Abstract
Abstract
Objectives
Specialty nurses play a significant role in improving patient care; however, little is known about the factors affecting their work engagement. This study aimed to explore the relationship between role stress and work engagement among specialty nurses in China.
Design
A descriptive, cross-sectional study was applied in this study.
Setting
The study was conducted in the Henan Provincial People’s Hospital in China.
Participants
From March to April 2023, we conducted a cross-sectional descriptive study, using convenience sampling to recruit 972 specialty nurses from 42 specialised fields in China.
Methods
An online questionnaire survey was conducted using the Basic Information Questionnaire, Role Stress Scale and Specialty Nurse Work Engagement Scale. The collected data were analysed by using SPSS 21.0 software. The differences in total work engagement scores between subgroups were investigated using a single-factor analysis of variance. A Spearman’s rank correlation and a Pearson’s correlation were used to determine the relationship between general information, role stress and work engagement. A ridge regression analysis explored the impact of role stress on work engagement.
Results
The total score of role stress was (52.44±19.92) and the total score of work engagement was (140.27±17.76). Among the scores of various dimensions of specialty nurses’ work engagement, the standardised score for work attitude was the highest (4.54±0.56), followed by work values (4.46±0.64); the standardised score of work enthusiasm and focus was the lowest (4.22±0.64). Additionally, role ambiguity (r=−0.352, p<0.001), role conflict (r=−0.367, p<0.001), role overload (r=−0.313, p<0.001) and role stress (r=−0.380, p<0.001) were negatively correlated with work engagement. The total score of role stress was negatively correlated with the total score of work engagement; the results of ridge regression analysis showed that age, professional title and role stress explain 14.6% of the variance in work engagement.
Conclusion
Our study found that specialty nurses’ work engagement was mid-level or above. Role stress was significantly and negatively correlated with specialty nurses’ work engagement, which was an important predictor of their work engagement. Nursing managers should instate effective measures to reduce role stress, thereby increasing work engagement.
Keywords: Nurses; Occupational Stress; Work Satisfaction; Factor Analysis, Statistical
STRENGTHS AND LIMITATIONS OF THIS STUDY.
This study focused on the work engagement of specialty nurses rather than general nurses.
Using large sample of specialty nurses, this study investigates the association of specialty nurses’ role stress and work engagement in China.
This study can provide new perspectives for nursing managers to develop strategies to improve specialty nurses’ work engagement.
This was a cross-sectional study, which makes it unfeasible for us to specify the effect of time.
Using a convenience sample may lead to an increased likelihood of sampling bias.
Introduction
The term ‘specialty nurses’ refers to registered nurses who have obtained the corresponding specialty nurse qualification certificate after systematic training and examination.1 Compared with general nurses in China, specialty nurses have profound theoretical nursing knowledge, expert nursing skills and rich clinical experience in a specific nursing field.1 They mainly play a role in specialised practice, scientific research, teaching, management, outpatient clinics, consultations and discussion of difficult cases.2 Studies have shown that specialty nurses play a significant role in improving patient care and treatment compliance, meeting all aspects of patient needs and improving patient health.3 4 Accordingly, how to improve the performance of specialty nurses and facilitate the full use of their roles has captured wide attention worldwide.
Work engagement has emerged as a crucial topic for the performance of specialty nurses while also serving as the basis for the competitiveness of hospitals.5 Schaufeli et al define work engagement as a positive, job-fulfilling state of mind characterised by energy, dedication and focus.5 Related research showed that the work engagement of nurses in countries such as the USA, Spain and Belgium was at a moderate to high level.6,8 Conversely, the level of work engagement among Chinese nurses is relatively low.9 10 Low work engagement may result in a significant decline in nurses’ subjective well-being, professional identity and work efficiency, which can severely affect the overall quality of medical services and jeopardise patient safety and health outcomes.11 Specialty nurses may face more severe pressure challenges due to their high degree of professionalism, significant responsibilities and multiple roles.12 Therefore, it is necessary to understand the current status of specialty nurses’ work engagement and clarify the influencing factors, thereby providing valuable evidence for intervention strategies.
Existing literature on work engagement among specialty nurses primarily focuses on dental, haematology, operating room nurses and the like.13,15 These studies were limited to specialty nurses in a particular field and were not adequately representative of the specialty nursing population. Studies have shown that five pivotal categories of factors-individual-related, organisational-related, job and role-specific, work–life harmony and workplace environment-collectively impact the nurses’ level of work engagement. Additionally, stress has been identified as a significant work environment factor that contributes substantially to work engagement.16,18 Role stress has been conceptualised as the result of a discrepancy between an individual’s perception of specific role characteristics and the actual implementation of such a role. Role stress occurs when a divergence exists between what is perceived to be the role expectations and what is being accomplished within the role.19 Nurses experience various sources of work-related stress, including shift work, heavy workloads, long hours and conflicting job demands.20 Specialty nurses, in particular, are required to simultaneously perform six clinical roles, as practitioners, coordinators, ethicomoral coordinators, consultants, educators and researchers.21 Thus, they undertake more challenging clinical tasks than general nurses do. Additionally, specialty nurses mainly engage in part-time work in China, which means that they are responsible for both routine clinical nursing responsibilities and professional nursing tasks, further intensifying their role stress.22 Although role stress is a common problem faced by specialty nurses, there is still a lack of relevant data to confirm its relationship with work engagement.
The job demands-resources (JD-R) model serves as a widely accepted theoretical framework for delineating the precursors and consequences of work engagement. It delineates two primary facets: job demands and job resources, each with distinct implications. Job demands encompass the physiological, psychological or organisational requisites that employees must satisfy, involving significant physical and mental exertion. Conversely, job resources catalyse an incentive process, fostering positive results related to performance.23 However, job demands can transition into job stressors when they require an individual to exert an elevated level of effort to meet these requirements,24 potentially yielding adverse effects such as nervousness and depression, which, in turn, influence employee engagement.25 Among specialty nurses, factors like role overload, role ambiguity and role conflict may lead to role stress, consequently diminishing their work engagement levels.26 Therefore, drawing from the JD-R model, we hypothesise a negative correlation between role stress and work engagement among specialty nurses, with role stress emerging as a pivotal predictor of work engagement in this demographic.
The purpose of this study was to fill a research gap in the relevant field by investigating the relationship between personal characteristics (such as hospital type, hospital grade, specialised fields, gender, age, educational level, professional title, work experience, mode of appointment, monthly income), participation in specialised nursing work (whether to participate in specialty nursing outpatient service, nature of specialty nurse position) and role stress in relation to work engagement among specialty nurses. The results of this study may provide a new perspective for nursing managers to improve work engagement among specialty nurses and to stabilise the specialty nursing team.
Research methods
Research approach
The study employed a descriptive, cross-sectional design to investigate the correlation between role stress and work engagement among specialty nurses in China. Several key factors informed the adoption of this survey approach. First, it offers simplicity in data collection and analysis.27 28 Second, the method facilitates the acquisition of precise data from a substantial pool of respondents within a constrained time frame. Additionally, empirical evidence supports the suitability of cross-sectional studies for both descriptive and comparative analyses, aligning closely with the objectives of our investigation.29
Participants
Convenience sampling was used to select specialty nurses from 42 different specialised fields, from March to April 2023, as the study participants. The inclusion criteria were as follows: (a) being a registered nurse, (b) having a specialty nursing training certificate, (c) having over one year of specialty nursing work experience and (d) volunteering to participate in the study. Additionally, we excluded those who did not belong to the hospitals being surveyed and those who took sick or maternity leave or were absent for more than 6 months.
Patient and public involvement
Patients or the public were not involved in this study.
Measurements
We used established measures for the constructs in this study, which have been extensively employed within the Chinese nurse population and have demonstrated robust reliability and validity. To enhance the study’s rigour, we recalculated the reliability. In this study, Cronbach’s α coefficient for the Role Stress Scale was 0.956, and for the Specialty Nurse Work Engagement Scale, it was 0.978.
General Information Survey Questionnaire
The following general information was collected from each participant: hospital type, hospital grade, department, sex, age, educational level, professional title, work experience, mode of appointment, monthly income, whether to participate in the specialty nursing outpatient service and nature of the specialty nurse position.
Role Stress Scale
The scale used in this study was a 23-item scale revised by Li, based on the original Role Stress Scale and Role Load Scale, to measure three dimensions: role ambiguity (6 items), role conflict (7 items) and role overload (10 items).30,32 Each item was scored on a 5-point Likert scale ranging from 1 (very inconsistent) to 5 (very fit), with a total score calculated as the sum of individual item scores, ranging from 0 to 115. The Content Validity Index for the overall scale (S-CVI) is 0.930. The Cronbach’s α coefficient for the scale was 0.961.
Specialty Nurse Work Engagement Scale
The Chinese version of the Specialty Nurse Work Engagement Scale developed by Qin et al was used in this study.33 This 32-item scale has five subscales: work attitude, work value, work recognition, work initiative, work enthusiasm and focus. Each item was scored on a 5-point Likert scale ranging from 1 (never) to 5 (always), with a total score out of 160 calculated as the sum of individual item scores. The S-CVI is 0.842 and Cronbach’s α coefficient for each domain ranged from 0.827 to 0.905, and for the total scale it was 0.958.
Data collection
An online survey was conducted in Henan Province, which is a populous province located in central China. The electronic questionnaire was developed on a widely used online platform, Wenjuanxing, which generated a website link to the electronic questionnaire. Before the survey, the managers of 42 specialty nurses’ training bases were contacted to inform them of the study’s aims and procedures. After obtaining permission, we sent them a website link to access the questionnaire, which they distributed through a WeChat group to specialty nurses who met the inclusion criteria. The first page of the questionnaire included standardised instructions to explain the survey purpose and methodology, as well as informed consent, which helped ensure that the recovered questionnaires were comprehensive and valid. Participants completed the questionnaire online via electronic devices (eg, smartphones). During the data collection phase, all items in the questionnaire were compulsory, to avoid omission of answers, and each internet protocol address was allowed to fill out the survey only once, to prevent duplicate responses. After questionnaire collection, two researchers who were uninformed of the study design entered the data after all surveys were completed, to ensure accuracy. Before analysing the data, they received training on the subject and were only allowed to participate in data entry if they passed the training exam. Two researchers jointly checked the questionnaires during data entry and eliminated those with obvious errors or inconsistencies.
Data analysis
A Kolmogorov-Smirnov test was used and indicated that the total scores of work engagement did not satisfy a normal distribution (p<0.05). However, Kim argues that if the sample is >300, normality should depend on the absolute values of skewness (absolute skew value >2) and the absolute value of kurtosis (absolute kurtosis >7) and be assessed reliably in conjunction with the visual appearance of distributions.34 In our study, the total scores of work engagement had an absolute skew value of −0.820 (SE=0.079) and an absolute kurtosis value of 1.195 (SE=0.158). Considering the results of these skewness and kurtosis values, along with the distribution plots (Q-Q plots), the total scores of work engagement in this study approximated normality.
Next, we employed tolerance and a variance inflation factor for collinearity diagnostics. The results showed that there is an internal link between the professional title and work engagement—this is referred to as multicollinearity. To maintain the integrity of the explanatory variables, the ridge regression analysis method was used.
The continuous data were described as means and SD, and categorical data were presented as frequencies and percentages. The differences in the total score of work engagement between subgroups were tested, using independent samples t-test or one-way analysis of variance (ANOVA), if the data met homogeneity of variance. Spearman’s correlation analysis to analyse the correlation between demographic variables and work engagement. The relationships between role stress and work engagement were explored using Pearson correlation analysis. Specialty nurses’ scores of work engagement were treated as dependent variables in the ridge linear regression analysis, the role stress and statistically significant factors in the univariate analysis as the independent variables, and the k value was set to 0.3. In ridge linear regression analysis, age, professional title and work experience are set as dummy variables, and the reference groups were aged ≤30 years, primary nurses and work experience ≤5 years, respectively. Statistical significance was set at p<0.05 (two-tailed test).
Results
Characteristics of the sample
The study received 972 questionnaires, of which 14 were excluded because of obvious errors (eg, all answers were the same and the options selected were regular). Finally, 958 valid questionnaires were included (98.5%). Among the included questionnaires, there were 909 females (94.9%) and 49 males (5.1%). The average age of the participants was (33.6±4.84) years. Detailed demographic characteristics are presented in table 1.
Table 1. Sample characteristics and differences in work engagement (n=958).
| Variables | Frequency (%) | Work engagement score (M±SD) | Statistic | P value |
| Hospital type | t=0.816 | 0.415 | ||
| General hospital | 937 (97.8) | 140.34±17.78 | ||
| Specialised hospital | 21 (2.2) | 137.14±17.01 | ||
| Hospital grade | t=−0.488 | 0.626 | ||
| Tertiary hospital | 806 (84.1) | 140.15±17.90 | ||
| Level II hospital | 152 (15.9) | 140.91±17.04 | ||
| Specialised fields | F=1.098 | 0.362 | ||
| Medical | 442 (46.1) | 140.91±17.84 | ||
| Surgical | 233 (24.3) | 140.32±17.13 | ||
| Paediatrics | 22 (2.3) | 141.68±17.99 | ||
| Gynaecological | 74 (7.7) | 141.96±16.25 | ||
| Emergency | 21 (2.2) | 134.71±13.97 | ||
| Intensive care unit | 75 (7.8) | 137.41±18.72 | ||
| Operating room | 76 (7.9) | 137.83±20.77 | ||
| Others | 15 (1.6) | 144.27±17.76 | ||
| Gender | t=−0.142 | 0.887 | ||
| Female | 909 (94.9) | 140.29±17.68 | ||
| Male | 49 (5.1) | 139.92±19.42 | ||
| Age (years) | F=3.055 | 0.028 | ||
| ≤30 | 252 (26.3) | 138.47±18.83 | ||
| 31–40 | 647 (67.5) | 140.55±17.51 | ||
| 41–50 | 50 (5.2) | 143.34±15.11 | ||
| >51 | 9 (0.9) | 153.33±9.21 | ||
| Educational level | F=1.812 | 0.164 | ||
| Diploma | 80 (8.4) | 137.29±19.25 | ||
| Bachelor’s degree | 831 (86.7) | 140.69±17.60 | ||
| Master’s degree | 47 (4.9) | 137.83±17.76 | ||
| Professional title | F=4.648 | 0.003 | ||
| Primary nurse | 23 (2.4) | 134.91±18.96 | ||
| Nurse practitioner | 264 (27.6) | 138.31±18.71 | ||
| Supervisor nurse | 631 (65.9) | 140.78±17.41 | ||
| Co-chief nurse | 40 (4.2) | 148.20±13.08 | ||
| Work experience (years) | F=3.762 | 0.001 | ||
| ≤5 | 138 (14.4) | 135.06±18.25 | ||
| 6–10 | 298 (31.1) | 139.77±17.93 | ||
| 11–15 | 373 (38.9) | 141.07±17.09 | ||
| 16–20 | 87 (9.1) | 143.20±19.74 | ||
| 21–25 | 40 (4.2) | 143.10±15.73 | ||
| 26–30 | 13 (1.4) | 149.46±10.44 | ||
| >31 | 9 (0.9) | 149.56±9.19 | ||
| Mode of appointment | F=1.667 | 0.189 | ||
| Contract system | 172 (18.0) | 138.03±18.37 | ||
| Human agency | 660 (68.9) | 140.73±17.84 | ||
| Official staffing | 126 (13.2) | 140.91±16.34 | ||
| Monthly income (yuan) | F=0.708 | 0.586 | ||
| ≤5000 | 219 (22.9) | 140.55±16.96 | ||
| <5000 to ≤10 000 | 427 (44.6) | 140.08±17.88 | ||
| <10000 to ≤15 000 | 278 (29.0) | 139.88±18.48 | ||
| <15000 to ≤20 000 | 32 (3.3) | 143.13±15.63 | ||
| >20 000 | 2 (0.2) | 157.00±1.41 | ||
| Whether to participate in specialty nursing outpatient service | t=1.464 | 0.146 | ||
| Yes | 89 (9.3) | 142.51±14.80 | ||
| No | 869 (90.7) | 140.04±18.03 | ||
| Nature of specialty nurse position | t=0.457 | 0.650 | ||
| Full-time job | 54 (5.6) | 141.15±14.33 | ||
| Part-time job | 904 (94.4) | 140.22±17.95 |
Univariate analysis of the different general information on work engagement of specialty nurses
Significant differences were found in the total work engagement score among specialty nurses when comparing different age groups, professional titles and years working in the hospital (p<0.05) (table 1). There was no statistically significant difference in role stress between specialty nurses who participate in specialty nursing outpatient service and those who do not participate in specialty nursing outpatient service. Meanwhile, the difference in role stress between full-time and part-time specialty nurses was also not statistically significant (p>0.05) (table 1).
Analysis of work engagement and role stress of specialty nurses
The total score of work engagement was 140.27±17.76 and the total score of role stress was 52.44±19.92. Detailed scores for each dimension of work engagement and role stress are shown in tables2 3.
Table 2. Specialty nurse’ work engagement dimension scores and total scores.
| Dimensions | Total score | Actual score | Standardised score |
| Work attitude | 40 | 36.33±4.45 | 4.54±0.56 |
| Work values | 30 | 26.74±3.87 | 4.46±0.64 |
| Work motivation | 45 | 38.91±5.46 | 4.32±0.61 |
| Work recognition | 20 | 17.17±2.94 | 4.29±0.74 |
| Work enthusiasm and focus | 25 | 21.11±3.22 | 4.22±0.64 |
| Total score of the work engagement | 160 | 140.27±17.76 | 4.38±0.56 |
Table 3. Specialty nurse’ role stress dimension scores and total scores.
| Dimensions | Total score | Actual score | Standardised score |
| Role overload | 50 | 26.43±9.87 | 2.64±0.99 |
| Role conflict | 35 | 14.79±6.75 | 2.11±9.64 |
| Role ambiguity | 30 | 11.21±5.67 | 1.87±5.67 |
| Total score of the role stress | 115 | 52.44±19.92 | 2.28±0.87 |
The correlation between specialty nurses’ general information, role stress and work engagement
As shown in table 4, the results of the Pearson correlation analysis indicated that the total score for work engagement was negatively related to the total scores for role stress (r=−0.380, p<0.001), role ambiguity (r=−0.352, p<0.001), role conflict (r=−0.367, p<0.001) and role overload (r=−0.313, p<0.001). The result of the Spearman’s correlation analysis revealed that age (r=0.061, p<0.05), professional title (r=0.088, p<0.05) and work experience (r=0.135, p<0.001) were positively associated with work engagement.
Table 4. Correlations between role stress and work engagement (n=958, r value).
| Variables | Work attitude | Work values | Work recognition | Work motivation | Work enthusiasm and focus | Total score of work engagement |
| Hospital type | −0.033 | −0.036 | −0.036 | −0.041 | −0.039 | −0.036 |
| Hospital grade | 0.027 | 0.044 | 0.001 | −0.011 | −0.022 | 0.015 |
| Department | −0.038 | −0.054 | −0.026 | −0.035 | −0.044 | −0.037 |
| Gender | −0.004 | 0.011 | −0.014 | −0.014 | 0.014 | −0.005 |
| Age | 0.114*** | 0.062 | 0.035 | 0.033 | 0.065** | 0.061** |
| Educational level | 0.013 | 0.017 | 0.006 | 0.035 | 0.015 | 0.017 |
| Professional title | 0.125*** | 0.115*** | 0.070** | 0.074** | 0.074** | 0.088** |
| Work experience | 0.176*** | 0.146*** | 0.104** | 0.101** | 0.118*** | 0.135*** |
| Mode of appointment | 0.054 | 0.041 | 0.027 | 0.029 | 0.042 | 0.049 |
| Monthly income | −0.016 | −0.029 | 0.010 | 0.032 | 0.028 | −0.001 |
| Whether to participate in specialty nursing outpatient service | −0.025 | −0.030 | −0.032 | −0.031 | −0.026 | −0.024 |
| Nature of specialty nurse position | −0.007 | 0.002 | 0.001 | 0.000 | −0.001 | 0.005 |
| Role ambiguity | −0.296*** | −0.322*** | −0.340*** | −0.325*** | −0.285*** | −0.352*** |
| Role conflict | −0.279*** | −0.322*** | −0.385*** | −0.342*** | −0.321*** | −0.367*** |
| Role load | −0.231*** | −0.266*** | −0.343*** | −0.289*** | −0.286*** | −0.313*** |
| Total score of role stress | −0.293*** | −0.333*** | −0.397*** | −0.352*** | −0.332*** | −0.380*** |
*p<0.01, ***p<0.001.
Analysis of factors influencing specialty nurses’ work engagement
According to the results of the independent samples t-test or one-way ANOVA, age, professional title and work experience were statistically significant general information variables, which were included in the ridge regression analysis. The results showed that when age, professional title, and role stress were entered into the regression model, they explained 14.6% of the variation in work engagement. Role stress had a significant negative effect on work engagement (β=−0.335, p<0.001). However, compared with specialty nurses aged ≤30 years, specialty nurses aged 31–40 years, 41–50 years or >51 years did not show significant differences in work engagement. Compared with specialty nurses with a professional title of primary nurse, specialty nurses with a professional title of nurse practitioner, supervisor nurse and co-chief nurse did not show significant differences in work engagement. Furthermore, compared with specialty nurses with work experience ≤5 years, specialty nurses who worked in a hospital for 6–10 years, 11–15 years, 16–20 years, 21–25 years, 26–30 years or >31 years did not report significant differences in work engagement (table 5).
Table 5. Results of ridge regression analysis of predictors for specialty nurses’ work engagement.
| Variable | UnstandardisedB | UnstandardisedSE | Beta.SD | T | P value | Adjusted R2 | F | P value |
| 0.146 | 13.624 | <0.001 | ||||||
| Constant | 152.517 | 2.062 | 0.000 | 73.967 | <0.001 | |||
| Age (31–40 years) | −0.190 | 1.277 | −0.005 | −0.149 | 0.882 | |||
| Age (41–50 years) | −0.526 | 2.729 | −0.007 | −0.193 | 0.847 | |||
| Age (>51 years) | 8.568 | 6.353 | 0.047 | 1.349 | 0.178 | |||
| Reference group: age ≤30 years | ||||||||
| Nurse practitioner | 0.488 | 1.369 | 0.012 | 0.357 | 0.721 | |||
| Supervisor nurse | 1.704 | 1.286 | 0.046 | 1.325 | 0.186 | |||
| Co-chief nurse | 5.571 | 2.678 | 0.063 | 2.080 | 0.038 | |||
| Reference group: primary nurse | ||||||||
| Work experience (6–10 years) | 1.765 | 1.219 | 0.046 | 1.448 | 0.148 | |||
| Work experience (11–15 years) | 2.464 | 1.292 | 0.068 | 1.907 | 0.057 | |||
| Work experience (16–20 years) | 3.426 | 1.858 | 0.055 | 1.844 | 0.066 | |||
| Work experience (21–25 years) | 3.260 | 2.789 | 0.037 | 1.169 | 0.243 | |||
| Work experience (26–30 years) | 4.016 | 4.574 | 0.026 | 0.878 | 0.380 | |||
| Work experience (>31 years) | 0.961 | 6.356 | 0.005 | 0.151 | 0.880 | |||
| Reference group: work experience ≤5 years | ||||||||
| The total score of role stress | −0.299 | 0.024 | −0.335 | −12.287 | <0.001 | |||
Discussion
The total score for work engagement was (140.27±17.76), with a mean item score of work engagement (4.38±0.56). This score surpasses the normative data for total work engagement scores of nurses (3.82±1.10) and is consistent with the findings reported by Qin et al and other studies.33 35 36 Our study indicates that the level of work engagement among specialty nurses is above medium level. This may be because specialty nurses play a crucial role in clinical practice and receive greater recognition from nursing managers than general nurses do. Nursing managers were more willing to provide specialty nurses with additional resources and opportunities to enhance their work engagement. Further analysis was made on the scores of all dimensions of specialty nurses’ work engagement, among which the standardised score of work attitude was the highest (4.54±0.56), followed by work values (4.46±0.64). This may be related to the increased recognition of specialty nursing work by patients, medical staff and society, which has greatly improved the existence and value of specialty nurses. However, the standardised score of work enthusiasm and focus was the lowest (4.22±0.64) among dimensions of work engagement. This may be related to factors such as ambiguous job responsibilities, significant disparities in salary and benefits, and excessive workload, which, in turn, can lead to negative emotions and professional stress among specialty nurses.37,39 These factors can diminish their sense of professional gains, thus exerting a negative impact on their work enthusiasm, motivation and focus.
The single-factor ANOVA showed that the differences in specialty nurses’ work engagement in terms of age, professional title and work experience were statistically significant (p<0.05). These findings are consistent with those of previous studies regarding general nurses.40,42 The reasons may be as follows. Specialty nurses are of different ages, and therefore, assume different family roles, leading to differences in their work–family conflict levels; this results in different levels of work engagement.13 Different levels of professional title or qualification affect specialty nurses’ earnings and their feelings of professional accomplishment.43 Therefore, they enjoy different benefits, demonstrate a different sense of work value and their level of work engagement varies. Further, specialty nurses with different levels of work experience may have differences in their professional knowledge and skill levels, resulting in differences in their ability to handle complex situations, meaning that their level of work engagement varies.44 However, age, professional title and work experience could not be entered into the regression equation, which could be because of the internal link between these factors influencing work engagement, leading to multicollinearity. Therefore, whether age, professional title and work experience are influencing factors of specialty nurses’ work engagement needs further research. Our study also observed variations in the number of specialty nurses across different specialised fields; however, these variances did not demonstrate significant differences in work engagement (p>0.05), consistent with previous research results.45 This could be attributed to the variations in demand for specialty nurses across different fields, as medical institutions allocate human resources based on specific requirements. For example, the intensive care unit often requires a larger team of specialty nurses owing to the specialised and demanding nature of the work, ensuring timely and proficient patient care.46 Nevertheless, further investigation is warranted to explore the phenomenon of non-significant differences in work engagement among specialty nurses across diverse specialised fields.
One interesting finding was that there was no statistically significant difference in role stress between specialty nurses who participate in specialty nursing outpatient service and those who do not. Moreover, the difference in role stress between full-time and part-time specialty nurses was also not statistically significant, which is inconsistent with the findings of previous reports.33 The reason may be related to the low proportion of full-time specialty nurses and specialty nurses participating in outpatient services in our study. It may also be related to the fact that our survey respondents came from different provinces in China, which have different post management systems, promotion systems and salary systems for specialty nurses. Therefore, the relevant government departments should comprehensively consider the opinions of various medical institutions, issue relevant policy guidance, realise homogeneous management of specialty nurses and improve the level of work engagement of specialty nurses.47
Our study further discovered that role ambiguity, role conflict, role overload and role stress were all negatively correlated with the work engagement of specialty nurses; this is consistent with previous studies regarding general nurses.48 49 In terms of role ambiguity, this issue arises when medical staff assumes multiple roles, such as treating patients, undertaking research, teaching junior colleagues and so forth.41 Unclear role positioning and job responsibilities lead to specialty nurses being unable to focus on their work.48 Regarding role conflict, specialty nurses have regular clinical nursing duties while also having to perform specialised nursing tasks.50 Moreover, most specialty nurses are women who have the additional responsibility of taking care of their families, which might lead to a reduction in the time and energy they invest in specialty nursing work.51 Finally, in the dimension of role overload, as most specialty nurses work part-time in China—meaning that specialty nurses are required to undertake more tasks such as scientific research, teaching and management—and deal with more complex work than general nurses, they are more susceptible to negative emotions and feelings of exhaustion, which reduces their work engagement.50 51 To address this, medical institutions should actively explore work management systems, salary systems and promotion systems for specialty nurses that are in line with their clinical environment, to thereby reduce the impact of role ambiguity, role conflicts and role overload on the work engagement of specialty nurses.51
The ridge regression analysis demonstrated that role stress was the primary factor influencing the work engagement of specialty nurses. Our results are consistent with those of previous studies on dental nurses.13 It may be related to that when specialty nurses are subjected to long-term pressure from their work, patients and environment, these role stressors can lead to fatigue and a decrease in enthusiasm and motivation, resulting in lower levels of work engagement and even turnover.42 Therefore, we suggest that nursing managers pay attention to role stress experienced by specialty nurses. To enhance communication and create a supportive environment for specialty nurses, establishing effective channels through which they can express their thoughts and feelings is crucial. This not only helps alleviate stress but also promotes a sense of psychological well-being. Furthermore, offering mindfulness training to specialty nurses could effectively reduce psychological pressure and boost work engagement.
Limitations
Despite its clear contributions, this study has certain limitations. First, this was a cross-sectional study, which makes it unfeasible for us to specify the effect of time. Second, this study collected data using an online questionnaire, which could potentially be subject to interpretation biases and deviations, due to individual misinterpretation. Third, the survey participants were not selected using probability-sampling strategies, which also limits the generalisability of our research findings. Lastly, the 5% male specialty nurses in our sample only represent the male specialty nurse population within mainland China; therefore, the applicability of our findings as a reference for developed countries is limited.
Conclusions
This work contributes empirically to the existing literature concerning specialty nurses’ engagement and the JD-R model by exploring the role stress-related aspects which assist in reducing the negative impacts on the engagement of specialty nurses. We conducted a large-sample survey to test the hypothesised relation between specialty nurses’ role stress and work engagement. Findings from this study suggest that specialty nurses’ work engagement was in the middle to upper range and higher than general nurses. Furthermore, role ambiguity, role conflict, role overload and role stress were negatively correlated with the work engagement of specialty nurses. Notably, role stress was the main factor influencing their work engagement. Given that the concept of work engagement has emerged as a significant driver for fostering positive attitudes and behaviours among specialty nurses, this study suggests that nursing managers should take specific measures to address the role stress of specialty nurses to reduce their stress and increase their work engagement.
Implications for nursing management
The results of this study indicate that the relevant government departments should comprehensively adopt the opinions of various medical institutions and issue relevant policy guidance. Moreover, each medical institution should actively explore work management systems. Nursing managers should also pay attention to the negative impact of role stress on work engagement and implement effective measures, such as creating a supportive environment for specialty nurses; establishing effective channels to express their thoughts and feelings is crucial and offering mindfulness training to specialty nurses, to thereby reduce their role stress and improve the level of specialty nurses’ work engagement.
Acknowledgements
The authors extend their deepest gratitude to the heads of the 42 specialty nurses’ training bases and the specialty nurses who assisted with data collection in the study.
The funder was not involved in the study design, collection, analysis, interpretation of data, writing of this article, or the decision to submit it for publication.
Footnotes
Funding: This study was funded by Henan Provincial Key Medicine Laboratory of Nursing 2022 Annual Open Subjects (No. HNSYHLKT202208).
Prepublication history for this paper is available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2023-079979).
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants and was approved by the Ethics Committee of Zhengzhou University (ZZUIRB2023192). Participants gave informed consent to participate in the study before taking part.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Contributor Information
Panpan Zhang, Email: zpanpan0722@163.com.
Yaru Li, Email: 1670320542@qq.com.
Songyao Li, Email: 1292441952@qq.com.
Liming Li, Email: 760729781@qq.com.
Shuying Chang, Email: 1061788382@qq.com.
Ziru Fang, Email: fangzr@gs.zzu.edu.cn.
Fangfang Liang, Email: 2256376662@qq.com.
Hongmei Zhang, Email: z126hm@126.com.
Data availability statement
Data are available on reasonable request.
References
- 1.Nie Y-Q, Jin R-H, Huai P-P, et al. Research progress on qualification certification of geriatric specialist nurses. Chin Nurs Res. 2022;36:3665–9. doi: 10.12102/j.issn.1009-6493.2022.20.018. [DOI] [Google Scholar]
- 2.Dong Z, Wei L, Sun X, et al. Experiences of nurses working in nurse-led clinics in Traditional Chinese Medicine hospitals: A focused ethnographic study. Nurs Open. 2023;10:603–12. doi: 10.1002/nop2.1326. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Hussain Rawther SC, Pai MS, Fernandes DJ, et al. Specialist nurse initiated interventions in breast cancer care: A systematic review of randomised controlled trials. J Clin Nurs. 2020;29:2161–80. doi: 10.1111/jocn.15268. [DOI] [PubMed] [Google Scholar]
- 4.Locatelli G. The multifaceted role of the Epilepsy Specialist Nurse: Literature review and survey study on patient and medical Staff Perceptions. Il ruolo multidimensionale dell’ infermiere specialistad’ epilessia: revisione della letteratura eindagine sulle percezioni dipazienti e medici. Prof Inferm. 2019;72:34–41. doi: 10.7429/pi.2019.720134. [DOI] [PubMed] [Google Scholar]
- 5.Schaufeli WB, Salanova M, Gonzalez-Roma V, et al. The measurement of engagement and burnout: a two sample confifirmatory factor analytic approach. J Happiness Stud. 2002;3:71–92. doi: 10.1023/a:1015630930326. [DOI] [Google Scholar]
- 6.Van Bogaert P, van Heusden D, Timmermans O, et al. Nurse work engagement impacts job outcome and nurse-assessed quality of care: model testing with nurse practice environment and nurse work characteristics as predictors. Front Psychol. 2014;5:1261. doi: 10.3389/fpsyg.2014.01261. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Sullivan Havens D, Warshawsky NE, Vasey J. RN work engagement in generational cohorts: the view from rural US hospitals. J Nurs Manag. 2013;21:927–40. doi: 10.1111/jonm.12171. [DOI] [PubMed] [Google Scholar]
- 8.García-Iglesias JJ, Gómez-Salgado J, Ortega-Moreno M, et al. Relationship Between Work Engagement, Psychosocial Risks, and Mental Health Among Spanish Nurses: a Cross-Sectional Study. Front Public Health. 2020;8:627472. doi: 10.3389/fpubh.2020.627472. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Wang Q-Q, Shang-S-M G-S, et al. Research on the status of work engagement and its influencing factors among clinical nurses. Chin Nurs Manag. 2018;18:1326–31. doi: 10.3969/j.issn.1672-1756.2018.10.007. [DOI] [Google Scholar]
- 10.Li L-Q, Fan Y-P, Gong S-Q, et al. Status quo in studies on work involvement of nurse in China: a bibliometric analysis. Chin J Pract Nurs. 2018;34:396–400. doi: 10.3760/cma.j.issn.1672-7088.2018.05.017. [DOI] [Google Scholar]
- 11.da Silva AG, Cabrera EMS, Gazetta CE, et al. Engagement in primary health care nurses: a cross-sectional study in A Brazilian city. Pub Health Nurs. 2020;37:169–77. doi: 10.1111/phn.12694. [DOI] [PubMed] [Google Scholar]
- 12.Vita A, Nibbio G, Marini M, et al. Psychological impact of Covid-19 pandemic in mental healthcare workers: a cross-sectional study in an Italian Department of Mental Health. Riv Psichiatr. 2023;58:271–83. doi: 10.1708/4143.41407. [DOI] [PubMed] [Google Scholar]
- 13.Wang Y-J, Gao Y-Q, Xun Y. Work engagement and associated factors among dental nurses in China. BMC Oral Health. 2021;21:402. doi: 10.1186/s12903-021-01766-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Cao X, Chen L. Relationships between resilience, empathy, compassion fatigue, work engagement and turnover intention in haemodialysis nurses: a cross‐sectional study. J Nurs Manag . 2021;29:1054–63. doi: 10.1111/jonm.13243. [DOI] [PubMed] [Google Scholar]
- 15.Liang R-C, Sun Z-K-J-M, Zeng L-N, et al. Analysis of work input level and influencing factors of specialized nurses in operating rooms in Sichuan Province. J Nurs. 2023;38:40–4. doi: 10.3870/j.issn.1001-4152.2023.04.040. [DOI] [Google Scholar]
- 16.Aungsuroch Y, Gunawan J, Juanamasta IG, et al. Updating Factors Influencing Nurse Work Engagement in the Hospital Settings: A Systematic Review. J Healthc Leadersh. 2024;16:157–76. doi: 10.2147/JHL.S451056. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Jiang H, Wang S-K, Tao R, et al. Bibliometric Analysis of Domestic Nurses7 Work Engagement. Med Info. 2024;37:14–8. doi: 10.3969/j.issn.1006-1959.2024.03.003. [DOI] [Google Scholar]
- 18.Ye W-X, Jin J-F, Lan M-J, et al. The current status and influencing factors of emergency specialty nurses’ work engagement. Chin J Nurs Educ. 2023;20:661–5. doi: 10.3761/j.issn.1672-9234.2023.06.004. [DOI] [Google Scholar]
- 19.Lambert VA, Lambert CE. Literature review of role stress/strain on nurses: An international perspective. Nursing & Health Sciences . 2001;3:161–72. doi: 10.1046/j.1442-2018.2001.00086.x. [DOI] [PubMed] [Google Scholar]
- 20.Nazir T, Umer M, Najam M, et al. Impact role stress on turnover intentions of Pakistan’s healthcare workers: Mediating and moderating role of organizational cynicism and self-efficacy. PLoS One. 2022;17:e0279075. doi: 10.1371/journal.pone.0279075. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Yang D, Zhang R, Kirkland-Kyhn H. Training and practice of wound ostomy continence nurse specialists in China. Wound Manag Prev . 2023;69:28–31. doi: 10.25270/wmp.22083. [DOI] [PubMed] [Google Scholar]
- 22.Lim JY, Kim GM, Kim EJ. Factors Associated with Job Stress among Hospital Nurses: A Meta-Correlation Analysis. Int J Environ Res Public Health. 2022;19:5792. doi: 10.3390/ijerph19105792. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Girardi D, Dal Corso L, Arcucci E, et al. Hair dehydroepiandrosterone sulfate as biomarker of employees’ well-being? A longitudinal investigation of support, resilience, and work engagement during COVID-19 pandemic. Front Psychol. 2024;15:1337839. doi: 10.3389/fpsyg.2024.1337839. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Morales-García WC, Vallejos M, Sairitupa-Sanchez LZ, et al. Depression, professional self-efficacy, and job performance as predictors of life satisfaction: the mediating role of work engagement in nurses. Front Public Health. 2024;12:1268336. doi: 10.3389/fpubh.2024.1268336. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Papworth A, Ziegler L, Beresford B, et al. Psychological well-being of hospice staff: systematic review. BMJ Support Palliat Care. 2024;13:e597–611. doi: 10.1136/spcare-2022-004012. [DOI] [PubMed] [Google Scholar]
- 26.Weigl T, Tölle A-S, Seppelfrick T. Differential aspects of chronic work-related stress predict depression in registered and geriatric nurses. Pflege. 2021;34:133–40. doi: 10.1024/1012-5302/a000802. [DOI] [PubMed] [Google Scholar]
- 27.Hussain M, Rasool SF, Xuetong W, et al. Investigating the nexus between critical success factors, supportive leadership, and entrepreneurial success: evidence from the renewable energy projects. Environ Sci Pollut Res Int. 2023;30:49255–69. doi: 10.1007/s11356-023-25743-w. [DOI] [PubMed] [Google Scholar]
- 28.Wang Z, Zaman S, Rasool SF, et al. Exploring the Relationships Between a Toxic Workplace Environment, Workplace Stress, and Project Success with the Moderating Effect of Organizational Support: Empirical Evidence from Pakistan. [DOI] [PMC free article] [PubMed]
- 29.Li X-Y, Kang X-P, Chi C-H, et al. Basic design and lmplementation steps for cross-sectional studies in general practice and primary care. Chin Gen Pract. 2024;27:1584–93. doi: 10.12114/j.issn.1007-9572.2022.0905. [DOI] [Google Scholar]
- 30.Li L-N. A study on the current status of role stress, delayed career satisfaction and work engagement among intern nursing students. Xinxiang Med Univ. 2022;79 doi: 10.27434/d.cnki.gxxyc.2022.000436. [DOI] [Google Scholar]
- 31.Rizzo JR, House RJ, Lirtzman SI. Role Conflict and Ambiguity in Complex Organizations. Adm Sci Q. 1970;15:150. doi: 10.2307/2391486. [DOI] [Google Scholar]
- 32.Robertson R, Biddle BJ, Thomas EJ. Role Theory, Concepts and Research. Br J Sociol. 1966;17:442. doi: 10.2307/589196. [DOI] [Google Scholar]
- 33.Qin H, Wu J-F, Wang T, et al. Preparation and validation of job involvement scale for specialty nurses. J Nurs Sci. 2022;37:56–9. doi: 10.3870/j.issn.1001-4152.2022.01.056. [DOI] [Google Scholar]
- 34.Kim HY. Statistical notes for clinical researchers: assessing normal distribution (2) using skewness and kurtosis. Restor Dent Endod. 2013;38:52–54. doi: 10.5395/rde.2013.38.1.52. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Shen X, Shen T, Chen Y, et al. The associations between benevolent leadership, affective commitment, work engagement and helping behavior of nurses: a cross-sectional study. BMC Nurs. 2023;22:407. doi: 10.1186/s12912-023-01581-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Hui‐ren Z, Li‐li M, Qin L, et al. Evaluation of the correlation between sleep quality and work engagement among nurses in Shanghai during the post‐epidemic era. Nurs Open. 2023;10:4838–48. doi: 10.1002/nop2.1735. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Huang J, Zhang Y, Li L-Z, et al. Problems and commences on current status of specialist nurses training management in China. Chin Nurs Manage. 2015;15:243–6. [Google Scholar]
- 38.Liu S, Duan X, Han P, et al. Occupational benefit perception of acute and critical care nurses: A qualitative meta-synthesis. Front Public Health. 2022;10:976146. doi: 10.3389/fpubh.2022.976146. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Xue X, Qiao J, Li Y, et al. Relationship between work engagement and healthy work environment among ChineseICUnurses: The mediating role of psychological capital. Nurs Open. 2023;10:6248–57. doi: 10.1002/nop2.1866. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Pericak A, Hogg CW, Skalsky K, et al. What Influences Work Engagement Among Registered Nurses: Implications for Evidence-Based Action. Worldviews Evid Based Nurs. 2020 doi: 10.1111/wvn.12469. [DOI] [PubMed] [Google Scholar]
- 41.Yang S, Qiu Y, He J. Meta-analysis of the impact of role stress on the turnover intention of medical staff in tertiary hospitals. Ann Palliat Med . 2021;10:469–78. doi: 10.21037/apm-20-2446. [DOI] [PubMed] [Google Scholar]
- 42.Mukaihata T, Fujimoto H, Greiner C. Factors influencing work engagement among psychiatric nurses in Japan. J Nurs Manag . 2020;28:306–16. doi: 10.1111/jonm.12923. [DOI] [PubMed] [Google Scholar]
- 43.Hao Y-Q. A study of the relationship between social support, core self-evaluation and work engagement among community nurses. Nurs Res. 2017;26:3317–9. doi: 10.3969/j.issn.1009-6493.2017.26.02. [DOI] [Google Scholar]
- 44.Ding Y-M, Wu X-J, Tian J-Y, et al. The current situation of the cultivation and development of specialty nurses in tertiary hospitals in China. Chin J Nurs. 2021;56:1357–62. doi: 10.3761/j.issn.0254. [DOI] [Google Scholar]
- 45.Alkorashy H, Alanazi M. Personal and Job-Related Factors Influencing the Work Engagement of Hospital Nurses: A Cross-Sectional Study from Saudi Arabia. Healthcare (Basel) 2023;11:572. doi: 10.3390/healthcare11040572. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Bae S-H. Intensive care nurse staffing and nurse outcomes: A systematic review. Nurs Crit Care. 2021;26:457–66. doi: 10.1111/nicc.12588. [DOI] [PubMed] [Google Scholar]
- 47.Qin Y-L. Core competencies and role orientation of specialized nurses for specific diseases. Chin J Mod Nurs. 2015;21:2233–6. doi: 10.3760/cma.j.issn.1674-2907.2015.19.001. [DOI] [Google Scholar]
- 48.Cao W-J. The research on the relationship of role stress, affective commitment and job involvement. Zhejiang Gongshang Univ. 2011 [Google Scholar]
- 49.Liang Y-M, Huang H-G, Cui H, et al. Investigation on the post management of specialized nurses in Chinese hospitals. Chin J Hosp Manage. 2020;40:76–9. [Google Scholar]
- 50.Schaufeli WB. Applying the Job Demands-Resources model: a “how to” guide to measuring and tackling work engagement and burnout. Org Dyn. 2017 doi: 10.1016/j.orgdyn.2017.04.008. [DOI] [Google Scholar]
- 51.Zhang M, Chen H, Wang N, et al. The mediating role of job satisfaction between psychological capital and work engagement among Chinese nurses during COVID-19 outbreak: A comparative study between nurse specialists and general nurses. Front Psychiatry. 2022;13:990216. doi: 10.3389/fpsyt.2022.990216. [DOI] [PMC free article] [PubMed] [Google Scholar]