Abstract
Background
The global nursing shortage, driven by high turnover rates, significantly impacts healthcare quality. Workplace psychological violence severely affects nurses' mental health and job satisfaction, leading to increased turnover. Despite extensive research on workplace violence, the specific impact of psychological violence on nurses' turnover intentions remains insufficiently explored. This study investigates the mediating role of job satisfaction in the relationship between workplace psychological violence and nurses' turnover intentions.
Methods
A workplace psychological violence scale, a job satisfaction scale, and a turnover intention questionnaire were utilized to survey 206 clinical nurses in a tertiary-level hospital in Guangzhou City. The study employed a convenience sampling method. Statistical analyses included correlation, mediation analyses., descriptive statistics, multivariate linear hierarchical regression analyses, Pearson correlation analyses, and structural equation models.
Results
Clinical nurses reported a workplace psychological violence score of 0.97 ± 0.79, job satisfaction of 3.16 ± 0.58, and turnover intention of 2.22 ± 0.92. Workplace psychological violence was negatively correlated with job satisfaction (r = -0.516, P < 0.01) and positively correlated with turnover intention (r = 0.418, P < 0.01). Turnover intention was negatively correlated with job satisfaction (r = -0.477, P < 0.01). Mediation analysis indicated that Job satisfaction partially mediated the association between workplace psychological violence and turnover intention. The total effect (β = 0.489) of workplace psychological violence on turnover intention included its direct effect (β = 0.274) and the indirect effect mediated through job satisfaction (β = 0.215), with the mediating effect accounting for 43.97% of the total effect.
Conclusions
Workplace psychological violence directly predicts nurses' turnover intention, with job satisfaction serving as a mediator in this relationship. Healthcare managers can mitigate psychological violence by improving mental health support, work environments, and organizational culture to enhance job satisfaction and reduce nurse turnover.
Keywords: Clinical nurses, Psychological violence in the workplace, Turnover intention, Job satisfaction, Mediating effect
Introduction
The global shortage of nursing staff is a serious issue, with high turnover rate as one of the principal contributing factors [1, 2]. Turnover intention is defined as the psychological tendency of employees to deliberately consider leaving their jobs after a period of contemplation [3]. In China, the prevalence of nurses' turnover intention ranges between 20.2% and 56.1% [4, 5]. This high propensity to leave leads to workforce instability and a shortage of nursing resources, significantly affecting the quality of nursing services [1]. To address current and future health challenges, the Healthy China 2030 Planning Outline proposes strengthening the nurse workforce, stabilising the nursing team, and promoting high-quality development in nursing services.
Workplace psychological violence refers to any non-physical act of psychological harm experienced by nursing staff, including workplace bullying, verbal aggression, and threats of intimidation [6]. The prevalence of psychological violence in the workplace ranges from 15% to 89.58% [7]. Nurses experiencing psychological violence in the workplace are highly susceptible to negative emotions, which severely impact their mental health, reduce work motivation and job satisfaction, and ultimately lead to turnover intentions or behaviours. This exacerbates the shortage of nursing staff and affects the overall stability of the healthcare workforce.
Although extensive research has been conducted on workplace violence both domestically and internationally, specific studies on workplace psychological violence, an essential component of workplace violence, remain relatively scarce. This is particularly true for research focused on nurses experiencing psychological violence at work, which is still in the exploratory stage. The mechanism by which workplace psychological violence affects clinical nurses' turnover intentions, especially its mediation effects, is not yet fully understood. Empirical studies [8] have shown a correlation between workplace violence and turnover intention, with job satisfaction significantly influencing this relationship. However, there is a lack of research examining the relationship between workplace psychological violence and nurses' turnover intentions with job satisfaction as a mediating variable. Therefore, this study uses data from clinical nurses to explore the mediating role of job satisfaction in the relationship between workplace psychological violence and nurses' turnover intentions. This investigation seeks to deepen the understanding of turnover mechanisms, draw the attention of hospital management to this issue, and provide practical recommendations for reducing turnover intentions among clinical nurses. By doing so, the study aims to protect nursing human resources, stabilize nursing teams, and promote the sustainable development of the nursing profession.
Methods
Study design and participants
Using the convenience sampling method, clinical nurses of A Tertiary Hospital in Guangzhou City were selected as the study subjects from December 2022 to May 2023. The inclusion criteria were as follows: registered nurses, being above 18 years old, having nursing experience of more than 1-year, informed consent, and voluntary participation in this study. Exclusion criteria included nurses who came to the hospital or went out for further research during the survey process, were nursing interns, were on leave for more than 1 week, and were pregnant or breastfeeding. The sample size of this study should be 174 ~ 348 by calculating the number of samples needed for the survey with 5 ~ 10 times the variables, combined with the 20% sample loss rate. The guiding principle for the optimal sample size of the structural equation model (SEM) is a minimum of 200 cases [9, 10]. Ultimately, this study included 206 valid questionnaires.
Research instruments
General information questionnaire
This self-designed tool amalgamates insight from prior research and expert opinions. It encompasses demographic details such as gender, age, education level, marital status, years of professional experience, job title, average weekly working hours, economic income, employment status, departmental affiliation, and alignment of personal interests with the nursing profession.
The Workplace Psychologically Violent Behaviours Instrument (WPVB)
The scale was developed by Turkish scholar Yildirim Dilek [11] in 2008. It comprises 33 items categorized into four dimensions: Individual Isolation at Work, Attack on Professional Status, Attack on Personality, and Direct Negative Behaviors. A Likert-6 scale was utilized, with respondents rating the frequency of each behaviour from 0 (never) to 5 (always). A mean score of ≥ 1 on the total scale indicated nurses' exposure to psychologically violent behaviour. The Cronbach's alpha coefficient for the total scale was 0.93; the dimensions, ranged from 0.72 to 0.91, indicating high internal consistency. It demonstrated good structural validity, with the four extracted factors explaining 58% of the total variance in WPVB. Additionally, the WPVB has been successfully employed in studies involving nursing faculty and healthcare professionals [12, 13].
The turnover intention scale
The scale was developed by Brough and Frame in 2004 [14]. It comprises three questions aimed at assessing individuals' inclination to leave their current job. The items were: Turnover intention I: How frequently have you considered leaving your job in the past six months? Turnover intention II: How likely are you to leave your job in the next six months? Turnover intention III: How often do you actively look for jobs outside of your current employer? Brough conducted internal consistency tests in two separate population groups, yielding Cronbach's alpha coefficients of 0.79 and 0.82, indicating good reliability. A Likert-5 scale was employed, ranging from 1 (never) to 5 (very high), with higher scores indicating a stronger propensity to leave the job.
The McCloskey/Mueller Satisfaction Scale (MMSS)
The scale was revised by McCloskey and Mueller in 1990 [15]. The scale consists of 31 items across 8 dimensions: benefits package, shift scheduling, balance between family and work, relationships with co-workers, opportunities for socializing, opportunities for professional development, praise and recognition for work, and control and responsibility. A Likert scale ranging from 1 to 5 was utilized, with 1 indicating "very dissatisfied," 2 for "dissatisfied," 3 for "fair," 4 for "satisfied," and 5 for "very satisfied." The overall Cronbach's alpha coefficient for the scale was 0.89, indicating high internal consistency, with coefficients for individual dimensions ranging from 0.60 to 0.84. A mean score of 3.03 or higher was considered the lowest indicator of job satisfaction. The MMSS has been widely utilized in various countries [16–18].
Data collection and quality control methods
Approval was secured from regulatory authorities and the Ethics Committee (approval number: SYSKY-2023–206-01) for adherence to ethical standards. Trained investigators distributed questionnaires online, ensuring compliance with inclusion and exclusion criteria. All questions were mandatory, and participants completed the questionnaire independently and anonymously. Measures were implemented to prevent duplicate responses based on IP addresses and registration information. Investigators provided standardized instructions to participants regarding the research purpose, questionnaire completion, and precautions. Data underwent thorough cross-checking by two researchers to exclude incomplete responses, ensuring data quality and research validity. These rigorous procedures uphold the integrity and scientific rigour of the research in healthcare management.
Data analysis
Data were analyzed using SPSS 29.0 and AMOS 26.0 software. Descriptive statistics were used to summarize measurement data as mean ± standard deviation, and count data were presented as frequency and percentage. Normality was assessed using the Kolmogorov–Smirnov Test, confirming a normal distribution. One-way analyses, including independent samples t-tests and ANOVA, were conducted. Pearson correlation analyses explored variable relationships, while multivariate linear hierarchical regression analyses identified factors influencing job turnover propensity. The Structural Equation Model was constructed tested and corrected using AMOS software. The Bootstrap method (5000 iterations) was employed to assess mediating effects. Significance was set at α = 0.05.
Results
Demographic characteristics
A total of 206 clinical nurses participated in the survey. The majority were female, accounting for 96.60%, while males comprised 3.40%. Regarding age, 62.62% were aged 30 years or younger, and 37.38% were older than 30 years. Regarding education, 28.16% of the nurses had a diploma, while 71.84% had a bachelor's degree or higher. In terms of marital status, 55.83% were unmarried, while 44.17% were married. Additionally, 41.75% of participants had children, and 58.25% did not. The nursing work experience distribution showed that 48.06% had 0–5 years of experience, 31.55% had 6–10 years, and 20.39% had more than 10 years of experience. Most nurses (88.83%) held a practitioner nurse title or lower, while 11.17% held a senior nurse title or above. Clinical nurses constituted 98.06% of the respondents, while nursing managers made up 1.94%. Regarding weekly working hours, 66.50% worked 40 h or less, while 33.50% worked more than 40 h. In terms of income, 73.79% earned between 0 and 10,000 RMB, and 26.21% earned over 10,000 RMB. Most of the nurses (88.83%) were on contract positions, with 11.17% holding permanent positions. Furthermore, 88.35% of participants rotated night shifts, while 11.65% did not. On a departmental level, 68.93% worked in inpatient wards, 25.73% worked in emergency/ICU/operating rooms, and 5.34% worked in outpatient or other departments. Finally, 48.06% of participants indicated that their personal interests aligned with the nursing profession, while 51.94% reported a mismatch., as detailed in Table 1.
Table 1.
Demographic characteristics of Participants (N = 206)
| Variables | Category | Number (%) |
|---|---|---|
| Gender | Male | 7(3.40%) |
| Female | 199(96.60%) | |
| Age (years) | ≤ 30 | 129(62.62%) |
| > 30 | 77(37.38%) | |
| Education | Below Bachelor | 58(28.16%) |
| Bachelor’s degree or above | 148(71.84%) | |
| Marriage | Unmarried | 115(55.83%) |
| Married/ divorce | 91(44.17%) | |
| Children | No | 120(58.25%) |
| Yes | 86(41.75%) | |
| Nursing experience(years) | 0–5 | 99(48.06%) |
| 6–10 | 65(31.55%) | |
| ≥ 10 | 42(20.39%) | |
| Professional title | Practitioner | 183(88.83%) |
| Senior nurse | 23(11.17%) | |
| Duty | Clinical nurse | 202(98.06%) |
| Nursing managers | 4(1.94%) | |
| Average weekly working hours | ≤ 40 h | 137(66.50%) |
| > 40 h | 69(33.50%) | |
| Average monthly income (RMB) | 0–10000 | 152(73.79%) |
| > 10,000 | 54(26.21%) | |
| Employment | Contract employed | 183(88.83%) |
| Officially employed | 23(11.17%) | |
| Night shifts | No | 24(11.65%) |
| Yes | 182(88.35%) | |
| Department | inpatient ward | 142(68.93%) |
| Emergency/ICU/Operating room | 53(25.73%) | |
| Outpatient and others | 11(5.34%) | |
| Hobbies matched to nursing | No | 99(48.06%) |
| Yes | 107(51.94%) |
Scores of WPVB, MMSS, and turnover intention among clinical nurses
The WPVB score among clinical nurses was 0.97 ± 0.79, the MMSS score was 3.16 ± 0.58, and the turnover intention score was 2.22 ± 0.92, as shown in Table 2.
Table 2.
WPVB, MMSS, and turnover intention scores (N = 206)
| Variables | Mean ± SD |
|---|---|
| Workplace psychological violence | 0.97 ± 0.79 |
| Individual isolation work | 1.20 ± 0.87 |
| Attack on professional status | 1.30 ± 1.09 |
| Attack on personality | 0.67 ± 0.82 |
| Direct negative behaviors | 0.29 ± 0.66 |
| Job satisfaction | 3.16 ± 0.58 |
| Salary and benefits package | 2.84 ± 0.76 |
| Working schedule | 3.03 ± 0.74 |
| Balance between family and work | 3.12 ± 0.67 |
| Relation with colleague | 3.58 ± 0.64 |
| Opportunities for social contact | 3.05 ± 0.71 |
| Opportunities for career advancement | 3.09 ± 0.64 |
| Recognition of work | 3.39 ± 0.58 |
| Work control and responsibility | 3.29 ± 0.63 |
| Turnover intention | 2.22 ± 0.92 |
| Turnover intention I | 2.47 ± 1.09 |
| Turnover intention II | 2.23 ± 1.07 |
| Turnover intention III | 1.95 ± 0.93 |
The status of workplace psychological violence, job satisfaction, and turnover intention among nurses
Following data analysis, the mean score of workplace psychological violence experienced by nurses was 0.97 ± 0.79. Of the participants, 15 nurses (7.28%) had an average item score of 0, 105 nurses (50.97%) had an average item score between 0 and 1, and 86 nurses (41.75%) had an average item score of ≥ 1, with a score of ≥ 1 indicating exposure to workplace psychological violence. The job satisfaction score was 3.16 ± 0.58, with 107 nurses (51.94%) scoring below 3.03, and 99 nurses (48.06%) scoring 3.03 or above; a score below 3.03 indicates job dissatisfaction. The turnover intention score was 2.22 ± 0.92, with 60 nurses (29.12%) scoring ≥ 3 and 146 nurses (70.88%) scoring below 3, where a score of ≥ 3 indicates the presence of turnover intention.
Correlation between workplace psychological violence, job satisfaction, and turnover intention
The findings reveal compelling associations among workplace psychological violence, job satisfaction, and turnover intention. Specifically, a pronounced negative correlation emerged between workplace psychological violence and job satisfaction (r = -0.516, P < 0.001), highlighting the adverse impact of such experiences on nurses' contentment with their work environment. Additionally, a noteworthy positive correlation was observed between workplace psychological violence and turnover intention (r = 0.418, P < 0.001), underscoring the detrimental effect of these occurrences on nurses' inclination to remain in their current positions. Furthermore, a significant negative correlation was identified between turnover intention and job satisfaction (r = -0.477, P < 0.001), emphasizing the interconnectedness between dissatisfaction and the propensity to leave one's job. Comprehensive details are presented in Table 3.
Table 3.
Analysis of the Correlation between WPVB, MMSS and Turnover Intention
| Variables | WPVB | MMSS | Turnover intention |
|---|---|---|---|
| WPVB | 1 | -0.516*** | 0.418*** |
| MMSS | -0.516*** | 1 | -0.477*** |
| Turnover intention | 0.418*** | -0.477*** | 1 |
WPVB Workplace Psychologically Violent Behaviours Instrument, MMSS McCloskey/ Mueller Satisfaction Scale
***P < 0.001, **P < 0.01, *P < 0.05
Univariate and regression analyses
Inter-group differences in demographic characteristics
The findings revealed notable disparities in job satisfaction among clinical nurses, contingent upon various demographic characteristics such as age, educational attainment, marital status, parental status, tenure in nursing, weekly working hours, and alignment of personal interests with the nursing profession (P < 0.05). Furthermore, significant variations in workplace psychological violence were discerned among nurses with differing average weekly working hours and degrees of alignment between personal interests and the nursing profession (P < 0.05). Regarding turnover intention, pronounced distinctions were evident across multiple demographic dimensions including age (in years), tenure in nursing, professional titles, weekly working hours, night shift schedules, departmental affiliations, and the congruence between personal interests and the nursing profession (P < 0.05). For comprehensive insights, please refer to Table 4 (Last two pages).
Table 4.
Inter-group Differences in Demographic Characteristics (Mean ± SD)
| Variables | Category | MMSS | WPVB | Turnover intention |
|---|---|---|---|---|
| Gender | Male | 3.36 ± 0.75 | 1.11 ± 0.66 | 2.24 ± 0.83 |
| Female | 3.14 ± 0.57 | 0.97 ± 0.80 | 2.21 ± 0.93 | |
| t | 0.975 | 0.468 | 0.067 | |
| Age (year) | ≤ 30 | 3.21 ± 0.61 | 0.92 ± 0.80 | 2.32 ± 0.92 |
| > 30 | 3.06 ± 0.51 | 1.05 ± 0.78 | 2.04 ± 0.91 | |
| t | 1.971* | -1.113 | 2.136* | |
| Education | Below Bachelor | 3.34 ± 0.63 | 0.87 ± 0.75 | 2.13 ± 0.91 |
| Bachelor’s degree or above | 3.08 ± 0.54 | 1.01 ± 0.80 | 2.25 ± 0.93 | |
| t | 2.799** | -1.147 | -0.808 | |
| Marriage | Unmarried | 3.23 ± 0.62 | 0.90 ± 0.82 | 2.22 ± 0.91 |
| Married Divorce | 3.06 ± 0.50 | 1.05 ± 0.74 | 2.21 ± 0.95 | |
| t | 2.118* | -1.358 | 0.089 | |
| Children | No | 3.23 ± 0.61 | 0.92 ± 0.81 | 2.21 ± 0.90 |
| Yes | 3.04 ± 0.51 | 1.04 ± 0.75 | 222 ± 0.7 | |
| t | 2.385* | -1.111 | -0.090 | |
| Nursing experience (year) | 0–5 | 3.27 ± 0.67 | 0.92 ± 0.82 | 2.29 ± 0.94 |
| 6–10 | 3.02 ± 0.44 | 1.00 ± 0.77 | 2.32 ± 0.92 | |
| ≥ 10 | 3.08 ± 0.46 | 1.06 ± 0.75 | 1.86 ± 0.81 | |
| F | 4.218* | 0.533 | 4.122* | |
| Professional title | Practitioner | 3.15 ± 0.57 | 0.96 ± 0.77 | 2.28 ± 0.92 |
| Senior nurse | 3.17 ± 0.68 | 1.02 ± 0.92 | 1.71 ± 0.82 | |
| t | -0.141 | -0.340 | 2.832** | |
| Duty | Clinical nurse | 3.15 ± 0.58 | 0.97 ± 0.80 | 2.23 ± 0.92 |
| Nursing Managers | 3.45 ± 0.34 | 0.90 ± 0.46 | 1.50 ± 0.43 | |
| t | -1.039 | 0.176 | 1.571 | |
| Average weekly working hours | ≤ 40 h | 3.24 ± 0.55 | 0.88 ± 0.75 | 2.09 ± 0.86 |
| > 40 h | 2.98 ± 0.60 | 1.15 ± 0.86 | 2.45 ± 1.01 | |
| t | 3.159*** | -2.227* | -2.901** | |
| Average monthly income (RMB) | 0–10000 | 3.15 ± 0.59 | 0.93 ± 0.77 | 2.25 ± 0.93 |
| > 10,000 | 3.17 ± 0.54 | 1.07 ± 0.83 | 2.10 ± 0.92 | |
| t | -0.243 | -1.126 | 1.022 | |
| Employment | Contract employed | 3.17 ± 0.58 | 0.93 ± 0.78 | 2.21 ± 0.92 |
| Officially employed | 3.01 ± 0.57 | 1.26 ± 0.85 | 2.22 ± 0.95 | |
| t | 1.295 | -1.923 | -0.012 | |
| Night shift | No | 3.30 ± 0.70 | 0.95 ± 0.85 | 1.63 ± 0.84 |
| Yes | 3.14 ± 0.56 | 0.97 ± 0.79 | 2.29 ± 0.91 | |
| t | 1.310 | -0.106 | -3.419*** | |
| Department | Inpatient ward | 3.14 ± 0.53 | 0.98 ± 0.80 | 2.30 ± 0.96 |
| Emergency/ICU/Operating room | 3.12 ± 0.69 | 0.99 ± 0.79 | 2.15 ± 0.79 | |
| Outpatient and others | 3.50 ± 0.55 | 0.73 ± 0.67 | 1.48 ± 0.66 | |
| F | 2.100 | 0.515 | 4.245* | |
| Hobbies matched to nursing | No | 2.91 ± 0.49 | 1.23 ± 0.82 | 2.61 ± 0.89 |
| Yes | 3.39 ± 0.54 | 0.73 ± 0.68 | 1.85 ± 0.80 | |
| t | -6.579*** | 4.786*** | 6.390*** |
WPVB Workplace Psychological Violence Behaviours, MMSS McCloskey/ Mueller Satisfaction Scale
***P < 0.001, **P < 0.01, *P < 0.05
Hierarchical regression analysis of turnover intention among clinical nurses
Hierarchical regression analysis was employed to investigate the predictors of turnover intention among clinical nurses. The turnover intention score served as the dependent variable, while demographic characteristics, workplace psychological violence, and job satisfaction constituted the independent variables. In the initial analysis layer, demographic factors such as age, nursing experience, professional title, average weekly working hours, night shift, inpatient ward, emergency/ICU/operating room and hobbies matched to nursing accounted for 24.60% of the total variance in turnover intention. Subsequently, workplace psychological violence was introduced as the second layer, contributing an additional explained variance of 32.50%. Finally, job satisfaction was incorporated as the third layer, resulting in a cumulative explained variance of 36.10%. Notably, inpatient ward, hobbies matched to nursing, workplace psychological violence, and job satisfaction emerged as primary determinants influencing turnover intention among clinical nurses. For detailed findings, please consult Table 5.
Table 5.
Regression analysis of the influence factor of turnover intention among clinical nurses (N = 206)
| Variables | Model 1 | Model 2 | Model 3 | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| β | SE | β' | t | β | SE | β' | t | β | SE | β' | t | |
| Constant | 1.880 | 0.582 | 3.230*** | 1.584 | 0.554 | 2.860** | 3.190 | 0.739 | 4.320*** | |||
| Age | -0.164 | 0.190 | -0.086 | -0.861 | -0.180 | 0.180 | -0.095 | -1.000 | -0.169 | 0.178 | -0.089 | -0.966 |
| Nursing experience | 0.069 | 0.122 | 0.059 | 0.568 | 0.033 | 0.116 | 0.028 | 0.286 | -0.046 | 0.115 | -0.039 | -0.397 |
| Professional title | -0.211 | 0.226 | -0.072 | -0.931 | -0.225 | 0.214 | -0.077 | -1.051 | -0.191 | 0.221 | -0.065 | -0.860 |
| Average weekly working hours | 0.394 | 0.120 | 0.202 | 3.282** | 0.303 | 0.115 | 0.155 | 2.635** | 0.217 | 0.128 | 0.111 | 1.690 |
| Night shift | 0.325 | 0.220 | 0.113 | 1.480 | 0.319 | 0.208 | 0.111 | 1.531 | 0.248 | 0.223 | 0.086 | 1.110 |
| Inpatient ward | 0.693 | 0.281 | 0.349 | 2.470* | 0.594 | 0.266 | 0.299 | 2.230* | 0.493 | 0.194 | 0.248 | 2.540* |
| Emergency /ICU/ operating room | 0.485 | 0.288 | 0.230 | 1.680 | 0.406 | 0.274 | 0.193 | 1.480 | 0.315 | 0.210 | 0.150 | 1.500 |
| Hobbies matched to nursing | -0.702 | 0.114 | -0.381 | -6.170*** | -0.520 | 0.114 | -0.282 | -4.558*** | -0.375 | 0.119 | -0.203 | -3.144** |
| WPVB | 0.353 | 0.072 | 0.302 | 4.875*** | 0.242 | 0.083 | 0.208 | 2.930** | ||||
| MMSS | -0.410 | 0.125 | -0.257 | -3.280*** | ||||||||
| F | 9.381*** | 11.943*** | 15.920*** | |||||||||
| R2 | 0.276 | 0.354 | 0.393 | |||||||||
| ΔR2 | 0.246 | 0.325 | 0.361 | |||||||||
In the department, the outpatient and others were used as the reference group. Model 1: Domestic characteristics; Model 2: Addition of WVPB; Model 3: Inclusion of MMSS
WPVB Workplace Psychological Violence Behaviors, MMSS McCloskey/ Mueller Satisfaction Scale
***P < 0.001, **P < 0.01, *P < 0.05
The mediating role of job satisfaction in the relationship between workplace psychological violence and turnover intention among clinical nurses
Utilizing the outcomes derived from the hierarchical regression analysis concerning factors influencing turnover intention among clinical nurses, a structural equation model (SEM) was meticulously crafted using Amos 26.0 software. Within this framework, workplace psychological violence was conceptualized as the independent variable, while job satisfaction assumed the role of a mediating variable, and turnover intention stood as the dependent variable. The SEM underwent rigorous fitting using the maximum likelihood method, yielding revised model fit indices: χ2/df = 2.107, RMSEA = 0.073, CFI = 0.964, TLI = 0.954, NFI = 0.935, indicative of a commendable alignment between the proposed model and the observed data patterns. For visual representation, kindly refer to Fig. 1.
Fig. 1.
The Mediation Model of Job Satisfaction in the Relationship Between Workplace Psychological Violence and Turnover Intention Among Clinical Nurses
Employing the Bootstrap method with 5000 resamples to examine the mediating effect revealed compelling results. Workplace psychological violence exerts a significant total effect (95% CI: 0.342–0.635), a direct effect (95% CI: 0.112–0.435), and an indirect effect (95% CI: 0.124–0.310) on turnover intention. Importantly, none of the confidence intervals for these effects encompassed zero, underscoring the substantive role of job satisfaction as a partial mediator in the relationship between workplace psychological violence and turnover intention. Specifically, the mediating effect contributes to 43.97% of the total effect. Refer to Table 6 for a comprehensive depiction of these findings.
Table 6.
The effect of job satisfaction on psychological violence in the workplace and turnover intention (N = 206)
| Effect | Estimate | SE(t) | 95% CI LL | 95%CI UL | P | Percentage |
|---|---|---|---|---|---|---|
| Total | 0.489 | 0.074 | 0.342 | 0.635 | < 0.001 | 100.00% |
| Direct | 0.274 | 0.082 | 0.112 | 0.435 | < 0.001 | 56.03% |
| Indirect | 0.215 | 0.047 | 0.124 | 0.310 | < 0.001 | 43.97% |
SE standard error, CI confidence interval, LL lower level, UL upper level
Discussion
Analysis of the status and influencing factors of WPVB, MMSS, and turnover intention among nurses
The results of this survey show that the average score for workplace psychological violence among clinical nurses was 0.97 ± 0.79, with 86 nurses (41.75%) having an average item score of ≥ 1, indicating that they had been exposed to workplace psychological violence. Notably, such violence is more prevalent among nurses working over 40 h per week and those whose vocational interests diverge from the nursing profession's core values. These findings align with previous research conducted in Korea [19, 20] and mainland China [21]. In Taiwan, the reported exposure rate was 51.4% [22], while it was 76% in Hong Kong [23]. In Japan, 27.5% of respondents reported experienced verbal violence [23]. The current study showed lower rates of workplace psychological violence compared to investigations conducted in Canada [24] and the United States [25]. This discrepancy may be attributed to the geographic scope of the survey and cultural variations between East and West. More concerning is that only 7.28% of clinical nurses reported not suffered from workplace psychological violence in the past 6 months, while 92.72% of nurses are either facing potential or current psychological violence. This prevalence mirrors the international situation, highlighting the widespread issue of workplace psychological violence among nurses. The psychological violence experienced by nurses in the workplace originates not only from patients and family members but also from colleagues. Psychological violence among colleagues is particularly detrimental to the mental health of nursing staff [26, 27].
Therefore, nursing managers must address the issue of psychological violence suffered by nurses in the workplace. First, formulate policies and procedures, regulate workplace behaviour, and establish a safe and anonymous reporting mechanism. These policies should cover incident prevention, post-exposure handling strategies, and reporting procedures. Secondly, comprehensive training and education should be provided, along with the establishment of support mechanisms and social support networks. Medical institutions can set up special in-hospital psychological counseling rooms and invite professional psychologists to offer services to employees. Regular interdisciplinary educational seminars for managers and professional psychological counselors can improve managers' ability to detect and address changes in employees' psychological states, allowing for early intervention. Additionally, counseling rooms can facilitate employee exchange activities to provide psychological comfort and spiritual encouragement and strengthen the social support network among employees to prevent the adverse effects of workplace psychological violence on nurses. Finally, managers should implement a regular evaluation and improvement mechanism to ensure the effectiveness of these measures, continuously support the mental health of the nursing team. By doing so, managers can better address nurses' exposure to psychological violence in the workplace, leading to a more positive work environment and increased nurses’ job satisfaction. This, in turn, can help reduce nurses’ tendency to leave their positions.
In terms of job satisfaction, the results of this study showed an average score of 3.16 ± 0.58, with 107 nurses (51.95%) scoring below 3.03, indicating that they were dissatisfied with their jobs, which is similar to the results of Zhou [28] in multiple countries and the United States. This study also found that clinical nurses over 30 years old, married with children, holding a bachelor's degree, with 6–10 years of work experience, and working more than 40 h a week are more likely to be dissatisfied with their jobs, which is consistent with previous research [29, 30]. This dissatisfaction may stem from age-related anxiety and social pressure, especially for nurses in the marriage age group. Nurses at this stage are often the backbone of the hospital, tasked with teaching responsibilities and facing increased work pressure, which may negatively impact their job satisfaction [31]. Clinical nurses who are married and have children, often struggle to find a balance between work and family responsibilities. This juggling act can lead to feelings of being overwhelmed, impacting their physical and mental health, increasing burnout, and ultimately reducing their job satisfaction [32–35]. In addition, the academic demands within large tertiary hospitals are constantly growing. This trend has resulted in an elevation of the overall academic qualifications of the nursing team, with high-quality resources and career development prospects becoming more accessible to those with higher education levels. Consequently, this shift has added pressure on undergraduate nurses. To this end, based on McClelland's "need for achievement theory" [36], it is essential to stimulate nurses' sense of responsibility by increasing their initiative and autonomy at work [37]. This can be achieved by giving nurses more decision-making power in areas such as work task allocation, training, work procedures, and methods, thereby enhancing their sense of participation and identity, and improving job satisfaction.
In this survey, the turnover intention score was 2.22 ± 0.92, with 60 nurses (29.12%) scoring ≥ 3, indicating that these clinical nurses exhibited turnover intention, a finding consistent with Gebregziabher [38]. Internationally, nurse turnover rates range between 4 and 54%, reflecting a high turnover rate [39, 40]. Differences in these results may be attributed to the legal frameworks and socioeconomic development of Eastern versus Western countries. Western nations have implemented protective legislation ensuring the personal rights and interests of nurses [41, 42], and place a strong emphasis on individual needs and feelings. Conversely, Chinese culture prioritizes collectivism, emphasizing unity and group harmony. In univariate analysis, night shift and turnover intention were found to be statistically significant. Stepwise regression analysis identified inpatient ward nurses, workplace psychological violence, job satisfaction, and a mismatch between personal interests and the nursing profession as the main influencing factors of turnover intention. These findings align with previous studies [43–45]. Compared to ward nurses, clinical nurses in other departments show a lower intention to leave, with night shifts being a significant factor for those wanting to leave [46]. Research suggests that night shift rotation lowers job satisfaction and impairs sleep quality, negatively impacting nurses' physical and mental health [47]. There have 73.5% of nurses consider leaving because of night shifts [48, 49].To address this issue, managers could optimize the night shift system and improve night shift compensation. Allowing voluntary applications for night shifts and providing sufficient compensatory time could enhance work autonomy and job satisfaction, thereby reducing nurses' turnover intentions.
In summation, the effective mitigation of workplace psychological violence and the enhancement of nurses' autonomy and job satisfaction necessitate a comprehensive suite of interventions encompassing policy formulation, training initiatives, support structures, and iterative evaluative mechanisms. Additionally, optimizing nocturnal duty arrangements and bolstering performance-based incentives have emerged as pivotal strategies for assuaging turnover intentions within the inpatient ward context.
Analysis of the correlation between workplace psychological violence, job satisfaction, and turnover intention
The results of this study showed that workplace psychological violence is negatively correlated with job satisfaction and positively correlated with turnover intention, while job satisfaction is negatively correlated with turnover intention, consistent with previous research findings [38, 43, 50]. This indicates that higher level of psychological violence experienced by nurses in the workplace lead to increased turnover intention. Workplace psychological violence not only leads to psychological fatigue for victims but can also result in adverse outcomes such as depression and anxiety [51], thereby decreasing job satisfaction. According to resource conservation theory, workplace psychological violence may damage various resources of nursing staff, increase work pressure, and reduce job satisfaction, thus prompting them to take measures to protect their resources, resulting in a tendency to leave. Experiencing psychological violence at work can lead to decreased work efficiency, professional burnout, and even resignation due to an unbearable work environment. Ongoing stress and anxiety might also cause physical health problems, reduce employees' quality of life, further deplete their future resources, and ultimately increase the turnover intention among nursing staff. Additionally, lower job satisfaction among clinical nurses correlates with higher turnover intention, consistent with previous findings [46]. Workplace psychological violence threatens the physical and mental health of nursing staff, particularly having significant psychological impacts. Victims may feel uneasy and anxious, become dissatisfied with their work tasks, and may even make nursing errors or accidents, leading them to consider seeking new career paths. Therefore, it is recommended that managers should provide support and training, such as mental health support services. Improving the work environment, offering reasonable working conditions and shift arrangements, and reducing nurses' workload and stress are essential. Providing leadership support and fostering teamwork can help establish a positive working atmosphere. Advocating for cultural reform, encouraging leaders and staff to collaboratively promote cultural change, and establishing a work culture based on respect, cooperation, and support are also essential. These measures, based on a comprehensive consideration of nurses’ health, work environment, and organizational culture, can help clinical nurses avoid or reduce workplace psychological violence, enhance job satisfaction, and thus reduce turnover intention.
Job satisfaction as a mediator between workplace psychological violence and turnover intention
This study examined the mediating role of job satisfaction in the relationship between workplace psychological violence and turnover intention among clinical nurses using a structural equation model. The results indicated that job satisfaction acts as a mediator between exposure to workplace psychological violence and intentions to leave. Specifically, workplace psychological violence was found to positively predict turnover intention among clinical nurses, consistent with findings from previous research [8]. Experiencing psychological violence in the workplace predisposes nurses to consider resigning from their positions. Further analysis revealed that the impact of workplace psychological violence on turnover intention is primarily driven by decreases in job satisfaction. This reduction in job satisfaction, in turn, heightens nurses' intentions to resign. This finding substantiates the conservation of resources theory within the context of clinical nursing. On one hand, workplace psychological violence can incite negative behaviours, disrupt the work environment, and diminish nurses' motivation and commitment. On the other hand, sustained psychological violence can negatively impact nurses' mental health and emotional well-being, subsequently leading to reduced job satisfaction. Nurses often find themselves unable to mitigate the stressors associated with workplace psychological violence independently. Prolonged exposure to such violence exacerbates negative emotions and depletes emotional resources. In such circumstances, nurses may seek to protect their remaining resources, often by attempting to leave the hospital environment, which can ultimately result in resignation [52]. Therefore, managers should focus on improving the clinical work environment and mitigating the adverse effects of workplace psychological violence on nurses' job satisfaction. By enhancing job satisfaction and reducing instances of psychological violence, managers can alleviate turnover intentions and stabilise the nursing workforce. This, in turn, will help retain skilled nursing staff, ensure better patient care, and foster a more cohesive and supportive work environment.
Limitations
This study has several limitations. Firstly, the use of convenience sampling, a non-probability sampling method, means that participants were selected based on their availability or willingness to participate. This may lead to selection bias. Future studies should consider employing more representative sampling methods to enhance the generalizability of the findings. Secondly, the participants in this study were primarily from a large tertiary hospital in one region, which may also introduce selection bias. Future research should aim to increase the sample size and include participants from a broader range of regions and institutions to balance the selection of research subjects from different areas.
Conclusions
This study revealed that clinical nurses experience moderate levels of workplace psychological violence and job satisfaction but have a high tendency to leave their jobs. Key factors influencing their turnover intention include being an inpatient ward nurse, experiencing workplace psychological violence, job satisfaction levels, and a mismatch between personal interests and the nursing profession. The structural equation model confirmed the mediating role of job satisfaction in the relationship between workplace psychological violence and turnover intention. Specifically, workplace psychological violence directly impacts turnover intention and exacerbates it by lowering job satisfaction. Managers can implement clear policies and procedures that encompass prevention, handling, and reporting mechanisms for workplace psychological violence. Psychological counselling and education, comprehensive training, mental health support services, and fostering a positive work environment are crucial measures. Additionally, optimizing the night shift system, improving performance compensation, and increasing nurses' autonomy at work can enhance job satisfaction and reduce turnover intention, stabilise the nursing workforce.
Acknowledgements
We thank all the participating nurses for their support and cooperation.
Abbreviations
- WPVB
Workplace Psychological Violence Behaviours
- MMSS
McCloskey/Mueller Satisfaction Scale
Authors’ contributions
Yanyan Luo and Minli Zhang are the primary researchers of this study. Yanyan Luo wrote the paper, and both Yanyan Luo and Shuliang Yu conducted the statistical analysis. Minli Zhang and Ting Zhong collected and organised the data. Yuanfang Li assisted in revising the manuscript. Qingcai Wu and Xiubi Guan supervised the survey and verified the data. All authors contributed to the final manuscript and approved it.
Funding
No funding was obtained for this study.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
The ethics approval was obtained from the ethics committee of Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University (the approval number: SYSKY-2023–206-01). The questionnaires used in the study follow unified guidance to explain the purpose, significance, and filling requirements. Each subject provided informed consent and participated voluntarily. They can quit at any time during the investigation, which will not have any impact on their work and life. Their information is protected anonymously, and the contents of the questionnaire are only used in this study and will not be leaked. The research team ensured adherence to this study's national and international ethical principles and codes of conduct.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yanyan Luo and Minli Zhang contributed equally to this work and share the first authorship.
Contributor Information
Qingcai Wu, Email: 369651520@qq.com.
Yuanfang Li, Email: Vefang@163.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.