The correlation analysis between the appearance anxiety and personality traits of the medical staff on nasal and facial pressure ulcers during the novel coronavirus disease 2019 outbreak

Abstract Aim To investigate the psychological status of medical staff with medical device‐related nasal and facial pressure ulcers (MDR PUs) during the outbreak of COVID‐19, analyse the correlation between their psychological status and personality traits, so as to provide a reference for personalized psychological support. Design A total of 207 medical staff who were treating the COVID‐19 epidemic from Hunan and Hubei provinces were enrolled in this analytic questionnaire‐based study. Methods We used these measures: Eysenck Personality Questionnaire Short Scale (EPQ‐RSC), Social Appearance Anxiety Scale (SAAS), Positive and Negative Affect Scale (PANAS) and demographic information forms online. Results Medical staff wearing protective equipment are particularly susceptible to nasal and facial MDR PUs, which is increasing their social appearance anxiety; neuroticism is significantly related to social appearance anxiety and negative emotion. We should pay more attention to their psychological state, cultivate good personality characteristics and reduce negative emotions, and thereby alleviate their MDR PUs‐related appearance anxiety.

were issued by the National Health Protection Commission (Trial).
It pointed out that medical personnel should use medical masks, goggles, protective mask/face screen, isolation clothing, protective clothing and latex inspection hand in the front-line areas of fever clinic, isolation ward and isolation intensive care unit (area) (Jie Xia, Cao, Zhang, Chan, & Wang, 2020).
Novel coronavirus front-line medical staff are facing high risk of exposure (Zhou, Huang, Xiao, Huang, & Fan, 2020). They need to wear medical protective equipment for a long time in the crowded and moist environment of protective clothing. It is very easy to cause local persistent pressure ischaemia and the skin problems such as nasal and facial pressure injuries (Kayser, VanGilder, Ayello, & Lachenbruch, 2018;Wen Huang, Wang, Xiao, & Li, 2020). As an important component of personal socialization, appearance abnormality caused by skin injury of nose and face is easy to trigger individual's dissatisfaction with their appearance and cause social appearance anxiety (van den Elzen et al., 2012), even affect work enthusiasm and enthusiasm. Research shows that (Davis, Dionne, & Shuster, 2001;Zhang, Chen, Wang, Xie, & Qiu, 2015) personality traits and appearance tendency have a certain linear correlation.
Neuroticism personality attaches great importance to personal appearance, and it is easier to produce appearance anxiety (Martin & Racine, 2017). There is a correlation between personality traits and nurses' emotions, which can lead to the difference of risk decision-making by affecting their emotions (Zhang, 2012).

| Research question
This study describes the COVID-19 epidemic situation and the psychological state of medical staff who had the nasal and facial pressure ulcers caused by the use of protective devices during the outbreak of new coronavirus and explores the correlation between different personality traits, positive and negative emotions and social appearance anxiety, in order to alleviate the degree of anxiety of the medical staff exposed to the nasal and facial pressure ulcers and provide more individual psychological support.

| Design and sample size
This was a cross-sectional study, which collected data using convenience sampling, between February and March 2020. Potential participants were those medical teams affiliated three hospitals of a university in Hunan Province sent to Hubei Province for epidemic prevention. A total of 210 questionnaires were sent out, and 207 effective questionnaires were finally recovered after screening. The effective rate of the questionnaires was 98.6%. Inclusion criterion was volunteered to participate in the study. Exclusion criterion was incomplete content. All the questionnaires were in the form of anonymity and confidentiality.

| Demographic information
Gender identity, age, BMI, accumulated first-line working time, average working hours per shift, preventive application of pressure sore, discomfort of wearing protective equipment, presence of symptoms related to pressure ulcers and other.

| Eysenck Personality Questionnaire Short Scale (EPQ-RSC)
The scale was compiled by Ming-yi Qian, Zhu, and Zhang (2000) and consists of four subscales: E (extraversion), N (neuroticism), P (psychoticism) and L (lie). They were used to measure the subjects' internal and external disposition, emotional stability, mental deviation and lying tendency. Cronbach's α coefficient of this scale is 0.79-0.84.

| Social Appearance Anxiety Scale (SAAS)
The scale was compiled by Hart et al. (2008) based on social anxiety level, self-image dissatisfaction and body deformation disorder measurement standard, translated by Kong Shanshan and Yang Hongfei, to evaluate the anxiety sensitivity related to appearance and the overall face of the individual (Shan-shan Kong, 2009). There are 16 items in this scale. The higher the score, the more serious the anxiety about social appearance. In this study, the internal consistency coefficient is 0.9288.

| Positive and Negative Affect Scale (PANAS)
There are 20 words describing emotion in the scale, which can be divided into two subscales: positive and negative emotion (Huang, Yang, & Li, 2003). A scale of 1 (few) to 5 (very frequent) was used.
A high positive emotional score indicates an individual's active and engaged emotional state; a high negative emotional score indicates an individual's low mood. In this study, Cronbach's α coefficients of these scales were 0.85 and 0.83, respectively.

| Analytic strategy
The questionnaire was collected, and the data were sorted out. SPSS 25.0 software was used to build the database for analysis. Take α = 0.05 as the test level, and p value takes the bilateral probability. The measurement data were described by mean ± standard deviation, the counting data were described by the number or percentage of cases, the influencing factors of stress injury events were analysed by chisquare test and logistic regression, the differences of social appearance anxiety scores were compared by the method of propensity score matching and t test of two samples, and the correlation between three scales was calculated by Pearson correlation analysis. The mediation effect was assessed by PROCESS module 4 in SPSS. Test criteria for mediation effect were as follows: ① the independent variable must be related to the intermediate variable; ② the independent variable must be related to the dependent variable; ③ when controlling the intermediate variable, the correlation between the independent variable and the dependent variable decreases significantly, if it is still statistically significant after the decline, it is the site mediating effect, if it becomes not statistically significant after the decline, it is the complete mediating effect (Zhong-lin Wen, Hou, & Liu, 2004).

| Ethic issues
After obtaining permission from the Hospital Ethics Committee, the researchers distributed questionnaires to medical staff who met the inclusion criteria and participated voluntarily, with informing the purpose of the study.

| Characteristics
A total of 207 first-line medical staff ranged from 19-49 years of age were surveyed, including 46 males (22.2%) and 161 women (77.8%). The majority were nurses (81.2%), and the others were doctors. More than half of them (50.7%) working in first line for 15-30 days and 36 people (17.4%) in 30-60 days, with 45 (21.7%) less than 15 days. The mainly average duration per shift was 4-6 hr, with 25.6% were 7-8 hr. During the epidemic period, the protective masks worn by the medical staff were all head-worn. 81.6% of the respondents felt discomfort such as nasal tenderness (88.7%) and ear pain (89.3%) after wearing the protective equipment for 2-4 hr (41.1%), and the pain score was (5.13 ± 2.77). 46.9% of the medical staff said that they did not use the preventive dressing of pressure ulcers during work.

| Risk factors of nasal and facial MDR PUs
The results showed that 192 (92.8%) of the respondents had pressure ulcers caused by using protective equipment, and the symptoms were erythema (91.6%) with intact local skin and invariable white pressure, or with complete serous blister (8.4%). About 79.2% of the medical staff reported that these symptoms could be relieved by themselves within 2 days, and 1.4% could not be relieved by themselves unless other measures were needed. ANOVA showed that there was a statistically significant difference between the age and the degree of pain in wearing protective equipment (p < .05) ( Table 1).
The variables with statistical significance in single factor analysis are included in the regression model, and the binary logistic regression model is established with whether there are pressure ulcers as the dependent variable and age and pain degree as the independent variable ( Table 2). The analysis shows that the less conscious pain of medical staff in using protective equipment, the greater the possibility of pressure ulcers.

| Personality traits, positive and negative emotions and social appearance anxiety of antiepidemic medical staff
The scores of extraversion, neuroticism, psychoticism and lie were (50.58 ± 10.98), (51.16 ± 11.71), (50.30 ± 8.46) and (55.00 ± 8.68), respectively; the scores of positive and negative emotions were (33.0 ± 6.30) and (24.60 ± 7.37), respectively, during the antiepidemic period; and the scores of social appearance anxiety of medical staff with and without MDR PUs were (40.72 ± 14.48), (36.73 ± 12.93) and (t = 2.548, p = .017). There was a statistical difference in the scores of social appearance anxiety between the medical staff with and without nasal and facial MDR PUs.

| Correlation analysis between personality traits, positive and negative emotions and social anxiety
The correlations among personality traits, social appearance anxiety, positive and negative emotions are presented in Table 3.
Extraversion has a statistically significant positive correlation with positive emotions during the epidemic (r = 0.180, p < .05), a statistically significant negative correlation with negative emotions (r = −0.147, p < .05) and no statistically significant correlation with appearance anxiety; negative emotions and appearance anxiety related to nasal and facial pressure ulcers were positively correlated with neuroticism (r = 0.245, r = 0.330, respectively, p < .05).
In addition, positive emotions during the outbreak were significantly negatively correlated with neuroticism (r = −0.260, p < .05).

| Negative emotion as a mediator variable in the association between neuroticism and SAAS
We further investigated the mediating role of negative emotion in the relationship between neuroticism and social appearance anxiety As can be seen, the mediation analysis confirmed a statistically significant positive effect of neuroticism on negative emotion, which proved to be a positive predictor of SAAS. A statistically significant total effect was also found of neuroticism on SAAS (β = 0.4052, p < .01, Boot SE = 0.0830, 95% CI = 0.2415-0.5690); however, this effect lessened when the mediator was entered into the model, which suggests a partial mediating effect. The bootstrap procedure was statistically significant for the TA B L E 1 ANOVA on nasal and facial MDR PUs of anti-epidemic medical staff (total = 207)    can be improved to make it more fit to the face and increase comfort , the production of MDR PUs can be further reduced.

| Mental state of medical staff with pressure ulcers of nose and face
As the carrier of human body image and appearance, appearance is not only the symbol of individual as social natural person, but also the function of transmitting social information and performing social functions (Yaman, 2017). It is one of the characteristics that human beings are most vulnerable to the influence of external factors (Frevert & Walker, 2014). The gap between human physical appearance and ideal appearance is an important cause of social appearance anxiety. However, the social appearance anxiety of human beings will have a negative impact on their lives (Yaman, 2017). This psychological feature may affect the work mood of anti-epidemic medical staff, leading to a decline in their work enthusiasm during the epidemic (He et al., 2012).

| Analysis of the relationship between personality traits, appearance anxiety, positive and negative emotional variables
Personality is a relatively stable psychological trait formed by individuals in social life and an important factor affecting mental health  (Hopwood et al., 2008). In this study, neuroticism was positively correlated with the appearance anxiety related to the stress injury of nose and face and the negative emotion during the epidemic period.
That is to say, the neuroticism of medical staff tended to be unstable after the stress injury of nose and face showed more anxiety and worry about their external image and was more likely to produce negative emotions such as panic and depression at work. Research (Bin zhang, 2017;Davis et al., 2001) also confirmed that neuroticism is related to appearance orientation. High scores on neuroticism factors show that individuals pay more attention to appearance, and individuals with neuroticism personality have the characteristics of excitability, emotionalization, anxiety, etc., and tend to adopt negative ways to deal with high-pressure environment, such as escape, self-blame, etc., which is a powerful predictor of negative emotions. is strong, which is conducive to resolving negative emotions (Ping . In addition, in the positive emotional state, the extroverted personality individuals will show stronger creativity, higher efficiency of problem-solving and more comprehensive decision-making (Zhang, 2012). Therefore, targeted psychological intervention and support for different personality traits of anti-epidemic medical staff will be conducive to the cultivation of good psychological status of medical staff and improve the quality of medical care.

| Intermediary effect of negative emotion during COVID-19
This study revealed that negative emotion could be a mediator between neuroticism and SAAS and the mediation analyses are consistent with previous studies that have demonstrated that neuroticism to be a predictor of negative emotion, and the negative emotion to be a predictor of social appearance anxiety (Mason et al., 2018;Noteboom, Beekman, Vogelzangs, & Penninx, 2016;Zhang & Zheng, 2019 Good personality characteristics of medical staff include noble moral sense and sincere sympathy, positive and stable emotions, good interpersonal relationship and communication ability (Li, Li, & Li, 2006). In order to cultivate good personality characteristics and improve psychological quality of medical staff, efforts should be made in the following aspects: special personnel should regularly carry out emotional management of anti-epidemic workers, pay at- that promote medical staff's mental health.

| CON CLUS IONS
Medical staff treating the COVID-19 pandemic are easily suffered the nasal and facial pressure ulcers. During the epidemic period, the neuroticism trait of medical staff can not only directly affect their social appearance anxiety, but also indirectly affect them through negative emotion as intermediary variables. Therefore, while actively developing comfortable protective equipment and adopting appropriate preventive dressings to protect the nose and face skin of medical staff, we should also pay more attention to improve their psychological quality and emotional self-management ability and relieve their anxiety about the appearance of the nose and face stress injury, so as to defeat the COVID-19 safely.

ACK N OWLED G EM ENTS
The authors are greatly thankful to the support of medical staff who fight against the novel coronavirus pneumonia. The survey and publication were supported by Xiangya Hospital of Central South University Management Research Fund (2017GL17).

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest relevant to this article.

PATI E NT CO N S E NT S TATE M E NT
There was oral informed consent between medical staff.