Serial multiple mediation of perceived stress and self-control in the relationship between neuroticism and career anxiety among nursing interns in China: a cross-sectional questionnaire survey

Nursing interns were selected as study participants using a convenience sampling method from five tertiary Grade A comprehensive hospitals in Xi’an, Shaanxi Province, between February and May 2023. The inclusion criteria for this study included a minimum internship duration of 6 months, informed consent, and voluntary participation. Students on vacation, in military service, or those who dropped out of the internship during the survey period were excluded.

The researchers selected two investigators from each of the five tertiary Grade A comprehensive hospitals. The participating investigators received standardized training and established communication with the head of the hospital’s teaching group. Once the purpose and content of the study were explained and consent was obtained, the pre-designed questionnaire was sent to the investigators via WeChat, who then forwarded it to the nursing interns. Additionally, the training personnel utilized the QuestionStar platform for questionnaire collection and quality control. Quality control measures included: informing participants about the anonymity of their responses and their right to withdraw at any time; the questionnaire featured mandatory and logically structured response options. To prevent duplicate submissions, each IP address was restricted to one response. Incentives, such as small gifts for completing the questionnaire, were provided as tokens of appreciation. In total, 517 questionnaires were collected for this study. After excluding questionnaires with missing responses, identical answers across all items, or completion times less than 5 min, we obtained a total of 499 valid questionnaires, yielding a valid response rate of 96.5%. Among the valid questionnaires, 13 were from male students and 486 were from female students.

IBM SPSS Version 27.0 and its plug-in PROCESS Macro version 4.0 were employed for statistical analysis. (1) The Harman single-factor test method was employed to examine potential common method biases [39]. (2) All data underwent standardization procedures. (3) Descriptive analysis included frequency, percentage, mean, and standard deviation. (4) Independent t-tests and one-way analysis of variance (ANOVA) were utilized to compare demographic characteristics (gender, being an only child, type of residence, family finances, extracurricular activities, likes nursing profession, academic atmosphere, and academic achievement) influencing career anxiety among nursing interns. (5) Pearson correlation analysis was conducted to explore the relationships among four variables: neuroticism, perceived stress, self-control and career anxiety. (6) Model 6 of the plug-in PROCESS Macro for SPSS, developed by Hayes, was employed to evaluate the mediating role of perceived stress and self-control in relationship between neuroticism and career anxiety, while controlling for demographic variables [40]. This approach is based on ordinary least-squares regression and the bootstrap method. Additionally, to assess the impact of neuroticism on career anxiety among nursing interns, a bias-corrected percentile bootstrap distribution with a 95% confidence interval was computed based on 5,000 bootstrap samples. Statistical significance was defined as a p-value < 0.05.

Results from exploratory factor analysis indicated the presence of 9 factors with eigenvalues exceeding 1. The primary factor accounted for 24.87% of the variance, falling below the critical threshold of 40%, thereby suggesting the absence of significant common method bias in this investigation [39].

The study enrolled 499 nursing interns, comprising 97.4% females, 78.4% non-only children, 58.8% originating from rural areas, 80.8% self-evaluated their family finances as moderate, 53.1% engaged in extracurricular activities, 22.6% harbored a preference for the nursing profession, 23.6% perceived a robust academic atmosphere, and 86.4% demonstrated moderate academic achievement (Table 1).

Table 1 shows significant differences between career anxiety and type of residence (F = 3.459, p = 0.032), family finances level (F = 3.288, p = 0.038), likes nursing profession (F = 21.806, p < 0.001), and academic atmosphere (F = 8.318, p = 0.032).

The means, standard deviations, and correlation coefficients of the four variables are presented in Table 2. Results showed that career anxiety was significantly and positively correlated with neuroticism (r = 0.384, p < 0.001) and perceived stress (r = 0.460, p < 0.001), and negatively correlated with self-control (r = -0.570, p < 0.001).

Figure 2 illustrates the mediating effects of perceived stress and self-control on the relationship between neuroticism and career anxiety. The total effect of neuroticism on career anxiety was significant (c = 0.365, SE = 0.040, t = 9.030, p < 0.001; Step 1). Furthermore, neuroticism had a positive direct effect on perceived stress (β = 0.385, SE = 0.039, t = 9.774, p < 0.001) and a negative direct effect on self-control (β = -0.237, SE = 0.042, t = -5.626, p < 0.001). The significant direct effect of perceived stress (the first mediating variable) on self-control (the second mediating variable) was observed (β = -0.355, SE = 0.044, t = -8.037, p < 0.001; Step 2). Examination of the direct effects of mediating variables on career anxiety revealed significant effects of perceived stress (β = 0.173, SE = 0.043, t = 4.009, p < 0.001) and self-control (β = -0.401, SE = 0.042, t = -9.668, p < 0.001; Step 3). Simultaneously entered of neuroticism and the two mediating variables into the model (Step 4) confirmed the significant direct effect of neuroticism on career anxiety (c’ = 0.149, SE = 0.040, t = 3.735, p < 0.001). Overall, these results revealed that serial-multiple mediation had occurred. Table 3 presents a comparison of the indirect and specific effects of neuroticism among nursing interns on career anxiety via perceived stress and self-control.

As seen in Table 3, when considering all variables (including covariates) in the tested model, the paths through single mediation of perceived stress [β = 0.066; 95% BC CI (0.028, 0.108)], single mediation of self-control [β = 0.095; 95% BC CI (0.057, 0.140)], and both perceived stress and self-control [β = 0.055; 95% BC CI (0.033, 0.081)] were all statistically significant. The total indirect effect was also significant [β = 0.216; 95% BC CI (0.159, 0.276)]. Specifically, the indirect effect of perceived stress accounted for 18.1% of the total effect, while self-control accounted for 26.0%. The serial mediation path through both perceived stress and self-control contributed 15.1% to the total effect.

In this study, we compared the strength of specific indirect effects of mediators and identified three pairs of contrasting results. As shown in Table 3, the 95% BC CI (Bias-Corrected Confidence Interval), which is considered significant if it does not include zero, indicating no significant statistical differences among the three indirect effect pathways. This follows Hayes’ recommendation to use bias-corrected 95% bootstrap confidence intervals (BC CI) for conducting mediation analyses, with intervals not containing zero considered to reflect a significant effect [40].

The study findings indicate that neuroticism has a significant direct effect on career anxiety, confirming hypothesis 1, suggesting that nursing interns with high neuroticism are prone to career anxiety tendencies. This result is consistent with previous research [37, 41, 42]. For example, Ibrahim et al. [41]. found that neuroticism is a key factor affecting anxiety levels in nursing students. Cañadas et al. [42]. also identified neuroticism as an important factor influencing career burnout and anxiety among nursing students. Our results further enrich the understanding that neuroticism is a common personality trait in all anxiety [7], indicating that neuroticism as a susceptible population significantly impacts individual development. In the high-stress ambulance profession, nursing interns may experience more fear, anxiety, and other negative emotions due to rescue events during their internship, affecting their career certainty and satisfaction, thereby increasing the likelihood of career anxiety.

Therefore, hospitals hosting internships should consider prioritizing targeted interventions for nursing interns with high neuroticism to help mitigate career anxiety in this group. These interventions could include providing additional psychological support, stress management training, and coping strategies to help these interns navigate the challenges of their clinical experience more effectively. By addressing the emotional and psychological needs of interns with high neuroticism, hospitals can enhance their overall well-being and reduce the likelihood of long-term career anxiety.

Neuroticism affects career anxiety through perceived stress, confirming hypothesis 2. Specifically, neuroticism positively predicts perceived stress, and perceived stress in turn positively predicts career anxiety, indicating that nursing interns with high neuroticism perceive greater stress, thereby experiencing more pronounced career anxiety. This study has found that neurotic personality positively predicts perceived stress, which is in line with previous research findings [43, 44]. Xu et al. [43]. also discovered that neurotic personality significantly predicts the stress perception of college students. Individuals with a high level of neuroticism usually have a more intense emotional response to external situations and tend to regard these situations as stressors. Besides, perceived stress positively predicts career anxiety, which is consistent with previous research results [45, 46]. A possible reason is that when an individual experiences a high level of stress, they are more likely to develop anxious emotions about their future career. At the same time, these findings further support the vulnerability-stress model, where the occurrence of negative emotions is related to individual personality traits and levels of stress perception [47]. The study found that although internship stress is the most direct and significant stressor for undergraduate nursing interns, effective measures to reduce perceived stress among nursing interns can significantly mitigate the impact of internship stress [31, 46]. Therefore, during internships, hospitals can establish stress relief rooms for nursing interns with high neuroticism and provide career counseling to help them regulate emotions, improve negative thinking, reduce sensitivity to stress perception, and enhance career satisfaction, thereby alleviating career anxiety.

Neuroticism significantly influences career anxiety through self-control, specifically manifested in neuroticism negatively predicting self-control, and self-control negatively predicting career anxiety, indicating a mediating role of self-control between neuroticism and career anxiety, confirming hypothesis 3. Specifically, neurotic personality negatively predicts self-control, which is consistent with previous research findings [24, 37]. A possible reason is that individual with high neuroticism are more likely to have intense negative emotional reactions, which in turn affect their self-control ability, leading to impulsive and uncontrollable emotions. In addition, this study also found that self-control negatively predicts career anxiety, and this result is similar to the research of Fang et al. [48]. found that self-control affects career decision-making by influencing social anxiety, and career decision-making in turn affects the quality and efficiency of employment. A possible reason is that people with stronger self-control can better manage their emotions and stress, thus showing a lower level of anxiety when facing career choices. This study further reveals that when the self-control ability of nursing interns with high neuroticism is low, they are more likely to experience high levels of career anxiety. Tangney et al. regard self-control as the ability for individuals to consciously overcome impulses, emotions, and adjust their cognition, emotions, and behaviors for long-term goals [17]. Research has shown that individuals experiencing depleted self-control resources find it more challenging to regulate their emotions while targeted training can enhance individuals’ self-control abilities [49]. Therefore, alongside reducing perceived stress among nursing interns with high neuroticism, it is crucial to implement methods to enhance their self-control and reduce self-depletion, which is vital for alleviating career anxiety among nursing interns.

This study confirms that neuroticism indirectly impacts career anxiety among nursing interns through the sequential mediating roles of perceived stress and self-control, validating hypothesis 4. The study found that perceived stress negatively predicts self-control, which is consistent with previous research results [24, 25, 50]. At the same time, this study supports the “self-control resource” theoretical model, that is, ego depletion leads to a decrease in self-control, indicating that the greater the stress perceived by nursing interns, the more severe the ego depletion, resulting in a reduction in self-control ability [26]. This result reveals the close relationship between perceived stress and self-control, and the relationship between the two can be explained from the following aspects. First, during the transition from school to hospital, nursing interns face an identity change, from students to interns, and they need to adapt to the pressure of clinical work and complex situations. In this process, nursing interns often experience emotional and cognitive burdens, and are prone to the phenomenon of ego depletion, which leads to a decline in their self-control ability, further increases job dissatisfaction, and ultimately triggers career anxiety. Second, the relationship between perceived stress and self-control can also be improved through environmental regulation. Through appropriate stress management strategies, such as stress relief and psychological counseling, it can effectively reduce the stress perceived by nursing interns at work, reduce ego depletion, and thus enhance their self-control ability.

Therefore, during the internship process, hospitals should provide effective psychological support and stress management tools to help nursing interns better cope with stress, reduce the depletion of self-control, improve their psychological resilience, and thus reduce the risk of career anxiety. It is important to acknowledge that the sample was drawn from only five hospitals in Xi’an, Shaanxi Province, which may limit the generalizability of the findings. Future studies should include more diverse and geographically varied samples to strengthen the external validity of the conclusions.

This study reveals the impacts of neuroticism, perceived stress, and self-control on the career anxiety of nursing interns, expands the influencing pathways of career anxiety among nursing interns, and meanwhile provides practical suggestions for nursing education and clinical practice. First, nursing educators should adopt strategies to help interns with higher neuroticism better manage stress. Through emotional regulation, self-control, and stress management training, their psychological resilience can be enhanced, and the risk of career anxiety can be reduced. Secondly, hospitals should provide stress-relief spaces and psychological support for interns. Regularly arrange career counseling and psychological guidance to help interns improve their self-control ability, reduce perceived stress, and prevent career anxiety. Finally, hospital management should provide resource support, such as a mentoring system and stress-management workshops, to help interns overcome emotional challenges, improve job satisfaction, and reduce long-term career anxiety. Through these measures, career anxiety can be effectively reduced, and a healthy nursing team can be cultivated.

This study has several limitations that should be addressed in future research. First, the sample was drawn from only five hospitals in Xi’an, Shaanxi Province, which may limit the generalizability of the findings to other regions or populations. While the study provides valuable insights within the local context, future research should aim to include a larger, more diverse, and geographically varied sample to enhance the external validity of the conclusions. Second, as a cross-sectional study, this research cannot establish causal relationships between the variables. The findings suggest associations, but they do not confirm causality. To address this limitation, future studies should consider longitudinal or experimental designs, which would allow for a better understanding of the directionality and long-term effects of neuroticism, perceived stress, and self-control on career anxiety. Lastly, career anxiety among nursing interns is influenced by a variety of factors not examined in this study. Future research should explore additional variables, such as environmental factors, personal coping mechanisms, and organizational support, to provide a more comprehensive understanding of the complex factors contributing to career anxiety in nursing interns.