Background
Worldwide, nursing is known to be a very stressful occupation. Studies from China reported that nurses work under great pressure because of a heavy workload, contending with death and dying, inter-staff conflict, lack of resources, and insufficient training [
1]. Long term stress may affect hospitals through nurses’ dissatisfaction, burnout, poor performance, or turnover intention [
2‐
5]. Since nurses are the frontline staff of the healthcare team this can reduce the quality of health services. Therefore, it is important for both nurses and their managers to take measures to reduce work stress.
Work stress can be defined as a mismatch between an individual and their environment [
6]. In general, the higher the imbalance between external demands and an individual’s abilities, the higher the level of stress that will be experienced [
7].
In recent years, there has been a substantial amount of research on the relationship between work stress and job performance. Some of this research revealed that high work stress lead to low job performance [
2]. However, a few studies found an inverted U-shaped relationship or a positive relationship between work stress and job performance [
8,
9]. Wu et al. asserted that a possible explanation for these inconsistent results might be existing variables to moderate the effect of stress on performance [
10]. A broad range of variables have been considered as potential moderators such as emotional intelligence, organizational commitment, and supportive leadership [
11,
12]. Folkman’s study showed that effective coping strategies can avoid or reduce stress levels [
13].
According to the Transactional Model of Stress, coping is an integral element in the stress process because coping strategies can help alleviate the effects of stressors on strains [
14].
Previous studies have identified two main types of coping strategies: emotion-focused and problem-focused strategies [
13]. Later analyses subdivided emotional-focused strategies into escape-avoidance, distancing, self-control, and positive reappraisal [
15]. Other researchers have categorized coping strategies into positive or constructive coping and negative or destructive coping [
16].
Recent research revealed that coping strategies played an important moderating role in work stress and well-being as well as job satisfaction among nurses and administrators [
17,
18]. However, there continues to be a lack of information on the moderating effects of coping strategies on work stress and job performance for Chinese nurses.
Based on the Transactional Model of Stress, the aim of this study was to examine the moderating effects of coping strategies on work stress and job performance. Specifically, we explore: (a) the levels of work stress, coping strategies, and job performance that occurs in nursing; (b) the associations among stress, coping strategies, and job performance; and (c) whether coping strategies moderate the relationship between work stress and job performance.
Discussion
The current study was one of the first of its kind to investigate the moderating effects of coping strategies on work stress and job performance among nurses in China. Results indicated that nurses used positive coping strategies more frequently than negative coping strategies. We also found that coping strategies had moderating effects on some of the work stress subscales and job performance.
In order to test the direct and moderating effects of coping strategies on work stress and job performance, a regression analysis was conducted (Table
3). First, when work stress variables were used (Model 1, Table
3), three subscales of work stress (i.e., Nursing Profession and Clinical Duty, Workload and Time, and Management and Interpersonal Relationship) had direct negative effects on job performance. These findings were consistent with previous studies that reported that excessive workload, lack of opportunities for promotion, and a lack of respect were major negative predictors of job performance [
25].
Second, including negative predictors of job performance into the analysis produced a significant increase in the variance explained in job performance (Model 2, Table
3). This finding supports our expectation that coping strategies would help explain job performance. Consistent with the study by Lu et al., positive coping strategies were positively related to job performance and negative coping strategies were negatively related to job performance [
26].
Furthermore, inclusion of the interaction terms (Stressors X Coping strategies) accounted for a larger proportion of the explained variance (Model 3, Table
3), indicating that coping strategies had a moderating effect. Specifically, we found that positive coping (e.g. looking for support from family or friends, utilizing others’ ways of dealing with similar problems) could reduce or buffer the negative effects of Patient Care on job performance. Negative coping strategies (e.g. procrastinating, relying on others, trying to forget about everything) can strengthen the negative effects of “Workload and Time” and “Working Environment & Resources” on job performance. Similarly, Atteya found that methods of coping with stress had an impact and exerted an influence on job performance [
27]. Taken together; the present findings have significant implications for both managers and nurses in their efforts to improve job performance.
First, since work-related stress is negatively related to job performance, managers should pay more attention to the stress level of the nurses they work with. This study found that Nursing Profession and Clinical Duty was the highest perceived workplace stressor, followed by Workload and Time. Both of these factors were negatively related to job performance. Similarly, a substantial amount of existing research suggested that workload and professional and career issues were primary work stressors for nurses in China [
23,
28‐
30]. There are several possible reasons for these findings. First, Chinese nurses have a relatively low social status and experience a lack of recognition by others. They often complain of verbal or physical violence by patients and their families. Second, compared to other health technical workers, nurses have few opportunities for promotion and further study [
21]. Furthermore, excessive documentation and shortage of nurses increases nurses’ workload [
31].
Second, nurses should adopt more positive coping strategies when faced with stress. This study revealed that positive coping strategies could reduce or buffer the negative effect of stress on job performance. Overall, respondents tended to use more positive than negative coping strategies contend with work stress. However, when work stress increased, the usage of positive coping strategies decreased and negative coping strategies increased (Table
2). Therefore organizations should create an environment that encourages workers to use more positive coping strategies when experiencing stress. The managers should investigate and analyze the causes and types of work stress, help nurses to recognize the stress and their own coping styles, and then make detailed stress-reduction plan for nurses on the level of organization. In the meanwhile, managers should carry out training about positive mood management, provide relevant information, and knowledge on stress management for nurses. Besides that, organizations can let nurses think their work is meaningful and beneficial work by developing scientific evaluation system based on key performance indicators.
Thirdly, coping strategies can only partly moderate the effects of work stress on job performance. Furthermore, the moderating effects on job performance were smaller under high stress than under low stress. Consequently, managers should take multiple measures to help nurses to reduce their work stress and in turn to improve the job performance such as creating a safe working environment, establishing adequate infrastructure and other resources, allocating a reasonable workload, and providing support when nurses experience challenges.
Conclusion
This study was a preliminary attempt to explore the relationship between work stress, coping strategies, and job performance for nurses in China. Results of this study indicate that positive coping strategies moderated the relationship between Patient Care and job performance, while negative coping strategies moderated the relationship between Workload and time and job performance as well as between Working environment and resources and performance. As coping strategies can only moderate the effects of some subscales of work stress on job performance, managers should utilize multiple measures to help nurses to reduce work stress.
Limitations
Three limitations of this study should be noted. First, performance was obtained from self-reports. Respondents may have underestimated or overestimated the level of their own performance. As we know, job performance can be assessed by objective indicators or subjective indicators. Different hospitals may have different performance evaluation index system, so it is difficult to assess job performance by objective indicators. Subjective assess can be reported by supervisors, colleagues and oneself. Job performance obtained from supervisors or colleagues may also reflect bias in reporting and the anticipated cost is high. So we use self-rated performance take into account the data availability, the accuracy and the cost. We recognized that this self- administration bias might have affected the results. Second, we used a cross-sectional survey, which may limit our ability to identify causal relationships between work stress and job performance. Thirdly, this study was based on a small sample of nurses in tertiary hospitals, which may limit the generalisability of the research findings. University-affiliated hospitals and non-affiliated hospitals may take on different tasks and workload, so a multistage, stratified sampling design was employed to ensure that study data were representative. In this study, two tertiary and two tertiary non-affiliated hospitals were selected. There were 8–10 types of clinical departments in these four hospitals. One sub-department was randomly selected in each kind of clinical department in each hospital.
Acknowledgements
We are thankful to all the nurses who participated in the study. We are also grateful to heads of the nursing departments of these four hospitals, who have worked closely with the team to ensure the field survey is successfully implemented.