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Applied Nursing Research 25 (2012) 60 64

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International Column

Job stress among nurses in China

Sui Yu Yau, MBA(HSM), MNurs a,, Xiu Ying Xiao, BN b ,
Linda Yin King Lee, PhD, MN a , Alan Yat Kwan Tsang, MN, PRD(HCE) a ,
Suet Lai Wong, MN, BN(Hons) a , Ka Fai Wong, MN, MSSC a
a

The Open University of Hong Kong, Hong Kong

b
Zhuhai People's Hospital, China
Received 28 September 2009; accepted 5 July 2011

Abstract

Job stress is a well-known situation for nurses, especially for those working in the clinical
environment. The purpose of this descriptive study was to examine the job stress level and stressors
among nurses in a Zhuhai hospital. Ninety-three nurses were recruited for the study. Findings were
that nurses had a relatively high level of stress, with Working Environment and Resources and
Workload and Time identified as the major stressors. This study provided preliminary insights on
relieving job stress among nurses in China.
2012 Elsevier Inc. All rights reserved.

1. Introduction
Nurses are the frontline staff of a health care team, and
many of them experience work-related stress. Studies from
China reported that nurses work under great pressure due to
heavy workload, poor staffing, dealing with death and dying,
and interstaff conflict (Xianyu & Lambert, 2006) and also
because of lack of resources, little training, excessive
paperwork, and limited shared governance in decision
making (Welker-Hood, 2006).
According to the U.S. National Institute of Occupational
Safety and Health, job stress is a harmful response physically
and emotionally when the employee's skills, resources, and
needs could not fulfill the requirement of the job (WelkerHood, 2006). Shirey (2006) refers to stress as a general
episode of organizations, and a person's competence to
positively confront stressors would determine the individual's success in overcoming the related stress reactions.
In general, past research reports the negative impact of
stressful situations on health outcomes: psychologically,
physically, and functionally (Shirey, Ebright, & McDaniel,

Corresponding author. Tel.: +852 27686807; fax: +852 27891170.

E-mail address: isyyau@ouhk.edu.hk (S.Y. Yau).
0897-1897/$ see front matter 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.apnr.2011.07.001

2008). The job stress level among nurses working in China

is believed to be higher because of the rapidly growing
economy and the ever-changing health care environment.
Chinese people articulate a high demand and expectation in
seeking health care services in terms of the quality of care,
the knowledge of health care professionals, and the
advancement of technology. The State Council of the
People's Republic of China issued the Nursing Ordinance
(Chapter 517) on the standard and quality of nursing in
2008 to strengthen nurse training, registration, power,
responsibility, and legal issues (Wan, 2008). With the
implementation of this ordinance, it may further increase
nurses' stress level when they are trying to keep up to the
standards of care and the demand by Chinese patients for
high-quality health care.
However, many of the studies about job stress have been
done in Western countries, and there are cultural differences
between Western and Chinese countries that may influence
job stress. With a strong influence from Chinese culture,
nurses in China may try to endure the stress rather than report
it to their senior colleagues. Thus, it is important to study
about job stress among nurses in China. With an understanding about the job stress among nurses in China, it may
be possible to provide a better blueprint for the health care
policy makers in planning to reduce the job stress level
of nurses.

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

2. Methods
A cross-sectional descriptive survey design was used.

61

stress level. Analysis of variance was performed to test the

difference in mean scores of stress level among the different
demographic groups. The level of significance was set at 5%.

2.1. Study participants

A convenience sample of 93 nurses working in a
Zhuhai hospital in China was recruited. The participants
included registered nurses, midwives, nursing officers, and
ward managers.
2.2. Data collection and management
The demographic data of each participant were collected
using the first part of the questionnaire. It included gender,
marital status, rank, years of working experience, current
working unit, educational level, whether they had any
training in stress management, and their perceived stress
level by using a 010 scale, with 0 representing no stress
and 10 representing the highest level of stress.
The second part of the questionnaire was Nurse Stress
Inventory (translated from the Chinese version), which was
a 35-item and 5-point Likert-type questionnaire developed
by Li and Liu (2000). The 35 items were categorized under
five domains with potential range of scores as follows:
Nursing Profession and Clinical Duty, 028; Workload and
Time, 020; Working Environment and Resources, 012;
Patient Care, 044; and Management and Interpersonal
Relationship, 036. The Likert-type scoring ranged from
0 to 4, with 0 = never, 1 = seldom, 2 = sometimes, 3 = often,
and 4 = always. The higher the score, the higher is the stress
level. This questionnaire was modified by Li and Liu (2000)
based on the Nurse Stress Scale developed by Gray-Toft and
Anderson (1981) and the Source of Stress Inventory
developed by Wheeler and Riding (1994). The modified
questionnaire was assessed by experts in China, the United
States, and Thailand who were experienced in the field of
nursing (Li & Liu, 2000). The overall Cronbach's alpha for
the modified questionnaire was .98 and that of each domain
was as follows: Nursing Profession and Clinical Duty, .95;
Workload and Time, .83; Working Environment and
Resources, .92; Patient Care, .94; and Management and
Interpersonal Relationship, .90 (Li & Liu, 2000). The
Cronbach's alpha for this study is .92.
Ethical approval for conducting this study was obtained
from the hospital. Participants were informed of the purpose
and procedure of the study, and their verbal consents for
participation were obtained.
2.3. Data analysis
The Statistical Package for Social Science Version 14 was
used for data analysis. Descriptive statistics including
frequency, percentage, means, and standard deviations
were used to summarize the data. Although inferential
statistics were also used for data analysis, Spearman's rankorder correlation (rho) was used to test the relationship
between the demographic data of the participants and the

3. Results
A total of 93 questionnaires were delivered, and the
response rate was 100%. The demographic characteristics of
participants are summarized in Table 1. All the participants
were women aged 19 to 50 years. Most of them were at the
management level (80.7%), whereas the remaining were
mostly clinical frontline staff. Their working experiences
ranged from 2 to 38 years, with about 25% working in

Table 1
Participants' demographic profiles (N = 93)
Characteristic
Gender
Female
Male
Age (years)
1838
3948
N48
Missing
Marital status
Single
Married
Divorced
Rank
Nurse
Midwife
Nursing officer
Ward manager
Other
Missing
Working experience (years)
010
1120
2130
N30
Missing
Working unit
Surgical
Medical
ICU
OT
OPD
Rehabilitation
O&G
Pediatric
Other
Missing
Educational level
Diploma
Bachelor
Missing

93
0

100
0

58
33
1
1

62.4
35.5
1
1

11
80
2

11.8
86.0
2.2

12
1
21
54
2
3

12.9
1.1
22.6
58.1
2.2
3.2

14
52
21
2
4

15.1
55.9
22.6
2.2
4.3

15
8
2
5
13
1
10
4
33
2

16.1
8.6
2.2
5.4
14.0
1.1
10.8
4.3
35.5
2.2

67
23
3

72.0
24.7
3.2

Note. ICU = intensive care unit; OT = operating theatre; OPD = outpatient

department; O&G = obstetrics and gynecology.

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

medical or surgical units. Concerning their educational level,

72% had a diploma in nursing, whereas 24.7% had a
bachelor's degree in nursing. Most, 89.2%, reported that they
had not received any stress management training, and the
perceived stress index was 7.4, with 10 as the highest stress
level and 0 as no stress.
When comparing the stress level of each domain, the
most 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 Interpersonal
Relationship (M = 1.65).
There was a statistically significant difference in the mean
score of Working Environment and Resources among
participants with different working units, F(8, 81) = 2.227,
p = .0034, in which participants working in pediatric unit
were found to have the highest stress level. There was no
statistically significant difference in the mean scores in other
four domains, and the total mean scores among participants
from the different working units were not different based on
descriptive results.
It was found that there was no statistically significant
correlation between participants' age and their mean scores
in the five domains and total mean scores. In addition, there
was no statistically significant correlation between participants' year of working experience and their mean scores in
the five domains and total mean scores.

4. Discussion
The participants in this study reported a relatively high
level of stress, with a perceived stress index of 7.4. These
results are consistent with those of other studies.
Callaghan, Shiu, and Wyatt (2000) investigated the factors
related to stress and coping among Chinese nurses in
Hong Kong; the findings suggested that the major source
of stress in their participants' lives was their work, such
as work overload and inadequate staffing. Barnard, Street,
and Love (2006) reported that many of the Australian
cancer nurses in their study had experienced all 50 items
of stressors. Because many nurses believed that their job
would directly affect their health and that job-induced
tension was the highest reported stress of the participants,
they felt that they were only at a fair health and seemed
to tire quickly (Callaghan et al., 2000). This finding
suggests that issues that cause job stress to nurses need to
be addressed.
Workload and Time was the most serious source of
stress as reported by the participants. This result is
supported by studies done by Li and Liu (2000) and
Xianyu and Lambert (2006), in which workload was also
found to be the major source of stress as reported by nurses
in China. China, as do many other countries, has a shortage
of nurses. Thus, there is an increased workload among
nursing staff, which may have a negative impact on nurses'

job satisfaction (Li & Lambert, 2008). As a result, the

heavy workload of nurses in China should be addressed. A
variety of coping strategies can be introduced, including
exploring peer support and social support, gaining
supervision from experienced colleagues, recognizing
their own limitations, and developing interests outside of
work (Edwards & Burnard, 2003).
With regard to Working Environment and Resources,
nurses working in pediatric units reported the highest level of
stress. This result can be explained by the study done by
Oates and Oates (1996), in which pediatric nurses perceived
a variety of stresses in their work such as keeping up-to-date
knowledge and dealing with conflict of communication
problem between doctors and nurses.
There are additional explanations for the high stress level
of participants: First, all participants in this study were
women. Generally, women are found to have more
psychological strains and depression (Liu, Spector, & Shi,
2008) and to experience greater sadness and anxiety
(Chaplin, Hong, Bergquist, & Sinha, 2008), and women
might be more vulnerable to repeated stress exposures
(Schmaus, Laubmeier, Boquiren, Herzer, & Zakowski,
2008). Under the Westernization and socioeconomic
changes in China, it is believed that Chinese working
women are at a high level of stress. Evidence suggest that
Chinese women report more physical and psychological
symptoms of stress than men do (Hamid, 2000), which may
be due to the high expectation of Chinese families requiring
women to take major responsibility for domestic work and
educating children (Xu et al., 2004) and, at the same time,
burden from their job.
Second, especially under the influence of Confucianism
in the Chinese culture, the emphasis is on self-cultivation
and socialpolitical reform; the pursuit of duo (road or
path); the ethical system of jen (humaneness), yi
(righteousness), and li (rules of propriety); and the moral
ideals of chun-tze (the superior man or gentlemen) (Tsai,
2006). As a result, in Chinese families, there may be a
more indirect way of exchanging information. In addition,
self-disclosure is uncommon in Chinese society, even
within families (Hamid, 2000). Traditionally, Chinese
families do not encourage open expression of emotion
because excessive emotion is harmful to one's mental and
physical health. It is important to keep one's emotions
under control and well balanced (Hamid, 2000). Thus, the
participants in this study may be reluctant to share their
stress among family members, hence reporting a high
stress level.
Third, 80.7% of the participants in this study came
from the management level. As reported by Xianyu and
Lambert (2006), with the health care system reform in
China, the head nurses needed to adapt to more complex
and difficult roles. In addition, nurse managers reported
overwhelming stress from the nature of the job and work
life imbalance with little support in the workplace (Shirey
et al., 2008).

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

According to the statistic from the Ministry of Health of

the People's Republic of China (2009), there are about 20%
of health care workers at the management level. There is no
doubt that the health care reformation in China over the past
years causes an unclear job description between clinical and
management duties for nurses working at the management
level. As stated by Xianyu and Lambert (2006), apart from
maintaining quality patient care, head nurses in China also
needed to participate in complex activities like taking part in
nursing education, research, finance management, supply
preparation, dispute handling, and collaboration with other
staff members. With such an unclear and complex role,
nurses may become exhausted and stressed.
Furthermore, there were 20,291 hospitals with 3,120,773
hospital beds in China, including comprehensive hospitals
(13,364), traditional Chinese medicine hospitals (2,728), and
specialty hospitals (3,716) in year 2009 (Ministry of Health of
the People's Republic of China, 2009). Despite the large
number of hospitals and hospital beds in China, there were
only 184 million nurses, equivalent to 1.39 nurses to 1,000
populations (Ministry of Health of the People's Republic of
China, 2009). When comparing with a Western country, for
instance, there were 5,815 hospitals in the United States with
951,045 hospital beds (American Hospital Association, 2009)
and there were 2,669,603 nurses, equivalent to 9.4 nurses to
1,000 populations (World Health Organization, 2009). With
such a shortage of nurses in China, nurses in the management
level not only need to tackle the clinical workload but also have
to oversee and manage multiple administrative tasks.
Lastly, it is known that China is a developing country
wherein the role of nurses may be different from that in
Western countries. When comparing with nurses in Western
countries, Chinese nurses identified a lack of autonomy and
were quite dependent on physicians' direction for practice
(Lambert, Lambert, Petrini, Li, & Zhang, 2007; Li &
Lambert, 2008). In addition, nurses sometimes reported not
being respected by physicians, patients, and patients'
relatives; being physically attacked and not trusted by
patients; and being yelled at by physicians. Most importantly,
nurses were not receiving sufficient respect and support from
hospital administrative staff (Lambert et al., 2007).
To reduce the stress level of nurses in China, it is
important to enhance the working environment in terms of
strengthening the social status of nurses in China by
empowering autonomy and maximizing health care resources. Nevertheless, the support from hospital administrative staff is of utmost importance, and stress management
training is highly recommended because it provides methods
for stressed nurses to reduce their job stress.

5. Limitation and recommendation

A limitation of this study is that the data were collected
from nurses in Zhuhai only; the stress level reported by
these participants may not be representative of those in

63

other areas in China. A second limitation is that many of

the participants are working in the management level.
Thus, the results may represent the stress levels of nurses
in management positions. Further study is recommended in
more diverse areas in China and to include more frontline
staff nurses.
In addition, because the number of participants recruited
in each working unit was limited, the finding could not be
grouped together to perform a post hoc test for determining
the statistical difference among different working units.
Thus, it is recommended to recruit a greater number of
participants in different working units in future studies, so
that a post hoc test can be performed.
6. Conclusion
This study investigated the job stress level and stressors
among nurses in China. Working Environment and Resources and Workload and Time were identified as the
two most important job stressors.
In summary, this study provided preliminary insights on
relieving job stress among nurses in China. They reflected a
relatively high level of job stress, and this situation should be
addressed to improve working conditions. Although there
are limitations to this study, the results can contribute to the
awareness and understanding to the present situation of job
stress among nurses in China.
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