Employment anxiety and its relationship with student nurse interns’ social support and job-seeking ecacy : a path analysis

Purpose This study was intended to explore the relationship of employment anxiety with student nurse interns’ social support and job-seeking ecacy. Method: This was a cross-sectional study conducted from three tertiary hospitals in Hunan Province, China.Student nurse interns were recruited conveniently from March to May 2020, to complete a questionnaire, which included demographic information, occupation anxiety of college students, job-seeking ecacy of college students, and social support scale. Descriptive statistics were used to summarize sample characteristics, while Pearson's correlation analysis was used to explore the relationship specied in the purpose of this study. Multiple linear regression analysis was used to determine factors that inuenced employment anxiety of student nurse interns, and then these factors were included in a path analysis model. imposed indirect by intermediate


Introduction
Clinical practicum experiences prepare student nurses for a smooth transition into professional nursing roles in that they translate classroom nursing skills, knowledge and judgment into clinical work [1] Numerous studies have reported that nursing students regard the practicum experience as one of the most anxiety-inducing aspects in the nursing curriculum [2][3] because it requires them not only to manage social and personal challenges related to attending university, but also to deal with additional demands associated with clinical practicums [4][5].As they come closer to the end of the nursing practice, the prospects of nding employment become one of the particular sources contributing to anxiety. In recent years, the number of quali ed nurses has been increasing rapidly due to the in ux of nursing colleges in China, In 2020, novel Coronavirus epidemic hit local economies hard, and the employment pressure of graduates in all countries increased dramatically,hence increasing the prevalence of unemployment among nursing graduates in China, which has in uenced many of them to be constantly looking for employment elsewhere [6].
Finding a job is generally a stressful and challenging process, associated with discouragement, frustration and anxiety. Employment anxiety can lead to ineffective learning, performance, and unhealth outcomes [7][8].In addition, previous studies showed that job self-e cacy was a predictor of employment anxiety.among graduates [9][10]. Also, higher levels of job-seeking self-e cacy have been found to be positively associated with lower anxiety [11]However, there has been no study on the relationship between employment anxiety and job seeking e cacy among student nurse interns. Another variable widely studied is social support. Social support has been identi ed as a protective factor for mental health [12], and is known to regulate the effects of stress on anxiety [13].

Literature Review
There were over 4 million registered nurses in China by 2018, with more than 70% of them having bachelor's degree [14]. The number of nursing graduates in China is increasing by about 150,000 every year. Therefore, the job market for quali ed nurses in China is correspondingly becoming highly competitive [6].thus leading to the growing prevalence of employment anxiety, which is an adverse emotion produced in the face of employment problems [15]. Alternatively, employment anxiety is a kind of nervous, uneasy, intense and lasting emotional experience, which is triggered psychologically and causes corresponding changes in cognition, physiology and behavior [7,15]. The prevalence of employment anxiety among student nurse interns ranged between 31.0% and 40.7% [16][17]. Numerous studies have demonstrated that unemployment exerted a negative impact on mental health. Young job seekers are exposed to considerable stress and vulnerable to mental disorders. However, few studies have examined the mental health status of young job seekers despite anxiety found to be a prominent issue among the Student Nurse Interns [18]. Previous studies have shown that mental health problems of nursing students were associated with self-esteem, stress and coping e cacy, and skills [19]. For instance, positive selfesteem enables students to cope with problems more effectively and is effective in the protection of their mental health.
In addition, job-seeking e cacy, also known as career decision-making self-e cacy, refers to the selfassessment and con dence of individuals in their ability to successfully complete various behavioral processes and achieve behavioral goals in the process of career choice s [20]. It was put forward after the self-e cacy theory was developed, and it was related to the job-seeking behavior process [21][22]. Jobseeking is a self-regulatory process in uenced by several variables [11].Among these variables, jobseeking e cacy has a principal role. A research [10] has shown that trait anxiety and positive in uence were important predictors of career decision-making self-e cacy. In the eld of nursing, most domestic researchers mainly focus on the curren situation and in uencing factors of job-seeking e cacy, and few studies focus on job -seeking e cacy and employment anxiety [9]. Furthermore, social support has a positive effect on coping with stress and thus, safeguards mental health [18]. Employment involves both personal and social factors; hence lack of social support could leave young job seekers in a state of crisis simply because this group stands at the crossroads of independence and were vulnerable to deviance and loneliness [22].Most studies have shown that social support can improve an individual's poor state of mental health due to stress, and can act as an intermediary factor between psychological stress and mental health [19,23]The main sources of social support for nursing students were their families, schools, practice units, parents and friends [12][13]24]. A growing number of studies have showed that lower levels of social support were negatively related to anxiety, whereas higher levels of social support could reduce anxiety among job seekers [25][26].
In summary, although some studies have recorded the characteristics of nursing students' anxiety, employment e cacy and social support, little was known about the employment anxiety of Student Nurse Interns and its relationship with job-seeking e cacy and social support in the context of China.
Therefore, the purpose of this study was to investigate employment anxiety and its association with social support and job-seeking e cacy among Student Nurse Interns in China. Additionally, a path analysis was used to explore the direct and indirect associations between risk factors and employment anxiety among the study subjects.

Theoretical Framework
Jiang put forward the stress reaction theory [27]in 2014 In this theory,interaction of various stressors can lead to physical, psychological and behavioral reaction. Various situations faced by nursing students in the process of employment included employment pressure, frustration and dilemma. The variables mediated by stress included social support, coping style, cognitive evaluation and personality characteristics of nursing students, and employment anxiety [28]. Based on this theory, this study made the following assumptions: employment anxiety was a psychological stress reaction under the mediating effect of job-seeking e ciency and social support. That is, when nursing students faced the stress of jobseeking, mediating variables affected their level of employment anxiety.

Design, Sample and Procedure
This was a cross-sectional study conducted from March to May 2020, Convenient sampling was used to recruit subjects from three tertiary hospitals. The inclusion criteria were as follows: 1) full-time training nursing students; 2) Student Nurse Interns in hospital; 3) nursing students in the nal year of educational system; and 4) nursing students preparing for job-seeking at the time of the study. The exclusion criteria were as follows: 1) nursing students unwilling to work; 2) nursing students preparing for postgraduate school or study abroad; and 3) not nursing students. All participants were given an informed consent to participate in the study, and they anonymously completed the questionnaires during the intensive training.
The reported prevalence of employment anxiety among nursing students was about 0.47 [29]. Therefore, the following sample size formula for cross-sectional studies was used to estimate a required sample size for this study: N=([µ_(α⁄ )]^2 π(1-π)) /δ^2, where parameters were assigned the following values: α was 0.05; detection π was 0.47; and allowable error, δ, was 0.05[] (Li Zheng, 2016). In this regard, minimum sample size was 375. Considering 20% of sample turnover, the nal sample size was determined as no less than 450 cases.

Demographic information
Measured demographic information included age, gender, permanent residence, type of degree, priority factors for choosing a career, whether employment training was received or not and GPA (grade point average).

Employment Anxiety Questionnaire
Employment anxiety was measured using the Employment Anxiety Questionnaire [30]. developed by Yu in 2009. The questionnaire comprises 26 items rated on a 5-point Likert scale (0 = strongly disagree to 5 = strongly agree). The 26-items form 4 subscales: pressure of employment competition (7 items), lack of employment support (6 items), lack of self-con dence (7 items), and worry about the employment prospects (6 items). The total score is calculated as the sum of points yielded by all the 26 items and this total score ranges between 26 and 130. Higher total scores indicate greater levels of employment anxiety. This questionnaire has shown good reliability. For example, the reliability and internal consistency coe cient of the questionnaire were 0.79 and 0.92, respectively [31] .

Job-seeking e cacy scale
The Chinese version of job-seeking e cacy scale short form (CDMSE-SF) [32] was used to measure jobseeking e cacy. This scale has 25 items and ve dimensions: self -assessment (5 items), information collecting (5 items), target selection (5 items), planning (5 items) and problem solving (5 items). Each item is rated on a 5-point Likert scale ("0 = no con dence" to "5 = fully con dent"). The total score ranges from 25-125, and higher scores indicate greater levels of job-seeking e cacy. The reliability of the scale was 0.851, and the homogeneity was 0.895.

Social support scale
Social support scale [23](Shui-yuan Xiao,1994) consists of three subscales with 10 items: objective support (3 items), subjective support (4 items) and the utilization degree of social support (3 items). Each item is scored from 1 to 4 points with total scores ranging from 11 to 53. The higher the score, the higher the degree of social support people have. The scale has been widely used in China. Cronbach's alpha coe cients of the total scale and three subscales were 0.770, 0.650, 0.680 and 0.710, respectively. 4.3 Data analysis SPSS 21.0 software(IBM Corp, Armonk, New York, USA) was used for data analysis. Double entry was used to establish database, and the data were checked again before processing. Descriptive statistics were calculated to describe the general characteristics of the sample. Correlation analysis was performed to examine relationships between job-seeking e cacy, employment anxiety and social support. In addition, multiple linear regression analysis was performed to determine factors that in uenced employment anxiety of the subjects, and then these factors were included in a path analysis model. The reported con dence intervals (CIs) were calculated at the 95% level and statistical signi cance was twosided and set at the 5% level.

Sample Characteristics
Sample characteristics are shown in Table 1. A total of 560 student nurse interns were issued questionnaires, but only 534 questionnaires were completed, representing a recovery rate of 95.4%. Nevertheless, 40 of the 534 questionnaires had considerable missing data and they were excluded; hence 494 valid questionnaires were included for analysis. Of the 494 subjects, 85.8% were female. Besides, mean age was 20.3 ± 2.12 years (range from 18 to 24). Also, majority of the subjects had a college degree (56.7%), followed by a bachelor's degree (41.7%). The common job intention was to engage in clinical nursing (81.6%). Location of workplace was the priority considered in job-seeking.   Table 3. The average total score of social support for nursing students was 37.80±6.05. The average total score of objective support was 7.11±2.38; the average total score of subjective support was 21.99±3.66; and the average total score of social support utilization was 8.69±1.86. Table 4 shows the result. Pearson correlation analysis results showed that employment anxiety was negatively correlated with jobseeking e cacy and social support, which was statistically signi cant. The results are shown in Table 5.

Multiple linear regression analysis of the associated factors of employment anxiety
In the multiple linear regression model, employment anxiety was a dependent variable, whereas demographic characteristics, job-seeking e cacy and social support were independent variables. The results identi ed four factors, including job-seeking e cacy, social support, Priority factors for nding job and received employment training, which were associated with employment anxiety. Lower job-seeking e cacy and social support contributed to higher employment anxiety. Student nurse interns who had received employment training had lower anxiety. Table 6 shows the details.

Discussion
Both existing nurses and nal year nursing students who will soon be on the job market are important human resources for health in the long term. There has been a greater demand from health institutions for nurses, especially for nurses with higher educational levels [33],Judging from the growth rate of nurses in the past 10 years, the importance of nurse supplement has attracted the attention of the national government in China [34].
The purpose of this study is to investigate the status of employment anxiety, job-hunting e ciency and social support among nursing students of their internship during the new Coronavera and analyze the relationship between them.The results of this study showed that the average total score of employment anxiety of student nurse interns was 71.49±17.28, suggesting that student nurse interns were generally in the state of anxiety. As regards the average scores of the four dimensions, it could be seen that the main cause of employment anxiety of student nurse interns was the lack of employment support, followed by the lack of self-con dence, worry about the employment prospects and employment competition pressure. Moreover, lack of employment support was the main source of employment pressure. These results are consistent with those of most studies conducted on nursing students. Employment anxiety is not a particular phenomenon for nursing students. Actually, it is very common among the Chinese graduates in general. For example, recent research results showed that some college graduates form incorrect employment perceptions, resulting in excessive anxiety experience in nding a job [35].This study found that job-seeking e cacy had the greatest effect and direct impact on employment anxiety. This result is comparable with those of previous studies, which indicated that job-seeking e cacy could reduce employment anxiety [17,36] .Students with high self-e cacy tend to be more con dent. That is, they are more con dent in choosing the target and collecting information related to the process of job hunting. They can also solve problems during the employment process more easily and make better career plans for themselves. Therefore, this explains why lower job-seeking e cacy was associated with high anxiety in this study. The factors associated with job-seeking e cacy were previously found to be the specialty identity degree and employment prospects [37] Those ndings implied that there is need for interventions targeting at improving specialty identity degree so as to decrease employment anxiety [38]. Furthermore, this study showed that social support had both direct and indirect impact on employment anxiety with a signi cant weak negative linear correlation. Similarly, previous studies found that low levels of social support were associated with high levels of anxiety, stress, and depression in college students. Besides, Glozah [39] reported that perceived social support could protect students from suffering mental health problems. Additionally, social support was not only signi cantly related to college students' psychological wellbeing but also their overall academic performance [40]. Thus, these ndings suggest that overall social support of students is signi cantly negatively associated with their levels of depression, anxiety and stress. The mechanism of social support on anxiety is not clear. Liu's study [41] showed that the sources and ways of social support were different, and there were signi cant differences in the degree of anxiety among college students. Some studies suggested that social support could enhance people's stress levels and play an important role in alleviating anxiety. In this regard, low social support given to nursing students may be related to their lack of social experience as well as low ability to seek for social support [42].Therefore, nursing students should also be taught social support seeking skills so that they would not lose out on the needed social support.
Additionally, priority factors for nding job and received employment training were inversely associated with employment anxiety in this study. Nursing students have their priority factors when nding jobs, such as salary, workplace location etc. However, the ideal employment was in con ict with serious employment situation, which could lead to anxiety [36]. Student nurse interns who had received adequate employment training had lower anxiety. Employment training programs have been offered to students in many colleges in China to reduce job-seeking anxiety in college graduates [17]. These programs aim to give students an employment overview, and help them to analyze situations in employment, which would cultivate student's ability to conduct a process of nding jobs successfully [25].
In China, with the increasing number of nursing students and the gradual saturation of nursing posts, employment anxiety has become an important mental health problem during the later period of nursing practice [16]. Therefore, interventions targeted at reducing employment anxiety among nursing graduates should include awareness campaigns for nursing educators to make them aware of the prevalence of employment anxiety among Student Nurse Interns, its implications and associated factors, because this would help the nursing educators to effectively implement technological and educational interventions for reducing this problem. In addition, this study found that job-seeking e cacy was predictive of employment anxiety, implying that paying attention to the improvement of students' self-e cacy would have positive signi cance to students' active employment. Social support also has a signi cant weakening, and relieving effect on psychological problems. For example, support from family, school and society can improve the self-e cacy of nursing students and further relieve their employment anxiety. Accordingly, it is suggested that nursing students should improve their job-seeking e ciency by learning about the employment situation and needs, participating in internships, serving as class cadres and participating in extracurricular activities. Moreover, teachers in schools and hospitals should strengthen employment guidance, such as vocational guidance and psychological counseling in order to relieve the employment anxiety of nursing students and improve their enthusiasm in nursing work.
There were some limitations in this study. The sample was drawn from three hospitals. The results may limit generalizability to other settings. Sample selection using convenience sampling method and the use of a self-reported data collection tool are among the limitations of the study.

Conclusions
The level of employment anxiety of nursing students is high,,Job-seeking e cacy was found to have the greatest effect on employment anxiety among the student nurse interns, followed by social support and then priority factors for nding a job. The impact of social support and having received employment training on employment anxiety were mediated by job-seeking e cacy. These ndings implied a need to develop policies for early interventions Strengthen psychosocial support, improve the e ciency of job selection to improve e cacy, and combining those policies with a long-term social support network, so as to prevent employment anxiety among the student nurse interns in China.

Con ict of interest
There is no con ict of interest.

Ethical Approval
This study was approved by the institutional review board of XiangYa Nursing School of Central South University (IRB no. 2018038) Funding Figure 1 Path analysis of employment anxiety among the Student Nurse Interns