The impact of nurses’ adversity quotient on their work stress: the mediating role of professional identity

Occupational groups usually suffer from health concerns caused by work stress, especially nursing staff. They consistently work in high-risk, high-pressure settings, which leaves them open to issues with their physical and emotional well-being [1, 2, 3]. First, an insufficiency in nursing personnel has adversely affected the global health system, a phenomenon that has been observed so far and is expected to continue in the future. The long-term shortage and high turnover of nurses have further increased the workload of nurses, bringing heavy pressure on the existing staff [4, 5]. This situation ultimately increases the potential risk of psychological problems, such as fatigue and stress [6]. Secondly, nurses often need to take care of patients under stress or individuals with high health risks and take responsibility for the care and safety of patients, which is what causes nurses to feel insecure. Lastly, shift workers have higher levels of work stress than day workers [7, 8]. Shift work is considered to be a stressful way of working [9], while nursing work often adopts a shift system [10, 11]. Moreover, the results of Harada et al. indicate that shift-related work stress is considered as a significant factor causing health-related complications [12]. It, therefore, appears that work-related stress profoundly impacts nurses’ mental and the physical health, subsequently influencing their time off work and the quality of care they provide [13]. A startling 68.3% of nurses in a cross-sectional survey done in China said they had severe levels of work stress [14]. Excessive work stress can result in a variety of physical or psychological diseases, including headaches, insomnia, anxiety, or depression, which may have potential adverse effects on the quality of care [15, 16]. Many previous studies have also shown that nurses are prone to anxiety, depression, frustration and other psychological and emotional disorders [17, 18]. According to a cohort analysis reported in 2018, the incidence of anxiety, depression, and stress was 41.2%, 32.4%, and 41.2%, respectively, in the nurse population [19]. Work stress levels arise from the interaction of personal characteristics and stresses [20]. It may be related to differences in factors such as nurses’ characteristics (age, marital status, working years, and professional title) [21, 22], ability to cope with adversity [23], or personality traits (professional identity) [24].

Adversity quotient (AQ) measures a person’s resilience and adaptability in the face of difficulties, stress, and setbacks [25, 26]. It is widely regarded as an important protective factor that can assist people in overcoming obstacles and adversity, and reduce the risk of job burnout. To measure adversity quotient, the following indicators are mainly considered: control, ownership, reach and endurance. Control is the capacity of an individual to perceive that he or she has control over a challenging situation. It involves a person’s perception and belief in their own behavior and the development of the situation, that is, the belief that they can take action to deal with difficulties and achieve positive results. Ownership refers to the individual’s responsibility for their own decisions and behaviors, acknowledging their agency in dealing with challenges and predicaments. Reach is the extent to which individuals perceive of favorable or unfavorable events as influencing other areas of their life. Endurance refers to an individual’s perseverance and endurance in the face of difficulties, the ability to withstand pressure and challenges without giving up easily. Together, these indicators form the assessment framework for adversity quotient, which is used to assess an individual’s ability and resilience to cope with challenges. The paradigm of stress management known as cognitive phenomenological transactional (CPT) theory highlighted the critical influence that personal assessment techniques have on how stress is managed [27]. Adversity quotient positively impacts the possessor’s performance, autonomy, and achievements. The low level of adversity quotient was closely related to a series of psychological and mental health as well as heightened vulnerability to stress [23]. Relevant studies on adversity quotient among teachers or company employees showed that adversity quotient was favorably connected with job performance, psychological contracts, or organizational commitments, while exhibiting a negative correlation with employee turnover rate or professional stress [25, 28, 29]. There are few studies on adversity quotient in nursing population. The related studies showed that people with high adversity quotient tend to adopt positive coping to manage their emotional exhaustion and increase work engagement, which was critical to maintaining nurses’ clinical performance and quality of care [30]. Thus, we predict:

The personality traits of medical personnel, especially their sense of professional identity (PI), have been proven to be potential predictors of their psychological stress. By enhancing the sense of purpose and intrinsic value of medical staff, their stress level can be effectively alleviated [24, 31]. By establishing a positive professional identity, medical staff will be better able to cope with challenges, work motivation and enthusiasm, and provide high-quality medical services. According to social identity theory, professional identity is a comprehensive psychological process that encompasses multiple aspects such as cognition, emotion, and behavioral tendencies. It represents an individual’s recognition and appreciation of the value and importance of their profession [32]. Positive emotional expression toward their nursing work was demonstrated by nurses with strong professional identities. Their sense of pride and work efficiency were improved, and they were more likely to achieve outstanding achievements and satisfaction in their work [33]. This enables people to fully dedicate themselves to their work and exhibit increased passion. Nurses’ job performance is greatly enhanced by their professional identity, which is essential for delivering high-quality care, reducing job unhappiness and weariness, and enhancing clinical performance [34, 35]. A study about front-line nurses in hospitals showed that they often face stress and tension, and indicated that their perception of this stress and tension was closely related to their level of professional identity [24]. When nurses have a positive attitude towards their profession, they have a relatively strong ability to resist stress and can partially alleviate dissatisfaction caused by the work environment [36]. Therefore, the pressure they feel will be greatly reduced. Thus, we propose Hypothesis 2.

Hunter et al. [37] pointed out that resilience can alleviate workplace stress in midwives, and that control (one of the indicators of adversity quotient) and professional identity are crucial findings for building resilience. However, no study has elucidated the connection between one’s professional identity and adversity quotient. An analysis of interviews with senior nurses [38] showed that difficult experiences of giving dying patients care can lead to conflicts between values, beliefs, and principles, changing nurses’ professional identity. However, experience and prompt assistance can help nurses lessen the negative effects of stressful situations. This mitigated the change in their professional identity [38]. Adversity quotient represents an individual’s ability and resilience to cope with challenges. Thus, we propose Hypothesis 3.

Meanwhile, the cognitive phenomenological transactional (CPT) stress theory emphasizes that stress depends on the individual’s cognitive evaluation of stressors and coping processes [39]. The cognitive evaluation consisted of two phases. Primary evaluation refers to an individual’s assessment of the harmfulness of an event, which may be a threat or benefit. Secondary evaluation refers to evaluating the individual’s resources and coping ability. We can speculate that at the primary cognitive assessment stage, nurses with higher adversity quotient perceive work stress as an opportunity for growth rather than a threat, which makes them see the possibility of career development and thus enhance their professional identity. In the secondary evaluation, nurses with higher adversity quotient perceived they had the resources to cope with work events and were more likely to adopt positive and effective coping strategies to relieve their stress. Lazarus et al. [39] emphasized the influence of individuals on stress. Professional identity as a personal trait may not only affect the primary cognitive evaluation of nurses, making them regard work stress as an important reflection of their value in their career, but also as a source of confidence and enthusiasm for their career in the secondary evaluation so that they are more willing to take the initiative to deal with work stress. Therefore, as shown in Fig. 1, we propose hypothesis 4.

In conclusion, the relationship between nurses’ adversity quotient and professional identity is unknown. Both adversity quotient and professional identity may affect the work stress level of nurses, and whether professional identity acts as a mediator in this process is still up for debate. Therefore, this study aimed to explore the influence of nurses’ adversity quotient on their work stress and to analyze whether nurses’ professional identity plays a mediating role in it.

The average score of the Stress Overload Scale of the surveyed nurses was 65.26 ± 17.93 points, and only 10.76% of the nurses had a work stress score lower than 50 points, which shows that clinical nurses generally face high work pressure. Another cross-sectional study conducted in Athens and Greece in 2020 had similar results to this study, reporting that more than 50% of nurses surveyed expressed moderate to high stress levels [16]. Nurses’ work stress might be influenced by several factors, including heavy workloads, insecurity, and shift work [49]. This study found that nurses aged ≤ 35 years, married or cohabiting, worked for ≤ 10 years, and had professional titles of senior nurse or below had higher work stress. This phenomenon may be related to young nurses’ short working time, inexperience, limited proficiency in complex nursing operations, and lack of experience in handling special situations. These factors may affect their ability to continue to perform their duties effectively, further exacerbating work-related stress.

Our results showed a significant negative relationship between professional identity and work stress, which is consistent with previous research results [50]. Increasing a sense of purpose and values could relieve stress among medical staff [51]. This may be because nurses with higher professional identity are keenly interested in nursing profession. Once they wholeheartedly embrace their profession, they perceive their work not merely as a means of livelihood, but as a source of profound fulfillment and joy. It becomes a vital pillar of their spiritual well-being, providing support and enrichment. Furthermore, there was a strong link between professional identity and individual susceptibility to perceived stressful events [36]. Nurses with a high level of professional identity had a strong sense of mission and belonging in their hearts. They have a double affirmation of their professional abilities, which makes it easier for them to achieve higher personal achievements [52]. However, the level of professional identity is not static but dynamic [53]. Medical institutions should strengthen the cultivation of nursing professional values to cultivate nursing professionals with a strong sense of professional identity. Nursing managers should guide nurses to think about the long-term prospects and sustainability of their careers and ensure stability in their professional identity. According to social exchange theory, when individuals feel supported by the organization and maintain a good affiliation with it, they tend to increase their self-efficacy and self-confidence, thereby adjusting their attitudes and behaviors in the organization. Such relationships of support and affiliation played a necessary role in the formation and reconstruction of personal and professional identity [54, 55]. Therefore, head nurses can provide appropriate psychological rewards and support to nurses so that they can gain a deep sense of achievement and satisfaction from their work. In short, psychological rewards and support act as catalysts for nurses to further demonstrate excellence, making them more willing to take on responsibilities and make meaningful contributions to their respective organizations [56]. At the same time, establishing a good communication environment is crucial to improving nurses’ professional identity, which involves interactions among nurses, head nurses, doctors, and patients. In such a communication environment, nurses can speak freely and express their thoughts and opinions, while superiors, doctors and patients can also understand and respect nurses’ professional knowledge and contributions. This open and supportive communication environment helps build trust and collaboration, which in turn enhances nurses’ professional identity [57].

The relevant analysis conducted in this study showed that the adversity quotient of nurses was positively correlated with their professional identity. In addition, the analysis results based on HMR and SEM showed that adversity quotient not only directly affected work stress, but also indirectly affected work stress through the influence of professional identity. The results support the hypothesized mediating role of professional identity. This is consistent with the principles of the cognitive phenomenological theory of stress. Nurses with higher adversity quotient indeed showed stronger professional identity. This may be because the adversity quotient, a type of positive psychological resource owned by individuals, is associated with good physical and mental health and a positive coping style [26], and ultimately alleviates their work stress. This is consistent with the cognitive phenomenological theory of stress that emphasizes cognitive evaluation and the role of internal resources in the process of stress. On the one hand, nurses with a higher level of adversity quotient generally show lower levels of neuroticism, are more cheerful and optimistic, and have higher levels of openness, extraversion, seriousness, and agreeableness [58]. Factors such as compassion, competence, confidence, responsibility, conscience and courage are key elements in building a good professional identity for nurses [59]. This social competence, self-confidence, and positive and optimistic tendencies may enhance an individual’s ability to cope with stressful events, which in turn affects the relationship between adversity quotient and work stress. On the other hand, individuals with different levels of adversity quotient have different ways of coping with stressful events. Individuals with high adversity quotient tend to adopt proactive strategies to increase their enthusiasm and engagement at work [23]. Zhang et al. believed that high work engagement was one of the ideal results of professional identity, reflecting the level of professional identity [60]. A systematic review of 38 articles found that increasing nurses’ adversity quotient can help them increase work engagement, alleviate emotional exhaustion, and improve their ability to effectively cope with workplace adversity [6]. Among multiple influencing factors, adversity quotient (as well as social support, empathy, and adversity quotient) had the strongest positive impact on work engagement [61]. Therefore, nurses with higher levels of adversity quotient tend to have a stronger sense of professional identity. They always put patients at the heart of their work and truly understand the pain they experience. At the same time, they strive to maintain moderate emotional regulation and focus wholeheartedly on their work. As a result, their perceived level of work pressure is considerably diminished [62].

Clinical nurses are under high levels of work stress, and identifying individual risk and protective factors is critical to finding personalized, targeted stress-relief interventions. Researchers believed that in the long run, enhancing adversity quotient can effectively protect individuals from the physical and psychological problems caused by stressors [63]. Mohd’s study showed that the pre-service teachers’ participation in activities such as camps, outdoor education, and clubs can help improve their adversity quotient [29]. It is, therefore, critical for nurse leaders to recognize and understand how to cultivate and apply adversity quotient among nursing staff. Yu’s research [6] indicated that work resources such as coping skills, self-efficacy, and social support could help cultivate nurses’ resilience, improve their adversity quotient, and promote a positive organizational work culture, thereby helping medical institutions recruit and retain nurses. Positive coping skills promote resilience in nurses [64]. Having high levels of self-efficacy and adequate social support and resources can help nurses reduce emotional exhaustion and burnout, thereby preventing attrition [65]. At the same time, mitigating nurses’ fatigue and burnout can improve their tolerance for shift work, allowing them to reach their full potential and achieve good outcomes in the face of workplace adversity [66]. Based on the cognitive phenomenological theory of stress, when implementing interventions to address work stress and provide psychological counseling, it is crucial to adopt targeted and individualized measures, considering each individual’s unique combination of characteristics. A unified and widely applicable intervention method cannot fully address the stress and health problems currently faced by medical personnel. Therefore, it is particularly important to actively build a social support system for nurses’ work adaptability and human resource management. Managers should proactively create an environment that promotes harmony, safety, and encouragement, while also providing timely guidance and support to nurses. In order to create a healthy nursing team, managers should properly plan the work and leisure activities of nurses, and provide specific relaxation training to help employees reduce stress and improve job satisfaction, so as to maintain the stability of the nursing team [67].

Clinical nurses suffer from heavy work stress, and it is imperative to identify personal risks and protective factors to develop targeted and personalized interventions to alleviate the stress. Adversity quotient was positively correlated with professional identity, while adversity quotient and professional identity were negatively correlated with work stress. Adversity quotient might affect work stress directly or indirectly through the mediating role of occupational identity. Consequently, to mitigate the negative effects of the adversity quotient on nurses’ work stress, tactics and actions to strengthen professional identity are anticipated.