Cross sectional case study

O R I G I N A L R E S E A R C H

Effects of job conditions, occupational stress, and

emotional intelligence on chronic fatigue among

Chinese nurses: a cross-sectional study This article was published in the following Dove Press journal:

Psychology Research and Behavior Management

Hao Huang 1

Li Liu 1

Shihan Yang 1

Xiaoxing Cui 2

Junfeng Zhang 2,3

Hui Wu 1

1Department of Social Medicine, School

of Public Health, China Medical

University, Shenyang 110122, People’s Republic of China; 2Nicholas School of

Environment, Duke University, Durham,

NC 27708, USA; 3Duke Global Health

Institute, Duke University, Durham, NC

27710, USA

Purpose: Nurses are undertaking considerable emotional and physical work, which may

lead to unrecoverable fatigue. This study aimed to evaluate the level of chronic fatigue and

explore its associated factors among Chinese nurses in the hope of providing scientific

evidence for fatigue-reduction strategies.

Methods: This cross-sectional study was carried out in Liaoning Province, China in 2018.

The study recruited 700 nurses and collected 566 effective respondents. Chronic fatigue,

demographic factors, job conditions, and emotional intelligence were assessed through

questionnaires. Chronic fatigue was assessed with the Fatigue Scale 11, occupational stress

with the Effort–Reward Imbalance Questionnaire, and emotional intelligence with the Wong

and Law Emotional Intelligence Scale. Hierarchical multiple regression was used to explore

factors related to chronic fatigue and to test the moderating effect of emotional intelligence

on the association between occupational stress and chronic fatigue. Simple slope analysis

was conducted to visualize the interaction.

Results: The mean score of chronic fatigue among the Chinese nurses was 17.14±6.16.

Being married, having long weekly work time, working night shifts, and discontent with the

nurse–patient relationship were positively associated with chronic fatigue. Effort:reward

ratio, overcommitment, and emotional intelligence were important factors related to chronic

fatigue. Emotional intelligence played a moderating role in the relationship between the

effort:reward ratio and chronic fatigue. When emotional intelligence was higher, the effect of

the effort:reward ratio on chronic fatigue became weaker.

Conclusion: Most nurses surveyed in China might have relatively high levels of chronic fatigue.

Our results highlight the importance of interventions on these factors for the reduction of fatigue

among nurses in China. Providing more opportunities and support and developing emotional

intelligence are crucial strategies to reduce chronic fatigue among nurses in China.

Keywords: chronic fatigue, occupational stress, emotional intelligence, nurses, moderating

effect

Introduction Fatigue is a common condition, and 5%–20% of the general population is reported

to suffer from it.1–3 Fatigue is defined by the North American Nursing Diagnosis

Association as a self-recognized state in which an individual experiences decreased

labor ability because of physical and mental overwork and feels an overwhelming

persistent sense of tiredness, weakness, and exhaustion that is not moderated by

rest.4 Several mental and physical consequences can result from fatigue, including

Correspondence: Hui Wu Department of Social Medicine, School of Public Health, China Medical University, 77 Puhe Road, Shenyang 110122, People’s Republic of China Tel +86 189 0091 0568 Email [email protected]

Psychology Research and Behavior Management Dovepress open access to scientific and medical research

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http://doi.org/10.2147/PRBM.S207283

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mood changes, decreased work capability, physical pain,

and diseases, which can lead to considerable economic

loss due to decreased productivity and increased health-

care expenditure.5 Obviously, unlike burnout or compas-

sion fatigue, which operate only at the psychological level,

the fatigue that we are interested in is a combination of

psychological and physical levels. Generally, fatigue is

divided into acute fatigue and chronic fatigue. Acute fati-

gue is a temporary state, while chronic fatigue is often

considered an illness or long-term condition.6 In this study,

our investigation focused on chronic fatigue.

Chronic fatigue can be common among nurses. It has

been reported that the level of fatigue is considerably

high among nurses.7 Another study also reported moder-

ate–high levels of acute fatigue and moderate levels of

chronic fatigue among nurses.8 As nurses are an essential

workforce at hospitals, chronic fatigue among them can

have substantial underlying impact, including job dissa-

tisfaction, adverse health outcomes, memory loss, pro-

longed reaction time, and decreased decision-making

abilities, which can make fatigued nurses more prone to

medical errors and may affect the quality of patient care

delivered.5,9 In summary, the considerable impact of

chronic fatigue on nurses and patients necessitates the

investigation of chronic fatigue and its associated factors.

Previous studies on fatigue have suggested that it is

associated with demographic factors and work conditions.

Finsterer et al10 reported that fatigue was influenced by

age and sex, specifically older age and being female pre-

disposing individuals to fatigue. Another study reported an

association between higher education level and higher

level of fatigue among nurses.11 Chen et al8 found that

married nurses experienced higher level of fatigue com-

pared to nurses with other marital status. As for work

conditions, Piko12 reported that long working hours and

high frequency of night shifts had strongly positive asso-

ciations with chronic fatigue among nurses. In addition, a

previous study reported that difficulties in the nurse–

patient relationship could induce adverse health outcomes,

such as depressive symptoms among nurses.13 Bültmann

et al14 suggested that relationships with others at work also

played a major role in the development of fatigue, as

specific psychosocial experiences can exacerbate mental

fatigue. Therefore, challenges in the nurse–patient rela-

tionship might have a significant impact on chronic fatigue

among Chinese nurses.

More importantly, under working conditions in China,

higher stress at the workplace is commonly found among

nurses, with a positive relationship with fatigue.15,16 The

effort–reward imbalance (ERI) model can be a helpful tool

in quantifying occupational stress.17 According to the ERI

model, job stress arises from an individual’s interactions

with the psychosocial work environment. The model has

three core elements: extrinsic effort, reward, and overcom-

mitment. Extrinsic effort represents external results of

one’s demands or obligations imposed on themselves.

Reward mainly comprises esteem, salary, and career

opportunities. Overcommitment is defined as a personality

characteristic reflecting a strong desire to be approved and

valued.17 Imbalance between extrinsic efforts and rewards

or high overcommitment will introduce occupational

stress, which can trigger psychosomatic responses and

bring about or aggravate fatigue.18,19 As a result, occupa-

tional stress may be a key factor associated with chronic

fatigue among nurses in China.

Increasing occupational stress and the constant need to

express empathy when delivering patient care can result in

potential difficulties in nurse–patient relationships.

Emotional intelligence can be one of the resources utilized

by nurses to cope with these emerging challenges. Emotional

intelligence has been defined as the ability of individuals to

understand the emotions of themselves or others and to

identify and use this information to control their own think-

ing or behavior.20 Generally, it is believed that utilizing

emotional intelligence on the job can have impacts on occu-

pational stress, burnout, work engagement, and interpersonal

relationships.21,22 Nurses who possess high emotional intel-

ligence have also been shown to have good health and gen-

eral well-being.23,24 As such, emotional intelligence may be a

crucial factor related to chronic fatigue at work. In addition,

to our knowledge, emotional intelligence can regulate indi-

vidual stress and reduce negative mood.25,26 Sharma et al27

reported emotional intelligence moderated the relationship

between occupational stress and psychological health.

Görgens-Ekermans et al28 also indicated that emotional intel-

ligence played a moderating role in the association between

work stress and burnout. Therefore, emotional intelligence

seems likely to be a moderator in the relationship between

occupational stress and chronic fatigue among nurses in

China. However, few studies have explored such associa-

tions, which necessitates our study.

In summary, the present study aims to explore associated

factors of chronic fatigue among nurses in Liaoning Province

of China and to examine whether emotional intelligence has

a moderating effect in the relationship between occupational

stress and chronic fatigue among them.

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Methods Ethics statement The procedures of this study were reviewed and approved

by the institutional review board of China Medical

University. Written informed consent was obtained from

each participant. All data collected from the subjects were

kept anonymous and confidential to protect their privacy.

Study design and data collection This cross-sectional study was conducted in Liaoning

Province, China in 2018. Participants were sampled

through a two-stage method. First, Liaoning Province con-

sists of five regions: eastern, western, southern, northern,

and central. In each region, two tertiary hospitals with

>500 beds were randomly selected, totaling ten large hos-

pitals. A total of 70 nurses as volunteers were randomly

selected in each sampled hospital, totaling 700 nurses.

Nurses who had worked <1 year were excluded from this

study. After informed consent had been obtained, a self-

administered questionnaire, which needed about 15 min-

utes to complete, was distributed to each study subject.

Finally, we collected 566 questionnaires, with an effective

rate of 80.9%.

Measurement of fatigue The Fatigue Scale (FS) compiled by Chalder et al has been

used and validated by a number of studies for measuring

the level of chronic fatigue.29 In our study, we used the

Chinese mainland version of the scale (FS11), a translation

of the original Chalder FS.30 The FS11 survey comprises

eleven questions, each of which has four options with a

score of 0–3 (0 = less than usual to 3 = much more than

usual), with a total score ranging from 0 to 33. Higher

scores indicate a higher level of chronic fatigue. Its valid-

ity and reliability have been tested among the Chinese

population by Jing et al.31 Cronbach’s α-coefficient for

the FS11 in this study was 0.724.

Measurement of demographic

characteristics Four demographic characteristics were collected from a

self-designed questionnaire: age, sex, marital status, and

education. Age was collected as a continuous variable.

Options for marital status included unmarried, married/

cohabitating, and divorced/widow/separated. Education

was divided into “junior college and below”, and “college

and above”.

Measurement of job conditions Three job factors — weekly work time, night shifts, and the

nurse–patient relationship — were assessed with three self-

designed questions. Using the domestic working-hour stan-

dard in China as the cut point, weekly work time was

divided into ≤40 hours/week and >40 hours/week. The night-shift question was yes/no. Nurse–patient relationships

were assessed with the question “How often have you been

dissatisfied with the nurse–patient relationship at work?”,

with five possible answers: never, rarely, sometimes, fre-

quently, and always. The response was further classified

into satisfaction (never), moderate dissatisfaction (rarely/

sometimes), or high dissatisfaction (frequently/always).

Measurement of occupational stress Occupational stress was measured by the ERI Questionnaire.

The ERI Questionnaire was originally designed by Siegrist in

1996, and was translated to Chinese by Li et al.32,33 The ERI

Questionnaire has been used widely by researchers and has

demonstrated adequate reliability and validity among

sampled populations in China.33,34 The 23-item ERI

Questionnaire measures extrinsic effort (six items), reward

(eleven items), and overcommitment (six items). It uses a 5-

point Likert scale for extrinsic effort and reward (1 = no

stressful experiences to 5 = very distressed) and a 4-point

Likert scale for overcommitment (1 = strongly disagree to 4

= strongly agree). Effort:reward ratio was calculated by

dividing effort by reward and multiplied by 11/6 to correct

for the item-number difference in the two dimensions. An

effort:reward ratio >1 means high cost and low gain, reflect-

ing a risk-imbalance condition. A higher effort:reward ratio

and overcommitment indicate higher occupational stress.

Reliability measured by Cronbach’s α-coefficient for extrin-

sic effort, reward, and overcommitment in this study were

0.866, 0.762, and 0.756, respectively.

Measurement of emotional intelligence Emotional intelligence was measured using the Wong and

Law Emotional Intelligence Scale (WLEIS).35 This scale

has been translated into Chinese and shown to have ade-

quate reliability and validity among individuals surveyed

in China.36 The WLEIS is a 16-item scale consisting of

four dimensions: self-emotion appraisal, appraisal of

other’s emotions, regulation of emotion, and use of emo-

tion. In this article, we focus on total emotional intelli-

gence. The response format is a 7-point Likert scale,

ranging from 0 = strongly disagree to 6 = strongly agree,

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with higher scores indicating higher emotional intelli-

gence. Cronbach’s α-coefficient for the total scale was

0.848.

Statistical analyses Mean fatigue scores in different categories of demographic

and job-condition factors were tested by t-test or one-way

ANOVA. Pearson correlation analysis was used to analyze

correlations among age, occupational stress, emotional intel-

ligence, and chronic fatigue. All variables related to fatigue

in univariate analysis (P<0.05) were entered in the hierarch-

ical multiple regression model, which was used to estimate

the contribution of different factors to the level of chronic

fatigue and to evaluate the moderating effect of emotional

intelligence on the relationship between occupational stress

and chronic fatigue. In the model, potential control variables

were entered in step 1. Occupational stress and emotional

intelligence were added in step 2. Finally, the product of

occupational stress and emotional intelligence was added in

step 3. The hypothesis of the moderating effect of emotional

intelligence was supported if the interaction were significant.

Simple slope analysis was conducted to visualize the inter-

action term. The variance inflation factor was used to esti-

mate whether a regression coefficient had increased because

of collinearity. In the present study, factor values <10 were

taken as multicollinearity not being an issue in the estimate.

All statistical analyses were performed with SPSS for

Windows 17.0, with two-tailed P<0.05 considered statisti-

cally significant.

Results Demographic characteristics and job

conditions The average score of chronic fatigue among the nurses

surveyed was 17.14±6.16. Results of univariate analyses

between chronic fatigue and each factor of demographic

characteristics and job conditions of study subjects are

shown in Table 1. Nurses who responded to the question-

naires were aged 34.35±8.95 years, 68.6% were married,

and 52.7% of them had an education level of college and

above. The proportion of the nurses whose weekly work

was >40 hours was 81.8%, 56.9% did night shifts, and

19.4% of felt high dissatisfaction with the nurse–patient

relationship. Furthermore, except sex, all the variables —

marital status, education, weekly work time, night shifts,

and nurse–patient relationship — were significantly asso-

ciated with chronic fatigue.

Correlations among chronic fatigue,

occupational stress, and emotional

intelligence Correlation coefficients between continuous variables are

presented in Table 2. The level of chronic fatigue was

positively correlated with effort:reward ratio and overcom-

mitment and negatively correlated with emotional intelli-

gence. Emotional intelligence was negatively correlated

with effort:reward ratio.

Associations of demographic

characteristics, job conditions,

occupational stress, and emotional

intelligence with level of chronic fatigue by

hierarchical multiple regression analyses In hierarchical regression models, demographic variables

(including age, marital status, and education) and job con-

ditions (including weekly work hours, night shifts, and

nurse–patient relationship) were entered in step 1.

Occupational stress (namely effort:reward ratio and over-

commitment) and emotional intelligence were added in

step 2. The interaction of occupational stress and emo-

tional intelligence was entered in step 3.

As shown in Table 3, in step 1 marital status, weekly work

hours, night shifts, and nurse–patient relationship were factors

related to chronic fatigue. The linear combination of these

variables partially explained the variance in chronic fatigue

(adjusted R2=0.146, ΔR2=0.156; P<0.01). In step 2, effort: reward ratio was found to be significantly and positively

related to chronic fatigue (β=0.282, P<0.01), while emotional

intelligence was significantly and negatively associated with

chronic fatigue (β=−0.267, P<0.01). Effort:reward ratio and emotional intelligence had significant effects on chronic fati-

gue (adjusted R2=0.297, ΔR2=0.152; P<0.01). In step 3, the effort:reward ratio × emotional intelligence interaction was

significantly and positively associated with chronic fatigue

(β=0.158, P<0.01). Therefore, emotional intelligence played

a moderating role in the relationship between effort:reward

ratio and chronic fatigue. Simple slope analysis of the interac-

tion is presented in Figure 1, which shows that the impact of

effort:reward ratio on chronic fatigue was different in low (1

SD below mean, β=0.444; P<0.001), mean (β=0.308,

P<0.001), and high (1 SD above mean, β=0.172; P<0.001)

levels of emotional intelligence. When emotional intelligence

was higher, the effect of effort:reward ratio on chronic fatigue

became weaker.

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As shown in Table 4, in step 2, after adjustment control

variables, overcommitment was found to be significantly and

positively related to chronic fatigue (β=0.275, P<0.01), while

emotional intelligence was significantly and negatively asso-

ciated with chronic fatigue (β=−0.321, P<0.01). Overcommitment and emotional intelligence had significant

effects on chronic fatigue (adjusted R2=0.297, ΔR2=0.152; P<0.01). In step 3, the overcommitment × emotional intelli-

gence interaction term was not significantly associated with

chronic fatigue (β=0.019, P>0.05). Therefore, emotional

intelligence did not moderate the relationship between over-

commitment and chronic fatigue.

Discussion The results of this study showed that the average chronic

fatigue score of nurses surveyed in China was 17.14

±6.16. This score was higher than that reported by gen-

eral communities and close to scores reported by

patients.37–39 This discrepancy may partly stem from the

different survey conditions and administration used.

However, this finding indicated that the chronic fatigue

among nurses was a very noticeable issue. As such,

finding the related factors of chronic fatigue and its

relevant interventions is needed in reducing chronic fati-

gue among nurses.

Table 1 Demographic characteristics and job conditions of study participants and univariate analysis of factors in relation to level of chronic fatigue (n=566)

Variable n (%) Chronic fatigue (mean ± SD) P-value

Sex 0.931

Female 552 (97.5%) 17.00±6.32

Male 14 (2.4%) 17.14±6.16

Marital status 0.001

Unmarried 160 (28.3%) 15.58±5.50

Married/cohabitating 388 (68.6%) 17.75±6.28

Divorced/widow/separated 18 (3.1%) 18.00±7.01

Education 0.002

Junior college and below 268 (47.3%) 16.29±6.23

College and above 298 (52.7%) 17.90±6.01

Weekly work time 0.001

≤40 hours 103 (18.2%) 15.24±7.04

>40 hours 463 (81.8%) 17.56±5.88

Night shifts <0.001

No 244 (43.1%) 18.12±5.91

Yes 322 (56.9%) 15.85±6.26

Dissatisfaction with nurse–patient relationship <0.001

Satisfaction 30 (5.3%) 12.57±6.50

Moderate dissatisfaction 426 (75.3%) 16.60±5.72

High dissatisfaction 110 (19.4%) 20.47±6.33

Table 2 Correlation coefficients among continuous variables (n=566)

Variable Mean ± SD 1 2 3 4

1. Chronic fatigue 17.14±6.16

2. Age 34.35±8.95 −0.017

3. Effort:reward ratio 1.07±0.41 0.405** −0.047

4. Overcommitment 16.23±3.09 0.337** 0.058 0.419**

5. Emotional intelligence 60.25±16.01 −0.359** 0.081 −0.186** −0.019

Note: **p<0.01 (two-tailed).

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In our study, we found that married status was sig-

nificantly associated with chronic fatigue, consistently

with previous studies.8,9 One possible reason might be

that due to social and cultural norms, married nurses not

only work hard in hospital to provide high-level service

but also undertake housework, care for children, and

support the elderly at home. Compared to nurses of

other marital status, married nurses in China also need

to spend considerable mental energy on working with

relationships with husbands and parents-in-law.

Therefore, this demand in balancing work–family time

may contribute to additional fatigue.40 As such, personal

time with family should be one of the factors considered

when arranging the shifts of nurses. A flexible working-

schedule system can effectively solve this problem.

However, it is not necessarily suitable for medical staff

in China, due to the heavy workload. Therefore, the

relevant strategies need to be further studied.

We also found working-environment factors were impor-

tantly related to the level of chronic fatigue among nurses

surveyed. Specifically, long weekly work time, night shifts,

and dissatisfaction with the nurse–patient relationship were

found to be significantly related to chronic fatigue, similarly to

the findings of previous studies.8,41,42 More than 80% of

nurses surveyed in this study had weekly work time >40

hours, which is higher than the domestic standard in China.

Work duration might be prolonged to meet the considerable

number of patients and related workloads at hospitals. This

prolongation of work time can leave nurses with less time to

relax and recharge, which impedes the timely reduction of

fatigue. As for night shifts, it is well accepted that working at

night requires a lot of energy and is more likely to lead to the

disorder of body rhythms, which may have a serious impact on

fatigue of nurses.43 In addition, we found nearly 20% of nurses

were highly dissatisfied with the nurse–patient relationship. In

fact, challenges in the nurse–patient relationship are on the rise

in China.44 At present, patients expect medical service of

higher quality, while nurses are short-staffed to accommodate

such expectations, which generates conflicts in the nurse–

patient relationship. Furthermore, due to heavy workload,

nurses have limited time to communicate with patients,

which can also contribute to nurse–patient conflict, triggering

negative emotions that contribute to perceived fatigue.44,45 As

a result, interventions might be needed to reduce the workload

and work time of nurses, such as increasing the number of

nurses that can share the workload and reducing night-shift

frequency. In addition, hospital administrators should improve

Table 3 Associations of demographic characteristics, job conditions, effort:reward ratio, and emotional intelligence with chronic fatigue (n=566)

Variable Step 1 Step 2 Step 3

Age −0.127* −0.070 −0.078

Married vs unmarried 0.185** 0.148** 0.162**

Divorced/widow/separated vs unmarried 0.110* 0.079 0.077

Education 0.058 0.049 0.044

Weekly work time 0.094* 0.082* 0.072*

Night shifts 0.148** 0.124** 0.113**

Nurse–patient relationship 0.251** 0.107** 0.098*

Effort:reward ratio 0.282** 0.305**

Emotional intelligence −0.267** −0.281**

Effort:reward ratio × emotional intelligence 0.158**

F 14.748** 27.503** 27.591**

Adjusted R2 0.146 0.297 0.320

ΔR2 0.156 0.152 0.024

Notes: *p<0.05; **p<0.01 (two-tailed).

Figure 1 Simple slope plot of the interaction between effort:reward ratio and emotional intelligence on chronic fatigue.

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protocols to increase service efficiency, but also enhance

nurses’ communication and nursing skills, and organize

some activities involving both nurses and patients to improve

the relationship between them.

The results also revealed that effort:reward ratio and

overcommitment were significantly and strongly associated

with fatigue. Previous studies had similar findings, and

suggested that the imbalance in effort:reward ration and

overcommitment can have direct effects on burnout.46,47

Nurses in China are undertaking significant workloads

while receiving somewhat disproportional reward, including

relatively low pay, insufficient respect from patients, and

limited opportunities of promotion and further education at

the workplace. Imbalance between efforts and rewards can

bring nurses a feeling of injustice and have a negative

impact on their self-esteem and emotion.48 The higher this

imbalance, the more the emotional exhaustion and occupa-

tional stress, contributing to higher levels of fatigue.49,50 On

the other hand, to our knowledge, medical work requires a

lot of responsibilities, which tends to produce high over-

commitment among medical staff. The higher the level of

overcommitment of nurses, the higher the possibility that

they will devote themselves to work, which can trigger

additional stress. Long-term accumulated psychological

pressure will lead to fatigue. As one of the possible solu-

tions, hospitals can establish more reward mechanisms for

nurses, including higher compensation and opportunities for

career advancement and further education, which could

bolster their professional identity and job satisfaction to

balance overcommitment.

In this study, emotional intelligence was found to have

a negative association with the level of chronic fatigue. In

addition, we also found that emotional intelligence mod-

erated the association of effort:reward ratio with chronic

fatigue, which partly confirmed our hypothesis. Results of

the simple slope analysis showed that the higher the emo-

tional intelligence, the weaker the effect of the effort:

reward ratio on chronic fatigue. Emotional intelligence is

one of the personal resources that can adjust psychological

factors by regulating emotions and help release pressure

proactively.25,51,52 As a result, nurses who have high emo-

tional intelligence may combat fatigue better, as they can

regulate their negative emotions, relax themselves in

timely fashion,and more easily recognize and manage the

stress. This finding indicated that if occupational stressors

are hard be reduce effectively, improving emotional intel-

ligence may be a good way to minimize the negative

impact of occupational stress on chronic fatigue.

However, we did not find an interaction between over-

commitment and emotional intelligence on chronic fati-

gue, which needs further research. Nevertheless, the

significant effect of emotional intelligence on fatigue

should be highlighted when formulating solutions for fati-

gue reduction. As emotional intelligence can be devel-

oped, hospitals can set up programs that facilitate the

growth of nurses’ emotional intelligence to improve their

ability to respond to negative emotions and help alleviate

fatigue, eg, introducing self-control and self-regulation

strategies for nurses to release psychological pressure

and to regulate emotions.53,54

Table 4 Associations of demographic characteristics, job conditions, overcommitment, and emotional intelligence with chronic fatigue (n=566)

Variable Step 1 Step 2 Step 3

Age −0.127 −0.085 −0.084

Married vs unmarried 0.185** 0.134** 0.134**

Divorced/widow/separated vs unmarried 0.110 0.065 0.066

Education 0.058 0.073 0.074

Weekly work time 0.094* 0.077* 0.075*

Night shifts 0.148** 0.096* 0.097**

Nurse–patient relationship 0.251** 0.131** 0.130**

Overcommitment 0.275** 0.274**

Emotional intelligence −0.319** −0.321**

Overcommitment × emotional intelligence 0.019

F 14.748** 27.480** 24.728**

Adjusted R2 0.146 0.297 0.296

ΔR2 0.156 0.152 <0.001

Notes: *p<0.05; **p<0.01 (two-tailed).

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Several limitations must be mentioned. The cross-sec-

tional design of this study keeps us from drawing any

conclusion of causal relationships between the factors

examined and chronic fatigue. Future longitudinal studies

are needed for exploration of causal relationships.

Secondly, participations in this study were recruited from

tertiary hospitals with >500 beds, and working conditions

there might be different from small clinics and thus limit

extrapolation to nurses who work in other type of clinical

facilities. Thirdly, data were collected by the subjective

measure of self-reported questionnaires from the subjects,

which may be subject to recall bias and response bias. Our

study tried to minimize such biases by using the FS11,

ERI, and WLEIS, that have been well validated for appli-

cation among subjects in China.

Conclusion In summary, based on this cross-sectional survey, our findings

revealed that most nurses surveyed in China might have

relatively high levels of chronic fatigue. Demographic factors,

work conditions, occupational stress, and emotional intelli-

gence were related to the development of chronic fatigue.

Emotional intelligence moderated the association of effort:

reward ratio with chronic fatigue. Our results highlight the

importance of intervention on these factors for the reduction of

fatigue among nurses in China. Providing more opportunities

and support, adjusting job conditions, utilizing self-control,

and developing emotional intelligence are crucial strategies

to reduce chronic fatigue among nurses in China.

Ethics approval and informed consent The procedures of this study were reviewed and approved

by the Institutional Review Board of China Medical

University. Written informed consent was obtained from

each participant. All data collected from the subjects was

kept anonymous and confidential to protect the privacy of

the study subjects.

Acknowledgments The authors would like to thank all the administrators in the

study hospitals who assisted in obtaining written informed

consent for the survey and in distributing questionnaires to

the subjects. This study was supported by the National

Natural Science Foundation of China (71673300).

Disclosure The authors report no conflicts of interest in this work.

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