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1. Introduction

heavy workload, pand interstaff conbecause of lackpaperwork, and

Safety and Health, job stress is a harmful response physically

2008). The job stress level among nurses working in Chinais believed to be higher because of the rapidly growing

ionals, and theCouncil of thersing Ordinancety of nursing in

implementation of this ordinance, it may further increase

Available online at www.sciencedirect.com

Applied Nursing Research 25and emotionally when the employee's skills, resources, andneeds could not fulfill the requirement of the job (Welker-Hood, 2006). Shirey (2006) refers to stress as a generalepisode of organizations, and a person's competence topositively confront stressors would determine the indivi-dual's success in overcoming the related stress reactions.

In general, past research reports the negative impact ofstressful situations on health outcomes: psychologically,physically, and functionally (Shirey, Ebright, & McDaniel,

nurses' stress level when they are trying to keep up to thestandards of care and the demand by Chinese patients forhigh-quality health care.

However, many of the studies about job stress have beendone in Western countries, and there are cultural differencesbetween Western and Chinese countries that may influencejob stress. With a strong influence from Chinese culture,nurses in China may try to endure the stress rather than reportit to their senior colleagues. Thus, it is important to studyabout job stress among nurses in China. With an under-standing about the job stress among nurses in China, it maymaking (Welker-Hood, 2006).According to the U.S. National Institute of Occupational

2008 to strengthen nurse training, registration, power,responsibility, and legal issues (Wan, 2008). With the Corresponding aE-mail address: is

0897-1897/$ see frodoi:10.1016/j.apnr.201oor staffing, dealing with death and dying,flict (Xianyu & Lambert, 2006) and alsoof resources, little training, excessivelimited shared governance in decision

the knowledge of health care professadvancement of technology. The StatePeople's Republic of China issued the Nu(Chapter 517) on the standard and qualiat nurses work under great pressure due to seeking health care services in terms of the quality of care,Nurses are the frontline staff of a health care team, andmany of them experience work-related stress. Studies fromChina reported th

economy and the ever-changing health care environment.Chinese people articulate a high demand and expectation inJob stress amonSui Yu Yau, MBA(HSM), M

Linda Yin King Lee, PhD, MNa, AlaSuet Lai Wong, MN, BN(Hon

aThe Open UniversitybZhuhai Peopl

Received 28 September

Abstract Job stress is a well-known situation for nenvironment. The purpose of this descriptive stuamong nurses in a Zhuhai hospital. Ninety-threthat nurses had a relatively high level of stressWorkload and Time identified as the major strelieving job stress among nurses in China. 2012 Elsevier Inc. All rights reserved.uthor. Tel.: +852 27686807; fax: +852 27891170.yyau@ouhk.edu.hk (S.Y. Yau).

nt matter 2012 Elsevier Inc. All rights reserved.1.07.001Column

urses in Chinarsa,, Xiu Ying Xiao, BNb,at Kwan Tsang, MN, PRD(HCE)a,, Ka Fai Wong, MN, MSSCa

ng Kong, Hong Kongspital, China

; accepted 5 July 2011

, especially for those working in the clinicalas to examine the job stress level and stressorsses were recruited for the study. Findings wereh Working Environment and Resources andrs. This study provided preliminary insights on

(2012) 6064www.elsevier.com/locate/apnrbe possible to provide a better blueprint for the health carepolicy makers in planning to reduce the job stress levelof nurses.

stress level. Analysis of variance was performed to test thedifference in mean scores of stress level among the differentdemographic groups. The level of significance was set at 5%.

3. Results

A total of 93 questionnaires were delivered, and theresponse rate was 100%. The demographic characteristics ofparticipants are summarized in Table 1. All the participantswere women aged 19 to 50 years. Most of them were at themanagement level (80.7%), whereas the remaining weremostly clinical frontline staff. Their working experiencesranged from 2 to 38 years, with about 25% working in

Table 1Participants' demographic profiles (N = 93)

Characteristic n %

GenderFemale 93 100Male 0 0Age (years)1838 58 62.43948 33 35.5N48 1 1Missing 1 1Marital statusSingle 11 11.8Married 80 86.0Divorced 2 2.2RankNurse 12 12.9Midwife 1 1.1Nursing officer 21 22.6Ward manager 54 58.1Other 2 2.2Missing 3 3.2Working experience (years)010 14 15.11120 52 55.92130 21 22.6N30 2 2.2

Educational levelDiploma 67 72.0

61S.Y. Yau et al. / Applied Nursing Research 25 (2012) 60642. Methods

A cross-sectional descriptive survey design was used.

2.1. Study participants

A convenience sample of 93 nurses working in aZhuhai hospital in China was recruited. The participantsincluded registered nurses, midwives, nursing officers, andward managers.

2.2. Data collection and management

The demographic data of each participant were collectedusing the first part of the questionnaire. It included gender,marital status, rank, years of working experience, currentworking unit, educational level, whether they had anytraining in stress management, and their perceived stresslevel by using a 010 scale, with 0 representing no stressand 10 representing the highest level of stress.

The second part of the questionnaire was Nurse StressInventory (translated from the Chinese version), which wasa 35-item and 5-point Likert-type questionnaire developedby Li and Liu (2000). The 35 items were categorized underfive domains with potential range of scores as follows:Nursing Profession and Clinical Duty, 028; Workload andTime, 020; Working Environment and Resources, 012;Patient Care, 044; and Management and InterpersonalRelationship, 036. The Likert-type scoring ranged from0 to 4, with 0 = never, 1 = seldom, 2 = sometimes, 3 = often,and 4 = always. The higher the score, the higher is the stresslevel. This questionnaire was modified by Li and Liu (2000)based on the Nurse Stress Scale developed by Gray-Toft andAnderson (1981) and the Source of Stress Inventorydeveloped by Wheeler and Riding (1994). The modifiedquestionnaire was assessed by experts in China, the UnitedStates, and Thailand who were experienced in the field ofnursing (Li & Liu, 2000). The overall Cronbach's alpha forthe modified questionnaire was .98 and that of each domainwas as follows: Nursing Profession and Clinical Duty, .95;Workload and Time, .83; Working Environment andResources, .92; Patient Care, .94; and Management andInterpersonal Relationship, .90 (Li & Liu, 2000). TheCronbach's alpha for this study is .92.

Ethical approval for conducting this study was obtainedfrom the hospital. Participants were informed of the purposeand procedure of the study, and their verbal consents forparticipation were obtained.

2.3. Data analysis

The Statistical Package for Social Science Version 14 wasused for data analysis. Descriptive statistics includingfrequency, percentage, means, and standard deviationswere used to summarize the data. Although inferentialstatistics were also used for data analysis, Spearman's rank-order correlation (rho) was used to test the relationshipbetween the demographic data of the participants and theBachelor 23 24.7Missing 3 3.2

Note. ICU = intensive care unit; OT = operating theatre; OPD = outpatientdepartment; O&G = obstetrics and gynecology.Missing 4 4.3Working unitSurgical 15 16.1Medical 8 8.6ICU 2 2.2OT 5 5.4OPD 13 14.0Rehabilitation 1 1.1O&G 10 10.8Pediatric 4 4.3Other 33 35.5Missing 2 2.2

62 S.Y. Yau et al. / Applied Nursing Research 25 (2012) 60644. Discussion

The participants in this study reported a relatively highlevel of stress, with a perceived stress index of 7.4. Theseresults are consistent with those of other studies.Callaghan, Shiu, and Wyatt (2000) investigated the factorsrelated to stress and coping among Chinese nurses inHong Kong; the findings suggested that the major sourceof stress in their participants' lives was their work, suchas work overload and inadequate staffing. Barnard, Street,and Love (2006) reported that many of the Australiancancer nurses in their study had experienced all 50 itemsof stressors. Because many nurses believed that their jobwould directly affect their health and that job-inducedtension was the highest reported stress of the participants,they felt that they were only at a fair health and seemedto tire quickly (Callaghan et al., 2000). This findingsuggests that issues that cause job stress to nurses need tobe addressed.

Workload and Time was the most serious source ofstress as reported by the participants. This result issupported by studies done by Li and Liu (2000) andXianyu and Lambert (2006), in which workload was alsofound to be the major source of stress as reported by nursesin China. China, as do many other countries, has a shortageof nurses. Thus, there is an increased workload amongnursing staff, which may have a negative impact on nurses'medical or surgical units. Concerning their educational level,72% had a diploma in nursing, whereas 24.7% had abachelor's degree in nursing. Most, 89.2%, reported that theyhad not received any stress management training, and theperceived stress index was 7.4, with 10 as the highest stresslevel and 0 as no stress.

When comparing the stress level of each domain, themost stressful domains were, in order, Workload and Time(M = 2.91), Working Environment and Resources (M =2.48), Nursing Profession and Clinical Duty (M = 2.18),Patient Care (M = 2.03), and Management and InterpersonalRelationship (M = 1.65).

There was a statistically significant difference in the meanscore of Working Environment and Resources amongparticipants with different working units, F(8, 81) = 2.227,p = .0034, in which participants working in pediatric unitwere found to have the highest stress level. There was nostatistically significant difference in the mean scores in otherfour domains, and the total mean scores among participantsfrom the different working units were not different based ondescriptive results.

It was found that there was no statistically significantcorrelation between participants' age and their mean scoresin the five domains and total mean scores. In addition, therewas no statistically significant correlation between partici-pants' year of working experience and their mean scores inthe five domains and total mean scores.job satisfaction (Li & Lambert, 2008). As a result, theheavy workload of nurses in China should be addressed. Avariety of coping strategies can be introduced, includingexploring peer support and social support, gainingsupervision from experienced colleagues, recognizingtheir own limitations, and developing interests outside ofwork (Edwards & Burnard, 2003).

With regard to Working Environment and Resources,nurses working in pediatric units reported the highest level ofstress. This result can be explained by the study done byOates and Oates (1996), in which pediatric nurses perceiveda variety of stresses in their work such as keeping up-to-dateknowledge and dealing with conflict of communicationproblem between doctors and nurses.

There are additional explanations for the high stress levelof participants: First, all participants in this study werewomen. Generally, women are found to have morepsychological strains and depression (Liu, Spector, & Shi,2008) and to experience greater sadness and anxiety(Chaplin, Hong, Bergquist, & Sinha, 2008), and womenmight be more vulnerable to repeated stress exposures(Schmaus, Laubmeier, Boquiren, Herzer, & Zakowski,2008). Under the Westernization and socioeconomicchanges in China, it is believed that Chinese workingwomen are at a high level of stress. Evidence suggest thatChinese women report more physical and psychologicalsymptoms of stress than men do (Hamid, 2000), which maybe due to the high expectation of Chinese families requiringwomen to take major responsibility for domestic work andeducating children (Xu et al., 2004) and, at the same time,burden from their job.

Second, especially under the influence of Confucianismin the Chinese culture, the emphasis is on self-cultivationand socialpolitical reform; the pursuit of duo (road orpath); the ethical system of jen (humaneness), yi(righteousness), and li (rules of propriety); and the moralideals of chun-tze (the superior man or gentlemen) (Tsai,2006). As a result, in Chinese families, there may be amore indirect way of exchanging information. In addition,self-disclosure is uncommon in Chinese society, evenwithin families (Hamid, 2000). Traditionally, Chinesefamilies do not encourage open expression of emotionbecause excessive emotion is harmful to one's mental andphysical health. It is important to keep one's emotionsunder control and well balanced (Hamid, 2000). Thus, theparticipants in this study may be reluctant to share theirstress among family members, hence reporting a highstress level.

Third, 80.7% of the participants in this study camefrom the management level. As reported by Xianyu andLambert (2006), with the health care system reform inChina, the head nurses needed to adapt to more complexand difficult roles. In addition, nurse managers reportedoverwhelming stress from the nature of the job and worklife imbalance with little support in the workplace (Shireyet al., 2008).

management duties for nurses working at the management

63S.Y. Yau et al. / Applied Nursing Research 25 (2012) 6064level. As stated by Xianyu and Lambert (2006), apart frommaintaining quality patient care, head nurses in China alsoneeded to participate in complex activities like taking part innursing education, research, finance management, supplypreparation, dispute handling, and collaboration with otherstaff members. With such an unclear and complex role,nurses may become exhausted and stressed.

Furthermore, there were 20,291 hospitals with 3,120,773hospital beds in China, including comprehensive hospitals(13,364), traditional Chinese medicine hospitals (2,728), andspecialty hospitals (3,716) in year 2009 (Ministry of Health ofthe People's Republic of China, 2009). Despite the largenumber of hospitals and hospital beds in China, there wereonly 184 million nurses, equivalent to 1.39 nurses to 1,000populations (Ministry of Health of the People's Republic ofChina, 2009). When comparing with a Western country, forinstance, there were 5,815 hospitals in the United States with951,045 hospital beds (American Hospital Association, 2009)and there were 2,669,603 nurses, equivalent to 9.4 nurses to1,000 populations (World Health Organization, 2009). Withsuch a shortage of nurses in China, nurses in the managementlevel not only need to tackle the clinicalworkload but also haveto oversee and manage multiple administrative tasks.

Lastly, it is known that China is a developing countrywherein the role of nurses may be different from that inWestern countries. When comparing with nurses in Westerncountries, Chinese nurses identified a lack of autonomy andwere quite dependent on physicians' direction for practice(Lambert, Lambert, Petrini, Li, & Zhang, 2007; Li &Lambert, 2008). In addition, nurses sometimes reported notbeing respected by physicians, patients, and patients'relatives; being physically attacked and not trusted bypatients; and being yelled at by physicians. Most importantly,nurses were not receiving sufficient respect and support fromhospital administrative staff (Lambert et al., 2007).

To reduce the stress level of nurses in China, it isimportant to enhance the working environment in terms ofstrengthening the social status of nurses in China byempowering autonomy and maximizing health care re-sources. Nevertheless, the support from hospital administra-tive staff is of utmost importance, and stress managementtraining is highly recommended because it provides methodsfor stressed nurses to reduce their job stress.

5. Limitation and recommendation

A limitation of this study is that the data were collectedfrom nurses in Zhuhai only; the stress level reported bythese participants may not be representative of those inAccording to the statistic from the Ministry of Health ofthe People's Republic of China (2009), there are about 20%of health care workers at the management level. There is nodoubt that the health care reformation in China over the pastyears causes an unclear job description between clinical andReferences

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Callaghan, P., Shiu, T. Y. A., &Wyatt, P. A. (2000). Factors related to stressand coping among Chinese nurses in Hong Kong. Journal of AdvancedNursing 31(6), 15181527.

Chaplin, T. M., Hong, K., Bergquist, K., & Sinha, R. (2008). Genderdifferences in response to emotional stress: An assessment acrosssubjective, behavioral, and physiological domains and relations toalcohol craving. Alcoholism: Clinical & Experimental Research 32(7),12421250.

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Li, X. M., & Liu, Y. J. (2000). Job stressors and burnout among staff nurses.Chinese Journal of Nursing 35(11), 645649.other areas in China. A second limitation is that many ofthe participants are working in the management level.Thus, the results may represent the stress levels of nursesin management positions. Further study is recommended inmore diverse areas in China and to include more frontlinestaff nurses.

In addition, because the number of participants recruitedin each working unit was limited, the finding could not begrouped together to perform a post hoc test for determiningthe statistical difference among different working units.Thus, it is recommended to recruit a greater number ofparticipants in different working units in future studies, sothat a post hoc test can be performed.

6. Conclusion

This study investigated the job stress level and stressorsamong nurses in China. Working Environment and Re-sources and Workload and Time were identified as thetwo most important job stressors.

In summary, this study provided preliminary insights onrelieving job stress among nurses in China. They reflected arelatively high level of job stress, and this situation should beaddressed to improve working conditions. Although thereare limitations to this study, the results can contribute to theawareness and understanding to the present situation of jobstress among nurses in China.

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64 S.Y. Yau et al. / Applied Nursing Research 25 (2012) 6064

Job stress among nurses in China1. Introduction2. Methods2.1. Study participants2.2. Data collection and management2.3. Data analysis

3. Results4. Discussion5. Limitation and recommendation6. ConclusionReferences