The nursing profession is characterized by high intensity and significant stress. Nurses must not only manage heavy workloads but also address diverse patient needs, engage in emotional labor, and cope with occupational exposure risks. These factors collectively contribute to substantial work-related stress for nurses. Currently, there is limited research on identifying distinct categories of nurse stress profiles and their influencing factors.
Objectives
This study aimed to explore the potential categories of perceived stress among nurses using Latent profile analysis (LPA) and to analyze the influence of sociodemographic factors, effort-reward imbalance, and perceived organizational support on perceived stress categories.
Design
Cross-sectional study
Methods
Data were collected via electronic surveys from 696 nurses in Shanxi Province, China, from February 18 to 28, 2023. The survey parameters included sociodemographic characteristics, nurse job stressors scale, effort-reward imbalance scale, and perceived organizational support scale. Latent profile analysis (LPA) was used to classify the perceived stress levels of nurses, and disordered multi-classification logistic regression was used to identify the influencing factors.
Results
The most suitable model was a three-profile model, comprising the “low perceived stress” group (10.5%), “moderate perceived stress” group (66.7%), and “high perceived stress” group (22.8%). Multi-classification logistic regression analysis showed that average working hours per day (OR = 3.022, p = 0.026), extrinsic effort (C2 vs. C1, OR = 1.589, p < 0.001; C3 vs. C1, OR = 2.515, p < 0.001), and perceived organizational support (C2 vs. C1, OR = 0.853, p < 0.001; C3 vs. C1, OR = 0.753, p < 0.001) were the factors influencing the classification of nurses’ perceived stress.
Conclusions
Latent profile analysis revealed that nurses’ perceived stress exhibits distinct characteristics. It is recommended that clinical administrators should identify these characteristics and the influencing factors of different nurse categories, and adopt targeted intervention strategies to reduce the levels of perceived stress.
Hinweise
Yajie Shi and Linying Wang contributed equally to this work.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Introduction
With the acceleration of life pace and changes in the medical environment, the mental health of nurses has become a significant concern. Nurses often work in high-pressure and complex environments, such as emergency rooms and intensive care units, where they are required to handle emergencies and complex patient needs under high-intensity and high-risk conditions [1]. In these settings, nurses frequently face the risk of occupational exposure, including contact with infectious diseases, handling toxic substances, and sustaining physical injuries. A study indicated that approximately 52.4% of nurses reported experiencing needlestick injuries, which increased their risk of contracting bloodborne infections [2]. Additionally, handling hazardous drugs, such as chemotherapy agents, pose significant health risks, with approximately 60% of nurses reporting accidental exposure [3]. These occupational risks substantially elevated stress levels, contributing to a high incidence of burnout in the profession [4].
Nurses are also required to engage in significant emotional labor, including communication with patients and their families, addressing patients’ pain and sorrow, and providing emotional support. This emotional labor often exacerbates psychological stress [5]. Coupled with prolonged shifts, irregular working hours, and imbalanced patient-to-nurse ratios, nurses experience significant physical and psychological fatigue. The necessity to ensure patient safety and deliver high-quality care without errors further adds to their stress levels [6]. Additionally, the continuously evolving medical knowledge and technology necessitate ongoing learning and skill enhancement, further contributing to career-related pressure [7]. A lack of supportive leadership, teamwork, or strained interpersonal relationships within departments can further increase work-related stress [8]. As a result, nursing is considered one of the most stressful occupations in the medical and health industries.
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Perceived stress refers to a person’s perception of the stress experienced at a certain period of time or at a specific point in time [9]. High levels of perceived stress can lead to psychological issues such as anxiety, depression, and burnout, negatively affecting nurses’ job satisfaction and motivation [10]. Prolonged exposure to high stress may also increase burnout and turnover intentions, worsening nursing staff shortages [6]. As integral members of the healthcare team, nurses’ work directly impacts patient care quality. Elevated stress can reduce their efficiency, increase error rates, and impair their attention, judgment, and decision-making abilities, thereby compromising the overall quality of healthcare services [11]. Therefore, studying perceived stress among nurses is crucial for understanding and addressing these challenges. Identifying stressors and their influencing factors can aid in developing effective interventions to enhance nurses’ work environments and psychological support systems.
Some perspectives on work stress were proposed as early as 1996 by Siegrist, who proposed the work stress theory of Effort-Reward Imbalance (ERI) [12]. This classical work stress theory posits that work stress occurs when an individual’s effort exceeds their rewards [12]. In addition, the theory suggests that the greatest stress levels and the highest turnover rates occur in the context of a high ERI, low perceived organizational support, and high over-commitment [13]. Perceived organizational support refers to the perceived help of the organization to the employees’ actual work, the material rewards for their efforts, and the recognition and praise for their work achievements [14]. This support is widely recognized as an important positive psychological resource, which is valuable in motivating individuals to work and promoting their psychological well-being. Therefore, this study is based on this theory to investigate the effects of effort-reward imbalance and perceived organizational support on perceived stress among nurses.
Huang et al. investigated the stress levels among neonatal nurses, revealing that the majority experienced moderate to severe levels of perceived stress [15]. Similarly, Rasheed et al. reported that 8.9% of nurses experienced low levels of stress, 87.6% experienced moderate levels, and 3.4% experienced high levels of perceived stress during the COVID-19 pandemic [16]. These previous studies on stress in nurses mainly used total scores to assess stress levels, which could not adequately distinguish the differences among various groups with different characteristics in the study population. This approach could limit the effectiveness of stress interventions.
Latent profile analysis (LPA) is the best method to solve this issue. LPA is a person-centered statistical method that groups individuals with similar personal and professional characteristics, traits, or behaviors based on their responses to a set of observations [17]. Previous research in the nursing field has applied LPA to identify subgroups in areas such as job demands, interaction styles, healthy pre-employment lifestyles, and ethical sensitivity [18, 19]. The strengths of conducting LPA in this study lie in its ability to provide a nuanced understanding of stress among nurses by identifying different subgroups of stress that may not be apparent with total scores alone. This approach can help care managers and other stakeholders develop interventions tailored to the unique needs of each subgroup, potentially leading to more effective stress management and improved overall well-being among nurses. Additionally, LPA can provide valuable insights into the complex relationships between various factors contributing to stress in nurses, informing future research and intervention development. Therefore, in the present study, LPA was used to classify perceived stress among nurses. Based on the work stress theory of ERI, this study further analyzed the influence of sociodemographic factors, effort-reward imbalance, and perceived organizational support on perceived stress categories. The findings of this study will provide a reference for developing scientifically sound and effective measures to reduce perceived stress among nurses.
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Methods
Design
This study employed a cross-sectional design to investigate the latent classes of perceived stress among nurses and to explore the impact of ERI and perceived organizational support levels on these latent classes of perceived stress.
Participants
The study used convenient sampling. The inclusion criteria were as follows: (a) they must be registered nurses from various departments across the hospital, not limited to specific or specialized units; and (b) they must provide informed consent and voluntarily participate in this study. Nurses undergoing refresher training and those with a history of psychological and physiological disorders were excluded from the study.
Sample size
Based on Yang’s recommendation, a minimum of 50 subjects per subgroup was needed for accurate model fit in LPA [20]. Since there were 3 subgroups in this study, the required sample size should have been at least 150, accounting for a 20% attrition rate. Therefore, the minimum sample size needed was 188. With 680 nurses in our study, the sample size was adequate for LPA-based analysis under these conditions.
Measures
(I)
General information questionnaire: The questionnaire for this study was designed by the investigators according to its purpose. It included two main categories of information about the participants: social information and career characteristics. The social information included variables such as sex, age, marital status, education level, number of children, and the presence of elderly family members requiring care. Career characteristics included aspects such as employment form, professional qualification, years of service, current department, transfers to other departments, average working hours per day, and the number of night shifts per week.
(II)
Nurse Job Stressor Scale: The Nurse Job Stressor Scale was developed by Li based on the two most commonly used nurse job stressor scales internationally [21‐23]. This scale was adapted for Chinese nurses with input from nursing experts in the United States, Thailand, and China, resulting in a revised version more suited to the Chinese nursing context. The scale comprises 35 items and is divided into five dimensions: nursing profession and work, time and workload allocation, working environment and resources, patient care, and management and interpersonal relationships. Each item is scored on a 4-point Likert scale, ranging from “no stress” to “a lot of stress.” A higher total score indicates greater stress. The Cronbach’s α coefficients for the overall scale, as well as the dimensions of nursing profession and work, time and workload allocation, working environment and resources, patient care, and management and interpersonal relationships, were 0.94, 0.80, 0.81, 0.83, 0.87, and 0.89, respectively [24]. These results indicate that the scale has good reliability. Additionally, confirmatory factor analysis showed that the cumulative contribution rate of the five factors was 56.96%, with factor loadings for all 35 items exceeding 0.4, suggesting that the scale has good construct validity [24].
(III)
Effort-Reward Imbalance Scale: In this study, we utilized the ERI scale developed by Siegrist [12, 25]. The Chinese version of the scale was translated from the English version and employed in this survey [26]. The scale consists of 23 items, divided into three dimensions: extrinsic effort, reward, and over-commitment. For the effort and reward dimensions, a 5-point Likert scale is used, where participants select “1” to indicate a non-stressful experience and “5” to indicate a very stressful experience. The over-commitment dimension is scored on a 4-point Likert scale, with “1” indicating disagreement and “4” indicating strong agreement. The scoring range for the effort dimension is 6 to 30 points, for the reward dimension 11 to 55 points, and for the over-commitment dimension 6 to 24 points. Previous research has shown that the Cronbach's alpha coefficients for the three dimensions of the scale were 0.89, 0.89, and 0.64, respectively, indicating good reliability [27]. The items on the scale have high loadings (> 0.4) on their respective dimensions, indicating good structural validity of the scale [26].
(IV)
The Perceived Organizational Support Scale was originally developed by Eisenberger and later adapted by Chen ZX [28, 29]. Subsequently, Zuo HM made appropriate modifications to tailor the scale specifically for nursing [30]. This scale consists of 13 items that assess emotional support and instrumental support. Responses are measured on a 5-point Likert scale, ranging from “very inconsistent” to “very consistent,” with total scores ranging from 13 to 65, where higher scores indicate stronger perceived organizational support. The Cronbach's alpha coefficient for this scale was 0.97, and for the two dimensions, 0.97 and 0.92, respectively [31]. Additionally, the scale’s items exhibit strong loadings (> 0.4) on their corresponding dimensions, demonstrating good construct validity of the scale [30].
Data collection
Prior to the start of the formal survey, 20 nurses who met the criteria were selected for a pilot survey using a convenience sampling method. The purpose of this survey was to assess the reasonableness and feasibility of the questionnaire. The results of the pilot survey showed that each item of the questionnaire was clear and unambiguous.
For the formal investigation, the leading researcher first sought and obtained permission from the Director of the Nursing Department. With the director’s assistance, chief head nurses from six departments (Internal Medicine, Surgery, Operating Room, Oncology, Critical Care, and Obstetrics & Pediatrics) were convened and designated as the researchers for their respective departments. The leading researcher first explained in detail the purpose and significance of this study, the criteria for participant selection, and the information related to assurance of the anonymity and confidentiality of the participants and the survey responses. The leading researcher also highlighted that the survey was conducted via the online questionnaire survey platform “Questionnaire Star” (www.wjx.cn), on which only a fully completed questionnaire could be uploaded. Specifically, we configured the platform to prevent the submission of multiple responses from the same IP address and responses completed within a short time (under 300s).
Once the briefing was completed, the chief head nurses provided the survey website link to the participants who met the criteria in their respective departments. After the participants were introduced to the study’s content, objectives, and completion process, and after obtaining their informed consent, they were able to complete the questionnaire. They could access the questionnaire using either a computer or a smartphone by opening the website link or scanning a quick response code. To address any questions or ambiguities, participants were encouraged to reach out directly to their respective chief head nurses, who had been briefed and trained by the leading researcher to provide clarification. If the chief head nurses encountered any questions they were unable to answer, they were instructed to consult the leading researcher for further guidance. This multi-tiered support system ensured that participants had the necessary assistance throughout the process. Finally, a total of 696 nurses participated and completed the survey.
Data analysis
LPA was conducted on the five dimensions of perceived stress (nursing profession and work, time and workload allocation, working environment and resources, patient care, and management and interpersonal relationships) using Mplus software (version 8.7). The optimal model was determined based on the main model fitting indices in LPA, including the Akaike information criterion (AIC), Bayesian information criterion (BIC), adjusted BIC (aBIC), entropy, Lo–Mendell–Rubin (LMR), and Bootstrapped Likelihood Ratio Test (BLRT), where smaller values of AIC, BIC, and aBIC indicated a better model fit. The entropy value was close to 1.0, indicating a high classification accuracy. In addition, the LMR and BLRT tests were performed to calculate the p-value, with p < 0.05 indicating that the model fit was optimal.
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Using SPSS version 26.0, the LPA categories were used as the dependent variable, and the sociodemographic factors of nurses and other related information that showed statistical significance in univariate analysis were used as independent variables to conduct logistic regression analysis. As three potential categories of perceived stress failed the parallel line test (χ2 = 29.851, p = 0.008), disordered multi-classification logistic regression was used. Statistical significance was defined as p < 0.05.
Ethical considerations
This study was approved by the Ethics Committee of Shanxi Bethune Hospital (Approval No. YXLL-2023-045). Participants were informed regarding the purpose and procedure of the survey, the contact details of the responsible personnel, and data security measures. All data collected were anonymized to ensure the confidentiality of the participants. Moreover, participants could withdraw from the study at any time without any prejudice.
Results
Basic characteristics
A total of 696 questionnaires were distributed, of which 680 were considered valid, resulting in an effective response rate of 97.70%. We describe the general information of the participants in terms of three aspects: social information and career characteristics. Out of the 680 respondents, 632 (92.9%) were female and 48 (7.1%) were male. The average age was 32.43 ± 5.92 years. In terms of education level, 4 (0.6%) held an associate degree, 653 (96.0%) held a bachelor’s degree, and 23 (3.4%) held a master’s degree or above. Other basic characteristics of the participants are shown in Table 1.
Table 1
Descriptive characteristics of the study sample (N = 680)
Variables
Groups
Mean ± SD/N (%)
Social information
Sex
Male
48 (7.1)
Female
632 (92.9)
Age
-
32.43 (5.92)
Marital status
Unmarried
194(28.5)
Married
486 (71.5)
Education level
Associate degree
4 (0.6)
Bachelor's degree
653 (96.0)
Master's degree or above
23 (3.4)
Number of children
0
232 (34.1)
1
281 (41.3)
2
163 (24.0)
≥ 3
4 (0.6)
Presence of elderly family members requiring care
Yes
503 (74.0)
No
177 (26.0)
Career characteristics
Employment form
Authorized personnel
186 (27.4)
Contract personnel
494 (72.6)
Professional qualification
Junior
316 (46.5)
Intermediate
327 (48.1)
Senior
37 (5.4)
Years of service
< 1
57 (8.4)
1–3
102 (15.0)
4–7
48 (7.1)
8–15
387 (56.9)
16–20
47 (6.9)
> 20
39 (5.7)
Current department
Emergency department
52 (7.6)
Intensive care unit
51 (7.5)
General unit
424 (62.4)
Others
139 (20.4)
Transferred to other departments
Yes
98 (14.4)
No
582 (85.6)
Avg. working hours per day
≤ 8
481 (70.7)
9–12
159 (24.4)
> 12
40 (5.9)
Avg. number of night shifts per week
0
171(25.2)
1–2
423 (62.2)
≥ 3
86 (12.6)
Note: N = available data; mean ± SD reported for continuous scores; N (%) reported for categorical measures; Avg, average
LPA of nurses’ perceived stress
A total of 1–4 latent profile models were fitted in this study, as shown in Table 2. With the increase in the number of categories, the values of AIC, BIC, and aBIC gradually decreased. When the three categories were retained, the entropy value reached its maximum, and the LMR value showed statistical significance (p < 0.05). Therefore, the latent profile model containing three potential categories was considered the best-fitting model. The probabilities of nurses belonging to each potential category were 0.907, 0.960, and 0.918, respectively, indicating that the three-category model was reliable.
Table 2
Latent profile analysis models and fit indices
Model
K
AIC
BIC
aBIC
Entropy
LMR P-value
BLRT P-value
1 profile
10
17914.343
17959.564
17927.813
-
-
-
2 profile
16
17003.799
17076.152
17025.350
0.775
0.0025
< 0.001
3 profile
22
16480.470
16579.956
16510.103
0.878
0.0318
< 0.001
4 profile
28
16237.587
16364.206
16275.303
0.839
0.1913
< 0.001
A potential profile was generated based on the classification results, as shown in Fig. 1. The chart shows that the overall trend of the three categories was consistent. The overall score of category Class 1 was low, with a total of 72 cases (10.5%), termed as the "low perceived stress" group. The Class 2 category fell between Class 1 and Class 3 in terms of scores, encompassing a total of 455 cases (66.7%), and is termed as the "moderate perceived stress" group. The Class 3 category scored the highest score, comprising a total of 153 cases (22.8%), and is termed as the "high perceived stress" group.
Fig. 1
Latent profiles of perceived stress among nurses
×
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Differences in general information and the two scales among the latent profiles of nurses’ perceived stress
Through the χ2/F/H test, the differences in the general information and the two scales among the three latent profiles of nurses’ perceived stress were compared. In terms of social information, the profiles showed statistically significant differences in terms of sex and the presence of elderly family members requiring care (p < 0.05; Table 3). In terms of career characteristics, the profiles showed statistically significant differences in the current department, average daily working hours, and the average number of night shifts per week (p < 0.05; Table 5). In terms of two scales, the total score of ERI, the dimension of extrinsic effort and over-commitment, and the score of each dimension of perceived organizational support among the three latent profiles showed significant differences (p < 0.05; Table 4).
Table 3
Differences in social information on latent profiles of nurses’ perceived stress
Characteristic
Potential categories
χ 2 /F/H
p-value
Class1
(n = 72)
Class2
(n = 455)
Class3
(n = 153)
Sex (N,%)
χ2 = 8.304
0.016
Male
11(22.9)
28(58.3)
9(18.8)
Female
61(9.7)
427(67.6)
144(22.8)
Age (M ± SD)
32.53(6.53)
32.36(6.05)
32.59(5.21)
F = 0.098
0.906
Marital status (N,%)
χ2 = 0.897
0.639
Unmarried
21(10.8)
134(69.1)
39(20.1)
Married
51(10.5)
321(66.0)
114(23.5)
Education level (N,%)
Associate degree
0(0)
4(100.0)
0(0)
H=0.649
0.892
Bachelor's degree
70(10.7)
436(66.8)
147(22.5)
Master's degree or above
2(8.7)
15(65.2)
6(26.1)
Number of children(N,%)
0
26(11.2)
160(69.0)
46(19.8)
H=1.662
0.893
1
28(10.0)
188(66.9)
65(23.1)
2
18(11.0)
104(63.8)
41(25.2)
≥ 3
0(0)
3(75.0)
1(25.0)
Presence of elderly family members requiring care(N,%)
Yes
48(9.5)
327(65.0)
128(25.4)
χ2 = 10.500
0.005
No
24(13.6)
128(72.3)
25(14.1)
Table 4
Differences in effort-reward imbalance and perceived organizational support on latent profiles of nurses’ perceived stress
Variables
Dimensions
Class1
(n = 72)
Class2
(n = 455)
Class3
(n = 153)
F
p-value
Mean
SD
Mean
SD
Mean
SD
Effort-reward
imbalance
Extrinsic effort
13.99
3.28
17.28
2.60
21.35
2.52
218.648
<0.001
Reward
29.49
3.82
29.38
2.09
29.44
254
0.462
0.630
Over-commitment
15.90
2.56
17.02
1.91
19.15
2.25
81.630
<0.001
Total
59.38
7.37
63.68
4.94
70.10
5.56
120.446
<0.001
Perceived
organizational
support
Emotional support
42.42
6.42
34.47
6.47
24.87
7.73
190.516.
<0.001
Instrumental support
13.60
1.54
11.61
1.79
9.07
2.69
147.806
<0.001
Total
56.01
7.65
46.07
7.84
33.93
9.71
202.398
<0.001
Table 5
Differences in career characteristics on latent profiles of nurses’ perceived stress
Characteristic (N,%)
Potential categories
χ 2 /H
p-value
Class1
(n = 72)
Class2
(n = 455)
Class3
(n = 153)
Employment form
χ2 = 0.900
0.638
Authorized personnel
23(12.4)
123(66.1)
40(21.5)
Contract personnel
49(9.9)
332(67.2)
113(22.9)
Professional qualification
Junior
32(10.1)
216(68.4)
68(21.5)
H=1.087
0.581
Intermediate
33(10.1)
218(66.7)
76(23.2)
Senior
7(18.9)
21(56.8)
9(24.3)
Years of service
< 1
11(19.3)
42(73.7)
4(7.0)
H=1.248
0.126
1–3
9(8.8)
68(66.7)
25(24.5)
4–7
5(10.4)
33(68.8)
10(20.8)
8–15
35(9.0)
254(65.6)
98(25.3)
16–20
7(14.9)
32(68.1)
8(17.0)
> 20
5(12.8)
26(66.7)
8(20.5)
Current department
Emergency department
5(9.6)
29(55.8)
18(34.6)
χ2 = 27.685
0.001
Intensive care unit
4(7.8)
34(66.7)
13(25.5)
General unit
37(8.7)
282(66.5)
105(24.8)
Others
26(18.7)
99(71.2)
14(10.1)
Transferred to other departments
Yes
8(8.2)
63(64.3)
27(27.6)
χ2 = 2.052
0.358
No
261(44.8)
392(67.4)
53(9.1)
Avg. working hours per day
≤ 8
50(10.4)
336(69.9)
95(19.8)
H=6.672
0.036
9–12
9(5.7)
96(60.4)
54(34.0)
> 12
13(32.5)
23(5.1)
4(10.0)
Avg. number of night shifts per week
0
23(13.5)
121(70.8)
27(15.8)
H=14.375
0.001
1–2
44(10.4)
285(67.4)
94(22.2)
≥ 3
5(5.8)
49(57.0)
32(37.2)
Disordered multi-classification logistic regression analysis of factors influencing latent profiles of nurses’ perceived stress
The latent profiles of nurses’ perceived stress were considered as dependent variables, and the statistically significant indicators identified in univariate analysis were used as independent variables for disordered multi-classification logistic regression analysis. Class 1 served as the reference category in disordered multi-classification logistic regression, and the results are shown in Table 6. The results showed that factors such as average daily working hours, extrinsic effort, and perceived organizational support significantly influenced the latent profiles of nurses’ perceived stress (p < 0.05).
Table 6
Multi-classification logistic regression analysis of influencing factors of the latent profiles of perceived stress
B
SE
Wald χ2
P
OR
95% CI
Class 2 referred to class 1
Avg. working hours per day (8–12)
1.106
0.495
4.986
0.026
3.022
1.145 ~ 7.978
Extrinsic effort
0.463
0.083
31.155
<0.001
1.589
1.351 ~ 1.870
Perceived organizational support
-0.159
0.023
46.326
<0.001
0.853
0.815 ~ 0.893
Class 3 referred to class 1
Extrinsic effort
0.922
0.107
74.809
<0.001
2.515
2.041 ~ 3.100
Perceived organizational support
-0.284
0.029
94.765
<0.001
0.753
0.711 ~ 0.797
Discussion
Categories and analysis of nurses’ perceived stress
This study analyzed the potential profile of nurses’ perceived stress. The results identified three stress categories: low perceived stress group (10.5%), moderate perceived stress group (66.7%), and high perceived stress group (22.8%). The overall trend of the three categories was consistent. The levels of stressors in the five aspects, ranked from high to low, were: patient care, management and interpersonal relationships, nursing profession and work, time and workload allocation, and working environment and resources. Accordingly, we analyzed stress in these aspects.
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Patient care is a significant stressor for nurses, especially due to prevalent doctor-patient conflicts in China, which are exacerbated by high medical costs and unmet expectations. These conflicts negatively impact nurses’ emotional well-being and job satisfaction [32]. Moreover, a lack of trust and respect from patients and their families further intensifies this stress [32]. In terms of management and interpersonal relationships, imperfect performance evaluations in China’s healthcare system contribute to stress by creating an imbalance between work intensity and compensation. This finding aligns with studies highlighting the correlation between organizational policies and employee stress levels [33]. Additionally, poor interpersonal relationships can increase psychological distance, leading to adverse emotional and psychological effects [34]. Professional demands, workload, and working conditions also significantly contribute to stress. Specifically, high job expectations, concerns about errors, limited promotion opportunities, and low wages exacerbate stress [32]. Furthermore, the lack of support systems, such as psychological counseling and professional training, compounds these issues [33]. Additionally, nurse shortages and inadequate resources further heighten stress, which reduces efficiency and increases error rates, ultimately affecting the quality of patient care [35]. Consequently, nurses with lower stress levels generally exhibit better emotional stability and efficiency, while those with higher stress levels experience greater fatigue, anxiety, and reduced performance, which adversely impacts care quality.
To address these stressors effectively, it is recommended that nursing managers should implement tailored intervention programs based on the specific stressors identified. Mindfulness-based training, which enhances awareness of physical, emotional, and cognitive states, is a key strategy for stress regulation [36]. This approach helps nurses manage stress by encouraging present-moment awareness and improving problem-solving skills [37]. Such methods offer valuable guidance for reducing stress among nurses. In summary, nursing managers should prioritize support for nurses with high perceived stress, offering timely interventions to facilitate their transition to lower stress levels.
Implications of extended working hours on nurses’ perceived stress
Regression analysis showed that nurses working 8–12 h daily were more likely to fall into the moderate perceived stress group, similar to findings from other studies [38]. The correlation between extended working hours and higher stress levels can have profound implications for nurses’ mental health. Prolonged exposure to stressors such as high patient loads, time pressures, and critical decision-making can exacerbate anxiety, depression, and other mental health issues [39]. The moderate perceived stress group in this study likely experiences these stressors more acutely, resulting in a higher incidence of psychological distress. And the extended working hours are linked to an increased risk of errors and adverse events, which may further affect the professional quality and safety of work [40]. These findings have far-reaching implications at organizational and policy levels.
Healthcare institutions must acknowledge the detrimental effects of extended working hours on nurses’ well-being and take proactive measures to address these concerns. To mitigate the adverse effects of extended working hours, it is recommended that nursing managers should prioritize monitoring nurses’ workloads, adopting flexible staffing strategies, implementing adaptable scheduling practices, and maintaining a balanced approach to personnel planning, skill allocation, and task delegation. Strategies such as shortening shift lengths, increasing staffing levels, and providing comprehensive mental health support can significantly reduce the stress burden experienced by nurses. Furthermore, it is imperative to institute policies that promote a healthy work-life balance and create opportunities for adequate rest and recovery. By addressing the root causes of occupational stress, healthcare institutions can foster a supportive work environment that prioritizes the well-being of nurses and, in turn, enhances the overall quality of patient care.
Implications of extrinsic effort on nurses’ perceived stress
In this study, extrinsic effort was found to be an important factor affecting nurses’ perceived stress. Higher levels of extrinsic effort correlate with increased perceived stress levels among nurses, which is consistent with a previous study [41]. In addition, nurses putting in a high extrinsic effort show higher negative stress response [42]. Nurses’ extrinsic effort manifest in various forms, including extensive working hours and frequent overtime, which are time-related efforts, as well as physical labor such as patient handling and prolonged standing, which are physical efforts. They are required to provide emotional support, calm anxious patients and their families, exhibit high empathy, continuously apply professional skills in medical care, and participate in ongoing education. Additionally, nurses must cope with high-pressure environments and complex cases, frequently encountering patient suffering and death, which can lead to emotional exhaustion and professional burnout. They also bear social responsibilities, participating in public health education and community service, with their work hours and stress impacting family life and social relationships. Despite these demands, nurses often face inadequate compensation and are exposed to occupational hazards such as disease infection and violence. These extrinsic effort need to be fully recognized and supported to alleviate nurses’ work stress and enhance their job satisfaction and well-being.
To effectively mitigate the impact of extrinsic effort on nurses’ stress, it is recommended that nursing managers should adopt comprehensive measures, including optimizing work schedules, increasing compensation, providing psychological support and professional development opportunities, improving working conditions, strengthening family and social support, and fostering multi-departmental collaboration. Specifically, this can involve establishing clear career development paths for nurses, offering continuous education and training opportunities to enhance job satisfaction and a sense of accomplishment. Additionally, implementing a reward system to recognize and reward outstanding nurses can boost their motivation and pride in their work. These measures can alleviate the pressure on nurses resulting from their extrinsic effort, enhance professional satisfaction and well-being, and thereby improve the quality of nursing services.
Implications of perceived organizational support on nurses’ perceived stress
Perceived organizational support was found to be an important factor influencing nurses’ perceived stress levels. Lower levels of perceived organizational support correlates with higher stress levels among nurses, which is consistent with the findings of other scholars [43]. An organization that provides adequate support can help nurses better cope with various challenges in their work, thereby reducing their perceived level of stress. Several aspects of organizational support are crucial in this regard. Firstly, psychological support is a critical component. When nurses face difficulties and challenges at work, having an organization that listens and provides support can make them feel more secure and confident, thus reducing stress [44]. Secondly, resource support is also essential. By providing resources such as training, tools, and equipment, organizations can help nurses better complete their tasks and reduce work stress [33]. Lastly, emotional support and recognition are key components of organizational support. When nurses feel valued and appreciated, they are more motivated to cope with the pressures of work and experience greater job satisfaction and well-being [44].
To enhance perceived organizational support and reduce nurses’ stress, it is recommended that nursing managers implement several measures. Firstly, establishing open communication channels to encourage nurses to share ideas and concerns, and providing timely feedback. Secondly, offering necessary resource support to ensure nurses have sufficient training and tools. Additionally, providing emotional support and recognition to make nurses feel valued. Implementing flexible work schedules to meet nurses’ needs for work hours. Establishing a mental health support system to focus on nurses’ health and safety. Strengthening teamwork to create a harmonious work environment. Finally, developing reward and incentive mechanisms to recognize outstanding performance and enhance nurses’ motivation and sense of pride. These measures can effectively enhance nurses’ perceived organizational support and alleviate stress.
Limitations
Our study has some limitations that should be considered. First, the research was conducted in only one hospital in Shanxi Province of China, using convenience sampling, and the range of data collected was limited. Therefore, the generalization of our research results may be limited. Second, this study adopted a cross-sectional design to evaluate the perceived stress of nurses at a specific time, and did not longitudinally track changes in stress levels at different time points. Third, the participants were only evaluated without implementing any interventions. Additionally, there may be other factors affecting the job stress of nurses that were not considered in this study.
Conclusions
The work-related stress experienced by nurses deserves attention. In this study, the nurses’ perceived stress was divided into three categories: “low perceived stress,” “moderate perceived stress,” and “high perceived stress,” using LPA. We suggest that nursing managers should focus on nurses who work 8–12 h per day and contribute considerable extrinsic effort. Moreover, it should be noted that relieving the work stress of nurses is not only an individual concern but also a major organizational issue for hospitals. Although nurses can mitigate some negative aspects of work stress independently, they cannot address all of them. Therefore, at the hospital level, efforts should be made to reduce the ERI, provide nurses with a healthy and safe working environment, and create a good atmosphere of organizational support, so as to reduce nurses’ perceived stress.
Acknowledgements
We would like to thank the faculty at the Shanxi Bethune Hospital (Shanxi, China) and the participants for their time. We also thank Bullet Edits Limited for the linguistic editing and proofreading of the manuscript.
Declarations
Ethics approval and consent to participate
The ethics committee of the Shanxi Bethune Hospital approved the study protocol (No. YXLL-2023-045). The procedures used in this study adhered to the principles of the Declaration of Helsinki. All the participants were volunteered for this investigation, and each provided written informed consent before participation in this study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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