Introduction
According to the International Council of Nurses (ICN), the global shortage of nurses is projected to reach 13 million by 2030 [1]. Due to excessive workload and burnout, many nurses are choosing to leave their positions, exacerbating the global nursing shortage [2, 3]. Studies have shown that the nurse turnover rates in New Zealand, Canada, and Australia are 44.3%, 19.9%, and 15.1%, respectively [4]. A survey of 10,781 young nurses in Chinese hospitals revealed that 33.5% have intentions to leave, with 3.8% having very strong intentions [5]. High turnover rates not only negatively impact the quality of care and patient health outcomes but also impose a significant economic burden on healthcare systems. Related surveys indicate that the turnover rate for nurses in U.S. hospitals was 25.9% in 2022, with the average cost of replacing a nurse being $46,100, leading to losses exceeding $5 million per hospital [6]. In the context of an aging population, the shortage of nurses has become a major challenge for global healthcare systems. The high turnover rate among nurses, as a critical factor contributing to this shortage, has garnered widespread attention from researchers. Therefore, exploring nurses’ turnover intentions and the influencing factors, as well as developing appropriate intervention strategies, has become a crucial issue in the field of nursing management. Currently, many scholars have conducted extensive research on the turnover intentions of nursing staff. Some studies have pointed out that turnover intentions are influenced by individual characteristics such as gender, marital status, and education level [7]. Other studies have found that factors such as the work environment, organizational climate, and leadership style are closely related to turnover intentions [4, 8‐10]. These findings provide important guidance for understanding and intervening in nurses’ turnover behaviors. However, the turnover intentions of nursing staff result from a combination of multiple factors. They are influenced not only by external environments but also significantly by personal psychological and emotional states.
Emotional exhaustion is a psychological state characterized by extreme fatigue and the depletion of emotional resources [11, 12]. Due to the unique nature of their work environment, nurses are more prone to experiencing emotional exhaustion. Studies have shown that nurse populations in different countries experience varying degrees of emotional exhaustion. In Turkey, Canada, and Germany, the proportions of nurses experiencing emotional exhaustion are 42.6%, 55.4%, and 44% respectively [11, 13, 14]. A survey conducted during the COVID-19 pandemic in China revealed that 60.5% of nurses experienced emotional exhaustion, with as many as 41.5% reporting high levels of emotional exhaustion [15]. Emotional exhaustion not only affects nurses’ mental health but also may lead to a series of negative outcomes, such as reduced quality of care and job performance, and diminished levels of organizational commitment [7, 16]. This is particularly concerning for Intensive care unit(ICU) nurses, who face more severe physical and mental challenges due to the closed nature of their work environment and the instability of patients’ conditions. The risk of emotional exhaustion for ICU nurses should not be underestimated.
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Organizational justice is a multidimensional concept that encompasses both the objective fairness in decision-making processes, resource allocation, treatment of employees, and employees’ subjective perceptions of this objective state. Organization-based self-esteem(OBSE), as an important psychological resource, can positively influence individual emotions and cognition, thereby improving behavior and significantly enhancing job performance [17, 18]. Current research has highlighted the connection between emotional exhaustion and turnover intentions among nurses [19]. However, studies on how external and internal resources simultaneously function to mitigate the negative effects of emotional exhaustion, particularly within the unique professional group of ICU nurses, remain relatively limited. ICU nurses, especially young nurses, form the core of the ICU care team. Their emotional and psychological states are not only directly related to the physiological health and life outcomes of critically ill patients but also significantly impact the efficient operation of the healthcare system.
Grounded in the Job Demands-Resources (JD-R) theory, this study explores the underlying mechanisms linking emotional exhaustion to turnover intention among young ICU nurses, with a specific focus on the moderating roles of organizational justice and OBSE as critical resources. Through an in-depth analysis of this specialized occupational group and its unique work context, this study not only expands the theoretical framework of the relationship between emotional exhaustion and turnover intention but also provides specific guidance for healthcare institutions and nursing managers on optimizing organizational resource allocation and developing effective talent retention strategies, thereby helping to alleviate the nursing staff shortage.
Theoretical basis
In the JD-R model, job characteristics are divided into job demands and job resources [20]. Job demands are factors that require employees to expend effort and resources to complete their work. These are the “negative factors” in a job that deplete employees’ energy. Excessive job demands can easily lead to negative outcomes. Job resources are the “positive factors” that help achieve work goals, reduce job demands and costs, and promote performance. Abundant job resources can have a positive impact [21]. In the context of emphasizing patient-centered care models [12], hospitals have placed higher job demands on nurses’ professional skills and emotional management abilities to provide high-quality medical services, especially for ICU nurses. In this scenario, the acquisition and utilization of internal and external job resources become particularly important. These resources can effectively reduce the costs associated with meeting job demands for ICU nurses and mitigate the negative impacts of high work demands. Therefore, the JD-R theoretical model is suitable for explaining this study.
Job demands and outcomes
The “dual-pathway” hypothesis is one of the three hypotheses proposed by the JD-R theory [20]. In the “dual-pathway” hypothesis, the health impairment pathway indicates that high job demands and a lack of job resources are likely to induce burnout, which in turn leads to negative outcomes such as low job performance and low organizational commitment. Job demands require employees to expend effort and emotional energy. If emotional resources are continuously depleted without replenishment, employees may reduce their work enthusiasm and motivation, adversely affecting both personal and organizational development. Research by Beehr et al. revealed that when employees face high job demands, they may experience physical or psychological health problems, which hinder work-related productive behaviors [22]. To prevent or reduce further resource loss, employees may adopt negative work behaviors. This has also been confirmed by the studies of Bruyneel and Saei [2, 8]. Based on this, we propose the following hypothesis:
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Hypothesis 1
Emotional exhaustion positively predicts turnover intentions.
Hypothesis 2
Job performance mediates the relationship between emotional exhaustion and turnover intentions.
Mediation through Job resources
The “buffering” hypothesis further posits that with the support of high job resources, the negative impact of job demands on employees can be weakened. This is because many employees face job demands that could harm their personal well-being, such as psychological health. However, they also acquire or utilize external and internal resources to handle these job demands and protect their well-being. External resources refer to the support provided by the work environment, typically stemming from the job position or at the organizational level. Organizational justice is an important external resource, closely related to organizational policies, goals, and management styles. Employees with a high sense of organizational justice, who feel respected by their leaders and recognized for their value by the organization, will strengthen their identification with the organization and enhance their sense of belonging. This has been confirmed by studies conducted by Strom et al. and Yu et al. [23, 24]. Internal resources refer to the personal resources that employees possess. These resources are defined as psychological characteristics that enable employees to effectively control or influence their environment [25]. The study by Tadić et al. found that personal resources can provide employees with the confidence and intrinsic motivation to act on behalf of the organization, which in turn can influence their work initiative and organizational commitment [26]. Among the various personal resources, OBSE, as a more motivational resource (rather than other more trait-like resources such as resilience), is the focus of this study. Based on this, we propose the following hypotheses:
Hypothesis 3
Organizational justice mediates the relationship between emotional exhaustion and turnover intentions.
Hypothesis 4
OBSE mediates the relationship between emotional exhaustion and turnover intentions.
The gain pathway in the “dual pathways” hypothesis suggests that abundant job resources can motivate employees to increase their job engagement, leading to positive outcomes. Additionally, the “coping” hypothesis proposes that employees under high job demands can better convert high job resources into high job performance. Based on this, we propose the following hypotheses:
Hypothesis 5
Organizational justice and job performance play a chain mediating role between emotional exhaustion and turnover intention.
Hypothesis 6
OBSE and job performance play a chain mediating role between emotional exhaustion and turnover intention.
Generally, individuals’ perceptions of the external environment influence their external behaviors through internal psychological mechanisms. Yu et al. validated that employees’ perception of organizational justice affects their job engagement through the internal psychological mechanism of professional identity, using the stimulus-motivation-behavior response model [23]. This is because individuals with high professional identity have a dual affirmation of themselves and their profession. They carry a sense of mission and belonging, which motivates them to actively engage in their work. Therefore, employees with a high sense of organizational justice, whether they choose to stay or increase their work engagement, are closely related to their psychological state. OBSE, as a psychological trait, may mediate this influence mechanism. We reasonably speculate that employees with a high sense of organizational justice will feel valued by both themselves and the organization, making them more likely to stay in their positions and engage in positive work behaviors to reciprocate the organization. Based on this, we propose the following hypotheses:
Hypothesis 7
Organizational justice and OBSE play a chain mediating role between emotional exhaustion and turnover intention.
Hypothesis 8
Organizational justice, OBSE and job performance play a chain mediating role between emotional exhaustion and turnover intention.
Methods
Design and participants
This study used a cross-sectional design and follows the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines(see Supplementary File 1). A convenience sampling method was employed to select young ICU nurses from four general hospitals in central China as the research subjects.
Following the World Health Organization’s definition of youth [27], the inclusion criteria for the study subjects were as follows: [1] 18–44 years old; [2] holding the nurse certificate and registered; [3] independently engaged in clinical work in the ICU for ≥ 1 year; [4] voluntarily participating in the study with informed consent. The exclusion criteria were: [1] ICU nurses who stopped participating in the study midway; [2] ICU nurses unable to participate in the study due to special circumstances occurring during the survey period. The formula N = 4Uα2S2/δ2 was used to calculate the sample size [28]. In the pre-survey, the standard deviation S = 0.53, with the allowable errorδset at 0.1 andαset at 0.05. Thus, N = 4 × 1.962 × 0.532/0.12≈432. Considering sampling error and the possibility of invalid questionnaires, we distributed a total of 490 questionnaires. After excluding 43 invalid questionnaires, 447 valid questionnaires were included in the final analysis. Additionally, research suggests that a sample size of ≥ 200 is suitable for SEM analysis [29, 30]. Therefore, the sample size of this study meets the basic requirements for model validation.
Data collection
Under the guidance of trained research assistants, participants provided information on sociodemographic characteristics, emotional exhaustion, organizational justice, OBSE, work performance, and turnover intentions. Before conducting the survey, researchers communicated with the nursing management departments of the target hospitals and obtained their consent. During this process, key details such as the specific time and location of the survey, as well as the expected number of participants, were confirmed in detail. During the survey, the researchers explained the study’s purpose, procedures, and potential risks to the participants. After obtaining informed consent, participants began filling out the questionnaires. Data collection took place from November to December2023.
Measurements
Emotional exhaustion
We employed the Emotional Exhaustion subscale from the revised Maslach Burnout Inventory-General Survey (MBI-GS), as adapted by Li et al. [31]. In this scale, the measurement of emotional exhaustion includes five items, including “work makes me feel tired”, “after a day’s work, I will feel exhausted”, etc., the scale options use Likert 5-point scoring method, 1 to 5 points respectively represent “completely inconsistent” to “completely consistent”, the higher the score indicates the higher the degree of emotional exhaustion. The Cronbach’s α coefficient for the original Emotional Exhaustion subscale was 0.89. In our study, the Cronbach’s α coefficient for the Emotional Exhaustion scale was also 0.88.
Organizational justice
This study utilized the Organizational Justice Scale developed by Wang et al. [32], which is tailored to the Chinese cultural context. The scale comprises three dimensions: distributional justice, procedural justice, and interactional justice, totaling 16 items. The specific items include statements like “Nurse managers and colleagues treat me with respect and sincerity.” The scale options use a 5-point Likert scale, with a score of 1 to 5 representing “completely disagree” to “completely agree”. Higher scores indicate a stronger sense of organizational justice. The original scale had a Cronbach’s α coefficient of 0.92, while in this study, the Cronbach’s α for the scale was 0.96.
Organization-based self-esteem (OBSE)
The OBSE Scale developed by Pierce in 1989 was adopted in this study [33]. It is a single-dimensional scale with 10 items, including “I feel that I am important in the organization” and “I feel that I have a significant impact in the organization.” Likert five-point scale was adopted, with 1 to 5 points representing “completely disagree” and “completely agree” respectively. A score higher indicates a higher level of OBSE. The scale demonstrates good applicability in the Chinese cultural context (Cronbach’s α = 0.90). In this study, the Cronbach’s α of the scale was 0.93.
Job performance
This study utilized the Nurse Job Performance Scale developed by Wang et al. [34], which consists of three dimensions: work cooperation, work enthusiasm, and work involvement. Specific items include “I closely collaborate with colleagues (physicians, nurses, and support staff)”, “I actively seek to participate in rescuing critically ill patients”, and “I am willing to take on additional tasks beyond my job duties and devote extra time and effort to work”. The scale uses a five-point Likert scale, with a score of 1 to 5 representing “completely disagree” to “completely agree”. A higher score indicates better performance. The original scale had a Cronbach’s α coefficient of 0.94. In this study, the scale’s Cronbach’s α was 0.95.
Turnover intention
This study used the Chinese version of the Turnover Intention Questionnaire (TIQ) translated and revised by Li et al. [35]. based on Michaels and Spector’s original scale. The scale consists of three dimensions: Turnover Intention I, II, and III. Turnover Intention I indicates the likelihood of quitting the current job, Turnover Intention II indicates the motivation to seek other employment, and Turnover Intention III indicates the perceived likelihood of obtaining external employment. The scale comprises six items, including specific items such as “Are you considering quitting your current job?” Each item utilizes a 4-point Likert scale, where “often” is scored as 4 points, “occasionally” as 3 points, “rarely” as 2 points, and “never” as 1 point. Finally, the scores are categorized into 4 levels based on the average score per item: very low (≤ 1), low (> 1, ≤ 2), high (> 2, ≤ 3), and very high (> 3 points). The original scale had a Cronbach’s α coefficient of 0.87. In this study, the scale’s Cronbach’s α was 0.80.
Ethical consideration
This study was approved by the Medical Ethics Committee of the researcher’s institution (Approval No. 2024ks-1w026). This study strictly adhered to the ethical principles of the Declaration of Helsinki. Before distributing questionnaires to participants, we obtained informed consent from the hospital’s nursing management department. We thoroughly explained the purpose and significance of the study to all participants, ensuring they understood the research content. On this basis, we obtained informed consent from all participants. To protect the privacy of participants, all data were anonymized.
Data analysis
Data analysis and model construction were performed using SPSS 27.0 and AMOS 25.0, respectively. First, descriptive statistical methods were used to analyze the general characteristics of the participants. Second, normality tests were conducted on continuous variables. If the continuous variables followed a normal distribution, Pearson correlation analysis was used to examine the relationships between the five variables and their dimensions; otherwise, Spearman correlation analysis was employed. Finally, structural equation modeling (SEM) was utilized to test the mediating roles of organizational justice, OBSE, and job performance in the relationship between emotional exhaustion and turnover intentions.
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Based on previous research on the SEM item parceling, we adopted the " item-to-construct balance " to parcel items for emotional exhaustion and OBSE [36]. To assess the model’s fit, the following indices were used: chi-square/degrees of freedom ratio (χ²/df), goodness-of-fit index (GFI), adjusted goodness-of-fit index (AGFI), comparative fit index (CFI), incremental fit index (IFI), root mean square error of approximation (RMSEA), and standardized root mean square residual (SRMR).χ²/df < 5,GFI > 0.90,AGFI > 0.90,CFI > 0.90, IFI > 0.90,RMSEA ≤ 0.08,SRMR < 0.05 indicated model fit [34, 37]. The bias-corrected percentile Bootstrap method was used, selecting 5000 Bootstrap samples to estimate the 95% confidence interval for the mediation effect. If the 95% confidence interval (CI) does not include 0, the effect is considered statistically significant.
Results
Participant characteristics
We distributed a total of 490 questionnaires and received 447 valid responses (a response rate of 91.2%). Among the participants, 92.6% were female and 7.4% were male. 15.9% of the nurses were 24 years old or younger, 74.9% were between 25 and 34 years old, and 25.1% were between 35 and 44 years old. 61.5% of the nurses were married. Over 80% of the nurses held a bachelor’s degree or higher. As shown in Table 1.
Table 1
Characteristics of Young Intensive Care Unit nurses (N = 447)
Variables | N | % | |
|---|---|---|---|
Gender | Male | 33 | 7.4% |
Female | 414 | 92.6% | |
Age | 18–24 | 71 | 15.9% |
25–34 | 335 | 74.9% | |
35–44 | 112 | 25.1% | |
Marital Status | single | 172 | 38.5% |
Married | 275 | 61.5% | |
Education Level | High school and below | 1 | 0.2% |
Junior college | 57 | 12.8% | |
bachelor’s degree | 386 | 86.4% | |
master’s degree or above | 3 | 0.7% | |
Professional title | Nurse | 110 | 24.6% |
Nurse practitioner | 162 | 36.2% | |
Nurse-in-charge | 172 | 38.5% | |
Associate professor of nursing or above | 3 | 0.7% | |
Work experience(years) | 1–5 years | 189 | 42.3% |
6–10 years | 115 | 25.7% | |
>10years | 143 | 32.0% | |
Labor and personnel relations | contract system | 67 | 15.0% |
personnel agency | 360 | 80.5% | |
formally in the compilation | 20 | 4.5% |
Pearson’s correlation analysis
The results of the Kolmogorov-Smirnov test indicated that emotional exhaustion, organizational justice, OBSE, job performance, and turnover intention all followed a normal distribution (P > 0.05). Therefore, we used Pearson correlation analysis to examine the relationships among the five variables.
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The results are presented in Table 2. The average score for emotional exhaustion was (2.80 ± 0.97), organizational justice (4.27 ± 0.68), OBSE (4.14 ± 0.63), job performance (4.38 ± 0.54), and turnover intention (2.06 ± 0.67). Pearson correlation analysis revealed that emotional exhaustion was positively correlated with turnover intention (r = 0.476, P < 0.01), and negatively correlated with organizational justice (r=-0.340, P < 0.01), OBSE (r=-0.358, P < 0.01), and job performance (r=-0.366, P < 0.01). Organizational justice was negatively correlated with turnover intention (r=-0.467, P < 0.01) and positively correlated with OBSE (r = 0.488, P < 0.01) and job performance (r = 0.482, P < 0.01). OBSE was negatively correlated with turnover intention (r=-0.532, P < 0.01) and positively correlated with job performance (r = 0.751, P < 0.01). Job performance was negatively correlated with turnover intention (r=-0.541, P < 0.01).
Table 2
Descriptive statistics and correlation analysis (r)
variable | EE | OJ | DJ | PJ | IJ | OBSE | JP | WC | WE | WI | TI | TII | TIII | TIIII | Range | Median | Mean ± SD |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EE | 1 | 1–5 | 2.80 | 2.80 ± 0.97 | |||||||||||||
OJ | − 0.340** | 1 | 1–5 | 5.00 | 4.27 ± 0.68 | ||||||||||||
DJ | − 0.334** | 0.961** | 1 | 1–5 | 5.00 | 4.22 ± 0.72 | |||||||||||
PJ | − 0.304** | 0.961** | 0.906** | 1 | 1–5 | 5.00 | 4.31 ± 0.69 | ||||||||||
IJ | − 0.320** | 0.951** | 0.848** | 0.901** | 1 | 1–5 | 5.00 | 4.27 ± 0.68 | |||||||||
OBSE | − 0.358** | 0.488** | 0.470** | 0.438** | 0.478** | 1 | 1–5 | 4.00 | 4.14 ± 0.63 | ||||||||
JP | − 0.366** | 0.482** | 0.456** | 0.443** | 0.481** | 0.751** | 1 | 1–5 | 4.36 | 4.38 ± 0.54 | |||||||
WC | − 0.341** | 0.481** | 0.458** | 0.447** | 0.474** | 0.676** | 0.943** | 1 | 1–5 | 4.33 | 4.45 ± 0.55 | ||||||
WE | − 0.336** | 0.465** | 0.435** | 0.424** | 0.474** | 0.722** | 0.963** | 0.866** | 1 | 1–5 | 4.25 | 4.37 ± 0.57 | |||||
WI | − 0.356** | 0.409** | 0.389** | 0.371** | 0.405** | 0.736** | 0.921** | 0.762** | 0.876** | 1 | 1–5 | 4.00 | 4.26 ± 0.62 | ||||
TI | 0.476** | − 0.467** | − 0.452** | − 0.436** | − 0.445** | − 0.532** | − 0.541** | − 0.507** | − 0.488** | − 0.532** | 1 | 1–4 | 2.00 | 2.06 ± 0.67 | |||
TII | 0.482** | − 0.484** | − 0.471** | − 0.458** | − 0.459** | − 0.480** | − 0.513** | − 0.484** | − 0.467** | − 0.496** | 0.877** | 1 | 1–4 | 2.00 | 2.08 ± 0.83 | ||
TIII | 0.429** | − 0.439** | − 0.423** | − 0.417** | − 0.424** | − 0.473** | − 0.509** | − 0.481** | − 0.457** | − 0.497** | 0.868** | 0.769** | 1 | 1–4 | 2.00 | 1.92 ± 0.86 | |
TIIII | 0.271** | − 0.261** | − 0.257** | − 0.236** | − 0.243** | − 0.405** | − 0.333** | − 0.297** | − 0.308** | − 0.342** | 0.763** | 0.532** | 0.434** | 1 | 1–4 | 3.00 | 2.48 ± 0.85 |
Mediating effect analysis
Fit indices were used to evaluate the degree of fit between the model and the actual data. The results of this study indicate that the model is acceptable (see Table 3).
Table 3
Model-fitting standard and fitting index of the final model
Model fit | \(\:{\varvec{x}}^{2}/\varvec{d}\varvec{f}\) | GFI | AGFI | IFI | CFI | SRMR | RMSEA |
|---|---|---|---|---|---|---|---|
Model-fitting standard | <5 | >0.90 | >0.90 | >0.90 | >0.90 | <0.05 | ≤ 0.08 |
Model-fitting index | 2.471 | 0.947 | 0.921 | 0.983 | 0.983 | 0.021 | 0.057 |
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SEM was used to examine the mediating roles of organizational justice, OBSE, and job performance in the relationship between emotional exhaustion and turnover intention. The results are shown in Fig. 1: emotional exhaustion positively predicts turnover intention (β = 0.31, P < 0.001), supporting Hypothesis 1. Job performance played a mediating role between emotional exhaustion and turnover intention (EE→JP, β = 0.08, P < 0.05; JP→TI, β=-0.21, P < 0.01); Organizational justice played a mediating role between emotional exhaustion and turnover intention (EE→OJ, β=-0.33, P < 0.001; OJ→TI, β=-0.24, P < 0.001); OBSE played a mediating role between emotional exhaustion and turnover intention (EE→OBSE, β=-0.23, P < 0.001; OBSE→TI, β=-0.15, P < 0.05); Organizational justice and job performance played a chain mediating role between emotional exhaustion and turnover intention (EE→OJ, β=-0.33, P < 0.001; OJ→JP, β = 0.13, P < 0.001; JP→TI, β=-0.21, P < 0.01); OBSE and job performance played a chain mediating role between emotional exhaustion and turnover intention (EE→OBSE, β=-0.23, P < 0.001; OBSE→JP, β = 0.68, P < 0.001; JP→TI, β=-0.21, P < 0.01); Organizational justice and OBSE played a chain mediating role between emotional exhaustion and turnover intention (EE→OJ, β=-0.33, P < 0.001; OJ→OBSE, β = 0.40, P < 0.001; OBSE→TI, β=-0.15, P < 0.05); Organizational justice, OBSE and job performance play a chain mediating role between emotional exhaustion and turnover intention (EE→OJ, β=-0.33, P < 0.001; OJ→OBSE, β = 0.40, P < 0.001; OBSE→JP, β = 0.68, P < 0.001; JP→TI, β=-0.21, P < 0.01)
Fig. 1
The mediating roles of organizational justice, OBSE, and job performance between emotional exhaustion and turnover intention. Abbreviations: EE, Emotional Exhaustion; OBSE, Organization-based self-esteem; OJ, Organizational Justice; DJ, Distributional Justice; PJ, Procedural Justice; IJ, Interactional Justice; JP, Job Performance; WC, Work Cooperation; WE, Work Enthusiasm; WI, Work Involvement; TI, Turnover Intention; TII, Turnover IntentionI; TIII, Turnover IntentionII, TIIII, Turnover Intention III. ***P < 0.001, **P < 0.01, *P < 0.05
×
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Subsequently, in order to test the mediating effect between emotional exhaustion and turnover intention, this study employed a bias-corrected percentile bootstrap method to calculate the 95% confidence interval of the mediating effect, and selected 5000 bootstrap samples to test the mediating effect. Following Preacher and Hayes’ recommendation46, significance of the indirect effects was determined by examining whether the confidence intervals (CI) excluded zero. The results indicated that all mediating pathways were statistically significant, as shown in Table 4.
Table 4
Bootstrap analysis of the mediating model
Effect | Path | Standardized β | SE | The size of effect | 95%CI | Hypothesis | ||
|---|---|---|---|---|---|---|---|---|
Lower | Upper | P | ||||||
Total | EE→TI | 0.524 | ||||||
Direct | EE→TI | 0.311 | ||||||
Indirect | EE→JP→TI | 0.017 | 0.011 | 3.24% | 0.004 | 0.041 | 0.015 | Hypothesis2: support |
EE→OJ→TI | 0.081 | 0.020 | 15.46% | 0.051 | 0.117 | 0.001 | Hypothesis3: support | |
EE→OBSE→TI | 0.035 | 0.018 | 6.68% | 0.010 | 0.071 | 0.018 | Hypothesis4: support | |
EE→OJ→JP→TI | 0.009 | 0.004 | 1.72% | 0.003 | 0.018 | 0.006 | Hypothesis5: support | |
EE→OBSE→JP→TI | 0.032 | 0.013 | 6.11% | 0.015 | 0.058 | 0.001 | Hypothesis6: support | |
EE→OJ→OBSE→TI | 0.020 | 0.010 | 3.82% | 0.007 | 0.039 | 0.018 | Hypothesis7: support | |
EE→OJ→OBSE→JP→TI | 0.019 | 0.007 | 3.63% | 0.009 | 0.034 | 0.001 | Hypothesis8: support | |
Discussion
This study is based on the JD-R theory framework and constructs a structural equation model to explore the potential mechanisms through which emotional exhaustion influences turnover intention among young ICU nurses. The research particularly focuses on how organizational justice and OBSE, as key job resources, function in the context of emotional resource depletion
In this study, turnover intention scores were relatively high, similar to the findings of Su et al. [4]. This result indicates that young ICU nurses have a high turnover intention, and it is urgent to take effective intervention measures to reduce the turnover intention. Our research confirmed that emotional exhaustion significantly predicts turnover intention among young ICU nurses, consistent with previous studies [19]. The demanding nature of ICU work exposes nurses to high-intensity occupational stress. Frequent emotional labor and long working shifts can lead to rapid depletion of their emotional resources. According to the Conservation of Resources (COR) theory, individuals prioritize the protection of their remaining resources. When nurses perceive excessive depletion of emotional resources without sufficient replenishment from the work environment, they may choose to leave the organization to avoid further emotional exhaustion( Hypothesis 1 supported) [8]. The findings revealed that job performance mediates the relationship between emotional exhaustion and turnover intention. Emotional exhaustion diminishes nurses’ energy and focus, leading to impaired job performance. Moreover, declining performance may exacerbate feelings of professional frustration and dissatisfaction. This negative cycle ultimately reinforces nurses’ intention to leave their jobs (Hypothesis 2 supported)
The score for organizational justice was higher than the results found in the previous study by Yu et al. [23]. This may be because ICU nurses, due to the nature of their roles and the hospital’s emphasis on their work, are more sensitive to perceptions of organizational justice. The results of this study indicate that organizational justice mediates the relationship between emotional exhaustion and turnover intention. This is because organizational justice involves perception of fairness in the allocation of resources, compensation, and opportunities, as well as equal treatment in interactions with others and transparency in decision-making processes [38]. When nurses are satisfied with distributional justice, they feel that their efforts and contributions are reasonably recognized and rewarded by the organization. In terms of interpersonal justice, when nurses feel respected and treated equally by nurse managers and colleagues, it enhances their sense of belonging to the organization. Regarding procedural justice, when nurses feel their voices are heard and the decision-making process is transparent, it enhances their loyalty and trust towards the organization. Overall, these perceptions help mitigate the negative effects of emotional exhaustion on work experience and enhance nurses’ organizational commitment(Hypothesis 3 supported). Meanwhile, the study reveals that organizational justice and job performance play a sequential mediating role between emotional exhaustion and turnover intention. When nurses perceive a higher level of organizational justice, a fair environment can motivate them to continuously engage in their work, improve work quality and efficiency, and thereby improve job performance (Hypothesis 5 supported) [4]
The score of OBSE is higher than that of Chen et al. [39]. The research results indicate that OBSE mediates the relationship between emotional exhaustion and turnover intention. This may be due to, on one hand, high levels of OBSE providing nurses with a sense of psychological support, enabling them to more actively regulate their mental state and alleviate negative emotions caused by work stress during emotional exhaustion. On the other hand, the perception of their own value enhances nurses’ sense of belonging and organizational commitment, thereby effectively reducing turnover intention (Hypothesis 4 supported) [11]. Furthermore, OBSE also serves as a motivating resource that encourages nurses to adopt more proactive work behaviors [17]. When nurses perceive their value within the organization, they are more likely to demonstrate work initiative and engage in behaviors beneficial to the organization, thus improving job performance (Hypothesis 6 supported)
This study also revealed the chain mediation role of organizational justice, OBSE, and job performance between emotional exhaustion and turnover intention. After undertaking intense and complex nursing tasks, when nurses feel that their compensation matches their effort, they are more likely to be satisfied with their work and hold a positive assessment of their abilities and value [7]. When nurses feel they have the opportunity to participate in decision-making processes and that decisions are based on fair procedures, they are more likely to develop positive feelings toward the organization and their work, and feel proud of their role within the organization. When facing work pressure, receiving encouragement and support from nurse managers and colleagues can make them feel understood and valued. Overall, nurses’ perception of organizational justice influences their evaluation of their worth and competence as members of the organization(Hypothesis 7 supported) [40]. In the context of emotional exhaustion, if nurses perceive organizational justice and affirm their own value and abilities, they are more likely to maintain a positive work attitude, improve their job performance, and be inclined to stay in their current positions(Hypothesis 8 supported) [32]
Limitations and future research
The limitations of this study are as follows: Firstly, this study employed a convenience sampling method, selecting young ICU nurses from four general hospitals in central China as the research subjects. While this sampling method is operationally feasible, it limits the generalizability of the findings. Future studies could expand the sample scope to include nurses from different regions and diverse cultural backgrounds to enhance the universality of the research conclusions
Secondly, this study primarily relied on self-reported data as the measurement method, which may introduce bias due to subjective assessments. For example, nurses might overestimate or underestimate variables such as OBSE or emotional exhaustion based on personal perceptions. Future research could incorporate more objective measurement methods, such as third-party evaluations or physiological indicators (e.g., stress hormone levels), to improve the accuracy and reliability of the data
Thirdly, although research assistants adhered strictly to principles of respecting nurses’ voluntary participation and ensured that participation was not directly linked to compensation or job evaluations, implicit participation pressure might still exist. Future studies could reduce this potential influence on data quality by employing more anonymous data collection methods (e.g., online questionnaires) or engaging independent external organizations to handle recruitment and data collection
Lastly, this study employed a cross-sectional survey design, which cannot explore causal relationships among variables. For instance, how organizational justice and OBSE moderate emotional exhaustion and turnover intention over time remains unclear. Future studies could adopt longitudinal research to dynamically track the interactions of these variables across different time points
Conclusion
Nurse shortages pose a significant threat to the stability of global healthcare systems and the quality of patient care. Young ICU nurses, given the unique demands of their work environment, face heightened vulnerability. This study, based on the JD-R theory perspective, thoroughly explores the relationship between emotional exhaustion and nurses’ turnover intention, highlighting the key role of organizational justice and OBSE in resource allocation
These findings provide new theoretical guidance for nursing management practice, urging healthcare institutions to optimize the allocation of organizational resources. Specifically, healthcare organizations and nursing managers should enhance nurses’ sense of organizational justice and improve their OBSE, creating a more supportive work environment, which in turn enhances the stability of the nursing workforce and ultimately improves the quality of healthcare services
Implications for nursing practice
This study provides important theoretical support and practical guidance for reducing turnover intentions among young ICU nurses and implementing effective interventions. Based on the findings, the following specific recommendations are proposed:
(1) Continuously Monitor Nurses’ Mental Health. Nurse managers should closely monitor the emotional states of nurses and establish systematic emotional support mechanisms to help alleviate stress. For example, healthcare institutions can regularly invite mental health professionals to conduct psychological counseling or stress management training to help nurses develop emotional regulation and coping strategies. Hospitals may also consider implementing Employee Assistance Programs (EAPs) to provide psychological counseling and support services, helping nurses manage work-related stressors and enhance their psychological resilience
(2) Enhance Organizational Justice and Resource Allocation Efficiency. Healthcare institutions and nurse managers should ensure fairness and transparency in resource allocation and decision-making processes. Specific measures include: Optimizing the Compensation System: Develop and implement a compensation system that matches nurses’ professional skills, responsibilities, and contributions, ensuring it remains competitive. Transparent Decision-Making Mechanisms: Promote open and transparent decision-making processes, explain the rationale behind decisions to nurses, and create opportunities for them to participate in decision-making, enhancing their sense of ownership. Balanced Resource Allocation: Distribute work resources equitably to avoid over-concentration on a select few individuals or departments, ensuring that all nurses receive adequate support to perform their duties efficiently
(3) Foster a Supportive and Inclusive Organizational Culture. A positive, supportive, and inclusive organizational culture can significantly enhance nurses’ sense of belonging and organizational commitment. Specific actions include: Regularly recognizing and rewarding nurses for their work performance and achievements, offering public acknowledgment and encouragement to boost motivation and a sense of accomplishment. Assisting nurses in establishing clear career development pathways and providing opportunities for growth and professional development, such as continuing education and leadership training, to facilitate their long-term career advancement. Promoting a “people-centered” management philosophy to ensure nurses feel respected and valued for their contributions, thereby enhancing their OBSE and satisfaction
By implementing these interventions, healthcare institutions and nurse managers can combine efforts in emotional support, equitable compensation, resource optimization, and cultural development. This comprehensive approach not only reduces turnover intentions among young ICU nurses but also promotes workforce stability and sustainable development, ultimately improving patient care quality and overall healthcare service standards
Acknowledgements
The authors particularly acknowledge the staff who helped collect dates and coordinate this survey and all participants who took part in this survey.
Declarations
Ethics approval and consent to participate
This study was approved by the Medical Ethics Committee of the researcher’s institution (Approval No. 2024ks-1w026). This study strictly adhered to the ethical principles of the Declaration of Helsinki. Before distributing questionnaires to participants, we obtained informed consent from the hospital’s nursing management department. We thoroughly explained the purpose and significance of the study to all participants, ensuring they understood the research content. On this basis, we obtained informed consent from all participants. To protect the privacy of participants, all data were anonymized.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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