Relationships between role stress profiles, psychological capital, and work engagement among Chinese clinical nursing teachers: a cross-sectional latent profile analysis

In the last 20 years, nursing education enrollment in China has increased dramatically, with the number of registered nurses increasing from 1.22 million to 4.1 million [1]. Clinical nursing practice has a significant meaning and role in nursing education [2]. It not only allows nursing students to verify the theories taught in class but also significantly impacts critical thinking development, decision-making abilities, and insight of future professional roles [3, 4]. Efficient clinical nursing practices under the guidance of clinical nursing teachers (CNTs) can promote patient safety and healthcare quality.

Nursing educators in China consist of two groups: university nursing faculty from universities and CNTs from hospitals. CNTs are registered nurses commissioned by nursing schools to instruct nursing students in clinical nursing practice following the teaching syllabus and are qualified to teach in hospitals [5]. Their prime role is as nurse in hospitals, and they have been appointed to implement the role of educators in their workplaces, part-or full-time. CNTs’ clinical specialties and teaching strategies substantially influence the quality and outcomes of students’ clinical nursing practices [6].

Previous studies found that most CNTs experienced high level of work stress and suffered multiple stressors (e.g., interpersonal stress, career development stress, and role stress) [7, 8, 9]. However, these studies examined multiple work stressors together and rarely studied role stress separately. Role stress is a condition in which external forces disturb the stability of an individual’s internal system and make the individual unable to perform appropriate role behavior in the social [10]. In addition, most current studies on CNTs’ stress have ignored the specificity of CNTs [11, 12]. Specifically, CNTs take on multiple roles (e.g., clinical educator, caregiver, interpersonal coordinator, and researcher, etc.), and also suffer from more stress due to multiple roles (e.g., lacking time to prepare for classes, teaching competencies assessment, etc.), which leads to CNTs experiencing excessive role stress [13, 14, 15]. However, high level of role stress among CNTs not only damages physiopsychological health, but also prevent them from accurately positioning at work, thus limiting role functions performance, increasing operational error incidences, adversely affecting healthcare quality, decreasing work engagement, and ultimately leading to the quality of clinical nursing teaching decline [16, 17, 18]. Thus, it is necessary to focus on the role stress among CNTs.

Existing researches on role stress use variable-centered approach that focuses on total scores of role stress, which is categorized role stress into four levels based on the addition or subtraction of one standard deviation above or below the mean [19, 20, 21]. For example, Huang et al. researchers found that the emergency nurses suffered high level of role stress [21]. This variable-centered approach assumes that participants are homogeneous, presents only the average image and results in simplification. This classification overlooks individual experiences, ignores heterogeneity among individuals, and fails to reflect CNTs differences in role stress at the individual level. However, latent profile analysis (LPA) is a person-centered approach that categorized individuals with similar personal and occupational characteristics, traits, or behavioral patterns into profiles based on their responses to a set of observed indicators [22]. This approach has higher specificity degree than variable-centered approach. Moreover, the heterogeneous differences in role stress among CNTs may be a vital point for effectively identifying, predicting, and targeting interventions according to their role stress profiles, which could contribute policymakers and hospital administrators taking targeted measures to prevent the negative physical and psychological effects of role stress and improve CNTs work engagement. Therefore, this study aimed to identify role stress profiles among CNTs by LPA.

Job demands resource (JD-R) model indicates both extrinsic resources (e.g., social support, salary) and intrinsic resources (e.g., psychological capital) influence the individual’s work stress level [23]. Current studies on the CNTs’ work stress have focused on extrinsic resources, and neglect intrinsic resources [7, 11]. Psychological capital is an intrinsic personal trait that influences an individual’s behavior and output and includes four positive psychological resources: self-efficacy, optimism, hope, and resilience [24]. Meanwhile, other studies show that individuals with levels of psychological capital tended to report higher job satisfaction, better job performance, lower levels of work stress, and lower turnover intention [25, 26]. Previous researches have only examined the association between psychological capital and work stress in the general population [27, 28, 29]. Moreover, to the best of our knowledge, no study has focused on the relationship between psychological capital and role stress profiles among CNTs. Thus, we examined the relationship between psychological capital and role stress profiles among CNTs.

Previous studies have demonstrated that individuals with higher role stress having less work engagement [30, 31]. Schaufeli defined work engagement as a positive, fulfilling, and work-related state of mind that encompasses three dimensions: vigor, dedication, and concentration [32]. According to stress cybernetic theory, individuals differ in the work performance in face of various stressors at work [33]. For example, study found that work engagement level varies with stress profiles among students [34]. However, few studies explore whether CNTs with different role stress profiles differ in work engagement. Thus, we examined whether role stress profiles among CNTs were related to work engagement.

Therefore, the first aim of this study was to identify the different profiles of role stress from a person-centered perspective. The second aim was to test the relationship between different role stress profiles and psychological capital and work engagement. This may be useful for better understanding the characteristics of CNTs role stress and for developing more targeted interventions for at-risk CNTs.

To the best of our knowledge, this study is the first to identify the unique profiles of CNTs based on role stress. We found that there were three heterogeneous profiles of role stress among CNTs: low role stress-high lack of teaching resources profile (34.3% of the sample), characterized by high education level, and without regular qualification audits; moderate role stress profile (57.0% of the sample), characterized by the fact that most of the CNTs were on the contract employment; and high role stress-low lack of teaching resources profile (11.7% of the sample), characterized by the low education level among CNTs. A unique relationship exists between these three profiles: psychological capital and work engagement. Specifically, Profile 1 was associated with the highest psychological capital and work engagement scores, followed by Profile 2. Conversely, Profile 3 had the lowest psychological capital and work engagement scores.

The results showed that profile membership can be predicted by several sociodemographic characteristics, such as education level, presence or absence of regular qualification audits, and method of employment. Specifically, individuals with higher education (bachelor’s degree and above) were more likely to belong to Profile 1 (low role stress-high lack of teaching resources profile) than those with associated degrees. This result is consistent with the findings of Khoa [42]. The possible reasons for this result were as follows. According to stress cybernetic theory, individuals with different education levels react differently to various role stress [33]. CNTs with higher education have higher cognitive levels than those with associated degree. Specifically, CNTs with associated degrees have weaker theoretical foundations and poorer understanding of clinical nursing teaching goals than others, and need to make more efforts in clinical nursing teaching [43]. CNTs with higher education have stronger professional skills, better research ability, and more career development opportunity. They can learn different role-related knowledge and understand clinical nursing teaching goals better, leading to lower role stress than those with associated degrees [44, 45]. However, CNTs with higher education are also expected to take on more roles by hospital administrators, and need more teaching resources (including time, efficient multimedia, and the latest textbooks) to fulfill various role expectations. Therefore, hospital administrators should realize the specific problem (lack of teaching resources) of CNTs with higher education. Hospital administrators should construct CNTs’ teaching resources demand assessment system, organize regularly dynamic assessment, and also carry out regular symposiums to solve teaching resources problems in time; rationally arrange the weekly frequency of clinical nursing teaching according to their clinical time; provide more clinical nursing teaching academic conferences, regularly conduct special lectures, etc., so as to continuously instruct CNTs with the latest teaching methods, enhance CNTs’ teaching ability, and thus improve CNTs’ work engagement.

In addition, the main characteristics of Profile 3 (high role stress-low lack of teaching resources profile) were CNTs with regular qualification audits. This finding is similar to that of previous study [46]. Hospitals with regular qualification audits for CNTs generally have stricter clinical nursing teaching management. Compared to CNTs employed on tenure-track basis without regular qualification audits, CNTs with regular qualification audits are usually core teachers in hospitals with high expectations of themselves. In addition, CNTs with regular qualification audits are at risk of being eliminated, and they are exposed to the latest teaching concepts and skills while preparing for each qualification audit. Through learning processes for qualification audits, CNTs improve clinical nursing teaching ability and gain clearer understanding of teaching tasks [47]. This also motivates them to pursue higher standards of clinical nursing teaching quality, leading to higher role stress.

The results also showed that individuals with contract employment were more likely to belong to Profile 2 (moderate role stress profile) compared to the CNTs of officially budgeted posts when Profile 1 was used as a reference. This result is consistent with a study of Iranian nurses [48]. Currently, most hospitals in China have adopted diversified employment systems, which affects CNTs’ role stress profile [49]. The requirements for CNTs in officially budgeted posts are higher; approximately half of the CNTs in hospitals are contract employees. They do same work. However, contract-employed CNTs are paid and treated differently to those in officially budgeted posts. This causes some psychological imbalance among contract-employed CNTs. Moreover, there was lack of continuing education and advancement opportunities compared to CNTs in officially budgeted posts. Finally, contract-employed CNTs may not feel secure enough and may risk losing their jobs if they make mistakes while working. These findings highlight the need for hospital administrators to pay more attention to contract-employed CNTs.

This study also found that individuals with lower psychological capital were more likely to be categorized into Profiles 2 and 3. Several variable-centered studies have shown that psychological capital negatively predicts role stress [28, 50]. Job demands resource (JD-R) model indicated that intrinsic resources, i.e., psychological capital, help individuals to fulfil their work goals, reduce work consumption, and promote individual progress in order to effectively alleviate their role stress level [23]. Specifically, CNTs with higher psychological capital possess more psychological resources, and when faced with the demands of numerous role stressors, they are better able to cope with different stressors because of their positive psychological traits. Meanwhile, self-efficacy and hope reduce low achievement associated with high role ambiguity, optimism reduces emotional exhaustion associated with role stress, and resilience positively adjusts coping strategies to deal with high role stress [51]. Finally, this study provides further evidence of the impact of psychological capital on role stress from an individual-centered perspective. Therefore, hospital administrators can select CNTs with high psychological capital in Profile 1 to share their experiences in dealing with role stress in clinical teaching work. Meanwhile, hospital administrators can also provide planned group counseling or psychological training to increase CNTs’ sense of self-efficacy, resilience and hope. Through these effective strategies, they can assist CNTs in improving psychological capital levels, and in tun, alleviate their role stress levels.

Finally, this study found significant differences in work engagement among the three role stress profiles. In particular, work engagement increased sequentially in Profiles 3, 2, and 1 and was lowest in the high role stress - low lack of teaching resources profile. Previous studies have shown that role stress is significantly and negatively associated with work engagement [31]. Meanwhile, stress cybernetic theory shows that when individuals are in long-term stressful state, if they do not actively deal with the stress, it leads to negative emotions, which eventually leads to negative behaviors, such as lower work efficiency [33]. Specifically, as role stress acts as a long-term stressor for CNTs, it can cause them feel tired and anxious, negatively affecting CNTs’ teaching behavior, and consequently negatively affecting their work engagement level and teaching quality. Therefore, hospital administrators should promptly identify high-perceived role stress profiles, through increasing staffing to help reduce their workload, rationally arranging training clinical nursing teaching theory and skills activities, etc. Simultaneously, CNTs should also enhance their work competence, correctly recognize role stress, improve their ability to cope with role stress, and find a balance among multiple roles in contributing to the decline their level of role stress and eventually improve their work engagement levels.

This study has some limitations. First, the cross-sectional design of the study limits the exploration of causal relationships. Second, this study only used self-report questionnaires to collect data, which carries the risk of individual recall bias and subjectivity. In addition, we only explored the effects of personal influence (psychological capital) on different profiles of role stress. Finally, owing to the limitations of human and material resources, only teaching hospitals in Shandong Province, China, were selected for the study.

In summary, obvious profile characteristics of role stress were found among CNTs, and the three-profile model was the best, including low role stress-high lack of teaching resources, moderate role stress, and high role stress -low lack of teaching resources profile. Approximately 68.7% of CNTs were in moderate role stress and high role stress-low lack of teaching resources profiles. Their profiles differed primarily in terms of sociodemographic characteristics, psychological capital, and work engagement. Thus, nurse administrators should provide regular qualification audits, opportunities to improve education levels, more effective teaching resources, The following is study implication. Hospital administrators can adopt targeted interventions based on the heterogeneity of CNTs role stress in human resource practices. For example, first, hospital administrators can screen suitable CNTs based on demographic and psychological capital characteristics. Second, based on the CNTs role stress profiles characteristics, different profiles’ work needs should be dynamically assessed regularly as to provide support, such as timely provision of more effective teaching resources, provision of regular qualification audits, opportunities to improve education level, and facilitate psychological capital for CNTs to decrease their role stress and improve their work engagement. Finally, future studies should (1) adopt a longitudinal study design is to explore the complex dynamics among psychological capital, role stress, and work engagement, (2) adopt a combination of self-assessment and other-assessment methods or include other objective indicators to conduct the study, (3) explore organizational factors (perceived superior social support) to understand individual differences in role stress better, and (4) use multicenter, large-sample designs. (i.e., including teaching hospitals in different countries with different provinces and education levels in the study).