Figures
Abstract
Objectives
This study aimed to determine the potential association between core self-evaluation and the burnout syndrome among Chinese nurses, and the mediating role of coping styles in this relationship.
Methods
A cross-sectional survey was conducted in Shenyang, China, from May to July, 2013. A questionnaire which consisted of the Maslach Burnout Inventory-General Survey (MBI-GS), the Core Self-Evaluation Scale (CSE), and the Simplified Coping Style Questionnaire (CSQ), was completed by a total of 1,559 nurses. Hierarchical linear regression analyses and the Sobel test were performed to determine the mediating role of coping styles on the relationship between CSE and burnout.
Citation: Li X, Guan L, Chang H, Zhang B (2014) Core Self-Evaluation and Burnout among Nurses: The Mediating Role of Coping Styles. PLoS ONE 9(12): e115799. https://doi.org/10.1371/journal.pone.0115799
Editor: Delphine Sophie Courvoisier, University of Geneva, Switzerland
Received: September 12, 2014; Accepted: November 27, 2014; Published: December 26, 2014
Copyright: © 2014 Li et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper and its Supporting Information files.
Funding: The authors have no support or funding to report.
Competing interests: The authors have declared that no competing interests exist.
Background
Burnout is the result of continuous work pressures that are not effectively handled [1] and is defined by three dimensions: emotional exhaustion (EE), cynicism (CY) and reduced professional efficacy (PE). Emotional exhaustion refers to an individual being overextended emotionally, which leads to the depletion of an individual's resources. Cynicism refers to a negative, callous or excessively detached response to various aspects of the job. Reduced professional efficacy represents a general sense of one's inefficacy at work and to a feeling of lack of professional success and competency [2]. Burnout has been recognized as an occupational hazard in various people-oriented professions [3]. In the area of healthcare, nursing staff face high demands in terms of quality services, and are subjected to numerous stressful situations. Therefore, nurses are at risk of burnout [4]. A severe nursing shortage and an increase in demanding workload in terms of physical, emotional and moral stress, combined with comparatively low wages and devaluation of the profession have caused nurses to experience burnout in China. Burnout among nurses can result in mental fatigue, anxiety, lack of motivation, and absence from work [5], which undoubtedly threatens not only their own health, but also that of their patients. Therefore, the prevention of burnout among nurses is essential for improving the quality of patient care.
With regard to personal resources, traditional research on personality and burnout has focused on the Big Five personality dimensions and emotional affectivity [6], [7]. However, recently, Core self-evaluation (CSE) has received a great deal of attention in personality research. CSE, a broad personality concept, which describes an individual's evaluation about themselves, their ability, and their control, consists of four traits: self-esteem, general self-efficacy, locus of control, and neuroticism [8]. Numerous studies have reported that CSE significantly influenced salary [9], goal setting [10], job satisfaction [11], job performance [10], [12], career commitment [13], and job burnout [13], [14]. In addition, Spence Laschinger et al. identified the important role of CSE on nurse managers' burnout [15]. However, previous studies did not determine how CSE influences burnout.
Stress is accompanied by the process of coping [16]. Coping styles are defined as stable psychological and behavioral strategies to overcome or tolerate external and internal challenges or stressors [17]. Some people cope with stress actively, while others cope passively. Active coping strategies are either behavioral or psychological responses designed to change the nature of the stressor itself or how one thinks about it, whereas passive coping strategies lead people into activities (such as alcohol use) or mental states (such as withdrawal) which prevent them from directly addressing stressful events [18]. Coping behaviors of individuals contribute to the explanation of why exposure to the same stressors may cause burnout in some subjects, but not in others [19]. A study conducted in Hong Kong by Wang et al. indicated that making use of effective coping strategies plays a pivotal role in reducing stress among nurses [20]. The coping strategies used by nurses may vary with respect to their personal, psychological, and cultural factors [21]. A previous study reported that Chinese nurses tended to cope actively with stress associated with decreased personal achievement, but passively when the stress originated from resource and environment problems, patient care and interaction issues, and from interpersonal relationships and management issues [22], suggesting regional differences in the coping styles of nurses. According to previous studies, burnout can be alleviated by coping strategies. Active coping may protect against the negative impact of stressors on adaptive outcomes by strengthening the person's coping efficacy in a specific situation [4]. However, Payne et al. [23] concluded that the investigation of problem-focused and emotion-focused coping in relation to burnout, oversimplied the coping-burnout relationship in a sample of hospice nurses. The association between CSE and burnout and the association between coping styles and burnout have been investigated in previous studies [5], [13], [14], [15], [23]. In addition, Kammeyer-Mueller et al. [24] investigated the role of CSE in the coping process, and demonstrated that individuals with high CSE practice less avoidance coping. However, to our knowledge, there has been no integrative effort to examine coping styles as a mediator in the relationship between CSE and burnout.
Nurses need to care for themselves before they can provide care for their clients. Given the high stress, difference in coping styles, as well as high workload in Chinese nurses, there is a need to develop an educational program and strategies for the prevention of burnout among nurses. For this purpose, it is important to clarify the relationships between burnout, CSE, and coping styles among Chinese nurses. In the present study, we examined the relationship between CSE and burnout and determined the mediating role of coping styles on the relationship between CSE and burnout using a cross-sectional survey of 1,559 Chinese nurses from Shenyang, China.
Methods
Participants and procedure
A cross-sectional survey was conducted in Shenyang, China from May to July, 2013. Respondents in this study were selected from five hospitals which included three university-affiliated hospitals, one provincial tertiary hospital, and one municipal tertiary hospital. The inclusion criteria required that an individual held the RN licensure granted by the Ministry of Health, PR China and was currently working in one of the hospitals as a registered nurse. Head nurses and administrators were excluded. Anonymous questionnaires were distributed and collected during staff meetings in all hospital units by the researcher (the third author) over a 4-week period. A sample of 1995 clinical nurses was recruited and 1,662 questionnaires were returned (return rate: 83.3%). 103 questionnaires were discarded due to incomplete data, resulting in 1,559 analyzed questionnaires.
Ethical approval of the study was given by the medical ethics committee of China Medical University. All participants signed an informed consent form.
Instruments
Core Self-Evaluation Scale (CSE).
This scale was developed by Judge et al. [8] and is a 12-item self-report measure of CSE. Items are rated from 1 (strongly disagree) to 5 (strongly agree). The scale scores are the sum of the ratings of the items. Relevant items were reverse-coded. The Chinese version of the CSE has previously been used in the Chinese population and demonstrated good reliability and validity [25]. In this study, the Cronbach's alpha coefficient for CSE was 0.745.
Maslach Burnout Inventory–General Survey (MBI-GS).
The MBI-GS was developed by Maslach et al. [26], [27] and is a 15-item self-report measure of job burnout which includes three dimensions, emotional exhaustion, cynicism, and professional efficacy. The items are scored on a Likert scale from 0 (never) to 6 (every day). Higher scores on emotional exhaustion and cynicism dimensions and lower scores on professional efficacy dimension indicated higher levels of burnout. The Chinese version of the MBI has been widely used in Chinese studies and has demonstrated satisfactory reliability and validity [28], [29]. In the present study, Cronbach's alpha coefficients for the three dimensions of MBI-GS were 0.896, 0.747, and 0.825, respectively.
The Simplified Coping Style Questionnaire (CSQ).
This questionnaire developed by Xie YN [30] was based on the Ways of Coping questionnaire by Folkman and Lazarus [31] and is a 20-item self-report that includes two dimensions, active coping (12-item) and passive coping (8-item). The items were measured using four-point Likert scales (0 = never; 3 = very often). The instrument has been commonly used in China and the internal consistency measured by Cronbach's alpha was reported to be 0.78 [30]. In this study, the Cronbach's alpha coefficients for the two dimensions of SCSQ were 0.796 and 0.728, respectively.
Demographic data sheet.
Demographic data including gender, age, educational level, work experience, and job rank were obtained from a structured questionnaire.“Educational level”was categorized as “high school or under”, “junior college” and “undergraduate or above”. “job rank” was categorized as “junior nurse”, “senior nurse” and “nurse-in-charge”.
Statistics
Data were imported to the Epidata 3.1 database. All analyses were conducted using SPSS 17.0 for Windows and all statistical tests were two-sided (α = 0.05). The distributions of dimensions of burnout in categorical demographic characteristics were tested by one-way ANOVA. Pearson correlation was performed to test the relationship between core self-evaluation, coping styles, and burnout. Baron and Kenny's [32] technique was used to test the mediating effect of coping styles on the relationship between core self-evaluation and burnout. According to Baron and Kenny [32], the following conditions should be satisfied to establish mediation: (1) The independent variable (CSE) is significantly associated with the dependent variable (Emotional exhaustion/Cynicism/Professional efficacy), (2) the independent variable (CSE) is significantly associated with the mediator (Active coping/Passive coping), and (3) the mediator (Active coping/Passive coping) is significantly associated with the dependent variable (Emotional exhaustion/Cynicism/Professional efficacy), and the effect of the independent variable (CSE) on the dependent variable (Emotional exhaustion/Cynicism/Professional efficacy) reduces when the mediator (Active coping/Passive coping) is added to the model (partial mediator). If the independent variable does not affect the dependent variable when the mediator is added to the model, then full mediation is established.
Before performing the regression analyses, all the continuous variables were centered in order to avoid multicollinearity [33]. In addition, tolerance and the variance inflation factor were used to check for multicollinearity. We performed Pearson correlation and one hierarchical linear regression analysis for each of the three burnout dimensions to test the mediating effect. In step one of the hierarchical linear regression analyses, the control variables and positive results of variance analysis were added to the model. In the present study, we included gender, age, educational level, work experience and job rank in the model as potential confounders. Because educational level and job rank are categorical variables without a linear trend, dummy variables for these two variables were set. For educational level, “High school or under” was set as the reference group. For job rank, “junior nurse” was set as the reference group. In step 2, core self-evaluation was added. In step 3, active coping and passive coping were added.
In addition, the statistical significance of the mediation effect was confirmed using the Sobel test.
Results
The demographic and working characteristics of the subjects and the distribution of each dimension of burnout in the categorical items are shown in Table 1. Mean emotional exhaustion, cynicism, and professional efficacy differed across the age and work experience groups. Nurses aged 30–40 years had the highest scores in emotional exhaustion and cynicism and nurses aged over 40 years had the highest scores in professional efficacy. The group with 10–15 years work experience had the highest scores in the three dimensions of burnout. Mean emotional exhaustion and cynicism differed between male and female nurses. Female nurses were more easily affected by emotional exhaustion and cynicism. Mean emotional exhaustion and professional efficacy differed among the job rank groups. Senior nurses had the highest scores in emotional exhaustion, whereas nurse-in-charge had the highest scores in professional efficacy. In addition, mean professional efficacy differed across the education level groups. Nurses with an undergraduate degree or above had the highest scores in professional efficacy.
Pearson correlations
The results of Pearson correlation analysis among core self-evaluation, coping styles, and burnout are shown in Table 2. The CSE scale was significantly correlated with the dimensions of burnout (r = −0.343, −0.345, 0.282, P<0.01), where nurses with a higher score on the CSE scale had better professional efficacy, whereas nurses with a lower score on the CSE tended to be more susceptible to emotional exhaustion and cynicism. In addition, CSE was significantly associated with the dimensions of coping styles (r = 0.314, −0.254, P<0.01), where nurses with active coping styles were found to have a higher score on the CSE scale and passive coping styles had a negative impact on the CSE score.
The mediating role of coping styles on the relationship between CSE and emotional exhaustion
As shown in Table 3, both CSE score and active coping style were negatively associated with emotional exhaustion (β = −0.500 and −0.148, respectively, P<0.01), the higher the score on the CSE scale and the more active coping style a nursing professional had, the lower the chance of emotional exhaustion. Conversely, a positive correlation between emotional exhaustion and passive coping style was observed in our subjects (β = 0.308, P<0.01). Importantly, coping styles (Active coping/Passive coping) had a partial mediating effect on the relationship between CSE and emotional exhaustion, in that the regression coefficient for CSE was reduced when coping styles were added to the model (from β = 0.500 to β = 0.396). The result of the Sobel test confirmed the significance of the mediating effect of active coping (z = −5.66, P<0.001) and passive coping (z = −6.44, P<0.001). In addition, gender, age, and job rank affected emotional exhaustion.
The mediating role of coping styles on the relationship between CSE and cynicism
As shown in Table 4, both CSE and active coping style were negatively associated with cynicism (β = −0.390 and −0.107, respectively, P<0.01). However, negative coping style was positively associated with cynicism (β = 0.288, P<0.01). Coping style not only directly impacted the cynicism score, but also affected it indirectly by partially mediating the relationship between CSE and cynicism. The regression coefficient for CSE in relation to cynicism score was reduced from 0.39 to 0.303 (P<0.01) when coping styles were added to the regression analysis. The result of the Sobel test supported the significance of the mediating effect of active coping (z = −5.26, P<0.001) and passive coping (z = −7.00, P<0.001). In addition, gender, age, and work experience also affected cynicism.
The mediating role of coping styles on the relationship between CSE and professional efficacy
The impact of coping styles on professional efficacy is shown in Table 5. Both CSE and active coping style were positively associated with professional efficacy (β = 0.413 and 0.329, respectively, P <0.01). However, passive coping style was negatively associated with professional efficacy (β = −0.148, P <0.01). More importantly, coping styles (active coping/passive coping) indirectly affected professional efficacy by partially mediating the relationship between CSE and professional efficacy, in that the regression coefficient for CSE decreased when active coping/passive coping was added to the regression analysis (from β = 0.413 to β = 0.283, P<0.01). The result of the Sobel test supported the significance of the mediating effect of active coping (z = 8.47, P<0.001) and passive coping (z = 3.54, P<0.001).
Discussion
This study investigated the relationship between CSE, coping styles, and burnout dimensions among Chinese nurses, and demonstrated that CSE was an integrated personality variable that may affect job burnout, and coping styles might have both a direct and indirect effect on burnout. Our data suggest that strategies which promote active coping styles among nursing professionals may help to reduce job burnout, and thus enhance nursing efficacy. With regard to the relationship between CSE and burnout, CSE was shown by our study and others [13], [14] to be a possible predictor of job burnout. This was supported by our data which showed that nurses with higher CSE scores had less emotional exhaustion and cynicism and higher professional efficacy. CSE is a deep personality trait. Those with higher CSE scores will always have higher self-confidence and esteem, and a more positive attributive style [13], which may result in lower levels of emotional exhaustion and cynicism. CSE reflects the long-term faith of individuals in their ability to maintain a stable self and a sense of control, which are important in the evaluation of individual ability [34], [35]. Thus, those with a higher CSE score might have a higher level of professional efficacy.
Positive factors relating to the prevention of nursing burnout such as hardiness, active coping, and social support were found to be the most important buffering factors [4]. In the present study, active coping was negatively associated with emotional exhaustion and cynicism, and was positively associated with professional efficacy. These findings contribute to the understanding that coping styles have a significant effect on burnout, and active coping may be a positive resource for combating burnout.
As shown in Table 3, as passive coping increased, emotional exhaustion scores increased accordingly. This is consistent with Gibbons' study [36], where active coping and older age played a clear role in decreasing vulnerability to emotional exhaustion and cynicism. It appears that younger nurses experience more burnout than their older colleagues. This may indicate that with increased life experience, individuals might have a lower tendency to use passive coping styles and more confidence, thus have less burnout. Active coping is helpful in preventing cynicism, and this is in agreement with a previous study which found that active coping style can decrease the negative impact of stressors by strengthening one's coping efficacy and dynamics in a specific situation [4]. Dysfunctional coping strategies in nurses results in the deterioration of nurse-patient relationships, and failures are increasingly experienced leading to a gradual sense of lack of personal accomplishment [4]. Nurses who usually face disease, death and other situations tend to develop emotionally-negative characteristics, and feelings of emotional exhaustion. If no effective resources are adopted to cope with exhaustion, this will lead to cynicism and reduced professional efficacy. Conversely, when a successful coping style is adopted (e.g., active coping), nurses can achieve their goals and professional efficacy improves. Moreover, Folkman and Lazarus [31] stated that the problem-solving coping style can result in an improvement in the person-environment relationship, thus achieving a better cognitive appraisal and a more positive emotional response. An optimistic coping strategy can result in nurses using problem solving to deal with their difficulties to effectively reduce their stress levels [37].
Our study revealed that coping styles (Active coping/Passive coping) partially mediated the effects of CSE on emotional exhaustion, cynicism and professional efficacy. Nurses with lower CSE might be more likely to use passive coping which in turn leads to higher levels of emotional exhaustion and cynicism, and lower levels of professional efficacy. Compared to changing the CSE score in nurses, it might be more positive and feasible for hospitals to conduct nurse training on problem-solving skills with the goal of helping nurses develop and employ active coping styles to deal with the stress they face at work. This type of training would be expected to improve nurses' health and well-being and to reduce professional burnout, and thus improve the quality of healthcare.
Although the present study demonstrates the important role of self-evaluation and coping styles on job burnout among Chinese nursing professionals, there are limitations regarding the design of the study. Firstly, we conducted this study in large general hospitals, which may not necessarily reflect the burnout experienced by nurses in different hospitals and community health centers. Secondly, the study relied only on self-report measures which may have introduced bias. Therefore, future studies in different hospitals and consisting of more objective parameters, such as behavioral and physiological indicators, as well as broader influencing factors, will provide more insightful knowledge regarding the inter-relationships between self-evaluation, coping styles, and nursing burnout. In addition, this was a cross-sectional study, thus the causality could not been established in this study. Prospective studies should be conducted in the future to confirm the findings obtained in this study.
Conclusions
The present study demonstrated that CSE may be a possible predictor of job burnout among nursing professionals, indicating that nurses with a high CSE score display less burnout. More importantly, coping style might be an important factor which can affect burnout directly or indirectly by partially mediating the relationship between CSE and job burnout. Our results suggest that when active coping strategies are adopted, burnout is likely to be reduced. Therefore, interventions focused on the improvement of coping strategies may be helpful in the prevention of job burnout in nurses, thus enhancing nursing care efficacy.
Supporting Information
S1 Table.
The clinical data of 1559 nurses, which were analyzed in this study.
https://doi.org/10.1371/journal.pone.0115799.s001
(XLS)
Acknowledgments
We would like to give our heartfelt thanks to all the nurses who participated in this study.
Author Contributions
Conceived and designed the experiments: XFL BZ. Performed the experiments: HC LG. Analyzed the data: HC. Contributed reagents/materials/analysis tools: XFL LG. Wrote the paper: XFL BZ.
References
- 1. Lin QH, Jiang CQ, Lam TH (2013) The relationship between occupational stress, burnout, and turnover intention among managerial staff from a Sino-Japanese joint venture in Guangzhou, China. J Occup Health 55:458–467.
- 2. Leiter MP, Maslach C (2009) Nurse turnover: the mediating role of burnout. J Nurs Manag 17:331–339.
- 3. Wang Y, Chang Y, Fu J, Wang L (2012) Work-family conflict and burnout among Chinese female nurses: the mediating effect of psychological capital. BMC Public Health 12:915.
- 4. Garrosa E, Rainho C, Moreno-Jimenez B, Monteiro MJ (2010) The relationship between job stressors, hardy personality, coping resources and burnout in a sample of nurses: a correlational study at two time points. Int J Nurs Stud 47:205–215.
- 5.
Wang S, Liu Y, Wang L (2013) Nurse burnout: Personal and environmental factors as predictors. Int J Nurs Pract.
- 6. Bakker AB, Van der Zee KI, Lewig KA, Dollard MF (2006) The relationship between the Big Five personality factors and burnout: a study among volunteer counselors. J Soc Psychol 146:31–50.
- 7. Hurtz GM, Donovan JJ (2000) Personality and job performance: the Big Five revisited. J Appl Psychol 85:869–879.
- 8. Judge TA, Erez A, Bono JE, Thoresen CJ (2003) The core self-evaluations scale: development of a measure. Pers Psychol 56:303–331.
- 9. Judge TA, Hurst C, Simon LS (2009) Does it pay to be smart, attractive, or confident (or all three)? Relationships among general mental ability, physical attractiveness, core self-evaluations, and income. J Appl Psychol 94:742–755.
- 10. Erez A, Judge TA (2001) Relationship of core self-evaluations to goal setting, motivation, and performance. J Appl Psychol 86:1270–1279.
- 11. Laschinger HK, Purdy N, Almost J (2007) The impact of leader-member exchange quality, empowerment, and core self-evaluation on nurse manager's job satisfaction. J Nurs Adm 37:221–229.
- 12. Kacmar KM, Collins BJ, Harris KJ, Judge TA (2009) Core self-evaluations and job performance: the role of the perceived work environment. J Appl Psychol 94:1572–1580.
- 13.
Peng J, Li D, Zhang Z, Tian Y, Miao D, et al.. (2014) How can core self-evaluations influence job burnout? The key roles of organizational commitment and job satisfaction. J Health Psychol.
- 14. Best RG, Stapleton LM, Downey RG (2005) Core self-evaluations and job burnout: the test of alternative models. J Occup Health Psychol 10:441–451.
- 15. Spence Laschinger HK, Finegan J (2008) Situational and dispositional predictors of nurse manager burnout: a time-lagged analysis. J Nurs Manag 16:601–607.
- 16. Gomes Sda F, Santos MM, Carolino ET (2013) Psycho-social risks at work: stress and coping strategies in oncology nurses. Rev Lat Am Enfermagem 21:1282–1289.
- 17. Zhao X, Li J, Huang Y, Jin Q, Ma H, et al. (2013) Genetic variation of FYN contributes to the molecular mechanisms of coping styles in healthy Chinese-Han participants. Psychiatr Genet 23:214–216.
- 18. Thiruchelvi A, Supriya MV (2012) An investigation on the mediating role of coping strategies on locus of control— wellbeing relationship. Span J Psychol 15:156–165.
- 19. Pejuskovic B, Lecic-Tosevski D, Priebe S, Toskovic O (2011) Burnout syndrome among physicians - the role of personality dimensions and coping strategies. Psychiatr Danub 23:389–395.
- 20. Wang W, Kong AW, Chair SY (2011) Relationship between job stress level and coping strategies used by Hong Kong nurses working in an acute surgical unit. Appl Nurs Res 24:238–243.
- 21. Kulbe J (2001) Stressors and coping measures of hospice nurses. Home Healthc Nurse 19:707–711.
- 22. Xie W, Zhang ZL, Zheng ZH, Liang BN (2005) Relationship among job burnout, job stressors, and coping ways of nurses. Chinese Journal of Behavioral Medical Science 14:462–463.
- 23. Payne N (2001) Occupational stressors and coping as determinants of burnout in female hospice nurses. J Adv Nurs 33:396–405.
- 24. Kammeyer-Mueller JD, Judge TA, Scott BA (2009) The role of core self-evaluations in the coping process. J Appl Psychol 94:177–195.
- 25. Du JZ, Zhang X, Zhao Y (2012) Reliability, Validation and Construct Confirmatory of Core Self-Evaluations Scale. Psychological Research 5:54–60.
- 26. Maslach C, Jackson SE (1981) The measurement of experienced burnout. J Occup Behav 2:99–103.
- 27.
Schaufeli WB, Leiter MP, Maslach C, Jackson SE (1996) Maslach Burnout Inventory-General Survey (MBI-GS); In MBI Manual.3rt edition. Edited by Maslach C, Jackson SE, Leiter MP, Palo A, C.A., Consulting Psychologists Pres.
- 28. Wu S, Zhu W, Wang Z, Wang M, Lan Y (2007) Relationship between burnout and occupational stress among nurses in China. J Adv Nurs 59:233–239.
- 29. Xie Z, Wang A, Chen B (2011) Nurse burnout and its association with occupational stress in a cross-sectional study in Shanghai. J Adv Nurs 67:1537–1546.
- 30. Xie YN (1998) Reliability and validity of the simplified coping style questionnaire. Chin J Clin Psychol 6:114–115.
- 31. Folkman S, Lazarus RS (1988) Coping as a mediator of emotion. J Pers Soc Psychol 54:466–475.
- 32. Baron RM, Kenny DA (1986) The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 51:1173–1182.
- 33.
Cohen J, Cohen P, West SG, Aiken LS (2003) Applied multiple regression/correlation analysis for the behavioral sciences. Hillsdale: Lawrence Erlbaum Associates.
- 34. Judge TA, Bono JE, Locke EA (2000) Personality and job satisfaction: the mediating role of job characteristics. J Appl Psychol 85:237–249.
- 35. Lian P, Sun Y, Ji Z, Li H, Peng J (2014) Moving away from exhaustion: how core self-evaluations influence academic burnout. PLoS One 9:e87152.
- 36. Gibbons C (2010) Stress, coping and burn-out in nursing students. Int J Nurs Stud 47:1299–1309.
- 37. Wong DF, Leung SS, So CK (2001) Differential impacts of coping strategies on trati the mental health of Chinese nurses in hospitals in Hong Kong. Int J Nurs Pract 7:188–198.