The study on influencing factors of nurses' job engagement in 3-Grade Hospitals in east China: a cross-sectional study

doi:10.21203/rs.3.rs-2452972/v1

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Research Article

The study on influencing factors of nurses' job engagement in 3-Grade Hospitals in east China: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-2452972/v1

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Objectives

Nurses' job stress perception and psychological capital affect their job engagement. This paper explores the effects of demographic characteristics, mental workload, and AQ on the job engagement of nurses in 12 hospitals in East China.

Methods

A cross-sectional study was conducted with a convenience sample. Data collection was performed from July 2020 to March 2021. Mean Rank and Median were used for descriptive statistical analysis. Mann–Whitney U Test and Kruskal–Wallis H Test compared the difference of different groups. Spearman correlation analysis was conduct to detect the correlation between mental workload, AQ, and job engagement. Binary logistic regression analysis explored the predictors and abilities of job engagement.

Results

labor and personnel relations, department, annual salary, marital satisfaction, social support, whether there is financial pressure or not, significant stresssignificant stress in the last six months, attitudes towards the nursing profession, attitude towards the current career position, the organization provides opportunities for further study, religious belief, study to get a degree or certificate in spare time were all influencing factors of job engagement. Job engagement has a remarkable positive correlation with AQ (r = 0.623, p＜0.001) and a negative correlation with mental workload (r = − 0.422, p＜0.001). Mental workload has an apparent negative correlation with AQ (r = − 0.250, p＜0.001). Department, study to get a degree or certificate in spare time, self-assessment, and endurance predicted nurses' job engagement.

Conclusions

This study is based on the JD-R model, and the results are helpful in understanding the effects of demographic characteristics, mental workload (job requirements), and AQ (job resources) on the job engagement of nurses. It is necessary to take a variety of measures according to the social-demographic characteristics, improve the AQ of hospital nurses, and evaluate the mental workload correctly, to improve the job engagement of nurses.

Nurses

Adversity quotient

Mental workload

Job Engagement

Nurses play a crucial part in preventing COVID-19, preventing its spread, and providing nursing services for patients as one of the largest groups of healthcare providers in the country. But they face with a higher risk of infection and an increasing workload when providing care services to patients[1]. A survey on nurses’ job burnout after the epidemic found that emotional exhaustion, job apathy, and lack of job achievement were much more severe than their own before the outbreak in China, mainly considering that the nurses faced the double burden of routine treatment, epidemic prevention and control during the fight against COVID-19. Nurses must be on the front line to do many job content, such as diagnosis, screening, medical observation, and specimen collection[2]. In addition, some nursing staff had been sent out to support in other affected areas by the hospital administrators, which increased the work tasks, and psychological pressure of the left-behind nurses indirectly then increased job burnout. Nursing staff with a high sense of job burnout have low job engagement.

Job engagement refers to the high degree of physical and psychological involvement of individuals in activities, which means the degree to which a person identifies with their work psychologically, and the degree to which they attach importance to themselves[3]. Work engagement is a positive, fulfilling state of mind about work in the nursing profession, which is characterised by vigour, dedication, and absorption[4]. Vigor means vital energy, psychological resilience, and eagerness to commit exertion in one's worth of effort. Absorption refers to being wholly concentrated and joy in one's cost of effort and having the challengeof detaching oneself from work. Dedication is characterized as high levels of involvement in one's cost of effort and a sense of meaningfulness, pride, challenge, inspiration, and enthusiasm[5].

The job demands-resources model (JD-R model) is a model used by management to study work. It believes that work conditions are divided into job demands, such as physical, psychological, social, or organizational aspects of work requiring effort and, or skills, and job resources, such as physical, psychological, social, or administrative aspects of work helping to achieve goals and reducing work pressure. The employee distress levels and engagement may be influenced by both of these job characteristics[6]. The JD-R model consists of two potential psychological processes: exhaustion and motivational processes. The exhaustion process thinks that high work demands in the absence of job resources will cause distress. The motivational process predicts that the presence of job resources will contribute to higher engagement and productivity [7–9])Promoting job engagement is the most direct way to improve job performance effectively, and it can help to improve the quality of nursing and ensure patient safety[10–13]. Previous research showed that success at work is associated with personal characteristics (e.g., job engagement, psychological capital, psychological contract ) and relationship characteristics (e.g., perceived organizational support[14–16]). Job engagement is affected by many factors, which can be divided into individual elements and organizational factors[17–19]. Personal factors include personal traits, occupational characteristics, family problems, and job orientation, and personality factors include stress, self-efficacy, and optimism[20–23]. Organizational factors mainly include realistic environment and social support.

The mental workload of nurses refers to the psychological load that nurses bear when completing nursing tasks, including cognitive and emotional loads. It is essential to guarantee the medical staff makes correct clinical decisions and ensures patient safety when bearing appropriate psychological burden[24.]High workload and stress affect job performance[25]. Job engagement is negatively correlated with workload[26], especially with the frustration dimension. Nurses’ perceived workload can predict their stress[27]. A study found that workload is negatively correlated with job engagement. That is to say, a lack of human and material resources will increase nurses' workload, thereby increasing job burnout and reducing job engagement [19].

The Adversity quotient (AQ) is an individual’s emotional state and reaction mode when encountering adversity. It indicates how individuals can manage difficulties and turn obstacles into opportunities when facing failure or frustration[28]. AQ has four dimensions, control, ownership, reach, and endurance, namely, which constitute the CORE model. AQ can not only predict a person’s career success but also predict, and influence all aspects of a person’s ability and performance[29]. In particular, a high mental workload will increase physical fatigue and mental stress in the clinical environment, hurt the work involvement of nurses potentially. According to a review of previous studies, with a significant positive correlation between AQ and job engagement[30], those who have a high AQ will see adversity as a specific event, feel capable of handling and minimizing its negative influence[31], and perform more efficiently and effectively[32]. Improving AQ is a correct view of difficulties and setbacks, failure and success, keeping hope in adversity, and an optimistic mentality. It is also a psychological ability to view the workload in nursing work correctly.

The purpose of this study is to explore the influencing function of demographic characteristics, mental workload, and AQ on job engagement of 3-grade hospital nurses in China, and provide a quantitative basis for improving their job engagement.

Design and Data Collection

The study was designed as a cross-sectional descriptive research adopting a convenient sampling method. The survey was conducted in Chinese, and online inquiry achieved through the Questionnaire network, the survey platform using self-report questionnaires from July 2020 to March 2021. Samples were selected based on informed consent, and respondents completed the questionnaires independently. To achieve better anonymity, their identities and name information have not been revealed in this study.

Sample and Setting

Participants were all registered nurses who were working in 12 hospitals, including the First Affiliated Hospital of Zhejiang University, the Second Affiliated Hospital of Zhejiang University, Zhejiang Provincial People’s Hospital, The First People’s Hospital of Hangzhou, the Second People’s Hospital of Hangzhou, and Zhejiang Provincial Hospital of Traditional Chinese Medicine, etc. Inclusion criteria were as follows: (a) nurses who have obtained the registered nurse qualification certificate. (b) nurses who were engaging in clinical nursing work. (c) nurses who agreed to join in this study. Exclusion criteria included (a) nurses who were not primarily involved in patient care and (b) nurses who could not participate in the study due to leaving or studying abroad during the survey. The effective questionnaire was determined by eliminating the fact that there was too many difference between the average answer time, and the choices presented some rules such as zigzag answers. A total of 25 discarded questionnaires were destroyed, and the actual valid questionnaires were 473, with an effective rate of 94.98%.

Measures

The questionnaire comprises a total of 76 items: 21 questions were used to describe the participants’ demographic characteristics, nine measurement items were used to measure job engagement, six things were for measuring mental workload, and 40 articles were to measure the AQ of nurses. The demographic characteristics Questionnaire was designed by the researcher, including gender, labor relations, length of service in nursing, education, job title, marital status, etc.

NASA Mission Load Index Scale for Nurses[33]: The National Aeronautics and Space Administration Task Load Index (NASA-TLX) developed by Hart[34]was designed to investigate the psychological load of nurses at work. The NASA task load index scale for nurses is formed through translation, back-translation, and cultural adjustment. It comprises six items: mental requirement, physical requirement, time limit requirement, effort level, self-expression, and frustration. NASA-TLX is divided into two dimensions: load feeling and self-assessment. Item score is marked with a line divided into 20 equal points representing 0–20 points, indicating mental workload from “low” to “high”; the item of “performance” is “perfect” to “failure” from left to right. The lower the score is, the more perfect the self-performance, and the lower the workload is. The higher the score is, the more failed the self-performance and the higher the workload are. Dimensions are divided into the sum of the corresponding item points, and the total score is the sum of all item points. The scale has good reliability and validity, and the internal consistency coefficient is 0.782. In this study, Cronbach's α coefficient of the scale was 0.756.

Job engagement scale[35]: we used the simplified version of the Utrecht Work Engagement Scale-9, compiled by Schaufeli[36]. The scale consists of nine items and three dimensions, namely, vigor, absorption in one’s work, and dedication, each of which contains three things. A Likert seven-point scale was used for the scale, and 0–6 points were assigned to “never,” “hardly,” “rarely,” “sometimes,” “often,” “usually,” and “always.” The total score was 0–54. The higher the score means, the higher the nurse’s job engagement is. The Cronbach’s α coefficient of the scale was 0.854 in this study.

The adversity quotient scale[37]: This study adopts the Adversity Response Profile compiled by Paul Stoltz (1997 ) and translated and revised by Li Bingquan and Chen Canrui[38], which mainly comprises four dimensions, control, ownership, reach, and endurance, including 20 types of adversity, and 40 entries. A 5-point Likert scale was used for each item, with a total score of 40–200. The higher the score means, the higher the AQ is. Stoltz divided the adversity quotient into five grades: very high (166–200), high (135–165), medium (95–134), low (60–94), and very low (< 59). The scoring standards of each dimension were as follows: low (10–23 points), medium (24–37 points), and high (38–50 points), and Cronbach's α coefficient of the scale was 0.76. In this study, it was 0.905.

Data Analysis

The collected data were analyzed using IBM SSPS 25.0. A descriptive statistical method was applied regarding the characteristics of the sample and research variables. Categorical variables were expressed as numbers and percentages, and continuous variables were expressed as mean ± standard deviation (SD). We tested that the normal distribution of the data was unsatisfactory. We compared the job engagement of individuals with different demographic variables using the Mann–Whitney U Test and the Kruskal–Wallis H Test. The correlation analysis results among them were processed using Spearman correlation coefficients. We divided SRL scores into binary variables with median values. The Box-Tidwell method tested the linearity between the continuous independent variable and the logit conversion value of the dependent variable. A total of 18 items were included in the linear test model, and the significance level after the Bonferroni correction was 0.0028. The linear test results showed a linear relationship between all continuous independent variables and the conversion values of the dependent variable logit. The binary logistic regression analysis was used to explore the influencing factors of job engagement. A p-value of < 0.05 and P < 0.01 were considered statistically significant.

Ethical Consideration

The protocol for this study was approved by the Ethics Review Committee of the Institutional Review Board of Zhejiang Shu Ren University(NO:20221022). The research process was conducted under the Declaration of Helsinki and its later amendments. Nurses were assured that participation was voluntary and they could withdraw anytime if they wanted to without any punishment.

Most respondents were female (n = 425, 89.85%). The average age was 26.38(SD = 1.76) ,most of them were 25 years-35 Years(51.59%). Those whose labor and personnel relations are compiled were the majority (n = 304, 64.27%), and length of service in nursing was mostly comprised of 2–5 years:114(24.10%),6–10 years: 120(25.37%),11–20 years:112(23.68%). A 30.23% proportion of respondents were in Internal medicine. The majority (n = 415, 87.74%) had an undergraduate record of formal schooling. Nurse-in-charge has the largest proportion(43.34%). Nurses with an annual salary of CNY100,000 to CNY150,000 yuan and CNY160,000 to CNY200,000 yuan take up a larger proportion, accounting for 36.58%, and 35.10%, respectively. The proportion of married (n = 283, 59.83%) was larger than other marital statuses. 62.37 percent of nurses were satisfied with their marriages. The proportion with better social support was 50.32%. The proportion of those with larger financial pressure was slightly higher, at 30.87%. 79.28% of nurses had no significant stress in the last six months. The proportion of nurses with a general attitude towards the nursing profession was slightly higher, at 46.30%.45.67 percent of nurses were satisfied with their current career position. 58.77% of nurses think that it is tough for nurses to be promoted, and 80.55% of nurses think that nursing scientific research is complicated. The majority (39.53%) thought that opportunities for further study were average. 84.57 percent of nurses had no religious belief. The proportion of nurses who still study in their spare time to obtain a degree or certificate was relatively low, at 47.99 percent. Most of them are the non-only children (62.37%). Table 1 presents the general characteristics of the participants, Mean Rank, Median, non-parametric test, and post-hoc test of job involvement. There are significant differences between different groups, such as labor and personnel relations, department, annual salary, marital satisfaction, social support, whether there is financial pressure or not, significant stress in the last six months, attitudes towards the nursing profession, attitude towards the current career position, the organization provides opportunities for further study, religious belief, study to get a degree or diploma in their spare time.

Table 1

**The results of Mean Rank, Median and non-parametric test and post-hoc test of job engagement**
Variables	N (%)	Mean Rank(Median)	P Value (pairwise comparisons)
Gender
Male	48(10.15)	225.34(41.00)	0.533
Female	425(89.85)	238.32(42.00)	0.533
Age
＜25 years	84(17.76)	224.74(42.00)	0.076
25 years to 35 years	244(51.59)	245.15(42.00)
36 years and 40 years	89(18.82)	250.06(42.00)
＞40 years	56(11.84)	199.13(39.00)
Labor and personnel relations
Have compiled	304(64.27)	270.49(44.00)	0.000
No staffing	169(35.73)	176.76(39.00)	0.000
Length of service in nursing
＜2 years	77(16.28)	230.97(43.00)	0.789
2–5 years	114(24.10)	241.7(42.00)
6–10 years	120(25.37)	247.35(44.00)
11–20 years	112(23.68)	231.77(41.00)
＞20 years	50(10.57)	222.44(39.50)
Department
Internal medicine	143(30.23)	243.27(43.00)	0.000
Surgery	126(26.64)	279.43(45.00)	(5 − 2,7 − 2)
Outpatient clinic	19(4.02)	193.24(39.00)
Emergency	11(2.33)	174.27(36.00)
ICU	43(9.09)	194.60(39.00)
Pediatrics	17(3.59)	174.26(38.00)
Others	114(24.10)	220.93(41.00)
Record of formal schooling
Technical secondary school	11(2.33)	213.73(39.00)	0.597
Specialized subject	20(4.23)	209.90(43.00)
Undergraduates	415(87.74)	240.19(42.00)
Master degree or above	27(5.71)	217.56(39.00)
The title
The nurse	75(15.86)	212.58(41.00)	0.261
Nurse practitioner	176(37.21)	240.15(42.00)
Nurse-in-charge	205(43.34)	245.54(42.00)
Deputy director nurse or above	17(3.59)	209.18(42.00)
Annual salary
＜CNY 100,000	69(14.59)	196.67(39.00)	0.044
CNY100,000-150,000	173(36.58)	239.45(42.00)	(1–3)
CNY160,000-200,000	166(35.10)	255.60(43.00)
CNY210,000–250,000	52(10.99)	229.75(41.00)
＞CNY 250,000	13(2.75)	210.08(41.00)
Marital status
Unmarried	164(34.67)	236.68(42.00)	0.514
Married	283(59.83)	241.39(41.00)
Divorced	9(1.90)	197.56(39.00)
Death of a spouse	6(1.27)	193.67(43.00)
Remarried	11(2.33)	184.64(42.00)
Marital satisfaction
Very satisfied	120(25.37)	300.34(47.00)	0.000
Be satisfied	295(62.37)	216.88(41.00)	(1–4,1–2,1–3)
In general	49(10.36)	218.40(41.00)
Not satisfied	9(1.90)	153.33(39.00)
Social support
Very good	131(27.70)	318.24(47.00)	0.000
Better	238(50.32)	217.57(40.00)	(4 − 3,4 − 2,4 − 1,3 − 1,2 − 1)
In general	89(18.82)	195.01(39.00)
Not so good	15(3.17)	84.83(35.00)
Financial pressure
Very large	65(13.74)	288.95(46.00)	0.010
Larger	146(30.87)	227.19(41.00)	(3 − 1,2 − 1)
In general	202(42.71)	222.66(41.00)
Smaller	45(9.51)	254.93(44.00)
No pressure	15(3.17)	246.77(43.00)
Significant stress in the last six months
Yes	98(20.72)	196.19(39.00)	0.001
No	375(79.28)	247.66(42.00)	0.001
Attitudes towards the nursing profession
Like very much	34(7.19)	409.41(55.50)	0.000
Prefer	192(40.59)	284.49(44.50)	(5 − 1,4 − 2,4-1.3-2,3 − 1,2 − 1)
In general	219(46.30)	184.71(39.00)
Don't like much	25(5.29)	113.10(38.00)
Hate	3(0.63)	93.50(29.00)
Attitude towards the current career position
Very satisfied	34(7.19)	391.37(49.50)	0.000
More satisfied	216(45.67)	285.97(45.00)	(5 − 3,5 − 2,5 − 1,4 − 2,4 − 1,3 − 2,3 − 1,2 − 1)
In general	195(41.23)	178.03(39.00)
Less satisfied	13(2.75)	149.62(39.00)
Not satisfied	15(3.17)	24.27(29.00)
The difficulty of promotion in nursing profession
High	278(58.77)	228.51(41.00)	0.145
Average	183(38.69)	251.90(43.00)
Low	12(2.54)	206.38(40.50)
The pressure of nursing science research
High	381(80.55)	236.67(42.00)	0.404
Average	83(17.55)	244.64(42.00)
Low	9(1.90)	180.33(38.00)
Opportunities for further study
A lot	32(6.77)	381.31(52.00)	0.000
More	156(32.98)	265.68(44.00)	(5 − 3,5 − 2,5 − 1,4 − 2,4 − 1,3 − 2,3 − 1,2 − 1)
Average	187(39.53)	215.67(41.00)
Less	82(17.34)	201.37(39.00)
None	16(3.38)	100.75(35.00)
Religious belief
Yes	73(15.43)	267.77(43.00)	0.036
No	400(84.57)	231.38(41.00)	0.036
Study to get a degree or diploma in their spare time
Yes	227(47.99)	271.41(43.00)	0.000
No	246(52.01)	205.25(39.00)	0.000
Whether they are the only child or not
Yes	178(37.63)	240.98(42.00)	0.622
No	295(62.37)	234.60(42.00)	0.622

As shown in Table 2, job engagement has a remarkable positive correlation with AQ (r = 0.623, p < 0.001) and a negative correlation with mental workload (r = − 0.422, p < 0.001). Mental workload has an apparent negative correlation with AQ (r = − 0.250, p < 0.001).

Table 2

**Correlation analysis of mental workload,AQ and job engagement**
Variables	1	2	3	4	5	6	7	8	9	10	11	12
1	1.000
2	0.889^**	1.000
3	0.873^**	0.770^**	1.000
4	0.836^**	0.644^**	0.619^**	1.000
5	-0.422^**	-0.426^**	-0.400^**	-0.347^**	1.000
6	-0.368^**	-0.383^**	-0.398^**	-0.281^**	0.941^**	1.000
7	-0.383^**	-0.361^**	-0.271^**	-0.387^**	0.669^**	0.408^**	1.000
8	0.623^**	0.561^**	0.552^**	0.544^**	-0.250^**	-0.215^**	-0.246^**	1.000
9	0.555^**	0.502^**	0.450^**	0.513^**	-0.321^**	-0.303^**	-0.230^**	0.842^**	1.000
10	0.297^**	0.258^**	0.297^**	0.254^**	-0.144^**	-0.143^**	-0.115^*	0.643^**	0.396^**	1.000
11	0.477^**	0.479^**	0.401^**	0.397^**	-0.073	-0.026	-0.176^**	0.810^**	0.558^**	0.501^**	1.000
12	0.576^**	0.534^**	0.550^**	0.484^**	-0.282^**	-0.243^**	-0.281^**	0.817^**	0.644^**	0.429^**	0.600^**	1.000

Note: 1 ~ 12 represent the job engagement, vigor, dedication, absorption in one^’s work, mental workload, load feelings, self-assessment, AQ, control, ownership reach, and endurance, respectively; 1) P < 0.01.

The results of binary logistic regression analysis on job engagement are shown in Table 3. Binary Logistic regression was used to evaluate the effects of demographic characteristics, mental workload, and AQ on the high job engagement of the subjects. The reference category is Last. The Logistic regression model was able to classify 89.4.0% of the observations correctly. 88.8% of nurses with high job engagement were predicted to have high job engagement by the model. 90.9% of nurses with low job engagement were expected to have low job engagement by the model. The positive predictive value and negative predictive value were 90.99 and 87.92%, respectively.

Among the independent variables included in the model, department, study to get a degree or certificate in spare time, self-assessment, and endurance had statistical significance. The multiple high job engagement of internal medicine and surgical nurses increased by 4.658, and 6.343 times, respectively, compared with nurses in other departments. Nurses who study to get a degree or certificate in their spare time increased their job engagement by 3.648 times, the multiple of high job engagement decreased by 10.6% for every point increase of self-assessment in mental workload. The tolerance range of AQ increased by one point. Its high job engagement multiplied by 36.6%%.

Table 3

**The results of binary logistic regression analysis on job engagement**
	B	S.E.	Sig.	Exp(B)	95% C.I.for EXP(B)
	B	S.E.	Sig.	Exp(B)	Lower	Upper
Labor and personnel relations(1)	0.294	0.395	0.457	1.341	0.619	2.908
Department			0.002
Department(1)	1.733	0.492	0.000	5.658	2.156	14.849
Department(2)	1.994	0.509	0.000	7.343	2.708	19.913
Department(3)	0.867	0.817	0.289	2.379	0.479	11.811
Department(4)	-0.384	1.356	0.777	0.681	0.048	9.715
Department(5)	0.811	0.648	0.211	2.250	0.632	8.013
Department(6)	0.459	1.019	0.653	1.582	0.215	11.657
Annual salary			0.000
Annual salary(1)	-1.2	1.345	0.373	0.301	0.022	4.209
Annual salary(2)	2.093	1.229	0.089	8.106	0.728	90.213
Annual salary(3)	0.277	1.216	0.820	1.319	0.122	14.304
Annual salary(4)	-0.596	1.258	0.636	0.551	0.047	6.486
Marital satisfaction			0.916
Marital satisfaction(1)	-0.458	2.42	0.850	0.633	0.006	72.680
Marital satisfaction(2)	-0.653	2.375	0.783	0.521	0.005	54.720
Marital satisfaction(3)	-0.271	2.432	0.911	0.763	0.006	89.629
Social support			0.000
Social supporti(1)	3.594	2.001	0.072	36.375	0.721	1835.480
Social support(2)	0.719	1.917	0.708	2.052	0.048	87.864
Social support(3)	1.423	2.009	0.479	4.148	0.081	212.726
Financial pressure			0.086
Financial pressure (1)	0.169	1.297	0.896	1.184	0.093	15.037
Financial pressure (2)	-1.286	1.187	0.278	0.276	0.027	2.829
Financial pressure (3)	-1.681	1.169	0.150	0.186	0.019	1.841
Financial pressure (4)	-1.753	1.272	0.168	0.173	0.014	2.095
Significant stress in the last six months	-0.465	0.508	0.360	0.628	0.232	1.700
-1	-0.465	0.508	0.360	0.628	0.232	1.700
Attitudes towards the nursing profession			0.032
Attitudes towards the nursing profession(1)	-17.459	6850.804	0.998	0.000	0.000
Attitudes towards the nursing profession(2)	-19.143	6850.804	0.998	0.000	0.000
Attitudes towards the nursing profession(3)	-20.413	6850.804	0.998	0.000	0.000
Attitudes towards the nursing profession(4)	-19.542	6850.804	0.998	0.000	0.000
Attitude towards the current career position			0.000
Attitude towards the current career position(1)	53.955	10924.131	0.996	################	0.000
Attitude towards the current career position(2)	34.186	9652.676	0.997	################	0.000
Attitude towards the current career position(3)	31.811	9652.676	0.997	################	0.000
Attitude towards the current career position(4)	31.647	9652.676	0.997	################	0.000
Opportunities for further study			0.084
Opportunities for further study (1)	1.112	2.547	0.662	3.039	0.021	447.205
Opportunities for further study (2)	2.739	2.332	0.240	15.475	0.160	1495.470
Opportunities for further study (3)	3.299	2.348	0.160	27.081	0.272	2700.932
Opportunities for further study (4)	2.163	2.388	0.365	8.699	0.081	938.540
Religious belief(1)	0.176	0.554	0.751	1.192	0.403	3.531
Study to get a degree or diploma in their spare time	1.537	0.362	0.000	4.648	2.286	9.451
-1	1.537	0.362	0.000	4.648	2.286	9.451
Load feelings	0	0.022	0.996	1.000	0.958	1.044
Self-assessment	-0.112	0.049	0.020	0.894	0.813	0.983
Control	0.028	0.042	0.500	1.028	0.948	1.116
Ownership	0.112	0.06	0.060	1.118	0.995	1.257
Reach	-0.052	0.067	0.435	0.949	0.833	1.082
Endurance	0.312	0.078	0.000	1.366	1.173	1.591
Constant	-28.102	6800.141	0.997	0.000

The chi-square value of the model is 369.09, p value is 0.000, Percentage Correct is 89.4. (1), (2), (3), (4), (5) and (6) are respectively dummy variable Settings for the sequential classification of corresponding classification variables.

During the COVID-19 epidemic, clinical nurses are under more significant pressure and responsibility than usual and are prone to negative emotions such as anxiety and depression. Clinical nurses were in the face of adversity, that is, the epidemic outbreak, and their physical and mental workload increased. Therefore, it is essential to understand the influencing factors of nurses' job engagement in 3-grade hospitals for efficient intervention to improve nurses' job engagement.

This study found no difference in gender, marital status, working years, monthly income, and educational background of nurses, which was similar to the results of Hu's research[39]. The differences mainly included the following aspects: First, the level of job involvement of nurses having compiled was significantly higher than that of nurses without staff. At present, China's third-class hospitals employ large-scale labor dispatch nurses to solve the problem of insuffcienit and shortage of nursing staff [40]. But the nurses who have compiled have better benefits(Ownership of archives, payment of wages, retirement benefits), and their work is more stable. However, the development prospect of No staffing nurses is worrying, which may lead to a reduction of their job engagement.

Secondly, this study found that the job engagement of surgical nurses was significantly different from that of nurses in pediatrics and other departments, which was different from Wang's study[41] that there was no difference between departments. This may be related to the short hospital stay of surgical patients, high admission and discharge rate, and relatively high salaries of nurses. Nurses in outpatient and supply departments work more efficiently than nurses in clinical departments. And there are no night shifts, so it doesn't require a lot of job engagement. The rapid progress and change of pediatric diseases, coupled with the easy occurrence of nurse-patient conflicts in pediatrics, increase pediatric nurses' job burnout and affect their job engagement. Regression analysis showed that the multiple high job engagement of internal medicine and surgical nurses increased by 4.658 and 6.343 times, respectively, compared with nurses in other departments. The buffering hypothesis of JD-R theory[42], shows that nurses, even in clinical work, face high job requirements. However, much clinical nursing knowledge and rich labor remuneration can be used as beneficial psychological capital and work resources to effectively buffer the loss of employees with high work requirements and increase job engagement.Thirdly, this study finds that the annual salary of CNY160,000-200,000 is better than that of nurses < CNY 100,000, indicating that the work effort has been rewarded accordingly, which stimulates nurses' enthusiasm. Some literature showed that job engagement is closely related to financial return, job performance, turnover intention, and employee creativity [43–46]. This result is different from Wang's [41].opinion that annual household income does not affect the job involvement of dental nurses. Also in Hu's[39] study of nurses in the emergency department, it was found that monthly salary did not affect their job engagement. Nurses with tremendous financial pressure have a higher level of job engagement. Considering that Hangzhou is a city with high housing prices and consumption, many nurses are under stress, such as mortgage repayment, and are more afraid of unemployment and losing stable salary support, so they work more carefully.

Fourthly, in terms of marriage and social support, the nurses with better marital satisfaction and social support have a higher level of job engagement. Support from family and society is a working resource that promotes job engagement. In a happy marriage, family members can give the individuals sufficient family support, which can provide individuals with emotional dependence and relaxation experience, help individuals resist pressure, improve happiness and maintain physical and mental health, and improve the level of job engagement correspondingly [47]. Studies have shown that social support, performance feedback, skill diversity, autonomy, and learning opportunities from managers and colleagues are positively correlate with job engagement [48]. At the same time, single nurses have less family support, which hurts their level of job engagement[49]. Fifthly, the results of this study showed that nurses' satisfaction with their nursing careers and their current position is closely related to their job engagement. This is consistent with the research results of Zou [50]. A higher sense of professional identity can form positive emotions and stimulate the clinical work of nurses, thus improving the level of job engagement in clinical nursing work. Occupational identity can promote job satisfaction through the single mediating effect and chain mediating effect of psychological empowerment and job engagement[51]. Studies [52] have shown that the higher the sense of organizational support nurses feel, the higher the level of job engagement. Sixth, nurses who had more opportunities for further study and study after work had higher levels of job engagement. A study found that job resources, such as employee empowerment, management support, feedback, and development opportunities, and personal resources, such as self-efficacy and optimism, are predictive factors of job engagement[53]. The nurses can further enrich their professional knowledge, and improve their professional skills through further study, thus forming positive feedback and improving their work efficiency and job satisfaction. And get more job engagement in work. Regression analysis results also confirmed that the job involvement of nurses who went to school in their spare time increased by 3.648 times. According to the JD-R theory, learning, and further study, these positive work factors that promote personal growth, learning, and development are all work resources which can encourage job involvement.In addition, the results of this study showed that the level of job engagement of nurses with religious beliefs was higher than that of nurses without it. It showed that the nursing profession itself has the spirit of dedication, and many religions also promote the spirit of sacrifice and commitment, and the higher level of dedication of nursing staff will lead to the essence of higher work commitment[54].Nurses who had not experienced significant stress in the last six months had higher levels of job engagement. Maintaining high levels of engagement over time depends on frequent positive experiences. Without sustained reinforcement, job engagement is likely to fade and decline significantly in daily work[55]. A martphone-based stress management progress could improve job engagement among Vietnamese nurses, which demonstrated that stress could affect job engagement indirectly[56].

Some studies found that the working pressure on nurses was at a moderately high level during the epidemic. The scores of different stressors from high to low were hospital protection, concern and expectation, self-psychology, disease-related problems, patient treatment, and work environment[57]. Workload includes objective workload and subjective workload. Subjective workload refers to the workload perceived by medical staff and is often measured by their personal feelings[24]. The mental workload was often linked to human performance and mental health[58]. The mental workload can indirectly lead to fatigue through stress and emotional disorders, thus highly predicting the level of job engagement[59]. Nursing managers are advised to guide the nurses to reinforce the correct perception of stress and respond positively. The mental workload w negatively correlated with job engagement in this study. The result was consistent with Wang’s study[60], which study found that after adjusting nurses’ population and occupation factors, job engagement of clinical nurses increased by 0.331 units for every 1 unit reduction in department-level workload. By contrast, the self-perceived workload was more correlated, consistent with Zhang’s research results[61]. This result indicated that nurses’ subjective workloads, such as nurse-patient ratio, relative working hours, nurse-patient conflict, and work difficulty, have a more significant impact on job engagement than those objective loads(labor intensity and working hours). As nurses with physical and mental labor, a specific power of workload is conducive to improving work performance and job engagement. The regression analysis found that with each increase of one point in the self-assessment dimension of the mental workload, the multiple of high job engagement was reduced by 10.6%. That is, the more the candidate's self-performance failure, frustration feeling more vigorous, as a negative factor in the work consumption of individual energy, and increased the psychological cost related to the job requirements, is bound to affect their work involvement.

In this study, AQ is positively correlated with job engagement, consistent with Liang’s research results[62]. Still, the correlations were vigor, absorption in one’s work, and dedication. Individuals with high AQ are more productive and creative, which can help them keep healthy, energetic, and happy to achieve better results. A positive, healthy mentality and stable spirit are conducive to job engagement undoubtedly. The regression analysis also confirmed that Endurance, one of the AQ dimensions, increased by one point, and the multiple high job engagement increased by 36.6%. People with high AQ would think that adversity would not exist for a long time, thus reducing the consumption of internal work resources and promoting job engagement.

In summary, improving the AQ level of clinical nurses is crucial to promote the smooth implementation of nursing work. As a result, assessing mental workload reasonably, enhancing the control of adversity, the sense of responsibility, and cultivating a positive perspective on the influence and scope of adversity can promote the mental health of clinical nurses effectively, to improve their work enthusiasm and job engagement, and thus ensure the quality of nursing. In previous studies, embedded adversity training education could improve the AQ level of nursing undergraduates[63], as well as correct attribution education[64]. AQ-related courses were also developed to master the psychological characteristics of different nurses and take individual measures to improve the ability of nurses to resist setbacks[65]

Limitations

It is essential to note that this study only included nurses from Grade 3, Class A hospitals in Hangzhou as subjects. It lacks Grade 2 hospital nurses and community nurses sampling, and lacks sample sources from the capital cities of under-developed provinces and regions in China. This study cannot represent Chinese regions with different economic and medical conditions, which is relatively limited. In addition, a self-evaluation questionnaire was adopted, lacking objective indicators. If the exploration results of the relationship between job engagement, mental workload, and AQ are extrapolated to other regions, it should be cautious. In this study, only some demographic characteristics, mental workload (job requirements), and AQ (job resources) were selected to explore the influencing factors of nurses' job engagement in China's third-grade Grade-A hospitals. As for the JD-R model, the research content has certain limitations. The research team will further explore other influencing factors of job engagement of hospital nurses and explore the practical effects of some interventions actively.

Based on the JD-R model, this study explored the influencing factors of job engagement of clinical nurses in China from the perspectives of sociodemographic characteristics, mental workload, and AQ. The results showed that having compiled, internal medicine or surgery department, annual salary, marital satisfaction, good social support, certain financial pressure, and no significant stress in the last six months, Satisfied with nursing career and satisfied with the present position, Study to get a degree or diploma in their spare time, and religious beliefs have high job engagement. Nurses who Study to get a degree or certificate in spare time, self-assessment in mental workload, and endurance in AQ can predict high job engagement of nurses. The results of this study have positive significance for guiding nurses to recognize mental workload correctly, and improving AQ, to promote their job engagement.

Ethics approval and consent to participate

The research conforms to the principles embodied in the Declaration of Helsinki. The Ethics Committee of the Institutional Review Board of Zhejiang Shu Ren University approved the study protocol (NO:20221022). We provided participants with information about their rights, study aims, ethical processing and preservation of data, and reporting of results. Participation was voluntary and written informed consent was sought from all participants.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available for the protection of the anonymity of the participants but are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research received funding：Scientific Research Project of Education Department of Zhejiang Province in 2020（Y202045141）, National Entrepreneurship Training Program for College Students of Zhejiang Province in 2020 (202011842026).

Authors’ contributions

Substantial contribution to study conception and design: Ling Li, Zhixian Feng, Mingling Zhu

Jialu Yang, Lili Yang. Data analysis: Ling Li, Lili Yang.Drafting of the manuscript: Ling Li

, Zhixian Feng, Lili Yang. All authors read and approved the final manuscript.

Acknowledgments

We are thankful for the generous contributions of the research participants and the staffs who assisted with data collection during the study.

Author details

1. Ling Li, School of Nursing, Zhejiang Shuren University, 8 Shuren Road, Hangzhou, ZheJiang 310015, PR China

2. Zhixian Feng, School of Nursing, Zhejiang Shuren University, 8 Shuren Road, Hangzhou, ZheJiang 310015, PR China

3.Mingling Zhu, School of nursing, Zhejiang Chinese Medical University, 548 Bin-wen Road, Hangzhou, Zhejiang 310053, PR China

4. Jialu Yang, School of Nursing, Zhejiang Shuren University, 8 Shuren Road, Hangzhou, ZheJiang 310015, PR China

5. Corresponding author: Lili Yang. School of nursing, Zhejiang Chinese Medical University, 548 Bin-wen Road, Hangzhou, Zhejiang 310053, PR China

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The study on influencing factors of nurses' job engagement in 3-Grade Hospitals in east China: a cross-sectional study

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