Li et al.

BMC Health Services Research (2017) 17:401

DOI 10.1186/s12913-017-2348-3

RESEARCH ARTICLE Open Access

Moderating effects of coping on work

stress and job performance for nurses in
tertiary hospitals: a cross-sectional survey in
China
Li Li1*, Hua Ai2, Lei Gao1, Hao Zhou3, Xinyan Liu1, Zhong Zhang1, Tao Sun1* and Lihua Fan1*

Abstract
Background: Work stress is a major problem for nurses and it can negatively influence job performance. Therefore,
it is critical to explore variables that can reduce or buffer the negative effects of work stress. This study explores the
moderating effects of coping strategies on the relationship between work stress and job performance for nurses in
China.
Methods: A cross-sectional survey of 852 nurses from four tertiary hospitals in Heilongjiang Province, China, was
conducted in 2013. Descriptive statistics were reported for socioeconomic status and demographic characteristics,
level of work stress, coping strategies, and job performance. Regression analysis was conducted to test the
interaction between work stress and coping strategies on job performance.
Results: Three subscales of work stress were negatively related to job performance. Positive coping strategies moderated
Patient Care and job performance while negative coping strategies moderated Workload and Time and performance, and
between Working Environment and Resources and performance.
Conclusions: Positive coping strategies reduce or buffer the negative effects of work stress on job performance and
negative coping strategies increased the negative effects.
Keywords: Coping, Nurses, Work stress, Job performance, Moderation

Background Work stress can be defined as a mismatch between an

Worldwide, nursing is known to be a very stressful occu- individual and their environment [6]. In general, the
pation. Studies from China reported that nurses work higher the imbalance between external demands and an
under great pressure because of a heavy workload, con- individual’s abilities, the higher the level of stress that
tending with death and dying, inter-staff conflict, lack of will be experienced [7].
resources, and insufficient training [1]. Long term stress In recent years, there has been a substantial amount of
may affect hospitals through nurses’ dissatisfaction, research on the relationship between work stress and job
burnout, poor performance, or turnover intention [2–5]. performance. Some of this research revealed that high
Since nurses are the frontline staff of the healthcare work stress lead to low job performance [2]. However, a
team this can reduce the quality of health services. few studies found an inverted U-shaped relationship or a
Therefore, it is important for both nurses and their positive relationship between work stress and job per-
managers to take measures to reduce work stress. formance [8, 9]. Wu et al. asserted that a possible explan-
ation for these inconsistent results might be existing
variables to moderate the effect of stress on performance
* Correspondence: healthlaw@[Link]; hydsuntao@[Link];
lihuafan@[Link]
[10]. A broad range of variables have been considered as
1
Department of Health Management, School of Public Health, Harbin potential moderators such as emotional intelligence,
Medical University, Baojian Road 157, Harbin, China organizational commitment, and supportive leadership
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Li et al. BMC Health Services Research (2017) 17:401 Page 2 of 8

[11, 12]. Folkman’s study showed that effective coping study was approved by Medical Ethic Committee of Harbin
strategies can avoid or reduce stress levels [13]. Medical University.
According to the Transactional Model of Stress, coping
is an integral element in the stress process because coping Assessment tools
strategies can help alleviate the effects of stressors on Job performance scale
strains [14]. In this study, we used a 5-item scale developed by
Previous studies have identified two main types of coping Williams and Anderson to examine in-role job per-
strategies: emotion-focused and problem-focused strategies formance (e.g. “I effectively fulfilled my roles and re-
[13]. Later analyses subdivided emotional-focused strategies sponsibilities concerning the hospital’s proposal
into escape-avoidance, distancing, self-control, and positive assignment”) [19, 20]. This self-report tool asked
reappraisal [15]. Other researchers have categorized coping participants to rate their responses on a 7-point scale
strategies into positive or constructive coping and negative ranging from 1 (highly disagree) to 7 (highly agree).
or destructive coping [16]. Then, scores were averaged across items to form a
Recent research revealed that coping strategies played an scale score. In terms of reliability, the Cronbach’s
important moderating role in work stress and well-being as alpha of the task performance scale in the present
well as job satisfaction among nurses and administrators study was 0.85. The result of correlation test showed
[17, 18]. However, there continues to be a lack of informa- that there was a significant correlation between the aver-
tion on the moderating effects of coping strategies on work aged scores and individual score of five items, which
stress and job performance for Chinese nurses. proved to be of good validity (correlation = 0.47–0.75).
Based on the Transactional Model of Stress, the aim of
this study was to examine the moderating effects of Work stress scale
coping strategies on work stress and job performance. Taking into consideration the Chinese cultural background
Specifically, we explore: (a) the levels of work stress, cop- of participants and acceptable reliabilities of available
ing strategies, and job performance that occurs in nursing; instruments, work stress was measured with a 35-item scale
(b) the associations among stress, coping strategies, and developed by Li and Liu which named Chinese Nurse Job
job performance; and (c) whether coping strategies mod- Stressors Questionnaire (e.g. “few opportunities for im-
erate the relationship between work stress and job provement”) [21]. This scale is composed of five subscales
performance. (i.e., Nursing Profession and Clinical Duty, Workload and
Time, Working Environment and Resources, Patient Care,
Methods and Management and Interpersonal Relationship).
Sample Respondents were asked to indicate the strength of their
A cross-sectional questionnaire survey was conducted in agreement with the statements on a 4-point scale ranging
Heilongjiang Province, China, from September 2013 to from 1 (highly disagree) to 4 (highly agree). The scale
December 2013. Two tertiary university-affiliated hospitals achieved reasonable reliability in our sample, obtaining an
and two tertiary non-affiliated hospitals were selected. overall Cronbach’s alpha of 0.92. In addition, the Cronbach’s
There were 8–10 types of clinical departments in these four alpha for the individual scales ranged from 0.81 to 0.88.
hospitals. One sub-department was randomly selected in Scores of 35items were averaged to form the general work
each kind of clinical department in each hospital. The data stress scores. We identified the general work stress as
were collected anonymously and the participants criterion validity. The result of correlation test showed that
completed the questionnaires privately to ensure confiden- there was a significant correlation between five
tiality. The questionnaire included a cover page explaining subscales of work stress and the general work stress.
the purposes and procedures of the study. Respondents (Correlation = 0.39–0.76).
were assured that participation in the survey was voluntary,
and the return of questionnaires represented informed con- Coping strategies scale
sent. Nurses who take part in the survey were able to The 20-item version of the Simple Coping Style Scale,
choose the best time to complete the questionnaire. Most which was developed by Xie was used to examine coping
questionnaires were collected on site by the investigator on strategies used by nurses [22]. The scale classified coping
the day of the visit. If some nurses did not finish that day, strategies into positive coping (12 items) (e.g. “looking
investigators set a date to retrieve the questionnaires. The for support from family or friends, utilizing others’ ways
questionnaire was relatively brief and no private personal of dealing with similar problems”) and negative coping
information was collected. In total, 1057 questionnaires (8 items) (e.g. “procrastinating, relying on others, trying
were distributed and 1027 questionnaires were returned for to forget about everything”). Respondents were asked to
a response rate of 97.2%. However, 175 were incomplete or indicate the frequency that they used each strategy with
even blank, which left 852 (80.6) valid questionnaires. This a 4-point scale ranging from 0 (never used) to 3 (often
Li et al. BMC Health Services Research (2017) 17:401 Page 3 of 8

used). In the present study, the scale demonstrated ap- Table 1 Demographic characteristics of respondents (N = 852)
propriate reliability and the Cronbach’s alpha was 0.86. Variables N (%)
Scores of 20 items were averaged to form a scale score. Gender Female 822 (96.5)
We identified the scale score as criterion validity. The Age in years <25 242 (28.4)
result of correlation test showed that there was a
25–34 502 (58.9)
significant correlation between positive coping strategies,
negative coping strategies and the scale score. 35–44 76 (8.9)
(Correlation = 0.29–0.74). ≥45 32 (3.8)
Mean age 28.20 ± 6.85
Data analysis Marital status Married 388 (45.5)
In this study, survey results were analyzed using SPSS Others 457 (54.5)
V.19.0. There were four main components to the data
Educational level Secondary technical certificate 20 (2.4)
analysis. First, descriptive statistics were reported for
socioeconomic and demographic status, work stress, coping Associate degree 271 (31.8)
strategies, and job performance. Second, correlations Bachelor’s degree 544 (63.8)
among work stress, coping strategies, and job performance Master’s degree 17 (2.0)
were assessed using correlational analysis. Third, regression Professional title Nurse 393 (46.1)
analysis was conducted to test potential moderating effects Nurse Practitioner 290 (34.0)
[23]. Centered scores were used for the interaction terms to
Nurse-in-charge 121 (14.2)
avoid multicollinearity. Finally, significant interactions were
explored by examining conditional effects with contrasts Associate professor of nursing 32 (3.8)

and plots, and simple effects tests were conducted to Professor of nursing 16 (1.9)
determine whether the slopes significantly differed from Administrative position Nursing assistant 24 (2.8)
zero. A p-value of 0.05 was considered to have statistical Clinical nurse 692 (81.3)
significance. Group leader nurse 77 (9.0)
Head nurse 59 (6.9)
Results
Monthly income (RMB) ≤2000 52 (6.1)
Description of respondents
Table 1 reports participants’ socioeconomic and 2001–4000 453 (53.2)
demographic characteristics. Participants were predomin- 4001–6000 289 (33.9)
antly female (96.6%) and had attained a bachelor’s degree 6001–8000 41 (4.8)
(63.8%). Only 5.7% had a senior professional title. The >8000 17 (2.0)
average age was 28 years and 87.7% of respondents were
Tenure (years) <5 471 (55.3)
under 35 years of age. About 80% had worked less than
10 years in their current position. In terms of marital status, 6–10 205 (24.1)

45.5% were married and 54.5% were single, separated, or 11–15 82 (9.6)
divorced. ≥16 94 (11.0)
From Table 2 it can be seen that Nursing Profession and
Clinical Duty (M = 3.17, SD = 0.62) emerged as the major strategies (r = 0.09 ~ 0.23, p < 0.01). In addition, positive
stressor, followed by Workload and Time (M = 2.93, coping strategies were positively correlated with job
SD = 0.61), Working Environment and Resources performance (r = 0.28, p < 0.01) and negative coping
(M = 2.67, SD = 0.77), Patient Care (M = 2.55, SD = 0.63), strategies were negatively correlated with job performance
and Management and Interpersonal Relationship (r = −0.14, p < 0.01).
(M = 2.46, SD = 0.61). Mean scores of positive and negative
coping strategies were 1.98 (SD = 0.55) and 1.37, respect- Testing direct effects and moderating effects
ively. Results also indicated the average level of job per- Table 3 demonstrates the three models used to test the
formance was 5.64 (SD = 0.59). direct effect and moderating effects of work stress and
coping strategies on job performance. In Model 1, the
Correlations among the study variables inclusion of the five work stress subscales resulted in
The correlations among the study variables are presented Nursing Profession and Clinical Duty, Workload and
in Table 2. Each subscale of work stress had a significant Time, and Management and Interpersonal Relationship
negative correlation with job performance and positive as negative predictors of job performance (adjusted
coping strategies (r = −0.09 to −0.52, p < 0.01) and a R2 = 0.36, p < 0.01). In Model 2, the inclusion of five
significant positive correlation with negative coping work stress subscales and coping strategies resulted in
Li et al. BMC Health Services Research (2017) 17:401 Page 4 of 8

Table 2 Means, standard deviations (SD), and correlations among work stress, coping strategies and job performance
Mean SD 1 2 3 4 5 6 7
1. Management and Interpersonal Relationship 2.46 0.61
2. Nursing Profession and Clinical duty 3.17 0.62 0.283*
3. Workload and Time 2.93 0.61 0.474* 0.595*
4. Patient Care 2.55 0.63 0.539* 0.227* 0.374*
5. Working Environment and Resources 2.67 0.77 0.481* 0.348* 0.433* 0.369*
6. positive coping 1.98 0.55 −0.211* −0.089* −0.180* −0.131* −0.089*
7. negative coping 1.37 0.67 0.229* 0.080* 0.089* 0.218* 0.181* 0.153*
8. job performance 5.64 0.59 −0.522* −0.387* −0.413* −0.321* −0.404* 0.279* -0.142*
*P < 0.01

three subscales of work stress (i.e. Nursing Profession (β = 0.44, P < 0.01). Negative coping strategies
and Clinical Duty, Workload and Time, and Management moderated the relationship between Workload and Time
and Interpersonal Relationship). In addition, negative and job performance (β = −0.47, P < 0.01), and the
coping strategies were negative predictors, while positive relationship between Working Environment and Resources
coping strategies were positive predictors of job perform- and job performance (β = −0.53, P < 0.05).
ance (adjusted R2 = 0.41, P < 0.01). The significant moderations were probed following the
Model 3 augmented Model 2 through inclusion of the procedures recommended by Aiken and West [24]. The
interaction terms (Work Stress × Coping Strategies). We values of the moderators (positive coping strategies and
found that positive coping strategies moderated the negative coping strategies) were chosen 1 SD above and 1
relationship between Patient Care and job performance SD below the mean to form simple regression equations.

Table 3 Regression analysis for testing moderation effects of coping on work stress and job performance
Variables Model 1 Model 2 Model 3
β p β p β p
Subscales of work stress
Nursing profession & clinical duty −0.39 0.00 −0.32 0.00 −0.31 0.04
Workload & time −0.19 0.00 −0.25 0.00 −0.51 0.00
Working environment & resources −0.06 0.12 −0.06 0.11 0.34 0.04
Patient care −0.00 0.97 0.03 0.44 −0.42 0.00
Management & interpersonal relationship −0.12 0.00 −0.10 0.00 0.16 0.25
Subscales of coping strategies
Positive coping strategies 0.24 0.00 0.22 0.00
Negative coping strategies −0.12 0.00 −0.16 0.00
Subscales of work stress × coping strategies
Nursing Profession and Clinical Duty × positive coping −0.18 0.43
Workload and Time × positive coping 0.045 0.81
Working Environment and Resources × positive coping −0.257 0.24
Patient care × positive coping 0.436 0.01
Management and Interpersonal Relationship × positive coping −0.054 0.73
Nursing Profession and Clinical Duty × negative coping 0.150 0.43
Workload & Time × negative coping −0.468 0.01
Working Environment and Resources × negative coping −0.531 0.01
Patient Care × negative coping 0.319 0.07
Management and Interpersonal Relationship × negative coping −0.327 0.06
Adj. R2 0.36* 0.41* 0.42*
R2-change 0.36* 0.05* 0.02*
*P < 0.01
Li et al. BMC Health Services Research (2017) 17:401 Page 5 of 8

Simple regression lines were generated by entering the that with an increase in work stress, nurses who used less
values of the latent benefit variable 1 SD above and 1 SD negative coping strategies reported significantly higher job
below the mean in the simple regression equation that performance than those who used more negative coping
was formed in the previous step. The interaction was then strategies.
plotted for each of the significant interaction terms to
demonstrate effect of coping strategies on the relationship Discussion
between work stress and job performance. The current study was one of the first of its kind to inves-
Plots illustrating the significant moderations are displayed tigate the moderating effects of coping strategies on work
in Figs. 1, 2 and 3. Simple effects tests were conducted to stress and job performance among nurses in China.
determine whether the slopes significantly differed from Results indicated that nurses used positive coping strat-
zero (Aiken and West, 1991). The significant interaction egies more frequently than negative coping strategies. We
term for Patient Care × positive coping strategies indicated also found that coping strategies had moderating effects
that for both more positive coping strategies (F = 92.54, on some of the work stress subscales and job
p < 0.01) and less positive coping strategies (F = 36.43, performance.
p < 0.01), increasing levels of work stress associated with In order to test the direct and moderating effects of
decreasing levels of job performance. It also indicated that, coping strategies on work stress and job performance, a
with an increase in work stress, participants who used more regression analysis was conducted (Table 3). First, when
positive coping strategies reported significantly higher job work stress variables were used (Model 1, Table 3), three
performance than those who used less positive coping subscales of work stress (i.e., Nursing Profession and
strategies. Clinical Duty, Workload and Time, and Management
The significant interaction term for Workload and Time and Interpersonal Relationship) had direct negative ef-
× negative coping strategies indicated that for less negative fects on job performance. These findings were consistent
coping strategies, increasing levels of work stress were with previous studies that reported that excessive work-
associated with decreasing levels of job performance load, lack of opportunities for promotion, and a lack of
(F = 67.49, P < 0.01) (Fig. 2). For more negative coping respect were major negative predictors of job perform-
strategies, no association was found between levels of ance [25].
work stress and levels of job performance. The significant Second, including negative predictors of job perform-
interaction term for Working Environment and Resources ance into the analysis produced a significant increase in
× negative coping strategies indicated that for both more the variance explained in job performance (Model 2,
negative strategies (F = 21.17, P < 0.01) and less negative Table 3). This finding supports our expectation that
strategies (F = 48.17, P < 0.01), increasing levels of work coping strategies would help explain job performance.
stress were associated with decreasing levels of job Consistent with the study by Lu et al., positive coping
performance (Fig. 2). Furthermore, Figs. 2 and 3 indicated strategies were positively related to job performance and

Fig. 1 Moderation of positive coping on patient care stress and job performance
Li et al. BMC Health Services Research (2017) 17:401 Page 6 of 8

Fig. 2 Moderation of negative coping on workload & time stress and job performance

negative coping strategies were negatively related to job that methods of coping with stress had an impact and
performance [26]. exerted an influence on job performance [27]. Taken to-
Furthermore, inclusion of the interaction terms (Stressors gether; the present findings have significant implications for
X Coping strategies) accounted for a larger proportion of both managers and nurses in their efforts to improve job
the explained variance (Model 3, Table 3), indicating that performance.
coping strategies had a moderating effect. Specifically, we First, since work-related stress is negatively related to
found that positive coping (e.g. looking for support from job performance, managers should pay more attention to
family or friends, utilizing others’ ways of dealing with simi- the stress level of the nurses they work with. This study
lar problems) could reduce or buffer the negative effects of found that Nursing Profession and Clinical Duty was the
Patient Care on job performance. Negative coping strat- highest perceived workplace stressor, followed by Work-
egies (e.g. procrastinating, relying on others, trying to forget load and Time. Both of these factors were negatively re-
about everything) can strengthen the negative effects of lated to job performance. Similarly, a substantial amount
“Workload and Time” and “Working Environment & of existing research suggested that workload and profes-
Resources” on job performance. Similarly, Atteya found sional and career issues were primary work stressors for

Fig. 3 Moderation of negative coping on working environment & resources stress and job performance
Li et al. BMC Health Services Research (2017) 17:401 Page 7 of 8

nurses in China [23, 28–30]. There are several possible managers should utilize multiple measures to help nurses
reasons for these findings. First, Chinese nurses have a to reduce work stress.
relatively low social status and experience a lack of recog-
nition by others. They often complain of verbal or physical Limitations
violence by patients and their families. Second, compared Three limitations of this study should be noted. First, per-
to other health technical workers, nurses have few oppor- formance was obtained from self-reports. Respondents
tunities for promotion and further study [21]. Further- may have underestimated or overestimated the level of
more, excessive documentation and shortage of nurses their own performance. As we know, job performance can
increases nurses’ workload [31]. be assessed by objective indicators or subjective indicators.
Second, nurses should adopt more positive coping Different hospitals may have different performance
strategies when faced with stress. This study revealed evaluation index system, so it is difficult to assess job
that positive coping strategies could reduce or buffer the performance by objective indicators. Subjective assess can
negative effect of stress on job performance. Overall, be reported by supervisors, colleagues and oneself. Job
respondents tended to use more positive than negative performance obtained from supervisors or colleagues may
coping strategies contend with work stress. However, also reflect bias in reporting and the anticipated cost is
when work stress increased, the usage of positive coping high. So we use self-rated performance take into account
strategies decreased and negative coping strategies in- the data availability, the accuracy and the cost. We
creased (Table 2). Therefore organizations should create recognized that this self- administration bias might have
an environment that encourages workers to use more affected the results. Second, we used a cross-sectional sur-
positive coping strategies when experiencing stress. The vey, which may limit our ability to identify causal relation-
managers should investigate and analyze the causes and ships between work stress and job performance. Thirdly,
types of work stress, help nurses to recognize the stress this study was based on a small sample of nurses in
and their own coping styles, and then make detailed tertiary hospitals, which may limit the generalisability of
stress-reduction plan for nurses on the level of the research findings. University-affiliated hospitals and
organization. In the meanwhile, managers should carry non-affiliated hospitals may take on different tasks and
out training about positive mood management, provide workload, so a multistage, stratified sampling design was
relevant information, and knowledge on stress manage- employed to ensure that study data were representative.
ment for nurses. Besides that, organizations can let In this study, two tertiary and two tertiary non-affiliated
nurses think their work is meaningful and beneficial hospitals were selected. There were 8–10 types of clinical
work by developing scientific evaluation system based departments in these four hospitals. One sub-department
on key performance indicators. was randomly selected in each kind of clinical department
Thirdly, coping strategies can only partly moderate the in each hospital.
effects of work stress on job performance. Furthermore,
the moderating effects on job performance were smaller Acknowledgements
We are thankful to all the nurses who participated in the study. We are also
under high stress than under low stress. Consequently, grateful to heads of the nursing departments of these four hospitals, who
managers should take multiple measures to help nurses have worked closely with the team to ensure the field survey is successfully
to reduce their work stress and in turn to improve the implemented.
job performance such as creating a safe working
Funding
environment, establishing adequate infrastructure and This study was funded by Young Seed Foundation of Public Health College
other resources, allocating a reasonable workload, and of Harbin Medical University.
providing support when nurses experience challenges.
Availability of data and materials
The data supporting our findings will not be shared, because we have
promised respondents not disclose any information in the questionnaire.
Conclusion
This study was a preliminary attempt to explore the rela- Authors’ contributions
LL was responsible for the study design, data analysis, the drafts and the
tionship between work stress, coping strategies, and job final manuscript. HA and LG, who contributed equally as the first author,
performance for nurses in China. Results of this study were responsible for study design, data collection and data analysis. HZ
indicate that positive coping strategies moderated the rela- provided statistical expertise. XL, ZZ and RP carried out data collection and
technical support. LF and TS provided administrative support. All authors
tionship between Patient Care and job performance, while read and approved the final manuscript.
negative coping strategies moderated the relationship
between Workload and time and job performance as well Competing interests
The authors declare that they have no competing interests.
as between Working environment and resources and per-
formance. As coping strategies can only moderate the ef- Consent for publication
fects of some subscales of work stress on job performance, Not applicable.
Li et al. BMC Health Services Research (2017) 17:401 Page 8 of 8

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