mental well-being (36), mindfulness and well-being, social support and mental well-being
(14), learning competency (37), study engagement (38), and psychological well-being (39) have been shown. Moreover,
the association of mindfulness and psychological capital with positive emotions has been shown by Avey et al (40). As
noted above, one of the preconditions of psychological capital is mindfulness(26, 40). Avey and colleagues comment
that mindfulness gives employees more opportunities to become aware of thought patterns that challenge their ability to
be hopeful, ecient, optimistic, and resilient at work.
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Mindfulness develops an individual’s cognitive capacity and consequently cognitive exibility (25), so can dramatically
reduce the inner resistance to making personal decisions. Simply put, peace and reconciliation are established within
people, so that they no longer ght with themselves. On one side of the struggle, the authentic self, the human being has
succeeded in identifying himself as a “superior self” separated from the “mental self.” Mindfulness reduces the inner
challenges that a person faces and thus signicantly increases people’s levels of inner and psychological energy. It acts
as a powerful spiritual and physical support and facilitates hard work and learning complex skills. In other words, it
enhances people's self-ecacy and resilience in the face of obstacles. At the same time, the role of mindfulness in the
development of positive thinking choices and performance(41) and its effect on positive and wise orientation (35) and
reducing pessimism (34) and promoting optimism (9) all mean that it leads to optimism. Furthermore, due to the self-
regulatory mechanism, mindfulness plays a signicant role in the development of conscious and autonomous behavioral
regulation(35); it can thus lead to hope, which is another component of psychological capital. As a result, the relationship
between mindfulness and employees’ psychological capital is inferred and the following hypothesis is proposed:
Hypothesis 1
Mindfulness would be positively associated with employees’ psychological capital.
Coping competence
The notion of coping competence was rst suggested in the theory of action control(42) which measures action versus
state orientation. Kuhl (42) divides individuals into two groups: the rst consists of state-centered individuals who focus
on past, present, and future states instead of available options for action in stressful situations. The second comprises
action-oriented people who focus on their options under stress. According to action control theory, the action-oriented and
state-centered approaches reect how individuals adapt to increasing demands (42). An action orientation means
responding to demands decisively and innovatively in a wide range of situations; it involves activating the metastatic
mode of control (i.e., promoting change). Based on coping theory, challenges are classied into three parts (43):
emotional challenges that require solutions to fundamentally emotional demands and situations, social challenges that
are largely related to social and interpersonal demands and situations, and success challenges that are related to goal-
based activities and initiatives such as cognitive and physical abilities and work-related and academic responsibilities
and demands. As described by Schroder and Ollis (44), coping competence is conceptualized as a protective factor
against the development of depression and helplessness because it enables the capacity to effectively deal with adverse
life events and failures. A reduced likelihood of reactions to helplessness and rapid recovery from any episode of
helplessness are signs of coping competence.
Studies show a negative correlation between coping competence and depression, neuroticism, stress response,
alienation, and dysfunctional coping and a positive correlation with well-being and life orientation, and self-ecacy (44).
The ability to deal effectively with life stressors is crucial for individuals and plays a substantial role in developing core
life skills (13). Coping competence in the work context is also vital, especially in high-risk occupations such as emergency
workers. Coping competence in such jobs enables employees to overcome and respond appropriately to stress in critical
situations. One factor inuencing coping competence is mindfulness. As noted above in discussing the relationship
between mindfulness and psychological capital, mindfulness reduces stress and increases employee resilience. These
outcomes are among the factors that allow individuals to tolerate painful and upsetting emotions by increasing their
awareness and attention (5). Therefore, mindfulness can improve coping skills. It also increases people's self-esteem
(45). Martins et al. (46) found that people with higher self-esteem are more resistant to life issues and problems and thus
more likely to succeed. Thus, mindfulness—by increasing people’s self-esteem, focus, attention, and awareness— would
be positively associated with the coping competence of employees. Individuals who experience mindfulness are less
likely to react in high-pressure situations and behave proactively. They possess a greater capacity to regulate their
emotions and behavior. Therefore, the following hypothesis is proposed:
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Hypothesis 2
Mindfulness would be positively associated with employees’ coping competence.
Flow
The theory of ow was rst proposed in 1975 by Csikszentmihalyi, one of the founders of positivist psychology. The
concept of ow comes from studies in the eld of positive psychology, the study of positive mental experiences,
individual characteristics, and organizations, and positive organizational psychology(47). According to Peterson (48),
these are the three pillars of positive psychology. Flow, as an optimal experience, is considered a branch of the rst pillar,
which is a positive mental experience. Csikszentmihalyi (49) denes a ow state as a set of purposeful, intensive,
logically organized experiences that are felt as meaningful and pleasing because of its inner order. Csikszentmihalyi (2)
states that in the ow state, one is fully involved in an activity for one’s own sake rather than thinking about the result. In
that state, people’s perceptions of time become distorted; they are fully engaged in their work and use all their skills to the
maximum. To achieve this experience, it is enough to feel that one’s skills are adequate to meet a given challenge in a
purposeful and law-abiding practice system that provides clear guidelines on how to perform. Under these circumstances,
people’s focus becomes so deep that they no longer pay any attention to irrelevant things or worry about problems. Self-
awareness disappears, and temporal perceptions become distorted. An activity that leads to such experiences is so
enjoyable that people are eager to do it even when it is dicult or dangerous, regardless of whether it benets them(50).
When people experience ow, they are completely engrossed in their tasks, their energy is fully concentrated, and they are
highly motivated to work (49). Bakker (51) conceptualized ow in a work context using three key dimensions: enjoyment,
intrinsic motivation, and complete immersion. This immersion follows a combination of awareness and action, so paying
attention and having awareness are requirements for ow at work. As noted above, the consciousness that exists in the
current moment due to attention to the goal, without moment-to-moment inference, is called mindfulness(5). According to
theoretical and experimental literature, deliberate regulation of attention is a central component of mindfulness. Some
studies have also linked the self-regulatory relationship of attention to ow (52–54). Therefore, since ow requires a high
level of activity-focused attention, the ability to control attention is a vital skill for the ow experience. Past research has
also shown the relationship between mindfulness and ow (4, 55–59), so it can be inferred that mindfulness is a path
toward experiencing ow. The present study seeks to investigate this association in the high-risk work context of pre-
hospital emergency personnel. In this regard, the following hypothesis is proposed:
Hypothesis 3
Mindfulness would be positively associated with ow.
The effect of psychological capital on the experience of ow can be explained according to the effects of each of its
dimensions of optimism, hope, resilience, and self-ecacy; each is detailed below. Psychological capital is a rich resource
for developing people’s intrinsic motivation and increasing their performance and achievements(60). In some previous
studies such as (61) the effect of cognitive resources on the ow experience has been mentioned. At the same time,
considering that intrinsic motivation is a key component of the ow experience, it is reasonable to posit that individuals’
psychological capital can help enable ow experiences. Scholars such as Du Plessis and Boshoff (62), Luthans et al.
(34), and Avey et al. (34, 40) have veried the effects of psychological capital on work engagement. As work engagement
is like the ow experience in certain ways, psychological capital may pave the way for the emergence of ow at work.
Some studies have examined the effects of each dimension of psychological capital on its own. Hope is a core
component of psychological capital in its turn enables a clearly dened goal and the perceived competence to achieve
that goal(63). Both aspects of hope are among the basic prerequisites of the ow experience. Research has revealed the
effect of hope on psychological engagement (64), engagement in general (62), and ow and engagement (65). Another
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component of psychological capital is self-ecacy. Stajkovic and Luthans (66) found that self-ecacious employees
believe in their competence and ability to accomplish a given task. Thus, we propose the following:
Hypothesis 4
Psychological capital would be positively associated with employees’ ow experience.
Coping competence is the capacity to deal effectively with failure and negative life events in such a way that its effects
are manifested by reducing helplessness reactions and facilitating rapid recovery from any sign of helplessness (44). So,
the core concept of coping competence is overcoming challenges and mitigating stress in turbulence, and one of the
central factors needed to enter the zone and oat in the ow channel is the capacity to overcome challenges. Based on
the principle of balancing challenges and skills, employees with high levels of coping competence are more likely to
experience ow. Schroder(67) found that coping competence is positively related to being life oriented, having an internal
locus of control, and believing in one’s self-ecacy. Having a clear orientation and goal and believing in one’s abilities to
perform successfully pave the way for experiencing ow, which leads to the following hypothesis:
Hypothesis 5
Coping competence would be positively associated with employees’ ow experience.
The mediating role of psychological capital in the relationship between
mindfulness and ow
Csikszentmihalyi (49) describes nine dimensions of ow: 1) the balance between the level of the work or activity
challenge and one’s level of skills, 2) specic goals, 3) immediate and clear feedback about performance, 4) a sense of
control over the work, 5) a distortion of the meaning of time, 6) a loss of self-awareness, 7) immersion in work and
consciousness in a fusion of consciousness and action, 8) a sense of intrinsic value in the experience, and 9) a high level
of focus on the present moment. The balance between the high level of both skill and the perceived challenge was
described by Jackson and Csikszentmihalyi (68) as the “Golden Law of ow” and is a fundamental condition for
awareness of the experience of ow (2). This dimension, along with the dimension of control over one’s work and
environment, is clearly related to self-ecacy, a key facet of psychological capital. Self-ecacy means having the
necessary self-condence and ambition to succeed in challenging tasks (33). To experience a ow state, one’s skills must
be commensurate with the demands of the environment and also thought and reection are crucial parts of developing
and maintaining a positive self-concept (2). Self-ecacy is part of a person’s self-concept. Some studies have
acknowledged the effect of self-ecacy on the experience of ow (69–71). However, according to the theory of
psychological resources (72), all dimensions of psychological capital play an integrated, synergistic role and help people
use these individual resources to manage other resources effectively and achieve the desired results (73). According to
Fredrickson (74), positive emotions develop the scope and depth of one’s attention; given the positive emotions generated
by psychological capital (40), it likely increases attention and concentration thus facilitating the experience of ow.
Because mindfulness affects a person's psychological capital, the following hypothesis is presented:
Hypothesis 6
Psychological capital mediates the relationship between mindfulness and ow.
The mediating role of coping competence in the mindfulness–ow
relationship
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Some studies have shown a high negative correlation between coping competence and variables like depression,
neurosis, stress response, and alienation(44, 67). In contrast, its positive relationship with ourishing (13), well-being, life
orientation, self-ecacy, and belief in one’s internal control center has been demonstrated (67). However, research on the
effect of coping competence on ow is limited, even though the positive consequences of coping competence suggest an
effect on the ow experience. As noted above, one dimension of ow is accomplishing work for work’s sake; this is an
autotelic experience driven by intrinsic motivation, rather than because of coercion or future benets. In other words, this
dimension of workow is the opposite of work alienation. Coping competence has a strong negative relationship with
alienation and thus increases the meaning of work. Other consequences of coping competence are self-ecacy, belief in
self-control, and life orientation, all of which are features that facilitate a sense of control over work and mitigate or
eliminate the fear of failure, each of which is a dimension of ow. Given the above prediction of the positive effect of
mindfulness on coping competence, it can be inferred that coping competence contributes to the effect of mindfulness
on ow. The following hypothesis is thus proposed:
Hypothesis 7
Coping competence mediates the relationship between mindfulness and ow.
The present study aims to investigate the direct and indirect effects of mindfulness on ow in a highly challenging work
environment. Although some researchers have acknowledged the effects of mindfulness on ow (e.g., (57, 59, 75, 76)),
they have rarely been investigated in a dynamic and challenging work context, specically in a pre-hospital emergency
environment, in which highly challenging situations are the norm. The path from mindfulness to ow experience through
the mediating role of the two critical factors of psychological capital and coping competence is explored in the present
study. Figure1 presents a conceptual model of the research.
Method
Research context
The survey data for this study were collected from pre-hospital emergency staff in Mashhad, Iran, during the COVID-19
pandemic crisis. Most experimental studies on ow at work have been conducted in sports and artistic endeavors. The
kinds of challenges in these areas differ from those in high-risk work settings. Many researchers examining the
mindfulness concept (e.g., (77, 78)) and ow (e.g., (79)) have acknowledged the lack of research in workplace contexts,
which is the rst motivation for obtaining data regarding employees in the context studied here. The second reason is the
challenging nature of this work, which connects with dependent and independent variables in the present study:
mindfulness and ow. Although all healthcare workers are faced with diculties and stress, emergency medical staff
encounter more dynamic and challenging issues, especially during the COVID-19 pandemic. Thus, we obtained data from
pre-hospital emergency employees.
Participants and procedures
The initial population for the survey on which the present study reports consisted of all employees (N = 550) of pre-
hospital emergency centers in Mashhad. Using a simple random sampling method and the Morgan table1, a sample
target of 220 people was selected. To account for the possibility of unreturned questionnaires, 250 surveys were
distributed; 225 questionnaires were ultimately analyzed. All respondents were male;2 48.3% of participants were between
ages 31 and 40, 21.9% were between 20 and 30 years old, and 29.8% were between 41 and 50 years old. Four-fths were
married, and one-fth were single. In terms of educational status, 22.2% had associate degrees, 56.1% had bachelor’s
degrees, and 21.7% had master’s degrees. Throughout the study period, the researchers committed to the principles of the
Helsinki Convention. Before gathering data, all participants conveyed their willingness to participate in the study, and all
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necessary permits were obtained from the Emergency Management Center of Mashhad Medical Sciences University.
Inclusion criteria were as follows: having an associate degree or higher in emergency medicine or nursing, having more
than a year of work experience in the operational unit, and being willing to participate in the study.
Measures
Measures included demographic questions about participants’ education, gender, years of work experience, and age,
along with scales for the different variables in the study. Before data collection began, we translated the English versions
of the scales into Farsi and slightly adapted these scales for use in the pre-hospital emergency context of the present
study. The scales used are presented below.
Work-related ow scale
We assessed ow at work with a nine-item scale adapted from the work-related ow scale found in Bakker (51), which
includes three subscales: absorption (e.g., “When I am working, I forget everything else around me”), work enjoyment (e.g.,
“I enjoy working in a pre-hospital emergency department”), and intrinsic work motivation (e.g., “The nature of emergency
work itself motivates me, not the rewards I receive”).
Mindfulness scale
Participant mindfulness was measured through a scale developed by Feldman et al. (80) that consists of 12 items and
uses a ve-point Likert-type scale. The responses range from one (never) to ve (always). Examples are “It is easy for me
to focus on what I am doing when dealing with emergency patients,” and “I pay attention to my thoughts without judging
them.”
Coping competence scale
We used the scale developed by Schroder and Ollis (44) to assess the coping competence of study participants. The
scale comprised 12 items. A sample item is “I often feel helplessness in the face of problems and patients' critical
situations.” The items were answered on a ve-point frequency scale ranging from one (completely disagree) to ve
(completely agree).
Psychological capital scale
Psychological capital was appraised with the Psychological Capital Questionnaire (33). The scale features 24 items
which were answered on a ve-point Likert-type scale ranging from one (completely disagree) to ve (completely agree).
Six items are used to assess each dimension of psychological capital (hope, self-ecacy, optimism, resilience). Examples
are as follows: “I believe those hopeful and positive things will happen in life after any dicult situation” (hope); “If I have
a dicult situation at work, I can nd a way to get rid of it” (resilience); “I feel condent analyzing a long-term problem to
nd a solution” (self-ecacy); and “Although there are many crises in my job, specically in the coronavirus period, I
always pay attention to the positive aspects of work issues” (optimism).
Data analysis
Due to the fact that the questionnaires used in this study are standard and have been used in many other studies, their
validity and reliability have already been established. However, the content validity of the questionnaires was reconrmed
by expert opinions of professors and subject matter experts. The Cronbach’s alpha coecient was used to determine the
reliability of the questionnaires, and SPSS (v. 25) and Amos (v. 24) statistical software packages were used to analyze
the data. Table1 presents the results of the reliability tests of the questionnaires and the descriptive information obtained
from their collection in the sample. As Table1 shows, all reliability coecients were about 0.7 or above; thus, the
reliability of the research questionnaires is conrmed.
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Table 1
Mean, Standard Deviation, Reliability and Correlation of variables
Variables Mean Standard deviation Cronbach's alpha Mindfulness
Mindfulness 3.223 0.464 0.680 1
Coping Competence 2.250 0.801 0.872 .225**
Psychological Capital 3.690 0.493 0.892 .261**
Flow 3.298 0.781 0.852 .370**
Explanation of the table above: ** Correlation at the signicance level of p < 0.001, the values in parentheses indicate the
Cronbach's alpha coecient.
[1] A table for determining sample size for a given population for easy reference.
[2] All pre-hospital emergency staff in Mashhad were male in the time of data collection.
Results
Assessment of research constructs
To evaluate and modify the studied constructs, exploratory and conrmatory factor analyses were used. Irrelevant
questions were identied at each stage and excluded. Table S1 (see supplemental Table1) presents the results of the
exploratory factor analyses that were carried out separately for each construct. The amount of variance explained by the
questions of the construct and the specic value of each extracted factor were determined, and the degree of correlation
of the questions in each construct, in general, was obtained. Finally, questions with factor loadings below 0.4 were
excluded from further analysis. The modied scale was examined with exploratory factor analysis and Cronbach’s alpha.
Questions that were still problematic in terms of factor loading or correlation were identied.
In the second stage, conrmatory factor analysis was performed separately on each construct. The results of the
questions of each construct along with the goodness-of-t indices obtained for the conrmatory factor analysis of that
construct were determined. The results of CFA for individual scales are presented in Table S2 (see supplemental Table2).
It is worth noting, the nal result provided by complete conrmatory factor analysis for the full measurement model,
which is discussed in the following.
As those results show, some constructs needed correction. The factor loadings obtained for questions 24 and 43 were
below 0.4, and the model t indices were not in the desired range. So, in the factor analysis of all constructs combined in
one model, those questions were excluded. Before implementing the structural model, it was necessary to examine the
measurement model, including the relationships between explicit and implicit variables. The overall t of the
measurement model is determined by conrmatory factor analysis. The results of the constructs in a complete
conrmatory factor analysis for the full measurement model are presented in Table S3 (see supplemental Table3); the
goodness-of-t indicators of the measurement model are in the desired range.
The measurement model t indicated that all components were signicant (p < 0.05), and all the t indices of the
measurement model conrmed the appropriateness of this model (see supplemental Table3). Thus, the measurement
model is adequate to t the collected data. In the next step, the structural model can be examined. The results of the
conrmatory factor analysis model are shown in Table S2.
In Table S4 (see supplemental Table4), the skewness and kurtosis coecients of each variable before checking
normality are presented. If the absolute value of the skewness coecients was less than three and the kurtosis coecient
Page 11/24
less than 10, the normality of the distribution of variables was accepted. After tting the conrmatory factor analysis
model, the research hypotheses were tested using the structural model shown in Fig.2. The tting indices and model
paths are presented in Table2.
Table 2
Fitness indicators of research models
Fitness indicator Value in measurement
model Value in structural
model Standard
value
Chi-square ratio to degree of freedom 1.425 1.54 Less than 3
Root means square error of approximation
(RMSEA) 0.049 0.055 Less than
0.08
Comparative t index (CFI) 0.957 0.945 Above 0.95
Tucker-Lewis index (TLI) 0.95 0.936 Above 0.95
Root mean square residual (RMSR) 0.0515 0.092 Less than
0.1
Table3 presents the results of the structural part of Fig.2, including the relationships of hidden variables to one another.
Table 3
Path coecients and signicance
Hypotheses Regression coecient
Standardized Unstandardized SE CR
p
-
value Results
1 Mindfulness →Psychological
capital 0.488 0.435 0.096 4.533 *** Veried
2 Mindfulness →Coping
competence 0.245 0.261 0.097 2.702 0.007 Veried
3 Mindfulness →Flow 0.15 0.172 0.114 1.507 0.132 Rejected
4 Psychological
capital →Flow 0.336 0.431 0.141 3.067 0.002 Veried
5 Coping
competence →Flow -0.11 -0.117 0.09 -1.308 0.191 Rejected
As Table3 shows, Hypothesis 1, which posits a positive and signicant effect of mindfulness on psychological capital, is
conrmed by a coecient of 0.488 (p < 0.001 < 0.05). The value of the path coecient (0.245) for Hypothesis 2 shows a
meaningful effect of mindfulness on coping competence (p = 0.007 < 0.05), so it is accepted. Hypothesis 3 posits that
mindfulness has a direct and positive effect on ow experience, but this effect is not signicant with a coecient of 0.15
(p = 0.132), so it is rejected. Hypothesis 4, which posits the effect of psychological capital on ow experience, is veried.
The effect is signicant with a coecient of 0.336 (P = 0.002 < 0.05). Hypothesis 5 dealt with the direct association of
coping competence with ow; the value of the coecient for this relationship (-0.11) is not signicant (P = 0.191 > 0.05),
so Hypothesis 5 is rejected.
The mediation relationships between research variables were examined by bootstrapping. It is a non-parametric method
that estimates standard errors through resampling and makes no assumptions about the normality of the sampling
distribution. The resampling method means that the bootstrap method selects many samples from the original sample.
Although bootstrap samples are similar in size to the original sample, some scores may not be included, while others may
be repeated in several samples (81). Table4 shows the results of examining indirect relationships using bootstrapping.
Page 12/24
Table 4
Indirect path bootstrap results
Path Bootstrap
Indirect
coecient Standard
errors Minimum
threshold Maximum
threshold
p
-
value Result
Mindfulness →Psychological
capital→Flow 0.188 0.101 0.044 0.458 0.006 Accepted
Mindfulness → Coping
competence→ Flow -0.031 0.031 -0.129 0.007 0.088 Rejected
Hypothesis 6posits an indirect effect of mindfulness on the experience of ow through psychological capital. According
to the bootstrap results, the amount of this effect is signicant at 0.188 (P = 0.006 < 0.05), so this hypothesis is
supported. For Hypothesis 7, which posits the indirect effect of mindfulness on the experience of ow through coping
competence, the result is different. According to the bootstrap results, the magnitude of this effect is -0.031, which is not
signicant (p = 0.088), and the hypothesis is thus rejected.
Discussion
The present study aimed to expand existing knowledge about experiencing ow at work, specically in the crisis context
of the COVID-19 period. The literature already contains evidence of the amplication of the challenges faced by
emergency staff during COVID (e.g., (82–85). We tried to determine whether and how employee mindfulness in highly
challenging and risky situations leads to work-related ow. Before examining the possible processes and mechanisms in
this relationship, we examined the mediating role of two variables: psychological capital and coping competence. These
are the main theoretical contributions of the present study. We proposed several hypotheses regarding the direct and
indirect effects of mindfulness on ow experience in pre-hospital emergency staff, who work in a highly challenging and
risky environment. Hypothesis 1 was conrmed; mindful employees have high levels of psychological capital. Those who
experienced mindfulness focused their awareness on the present moment non-judgmentally. They displayed no sense of
the past and made no projections for the future. Thus, even in dicult conditions that cause unease and discomfort,
mindfulness can reduce employee stress and anxiety and increase employee resilience. As Luthans and Broad (86) have
noted, mindfulness can protect individuals against stressors and help them cope with the challenges of an uncertain
environment. For emergency staff struggling to save dying patients in the rst COVID surge—when their survival was at
stake—it could have been too dicult a situation to cope with. However, mindfulness made it possible by reducing stress
and worry. Moreover, as some previous research shows (e.g., (87), mindfulness reduces depression, so it is reasonable to
posit that mindfulness increases hope. In other studies (8, 25) mindfulness has been shown to help people avoid
focusing on negative thoughts and to reduce psychological distress. Stedham and Skaar (25) emphasize that
mindfulness promotes more neutral evaluations and results in a possible reconguration of a negative or stressful event
as benecial and meaningful, so we can infer that it causes employees to be optimistic. Mindfulness also serves as an
interpersonal resource that can help people cope with the challenges of an uncertain environment (88) and facilitate
personal accomplishment (89). Therefore, mindfulness among emergency staff can improve their self-ecacy. Overall,
as the test of Hypothesis 1 showed, mindfulness among emergency staff increases their psychological capital. This
result is congruent with prior studies such as Roche et al. (35) and Biswal and Srivastava (89).
Hypothesis 2suggested that mindfulness has a positive effect on coping competence and was veried in the present
study. The concept of coping competence and its antecedents and consequences have largely been neglected in the
organization and management literature; in addition, the effect of mindfulness on coping competence has only rarely
been investigated in previous studies. However, Akin and Akin (13) examined the effects of mindfulness on coping
competence; their results accord well with those of the present study. As we predicted in Hypothesis 2, coping
Page 13/24
competence was observable among those emergency staff who experienced mindfulness. Since mindfulness in
employees can help them regulate their emotions (26, 27), it can pave the way for them to develop and display coping
competence. Employees with high levels of coping competence are capable of effectively dealing with their work
stressors. Coping competently with challenging situations or crises—which are inherent in the work of emergency
healthcare staff—requires exibility in behavior and high levels of emotional effort. Several studies demonstrate the
effects of mindfulness in reducing psychological distress (8, 11, 13), stress reactions, anxiety, and depression (11) and its
positive correlation with emotion-focused coping and behavioral regulation (44). Researchers such as Weinstein et al.
(90), Shapiro et al. (91), and Dane and Brummel (77) have acknowledged that mindfulness actively helps individuals
overcome challenging and stressful situations. These benets of mindfulness may help employees to act proactively
rather than reactively in handling distress at work and thus cope competently in caring for emergency patients. Moreover,
as Stanley (92) notes in the context of soldiers facing the possibility of losing their lives, the two main benets of
mindfulness are a heightened tolerance for challenging experiences and the ability to control one’s attention. These two
key benets are also prerequisites of coping competence, especially in challenging jobs like emergency care.
Despite our prediction in Hypothesis 3 of a positive effect of mindfulness on ow, the results did not demonstrate such a
relationship, and that hypothesis was rejected. Few studies have examined the effect of mindfulness on ow, with most
carried out in the eld of sports psychology and among athletes (e.g., (53, 55, 93)). Some of this research, contrary to the
results of the present study, did demonstrate a positive effect of mindfulness on ow, but others rejected any such
connection, in line with the results presented here. The role of mindfulness as a facilitator of ow realization among
employees has been demonstrated(55). When individuals experience ow, no internal or external factors distract them
from their focused state because they are fully in the present moment, which accords with the goal and experience of
mindfulness. Further, as Jackson (57) states, ow, and mindfulness are different mental states but are closely related to
each other in that they are positive, present-centered states of mind. It can thus be inferred that mindfulness facilitates
the creation of ow conditions. So, based on existing studies, it was predicted that mindfulness among emergency
personnel would have a positive effect on their ow experience. This hypothesis has been conrmed in some previous
studies, especially among athletes Aherne et al. (55), Kee and Wang (58), Aherns, Moran, & Lonsdale (55), Moore (4),
Kaufman et al. (93), Pineau, Glass & Kaufman (94), and Jackson and Eklund (53).
Although previous research (57) has suggested that mindfulness provides one pathway to developing a state of mind
that can help unlock the door to ow, it appears that developing mindfulness enhances the opportunity for ow
experiences but is not—in and of itself—enough to experience ow, especially in challenging work contexts. Flow involves
a total focus on the task at hand and experiencing selessness, while mindfulness is awareness of one’s here-and-now
experience. This subtle distinction between the two concepts has been analyzed by Ivtzan and Lomas(56). As mentioned
above, most studies that demonstrate a positive effect of mindfulness on ow—in contrast to the results of testing
Hypothesis 3 in the present study—were conducted among athletes and in sporting contexts that have signicant
differences from high-stress work environments like emergency healthcare settings. Numerous studies have reported high
levels of stress and anxiety among emergency medical personnel (95) which increased during the pandemic (83). Anxiety
among healthcare staff is a signicant problem, especially being in the vanguard during the pandemic (83). (96) In their
study emphasized on increasing level of stress among nurses and its subsequent effect on decreasing ow experience.
Frontline healthcare professionals were particularly vulnerable during the pandemic because of their commitment to
containing the disease (84). Therefore, the conrmation of the positive effects of mindfulness on ow experience among
athletes and the lack of conrmation of this relationship among emergency healthcare staff are not entirely surprising. It
is worth noting that some researchers emphasize the difference between mindfulness and ow, such as Sheldon et al.
(76), who conclude that mindfulness can impair a person’s ability to absorb the experience of ow: self-awareness is part
of mindfulness processes, whereas selessness is a core part of experiencing ow. Therefore, a person who experiences
mindfulness does not necessarily experience ow. In ow, there is a kind of spontaneity, while mindfulness is entirely
about the awareness of thoughts, behaviors, emotions, and feelings and is a special, highly rened form of attention (5).
Page 14/24
Mindfulness is associated with maintaining self-awareness during an activity; in that sense, it can be contrasted with
ow (97). Furthermore, as Csikszentmihalyi’s nine-dimensional model of ow (79). shows, there are prerequisites for ow
to occur; the absence of even one of these components may mean that ow may not occur.
As Csikszentmihalyi (49) states, individuals in a ow state become entirely absorbed in their activities. They forget
themselves and begin to act effortlessly: “One prerequisite of ow is the ability to concentrate on goals without concern
for anything irrelevant to the task. But how can one achieve such focus if the environment is unstable and may even
come crashing down at any minute?” (98). Kee and Wang (2008) refer to ow as an “elusive” state. Moreover, although
Jackson (57) and Kee and Wang (99) suggest a symbiotic relationship between mindfulness and ow, experiencing
mindfulness occurs deliberately the optimal ow experience happens unintentionally. One of the main prerequisites of
ow is a balance between challenges and skills. If a person’s level of work challenge is high but his or her skill level is low,
this mismatch will cause anxiety and worry; ow will occur only when the levels of challenge and skill are effectively
equal. Given that the present study was conducted during the rst wave of the COVID-19 epidemic in Iran (March to May
2020) among emergency personnel, the individuals surveyed were facing a work challenge that they had not previously
experienced. The unknown nature of the virus at that point and its life-and-death nature taxed employees’ abilities in
ways they had not seen before, so that even if they were able to achieve mindfulness, a ow experience would not
necessarily emerge. A new challenge for emergency staff was concern about their family’s health and their family’s
concerns about them. Further, they had to be isolated to prevent the possible transmission of the virus to family
members. Beyond these emotional concerns, the heavy workload and constant exposure to COVID-19 patients, fear of
infection and/or infecting others, and witnessing the sudden deaths of colleagues were all factors that increased their
work pressure, stress, and anxiety. Negative outcomes of covid such as psychological anxiety, Compassion fatigue, and
psychological distress in healthcare workers also have been emphasized in an array of studies (e.g., (100, 101)). In that
context, many may have been able to focus enough to achieve mindfulness but could not reach a ow state. Furthermore,
according to Csikszentmihalyi (93), when the level of a challenge does not match an individual’s skill level, there is little
intrinsic motivation to become deeply invested in a task. Emergency personnel was dealing with critically ill patients with
their own health endangered, and the ambiguity and lack of knowledge about the virus at the beginning of the outbreak
exacerbated the challenges they faced and made it dicult to enter a ow state.
Hypothesis 4posited a positive relationship between psychological capital and ow experience among emergency
personnel, and the ndings showed the most signicant relationship among all the relations proposed in the present
study. Every dimension of psychological capital had positive outcomes; the combination of these psychological
resources created synergistic outcomes that Luthans et al. (33) call higher-order constructs. They (33) state that
psychological capital leads to productivity and energy at work, which is a sign of an autotelic personality that is a core
component of the ow experience. Csikszentmihalyi (102) states that ow involves the use of high levels of energy and
skills, and psychological capital is the main resource drawn upon in this regard. People with high levels of psychological
capital have a sense of enjoyment and meaningfulness that generally act as intrinsic motivation that can facilitate the
ow experience. In line with the results of previous research (103–105) the results of investigating this hypothesis
showed a signicant effect of psychological capital on ow.
We also hypothesized that coping competence would inuence the ow experience. Due to the increasing pressure on
and challenges faced by emergency personnel during the pandemic and keeping in mind the high level of challenge
needed to experience ow emphasized in the literature, we examined whether overcoming challenges could lead to
experiencing ow, even in crises. The results are somewhat contradictory and diverged from our prediction. Although to
our knowledge the effects of coping competence had not been explicitly investigated in prior research, it is reasonable to
posit that coping with challenges may lead to ow, especially because Csikszentmihalyi (3) insists that ow occurs in
highly challenging activities. Of course, what is essential is a balance between challenge and skill. In contrast to his view,
the present study found no signicant relationship between coping competence and ow experience. The reason for this
Page 15/24
outcome may be related to the inspiring and motivating nature of challenges, although some previous studies have not
considered this point. For example, Basyouni et al. (106) found that job insecurity among employees was regarded as an
effective challenge in enabling ow. Moreover, as noted in previous research (e.g., (107)), demands that are beyond the
control of an individual decrease the possibility of ow. furthermore, the absence of job resources and a high level of job
demands correlate with exhaustion and disengagement (108), Both of which are opposed to the experience of ow. As
Olafsen & Frølund (109) pointed out in their study, despite the motivating role of job challenges, job hindrance is energy-
depleting. At times, coping with such hindrances becomes little more than tolerating an ongoing crisis state, which
dramatically reduces the psychic energy needed to experience ow. We regard the rejection of Hypothesis 5 as largely
attributable to the intense pressure and extremely risky work conditions of pre-hospital emergency staff during the
pandemic.
Hypotheses 6 and 7 proposed indirect effects of mindfulness on the ow experience of employees through psychological
capital and coping competence, respectively. The results allow us to state, as proposed in Hypothesis 6, that employees’
mindfulness can lead to their experience ow by improving and expanding their psychological capital. In line with the
discussion of Hypothesis 1, on the effect of mindfulness on psychological capital, and Hypothesis 4, on the effect of
psychological capital on ow, the verication of Hypothesis 6 should not be surprising. Mindful employees in pre-hospital
emergency settings who have elevated levels of psychological capital make effective use of their psychic repertoires.
Despite highly challenging situations, those who broaden their psychological capital through mindfulness can experience
ow. One explanation may be that mindful employees who have successfully accessed the components of psychological
capital will experience enjoyment and intrinsic motivation, which are the core factors in developing an autotelic self and
in the emergence of ow (110). A sense of control over the action and a reasonable chance of completing a clear goal all
come from self-ecacy, optimism, hopefulness, and resilience, which are among the major components of enjoyment.
Another reason for the nding may be that employees who experience mindfulness have enough psychological capital to
draw on for expanding the high levels of psychic energy that are needed for emotional experiences and full absorption in
an activity. To test Hypothesis 7, we examined the mediating role of coping competence in relation to mindfulness and
ow. The nding, in this case, was counter to our prediction, so this hypothesis was rejected. We had supposed that
coping with negative events and high-risk situations helps employees focus wholeheartedly on their tasks, but that does
not appear to be sucient to ensure an optimal experience. Emergency staff encountered many challenges, ranging from
job insecurity to the unpredictable COVID crisis, which combined to make them unable to remove obstacles despite
successfully coping with them. Indeed, there was a conict between what they believed was their goal and the goal that
was dened for them. This dissonance makes it dicult for them to focus their attention fully on their work. Cacioppe
(111) indicates that this inability of employees to achieve a ow state stems from their diculty in maintaining their
attention on their tasks. Csikszentmihalyi (49) states that some people are unable to manage their attention on their work
because external stimuli make their attention fragmented and prevent them from entering the ow state. In most studies
(e.g., (49, 112)), researchers regard an appropriate external environment as a key condition that must be met to
experience ow. External environmental factors include leaders’ actions like setting challenging tasks that match
employees’ abilities, providing suitable workspace, empowering staff, improving employees’ skills, and, most importantly,
providing sucient psychological and physical resources (113). Salanova et al. (71) also emphasize organizational
resources as a predictive factor for experiencing ow at work. So, when the necessary conditions are met, not only do
mindfulness and ow emerge in the work context, but there is also an ideal state of mind referred to as “mindow” (113)
that arises through a synergistic combination of mindfulness and ow.
limitation
The present study has a limitation regarding the ow measurement tool. Considering the acute conditions of the
pandemic peak and the critical situation of pre-hospital emergency staff during this period, they were unable to
participate in longitudinal research because of time limitations and extremely demanding workloads. Thus, applying a
Page 16/24
more concise tool for data collection through cross-sectional research might increase data accuracy and rigor. Future
studies could use alternative tools like the experience sampling method (49) or a non-disruptive method like the ow
observational grid method (114) or OPV method (115).
Conclusion
During the COVID-19 pandemic, frontline emergency healthcare staff were among the most vulnerable workers, and pre-
hospital emergency staff is generally among the most vulnerable of all healthcare personnel. In addition to their crucial
role in that period, they encountered many unpredictable challenges that often remained unresolved. The results of the
present study show that the only way that mindfulness inuences ow is through psychological capital. In the context
under examination here, intrinsic motivation for and enjoyment in doing tasks are both crucial factors in experiencing
ow. Employees who lack these two factors, even if they are largely successful in coping with the challenges they face,
may never experience ow. In the worst cases, if challenges are not motivating, they can become crises that do little more
than sap the energy of all involved. In such an environment, there is not enough psychic energy for employees, which
makes it extremely dicult for them to focus on their tasks. Mindfulness in employees increases their levels of
psychological capital, which in turn facilitates the ow experience. Psychological capital makes it possible for employees
to access their psychic repertoires. Employees with sucient psychic repertoire feel empowered in doing their tasks.
Empowerment raises employees’ levels of joy and belief in their skills. In jobs that are both highly challenging and critical
for society, like the emergency healthcare context of our study, providing opportunities for ow leads to high employee
performance, even in dicult situations. Mindfulness training can be one way in which emergency staff can improve their
psychological capital. High levels of self-ecacy, hope, optimism, and resilience among pre-hospital emergency staff
help them raise their skills to a level consistent with the challenges they face. So, the actual use of their strength can be a
prelude to the occurrence of ow (116). The risk of developing high levels of anxiety among pre-hospital emergency staff
is inevitable, and it increased dramatically during the peak of the pandemic. In such a situation, employees consider their
tasks to be a burden imposed on them. Therefore, healthcare managers should provide psychological support and safe
conditions—in both the physical and psychological senses—in which employees can focus wholeheartedly on their jobs
and deliver optimal performance. Initiatives like safe employment contracts, mindfulness training, and courses that
improve employee skills and broaden their psychological capital can all facilitate the optimal experience.
Declarations
Ethics approval and consent to participate
The Data Collection Approval Letter (NO 1402 /49898) was received from Emergency Management Center of Medical
Sciences University of Mashhad. The study got approval ID (IR.UM.REC.1402.025) from Ethics Committee of Ferdowsi
University of Mashhad. Throughout the study period, the researchers committed to the principles of the Helsinki
Convention. Before gathering data, all participants conveyed their willingness to participate in the study. Written informed
consent was obtained from all participants, and participants consented to publish the ndings.
Consent for publication
Not applicable
Availability of data and materials
The analyzed and the used data sets of the current study are available. For accessing this data, please contact the
corresponding author with this following email address: malekzadeh@um.ac.ir
Competing interests
Page 17/24
The authors ensure that there are no conicts of interest to disclose.
Funding
Not applicable
Authors' contributions
NR, GH.M and MM contributed to the conception and design of the study. NR wrote the rst draft of the manuscript. MM
has done the nal editing of the manuscript. All authors contributed to the manuscript revision, and read, and approved
the submitted version.
Acknowledgements
The researchers express their gratitude to Dr. Morteza Ehtesham Far, the then Executive Advisor of the head of Medical
Sciences University in Mashhad and, Dr. Ali yazdani the Director of the Medical Emergency and Accident Management
Center, for their support and to the emergency personnel who, with their helpful cooperation despite their workload, make
the process of collecting data as simple and effective as possible during a pandemic (March to May 2020).
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Figures
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Figure 1
Research model
