Introduction
Nursing practice represents a delicate interplay of cognition, emotion, and action, demanding that nurses not only possess expert knowledge and technical proficiency but also the capacity to swiftly adapt to sudden changes in dynamic clinical settings, making prompt and well-informed nursing decisions [1, 2]. Clinical reflection involves nurses critically re-evaluating their interactions with patients, scrutinizing their behaviors through accumulated experiences, assigning new meaning to their actions and thoughts, and synthesizing these elements into practical wisdom [3]. The reflective capacity of clinical nurses encompasses the conscious review of their nursing practices, the understanding of their own cognitive and behavioral patterns, and the ability to derive practical wisdom from their clinical encounters [4]. Enhancing the reflective capacity of clinical nurses is instrumental in driving the ongoing refinement of their clinical decision-making and nursing practices.
Globally, reflective capacity is increasingly recognized as a critical factor in enhancing the quality of nursing care and fostering professional development among clinical nurses [2]. In Australia, reflective capacity has been designated as one of the core competencies for nursing practice [3]. However, the state of reflective capacity and its integration into training programs varies considerably across different countries. Nations such as Japan exhibit relatively high levels of reflective capacity among clinical nurses [5]. In countries like the UK, Australia, and New Zealand, reflection has been fully integrated into nursing education and professional development frameworks, becoming a fundamental component of clinical competency assessments. Reflective practice is widely endorsed as an effective strategy for advancing nursing professionalism [3]. In contrast, the development of reflective capacity among clinical nurses in China remains in its nascent stages [6]. Although an increasing number of nursing education programs in China are beginning to emphasize reflective learning, clinical nurses are often hindered by work-related challenges such as resource constraints and heavy workloads, resulting in generally lower levels of reflective capacity [7].
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Background
As the healthcare environment becomes increasingly complex, with diversified patient needs and a shortage of healthcare personnel, work-related stress among nurses has been escalating, particularly for mid- to senior-level nurses with over five years of experience [8]. Although these nurses accumulate extensive clinical experience, develop advanced professional skills, and exhibit strong leadership abilities with increasing years of service, the expansion of their responsibilities requires them to manage not only heavy clinical duties but also additional roles in education, training, and management. This results in exposure to increasingly complex occupational stress [9].
Work-related stress has a dual nature, encompassing both challenge stress, which can facilitate career development, and hindrance stress, which negatively impacts work performance. Challenge stress refers to stressors that can be effectively managed and promote career growth, while hindrance stress refers to stressors that impede work progress and lead to negative consequences [10]. Prolonged high-pressure environments may make it difficult for these nurses to focus on deep self-reflection, especially when facing negative work stress. In such cases, they are often forced to deal with external unfavorable conditions, leading to superficial reflection that fails to explore the underlying issues or seek innovative solutions [11]. Existing research indicates that work-related stress negatively impacts the reflective ability of mid- to senior-level nurses, but the specific influence of the dual nature of work stress on the development of reflective capacity has yet to be clarified. Therefore, a deeper exploration of how the dual nature of work stress influences the reflective capacity of mid- to senior-level nurses will not only enhance their reflective ability but also provide targeted recommendations for improving their work environment and advancing their professional skills.
In high-pressure, low-autonomy work environments, it is crucial for mid- to senior-level nurses to effectively manage stress and promote their professional development [12]. As a proactive career coping strategy, off-duty professional growth has shown significant effectiveness. Off-duty professional growth refers to a series of activities in which individuals actively engage in goal setting, interpersonal relationships, learning, and personal development [13]. This strategy not only transcends the limitations of routine nursing tasks but also provides mid- to senior-level nurses with time and space to detach from the high-pressure work environment, helping them gain diverse feedback and perspectives, reflect on themselves from different angles, deepen their understanding of nursing work, and maintain professional sensitivity [14, 15]. Although existing studies have shown that off-duty professional growth can effectively alleviate work-related stress and enhance reflective ability, the specific mechanisms by which it operates within the mid- to senior-level nursing group remain unclear. In particular, how off-duty professional growth influences nurses’ perceptions of the dual nature of work stress, and how this dual work stress further affects the development of their reflective capacity, has yet to be explored.
To better understand this issue, the present study will explore the mechanisms of off-duty professional growth based on the Job Demands-Resources (JD-R) model. The JD-R model emphasizes that work resources alleviate stress and enhance job performance through buffering and gain pathways [16]. In the buffering pathway, off-duty professional growth, as a personal resource, helps mid- to senior-level nurses temporarily detach from the busy work environment and objectively assess their professional roles and nursing practices. By reviewing emotional experiences, challenges, and achievements, off-duty professional growth helps nurses explore their self-worth, seek a sense of professional accomplishment, and reduce the perception of hindrance stress, thereby creating favorable conditions for enhancing reflective ability. On the other hand, off-duty professional growth may also enhance the positive effects of challenge stress through the gain pathway. Specifically, off-duty professional growth provides mid- to senior-level nurses with outlets for emotional release and psychological support, enhancing their positive perception of stress and providing intrinsic motivation for deeper reflection. This not only facilitates the development of critical thinking and reflective ability but also provides room for nurses to further enhance their job skills and professional growth. Therefore, this study aims to test the mediating effect of dual work stress (challenge and hindrance) in the relationship between off-duty professional growth and reflective ability among mid- to senior-level nurses by constructing a structural equation model.
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Study assumptions are as follows:
Hypothesis 1
Off-duty professional growth is positively correlated with reflective ability;
Hypothesis 2
Off-duty professional growth is positively correlated with challenge stress and negatively correlated with hindrance stress;
Hypothesis 3
Reflective ability is positively correlated with challenge stress and negatively correlated with hindrance stress;
Hypothesis 4
Challenge and hindrance stress partially mediate the relationship between off-duty professional growth and reflective ability.
Objectives
This study aims to: (1) Investigate the current status of reflective ability, off-duty professional growth, and work stress among mid- to senior-level nurses; (2) Explore the interrelationships between reflective ability, off-duty professional growth, and work stress among mid- to senior-level nurses; (3) Analyze the mediating role of work stress in the relationship between off-duty professional growth and reflective ability.
Methods
Study design and participants
This study adheres to the STROBE guidelines for observational research, specifically the recommendations for cross-sectional studies, and was conducted between June and December 2023. A convenience sampling method was used to recruit mid- to senior-level nurses from three tertiary hospitals in Jiaxing, Zhejiang Province. Inclusion criteria required participants to have at least five years of clinical nursing experience, hold a valid nursing qualification and registration license, be actively engaged in front-line clinical nursing work, and consent to participate in the study. Nurses currently undergoing training or in an internship period, as well as those on leave, were excluded from the study.
Sample size calculation was based on the formula N = (Zα²*σ²)/δ² [17], where the standard deviation was 10.90 [5], the allowable error δ = 1, and the two-sided α = 0.05. Considering a potential dropout rate of 10–20%, the minimum required sample size was 502. A total of 600 questionnaires were collected, with 66 incomplete responses excluded, resulting in 534 valid questionnaires and an effective response rate of 89.0%.
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Instruments
General information questionnaire
Based on the research objectives and content, the researchers designed a questionnaire to collect demographic information from mid- to senior-level nurses. The questionnaire included twelve variables reflecting the socio-demographic characteristics of these nurses, specifically: gender, age, working years, relationship status, educational levels, job title, monthly household income, number of night shifts per month, average weekly overtime hours, whether working as a department manager, whether working as a student leader, and whether they have plans for continuing education.
The leisure crafting scale
In this study, the Leisure Crafting Scale was used to assess off-duty professional growth. Originally developed by Bakker [13], the scale was later translated into Chinese by Guo [18]. The Chinese version of the scale was employed to evaluate the level of off-duty professional growth among mid- to senior-level nurses. The scale consists of a single dimension with 9 items, rated on a 5-point Likert scale, ranging from “Strongly Disagree” (score 1) to “Strongly Agree” (score 5). The total score ranges from 9 to 45, with higher scores indicating a greater ability for leisure crafting. The Cronbach’s α coefficient for the Chinese version of the scale is 0.953. In this study, the scale’s Cronbach’s α coefficient was 0.949.
The challenge-hindrance work stress scale
The Challenge-Hindrance Work Stress Scale was developed by Cavanaugh [10] and later translated into Chinese by Zhang [19]. The Chinese version of the scale was used in this study to measure work stress among mid- to senior-level nurses. The scale consists of two subscales: 6 items assessing challenge stress and 5 items assessing hindrance stress, for a total of 11 items. Responses are rated on a 5-point Likert scale, ranging from “No stress at all” (1 point) to “Extreme stress” (5 points), to assess perceived stress levels. Higher scores on each subscale indicate greater perceived stress in that dimension. The Chinese version of the scale has a total Cronbach’s α coefficient of 0.910, with 0.92 for the challenge stress subscale and 0.820 for the hindrance stress subscale. In this study, the total Cronbach’s α coefficient for the scale was 0.911, with 0.932 for the challenge stress subscale and 0.883 for the hindrance stress subscale.
The clinical nurse reflective ability scale
The Clinical Nurse Reflective Ability Scale was developed by Nishimoto [4] and later translated into Chinese by Shao et al. [20]. In this study, the Chinese version of the scale was used to assess the reflective capacity of mid- to senior-level nurses. The scale includes three dimensions: reviewing nursing practice (8 items), reflecting on nursing practice (6 items), and expanding nursing practice (5 items), with a total of 19 items. Responses are rated on a 6-point Likert scale, ranging from “Strongly disagree” (1 point) to “Strongly agree” (6 points), with a total score range of 19 to 114. Higher scores indicate stronger reflective capacity. The Cronbach’s α coefficient of the Chinese version of the scale is 0.901, with 0.922 for reviewing nursing practice, 0.918 for reflecting on nursing practice, and 0.885 for expanding nursing practice. In this study, the total Cronbach’s α coefficient for the scale is 0.948, with 0.951, 0.930, and 0.926 for the three dimensions.
Data collection
The electronic questionnaire was created using the Questionnaire Star platform. It included instructions detailing the research purpose, significance, and completion guidelines. After receiving approval from the hospital’s nursing department and department heads, the questionnaire QR code was distributed in the nurses’ WeChat groups. Nurses voluntarily completed the survey anonymously after providing informed consent. To ensure data quality, the questionnaire was designed for a 4–8 min completion time based on pre-survey feedback, and duplicate submissions were automatically rejected. The system prompted users to correct any blank fields or errors.
Data analysis
Data were analyzed using IBM SPSS 26.0 and AMOS 24.0. Categorical data were reported as frequencies and percentages, while continuous data with normal distribution were presented as mean ± standard deviation (x ± s). Pearson correlation analysis examined the relationships between job crafting, challenge stress, hindrance stress, and reflective capacity in clinical nurses. A structural equation model (SEM) was constructed using AMOS 24.0, with full information maximum likelihood to estimate variable relationships and parameters. A bootstrap analysis with 5,000 resamples assessed the mediating effect of job stress on the relationship between job crafting and reflective capacity. Direct and indirect effects were tested using 95% confidence intervals (CI), with significance set at α = 0.05.
Ethical considerations
The study was approved by the Medical Ethics Committee (Approval No: 2023-LY-427) and adhered to the principles of the Declaration of Helsinki. Participants provided informed consent, voluntarily participated, and could withdraw at any time without affecting their employment or personal life. Confidentiality was strictly maintained, with data used solely for research purposes and not disclosed to unauthorized parties. The research team ensured compliance with both national and international ethical standards throughout the study.
Results
Demographic characteristics
A total of 534 clinical nurses participated in this study, consisting of 62 males and 472 females, with ages ranging from 26 to 54 years. Among them, 308 had 6–10 years of working years, 189 had 11–20 years, and 37 had over 21 years of working. Regarding relationship status, 34 were unmarried, 189 were married, and 27 were divorced or widowed. In terms of education, 75 nurses held a diploma, 434 had a bachelor’s degree, and 25 had a master’s degree or higher. As for professional titles, 147 nurses held junior titles, 202 held intermediate titles, and 23 held senior titles. The general demographic characteristics are summarized in Table 1.
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Table 1
Data on demographic characteristics of the participant (n = 534)
Demographic variable | Groups | Frequency (n) | Percentage(%) |
|---|---|---|---|
Gender | Male | 62 | 11.6 |
Female | 472 | 88.4 | |
Age(years) | 26- 30 | 153 | 28.7 |
31- 40 | 307 | 57.5 | |
≥ 41 | 74 | 13.8 | |
Working years(years) | 6-10 | 308 | 57.7 |
11-20 | 189 | 35.4 | |
≥ 21 | 37 | 6.9 | |
Relationship status | Single | 34 | 6.3 |
Married | 473 | 88.6 | |
Widowedor separated | 27 | 5.1 | |
Educational levels | Junior college | 75 | 14.0 |
Undergraduate | 434 | 81.3 | |
Master degreeor above | 25 | 4.7 | |
Job title | Primary title(1) | 147 | 27.5 |
Primary title(2) | 202 | 37.8 | |
Intermediate title | 162 | 30.4 | |
Senior title | 23 | 4.3 | |
Monthly household income | ≤ 5000RMB | 51 | 9.5 |
5001-7000RMB | 189 | 35.4 | |
7001-9000RMB | 200 | 37.5 | |
≥ 9001RMB | 94 | 17.6 | |
Number of night shifts(months) | 0 | 100 | 18.7 |
1-3 | 213 | 39.9 | |
≥ 4 | 221 | 41.4 | |
Average weekly overtime hours (overtime includes business studies, meetings, preparation for inspections, exams) | None | 18 | 3.4 |
<5 h/w | 236 | 44.2 | |
5-10 h/w | 180 | 33.7 | |
11-15 h/w | 63 | 11.8 | |
>15 h/w | 37 | 6.9 | |
Whether working as a department manager | Yes | 73 | 13.7 |
No | 461 | 86.3 | |
Whether working as a student leader | Yes | 164 | 30.7 |
No | 370 | 69.3 | |
Whether you had a plantoim prove your academic qualifications | Yes | 286 | 53.6 |
No | 248 | 46.4 |
Testing of common method deviations
To assess potential common method bias, Harman’s single-factor test was performed using unrotated exploratory factor analysis on all items from the leisure crafting, work stress, and reflective capacity scales. The analysis identified six common factors with eigenvalues greater than 1. The first common factor explained 35.750% of the total variance, which is below the 40% threshold. This suggests that there is no significant common method bias in the data collected for this study.
Means, standard deviations, and correlations between major variables
The leisure crafting score for 534 mid- to senior-level nurses was (23.82 ± 9.17), the challenge stress score was (16.97 ± 6.49), the hindrance stress score was (16.65 ± 5.44), and the reflective ability score was (56.26 ± 19.09). Pearson correlation analysis showed that challenge stress was positively correlated with both leisure crafting and reflective ability (r = 0.399, P < 0.001; r = 0.350, P < 0.001). In contrast, hindrance stress was negatively correlated with leisure crafting and reflective ability (r = -0.367, P < 0.001; r = -0.417, P < 0.001). Furthermore, leisure crafting was positively correlated with reflective ability (r = 0.389, P < 0.001). Further details can be found in Table 2.
Table 2
Means and correlation among RA, CS, HS, and LC (n = 534)
Mean ± SD | RA | RNP | RONP | ENP | CS | HS | LC | |
|---|---|---|---|---|---|---|---|---|
RA | 56.26 ± 19.09 | 1 | ||||||
RNP | 22.69 ± 9.80 | 0.842 | 1 | |||||
RONP | 16.01 ± 6.90 | 0.811 | 0.444 | 1 | ||||
ENP | 14.56 ± 6.28 | 0.835 | 0.512 | 0.674 | 1 | |||
CS | 16.97 ± 6.49 | 0.350 | 0.254 | 0.316 | 0.319 | 1 | ||
HS | 16.65 ± 5.44 | -0.417 | -0.310 | -0.399 | -0.345 | -0.480 | 1 | |
LC | 23.82 ± 9.17 | 0.389 | 0.317 | 0.346 | 0.309 | 0.399 | -0.367 | 1 |
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Results of a hypothetical structural equation modelConstruction of an mediating effect model
Based on the correlation analysis results, a structural equation model (SEM) was constructed with leisure crafting as the independent variable, challenge and hindrance stress as mediating variables, and reflective capacity as the dependent variable, as shown in Fig. 1. The structural equation model was refined and fitted using the maximum likelihood estimation method. The model fit indices were as follows: Chi-square/df (χ²/df) = 2.874, Goodness-of-Fit Index (GFI) = 0.990, Adjusted Goodness-of-Fit Index (AGFI) = 0.965, Root Mean Square Error of Approximation (RMSEA) = 0.059, Comparative Fit Index (CFI) = 0.988, Incremental Fit Index (IFI) = 0.988, Tucker-Lewis Index (TLI) = 0.969, and Normed Fit Index (NFI) = 0.981. These values indicate that the model provides a good fit.
Fig. 1
Path analysis diagram for prediction of Reflective ability (mediation effect). Note: all P < 0.001
×
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Mediating effect test
Model validation was performed using the bootstrap analysis method with 5,000 iterations and a 95% confidence interval. The results showed that the 95% confidence intervals for both the direct and indirect effects of leisure crafting on reflective ability did not include zero. This indicates that challenge stress and hindrance stress partially mediated the relationship between leisure crafting and reflective ability. Further details are provided in Table 3.
Table 3
Break down table of the total effect, directeffect, and the mediating effect
Model pathways | Effect | Standardized effect (β) | BootSE | 95%LLCI | 95%ULCI | Effect size |
|---|---|---|---|---|---|---|
LC → RA | Direct effect | 0.244 | 0.037 | 0.089 | 0.232 | |
LC → CS → RA | Indirect effect | 0.060 | 0.014 | 0.014 | 0.070 | 19.7% |
Total effect | 0.304 | 0.038 | 0.125 | 0.274 | ||
LC → HS → RA | Indirect effect | 0.109 | 0.017 | 0.042 | 0.110 | 30.8% |
Total effect | 0.353 | 0.041 | 0.152 | 0.311 |
Discussion
Analysis of the current situation of off-duty professional growth, work stress, and reflective ability among mid- to senior-level nurses
The results of the study indicated that the leisure crafting score for mid- to senior-level nurses was 23.82 ± 9.17, reflecting a moderately low overall level. This was lower than the results found by Guo et al. in their study of nurses in Shandong Province [18]. This difference may be attributed to the relatively higher seniority of nurses in this study, suggesting that there is still considerable room for improvement in off-duty professional growth among mid- to senior-level nurses. Existing research has shown that off-duty professional growth is influenced by time management during leisure hours [17]. Firstly, the high job demands placed on mid- to senior-level nurses, along with the fact that 96.6% of them report having to work overtime, reduce their motivation to enhance skills or develop personal interests during off-duty time [21]. Secondly, all participants in this study were aged 26 or older, with over 80% being female nurses. Traditional societal expectations of female roles place a heavy burden on female nurses, particularly in terms of family responsibilities, such as caregiving and child-rearing [22]. These responsibilities consume significant amounts of their free time and energy, thereby limiting their ability to engage in personal development during off-duty hours.
This study shows that the challenge stress score for mid- to senior-level nurses was16.97 ± 6.49, and the hindrance stress score was 16.65 ± 5.44, both of which are at an upper-middle level, similar to the findings by Li in a study on emergency department nurses in China [23]. This indicates that mid- to senior-level nurses generally experience higher levels of challenge stress, while also facing significant hindrance stress. This phenomenon may be related to the multiple sources of stress that these nurses face over time [24]. Firstly, the modern healthcare environment demands higher levels of nursing skills and service quality. More than half of the mid- to senior-level nurses actively participate in continuing education and pursue higher qualifications to improve their professional skills and clinical decision-making abilities, which helps them cope with challenge stress [25]. However, the lack of flexibility in nursing shifts, along with high expectations for nursing services from patients and their families, results in significant pressure due to the heavy workload [26]. Additionally, unfair salary distribution further exacerbates hindrance stress. This study found that only 17.4% of the nurses reported earning more than 9,000 RMB, and the discrepancy between high work demands and low pay increases the sense of professional disparity [27]. According to the effort-reward imbalance model, the mismatch between high effort and low reward intensifies psychological burden, thus worsening hindrance stress and affecting career development stability [28].
The overall reflective ability score of mid- to senior-level nurses was 56.26 ± 19.09, reflecting a moderately low level of reflective ability that requires improvement. This score is lower than the findings reported by Nishimoto in a study of nurses in Japan [5], which may be attributed to several factors. First, the reflective education system in China is still underdeveloped, and many nurses lack sufficient awareness of the importance of reflection. This results in lower reflective motivation, thereby limiting the enhancement of reflective capacity [29]. Second, with the ongoing development of the nursing discipline and the increasing demand for specialization, the focus of reflection for mid- to senior-level nurses has gradually shifted from traditional clinical practice to research and innovation [30]. However, research reflection demands more than traditional clinical reflection; it not only requires critical thinking but also systematic analytical skills. Furthermore, the heavy clinical workload takes up a significant amount of time and energy, limiting opportunities for nurses to engage in research-related reflection [31]. Additionally, research reflection often relies on technical support and professional tools, which are limited in domestic hospitals, including inadequate access to tools such as data analysis software and literature management systems. This lack of resources hinders the guidance and support for reflection, thus impeding the development of innovative and critical thinking in mid- to senior-level nurses [32].
The interrelationship between reflective ability, off-duty professional growth, and work stress among mid- to senior-level nurses
The results of the study indicated a positive correlation between leisure crafting and reflective ability in mid- to senior-level nurses (r = 0.389, P < 0.001), confirming Hypothesis 1: the higher the level of off-duty professional growth, the stronger the reflective capacity of mid- to senior-level nurses. This finding aligns with Zhou’s study on junior nurses [7], further emphasizing the significant role of off-duty professional growth in enhancing nurses’ reflective abilities. According to the Integrated Need Model of Job Crafting [33], off-duty professional growth is closely related to professional attitudes, suggesting that it not only fulfills mid- to senior-level nurses’ personal growth and career development needs but also fosters the maintenance of a positive professional attitude, which in turn drives reflective practice. Additionally, by participating in off-duty activities such as research lectures and training, mid- to senior-level nurses are exposed to the latest nursing research methodologies, which enhance their reflection on innovative work models and improvements in nursing quality [34]. These activities broaden their professional horizons, stimulate innovative thinking, and ultimately enhance their reflective abilities. Nursing managers should regularly organize diverse off-duty activities to encourage a positive attitude and provide the necessary support for reflective practice.
The results of the study indicated that leisure crafting was positively correlated with challenge work stress (r = 0.399, P < 0.001) and negatively correlated with hindrance work stress (r = -0.367, P < 0.001), thereby confirming Hypothesis 2. Specifically, the higher the level of off-duty professional growth among mid- to senior-level nurses, the greater the perceived challenge stress and the lower the hindrance stress. This result is consistent with Zhang’s study on teachers [35], further supporting the positive role of off-duty professional growth in modulating work stress perception.Off-duty professional growth enhances nurses’ self-efficacy by providing team feedback and peer support [17]. Through interactions with team members, mid- to senior-level nurses can identify their strengths and weaknesses, which boosts their confidence in problem-solving and enables them to proactively manage challenge stress. At the same time, although hindrance stress has a negative impact, off-duty activities help nurses access stress management resources, gain insights from others’ experiences, and improve their ability to cope with complex tasks. These activities not only reduce the negative effects of hindrance stress but also enhance nurses’ sense of control and autonomy over professional challenges [36]. Therefore, off-duty professional growth not only helps mid- to senior-level nurses respond more positively to work stress but also transforms stress into a driving force for career development, mitigating its negative impact. Nursing managers should implement comprehensive strategies, including providing organizational support, promoting knowledge updates, and offering emotional care, to facilitate personal growth and help mid- to senior-level nurses cope with stress effectively.
The results of the study indicated a positive correlation between challenge stress and reflective ability in mid- to senior-level nurses (r = 0.350, P < 0.001), while hindrance stress was negatively correlated with reflective ability (r = -0.417, P < 0.001), confirming Hypothesis 3. This suggests that challenge stress enhances reflective ability, whereas hindrance stress diminishes it. These findings align with Zhang’s research on preschool teachers [37], further supporting the dual influence of work stress on the reflective ability of mid- to senior-level nurses. Specifically, challenge stress typically arises from job responsibilities and tasks that require high cognitive and emotional engagement [38]. Moderate levels of challenge stress can enhance mid- to senior-level nurses’ psychological resilience, fostering self-reflection, which in turn helps them more effectively cope with emotional burdens and work demands [39]. In contrast, hindrance stress is often caused by factors such as inflexible schedules and frequent night shifts, leading mid- to senior-level nurses to feel a lack of professional autonomy and difficulty balancing work and life [40]. This negative work environment restricts their career development and, if prolonged, may lead to burnout, inhibiting the development of reflective abilities. Therefore, nursing managers should implement comprehensive stress management training, pay attention to the psychological well-being and career development of mid- to senior-level nurses, optimize the work environment, and appropriately leverage challenge stress while mitigating the negative impact of hindrance stress. This approach will enhance their sense of professional autonomy and encourage deeper reflective practice.
The mediating role of work stress between off-duty professional growth and reflective ability in mid- to senior-level nurses
The results indicate that both challenge and hindrance stress partially mediate the relationship between leisure crafting and reflective ability (β = 0.060, 0.109, P < 0.001), accounting for 19.7% and 30.8% of the effects size, respectively, thus confirming Hypothesis 4. This suggests that off-duty professional growth not only directly enhances the reflective ability of mid- to senior-level nurses but also indirectly improves their reflective ability by influencing their dual perception of work stress.
According to the JD-R (Job Demands-Resources) model, off-duty professional growth positively influences the reflective ability of mid- to senior-level nurses through both buffering and gain paths. Firstly, off-duty professional growth activities help nurses regulate their physical and mental states and replenish psychological resources through the buffering path, thereby alleviating the negative effects of high-intensity work and emotional labor. These activities not only improve emotional well-being but also enhance professional identity, providing a positive psychological environment for reflection by reframing stress perceptions [41]. In addition, these activities offer nurses interdisciplinary experiences and diverse ways of thinking, broadening their professional perspectives, enriching their knowledge base, and fostering multidimensional thinking skills. These factors collectively enhance the depth and breadth of nurses’ reflection, enabling them to more comprehensively assess and optimize clinical practices, thereby improving professional competence and clinical decision-making skills [42].
Secondly, along the gain path, off-duty professional growth enhances mid- to senior-level nurses’ cognitive flexibility and emotional recovery abilities through diverse off-duty professional growth experiences. Leveraging their rich clinical experience, they can quickly apply new knowledge gained from off-duty professional growth activities to practical work, enhancing their problem-solving skills and ability to analyze from multiple perspectives [42]. The enhancement of cognitive flexibility makes them more open during reflection, combining new information and experiences to stimulate innovative thinking. At the same time, emotional regulation abilities help mid- to senior-level nurses remain calm and focused, enabling them to approach stress challenges and unexpected events with a more positive attitude [43]. This enhancement in both cognitive and emotional dimensions facilitates reflective practice, driving continuous improvement in work methods and the quality of nursing care.
Therefore, nursing managers should implement diversified team-building activities, provide psychological health support, and offer skill training to balance work resources and demands for mid- to senior-level nurses, while fostering an open and supportive team culture that encourages reflection and growth.
Practical implications
Reflective ability is critical to the ongoing development and advancement of the nursing profession. This study, focusing on mid- to senior-level nurses, examines how various forms of work stress influence off-duty professional growth and reflective ability. Nursing managers should recognize the central role that off-duty professional growth plays in fostering the professional growth of mid- to senior-level nurses, considering their unique characteristics and challenges. It is essential that nursing leaders create a supportive work environment and implement comprehensive stress management programs to provide the necessary support for enhancing reflective capacity. Furthermore, mid-to-senior nursing staff should be encouraged to cultivate their off-duty professional growth, empowering them to better recognize and manage work-related stress. By doing so, they can mitigate the negative effects of stress, ultimately enhancing their reflective ability and contributing to better clinical practice and decision-making.
Conclusion
In summary, this study found that the off-duty professional growth and reflective ability of mid- and senior-level nurses were at a moderately low level, with challenging stress at a moderate level and hindering stress at a moderately high level. First, off-duty professional growth has a direct, positive impact on the reflective ability of mid- and senior-level nurses. Second, dual work stress partially mediates the relationship between off-duty professional growth and reflective ability. Challenging stress encourages mid- and senior-level nurses to engage in active reflection on their practices and decisions, while hindering stress worsens burnout symptoms, leading to passive coping strategies that restrict their reflective behaviors. These findings align with the JD-R (Job Demands-Resources) model, where off-duty professional growth serves as a personal resource that helps buffer against the negative impacts of hindering stress. Based on these findings, it is recommended that nursing managers adopt targeted strategies to enhance the off-duty professional growth of mid- and senior-level nurses, thereby helping them better manage work-related stress. The positive effects of challenging stress should be encouraged, while the negative impact of hindering stress should be minimized. Additionally, strengthening reflective training and creating a supportive work environment will further facilitate the implementation of reflective practices, ultimately improving the reflective ability of mid- and senior-level nurses.
Limitation
Several limitations of our study should be acknowledged. Firstly, this study was conducted with data exclusively from mid- and senior-level nurses in three tertiary hospitals in Jiaxing, Zhejiang Province. The definition of “mid- and senior-level nurses” can vary across different regions, which limits the generalizability of the findings. As a result, the cross-cultural applicability of the study’s conclusions may be constrained. Future research should consider multi-center studies to validate these conclusions more broadly.
Secondly, data were collected through self-reported questionnaires. Although participation was voluntary and anonymous, there is still the possibility that responses may have been influenced by social desirability or self-image concerns, potentially introducing social desirability bias. Furthermore, this study was conducted over a specific time period, limiting its ability to capture long-term trends or dynamic changes in reflective capacity and work stress over time.
Lastly, as this study utilized a cross-sectional design, establishing causal relationships between variables is difficult. In conclusion, the study’s limitations include concerns related to sample representativeness, cultural and individual differences, self-report bias, and the inability to make causal inferences due to the cross-sectional design. Future research could address these limitations by expanding the sample size, using diverse data collection methods, or adopting a longitudinal design.
Acknowledgements
We thank all the participating nurses for their support and cooperation.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Review Committee of The First Hospital of Jiaxing (approval number: 2023-LY-427) and complies with the Declaration of Helsinki. The questionnaires used were accompanied by standardized instructions outlining their purpose, significance, and completion requirements. Each participant provided informed consent and participated voluntarily, with the option to withdraw at any time without affecting their work or daily life. Personal information was anonymized, and the questionnaire data were used solely for this study, ensuring confidentiality. The research team strictly followed national and international ethical standards throughout the study.
Clinical trial number
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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