Investigation of Potential Profiles and Influencing Factors of Voice Behavior among Chinese Nurses

A convenience sampling method was utilized to select the hospitals and samples. The present study employed a cross-sectional research design, utilizing a sample of 3528 nurses from 552 medical institutions across 21 provinces, 4 municipalities, and 3 autonomous prefectures in China from November 2023 to January 2024(Fig. 1, generated using ArcGIS 10.8 software). The survey design specifically focused on three key dimensions: individual factors, environmental aspects, and behavioral patterns. This study received approval from the heads of the nursing departments at each participating hospital. Subsequently, a 72-item questionnaire was distributed to nurses across various departments through the WenJuanXing platform (https://​www.​wjx.​cn) by the respective nursing departments. The purpose and significance of the study were explained to the research subjects before the investigation began, and their consent was obtained before they signed written informed consent and answered the questionnaire. It was made clear that personal privacy would not be compromised, information would be kept confidential, and voluntary participation was emphasized without any negative consequences. Surveys were administered during the nurses' working hours.

Current medical statistical guidelines indicate that the sample size should be a minimum of 5 to 10 times the number of items in the questionnaire [8]. The study collected data from 3528 nurses who successfully completed the survey. On average, each nurse required 516.56 s to complete the questionnaires.

Out of the total 3,528 respondents who participated in the survey, 95.38% (N = 3365) were female and 4.62%(N = 163) were male. The majority of nurses in China are young, 27.44% (N = 968) were 20–29 years of age, 46.97% (N = 1657) were 30–39 years of age, 20.58% (N = 726) were 40–49 years of age and 5.02% (N = 177) were more than 50 years old. The majority of the nurses were married (73.04%, N = 2577).Data was primarily sourced from tertiary hospitals (91.44%, N = 3226) and general hospitals (58.56%, N = 2066). Respondents mainly work in the fields of internal medicine (36.79%, N = 1298) and surgery (21.80%, N = 769). In terms of education, the majority (88.27%, N = 3114) possess bachelor's degrees. The demographic information is presented in Table 1.

In this study, we utilized the LIANG et al. (2012) scale to measure voice behavior [9]. The scale comprises two dimensions: promoting voice behavior (5 items) and inhibiting voice behavior (6 items), totaling 11 items. Participants are instructed to select their responses based on their typical reactions when faced with challenges. The total score of the scale is the sum of the scores from both dimensions, ranging from 5 to 55 points. This scale has been validated in relevant domestic and international studies, demonstrating good reliability and validity with a Cronbach's α coefficient of 0.930 [9].

We assessed personality using the simplified Personality Scale revised by Wu Qiong et al., based on the simplified Personality Scale of CFPS 2018 [10]. This scale includes 5 relevant dimensions: conscientiousness, extroversion, agreeableness, openness, and emotional instability, with a total of 11 items. The average score of the items within each dimension reflects the individual's personality score for that particular dimension. It was confirmed that the Cronbach's α coefficients for conscientiousness, extroversion, agreeableness, openness and emotional instability were as follows: 0.651, 0.558, 0.625, 0.637 and 0.573 respectively [10].

We evaluated organizational justice using the Liu Ya (2003) scale, which consists of four dimensions: procedural justice, distributive justice, leadership justice, and information justice [11]. The internal consistency coefficient of the entire questionnaire is 0.95, indicating good homogenous reliability. A higher score indicates a greater perceived level of organizational justice. Currently, there is no standard for categorizing perceptions of organizational justice. However, it is generally accepted that scores falling within the range of 1–2 represent a low level of organizational justice, while scores between 3 and 4 indicate a medium level; scores exceeding 4 are considered high levels. The internal consistency coefficient for all dimensions of the scale exceeds 0.78 and the Cronbach's α coefficient for the entire scale is calculated at 0.910 demonstrating strong reliability and validity [11].

In 1995, Zhang Jianxin introduced the Schwarzer et al. (1981) General Self-Efficacy Scale (GSES) to China [12]. The self-efficacy of nurses was assessed using the Chinese-adapted version of the scale developed by Zhang Jianxin et al. (1995). This scale was assessed using a 4-point Likert scale, ranging from 1 (none at all) to 4 (a lot). A higher score indicates a higher level of self-efficacy. Chinese scholars have verified that the Cronbach's α of this scale ranges from 0.76 to 0.90, most of which are greater than 0.80. The measurement reliability is between 0.55 and 0.75 and is mainly used to measure the level of self-efficacy in non-specific fields [12‐14].

EpiData3.1 was utilized for data entry, mean ± standard deviation was employed for measurement data, and ANOVA was utilized for inter-group comparison. Counting data were presented as frequency and percentage, and chi-square test or rank sum test were utilized for group comparisons.

Mplus 8.3 provides a user-friendly interface along with comprehensive graphical representations of data and analysis outcomes, offering researchers an extensive array of models, estimators, and algorithms. This software is capable of addressing both observed and unobserved heterogeneity across diverse populations. Consequently, Mplus 8.3 was employed to perform a latent profile analysis based on the voice behavior scores of nurses. Taking the score of the voice behavior scale as the explicit index and the initial model as the starting point, the number of categories is systematically increased until the model with the best fitting data is found. Key indicators for testing model fit include Log likelihood (LL) test, as well as information evaluation indicators such as Akaike information criterion (AIC), Bayesian information criterion (BIC), Sample calibrated BIC (aBIC), and entropy indices. Additionally, likelihood ratio test indicators LoMendell-Rubin(LMR) and Bootstrap-based likelihood ratio test (BLRT) were considered. Smaller values for LL, AIC, BIC, and aBIC indicate better model fit, while an entropy level close to 1.0 is deemed more predictive. An entropyvalue around 0.8 indicates classification accuracy of over 90%. Furthermore, significant P-values for LMR and BLRT suggest that a model with k categories is significantly superior to a model with K-1 categories.

The data used to support the findings of this study are available from the corresponding author on request.

The potential profile analysis of 3528 nurses' voice behavior was conducted to fit one to five potential categories simultaneously, and the fitting indexes for each potential category model were obtained (Table 2).

The AIC, BIC, and aBIC indices gradually decreased with the increase in the number of categories, reaching an inflection point at the three category; The entropy values all exceed 0.80, and both the LMR and BLRT tests revealed statistically significant differences between k and K-1 categories; The proportion of categories was found to be less than 8% when considering four categories, indicating an underrepresentation of the categories.The average probability of each potential category surpassed the threshold of 0.80, indicating a high level of classification accuracy (Table 3).

The potential profile of nurses' voice behavior was analyzed. To identify the optimal model, two dimensions of voice behavior were selected as indicators. Scores from each dimension were used to fit 1–5 potential categories simultaneously, as presented in Table 2. The one-category model serves as the baseline (zero) model and exhibits the poorest fit. As the number of categories increases: (1) AIC, BIC, and aBIC values gradually decrease, with three categories marking the inflection point for this decline; (2) The entropy values for the three-category and four-category models are higher compared to other models; (3) LMR indicators suggest that a three-category model is superior to a two-category model, while there is no significant difference between the three-category and four-category models. Additionally, as shown in Table 3, the category attribution probability matrix indicates that the average probability of each profile belonging to its respective category exceeds 95%, suggesting that the three-category model is reliable. Considering both simplicity and interpretability, the three-category model is deemed the optimal classification for nurses' voice behavior. Both C4 and C5 models account for less than 8%, indicating that they are underrepresented and may have limited significance in this context.

According to the conditional mean value of each potential category on voice behavior, category 1, referred to as C1, accounted for 21.1% (N = 746) and was classified as the “low voice behavior group”. The average scores for each item in this particular nursing type were comparatively low, exhibiting fluctuation in inhibiting voice behavior while remaining relatively stable in the promoting voice behavior. Category 2, referred to as C2, was designated as the "medium voice behavior group", constituting the largest proportion among the three categories and accounting for 60.9% (N = 2147). Additionally, there was minimal variation in scores between items. Category 3, referred to as C3, was designated as the "high voice behavior group", accounting for 18.0%(N = 635). The average score for each item of this particular type of nursing was higher, with a significantly elevated score in the promoting voice behavior (Fig. 2).

After conducting Chi-square tests and ANOVA, we observed statistically significant differences (P < 0.05) in age, marital status, department, department workload, professional title, position, nursing experience, labor and personnel relations, average monthly income, monthly night shift frequency and sleep quality among various potential categories. The relevant details are presented in Table 4.

The dependent variables in this study were the three categories of nurse's behavior (C1; C2; C3). Multivariate analysis was conducted using univariate tests to identify significant variables, and variable screening was performed using the forward method. Ultimately, department busyness, professional title, nursing service years, average monthly income, monthly night shift frequency, sleep quality, health status, personality, organizational justice and self-efficacy emerged as influential factors on potential categories of voice behavior.

Compared to C1, nurses working in departments with average busy loads, relatively busy departments, and busy departments were more likely to be classified as C2 compared to those working in very busy departments.Nurses with very good sleep quality, good sleep quality, average sleep quality, and poor sleep quality were more likely to be classified as C2 compared to those with very poor sleep quality. Senior nurses were less likely to be classified as C2 compared to chief nurses. Additionally, nurses with 0–5 years of experience, 6–10 years of experience, and 11–20 years of experience were less likely to be classified as C2 compared to those more than 20 years of experience. The higher the scores on personality, organizational justice, and self-efficacy among nurses, the more likely they belonged to the middle voice behavior group (Table 5).

Compared to C1, junior nurses, senior nurses and supervisor nurses were less likely to be classified as C3 than chief nurses. The probability of being classified as C3 was lower for individuals with 0–5 years, 6–10 years, and 11–20 years of nursing experience compared to those with more than 20 years of experience. The likelihood of falling into category C3 was lower for nurses with an average monthly income ranging from 2000–5000 yuan and 6000–10000 yuan compared to those earning 10,000 yuan. The higher the scores in personality, organizational justice, and self-efficacy, the greater the likelihood for classification as C3 (Table 6).

Compared to C2, a monthly night shift frequency of 1–4 times was found to have a higher likelihood of being classified as C3 compared to frequencies ≥ 12 times. The busyness of the department in which they worked was average, relatively busy and busy departments were less likely to be classified as C3 compared to very busy departments. Junior nurses, senior nurses and supervisor nurses were less likely to be classified as C3 than chief nurses. Those who had been engaged in nursing for 0–5 years, 6–10 years, and 11–20 years were less likely to be classified as C3 compared to those who had been engaged in nursing for more than 20 years. The average monthly income of 2000–5000 yuan and 6000–10000 yuan was less likely to be classified as C3 compared to that of more than 10,000 yuan.The likelihood of being categorized as C3 increased when individuals scored higher in personality, organizational justice, and self-efficacy (Table 7).

By employing LPA, we have identified three distinct profiles of nurses' voice behavior: C1, C2, and C3. The heterogeneity observed in nurses' voice expressions highlights the need for targeted interventions tailored to their individual characteristics.

The proportion of nurses with C3(18%) was the smallest, whereas the proportion of C2(60.9%) was the largest. Nurses classified as C1(21.1%) also constituted a significant portion of the overall population. Consequently, nurse voice behavior in second-class and three-class hospitals in China can be considered to be at a moderate level.

Managers should focus on cultivating C1 nurses' assertiveness and guide them towards becoming a cohesive group with strong vocal presence, while acknowledging and encouraging the active involvement of C2 and C3 nurses in departmental development.

The logistic regression analysis revealed that among nurses with less than 20 years of experience, the longer their tenure in the nursing profession, the greater their likelihood of being classified in the C3 group today. The deputy chief nurse and the chief nurse also exhibit a higher level of voice behavior compared to other professional nurses. This is primarily attributed to the fact that senior nurses possess more extensive experience and are better equipped to recognize issues in clinical practice and suggest potential solutions.

The number of head nurse, deputy director of nursing department and director of nursing department in C3 accounted for a higher proportion of their total number (> 30%) than that of other post and non-post nurses. The competence in nursing management necessitates a strong proficiency in clinical practice, leadership, nursing education, and coordination abilities, along with a high level of voice behavior [15].

The logistic regression analysis revealed that the number of monthly night shifts had a significant impact on nurses' voice behavior. The monthly occurrence of night shifts, ranging from 1 to 4 times, is more likely to be classified into the C3 group compared to those occurring ≥ 12 times. The applicability of the hospital's process system varies across different time periods. During the night shift, certain issues may become apparent, leading to an increased manifestation of voice behavior among nurses. The excessive number of night shifts, however, can lead to fatigue among nurses, diminish their work enthusiasm, and negatively influence promotive voice behavior [3, 16]. Consequently, our survey revealed a significant decrease in nurses' voice behavior when the frequency of night shifts exceeded 12 times per month. Similarly, nurses could easily identify work-related issues and enhanced their voice behavior through the engagement of appropriate busy work, while the likelihood of nurses falling into the C1 group increased when they were engaged extremely busy work.

Due to the detrimental physical, psychological, and economic impacts of shift work disorders and heavy work on individuals, implementing strategies to alleviate work-related stress, optimize scheduling practices and augment nursing staff in medical centers would prove advantageous for employees.

The statistical findings from our data indicate that nurses with good sleep quality and health status exhibit a higher level of voice behavior compared to those with average, poor, or very poor conditions. The nursing profession entails immense work pressure, with a majority of nurses being required to undertake night shifts, which disrupts their normal working and resting patterns. Consequently, this disruption affects their biological clock, thereby impacting sleep quality and overall health status.

By being aware of the impacts of overloaded work and implementing measures to safeguard nurses' health, professional and non-professional errors in their workplace caused by insomnia, fatigue, difficulty in maintaining focus, and memory lapses can be prevented [17]. The implementation of proactive measures such as well-designed shift schedule, routine health screenings and counseling initiatives would yield significant benefits for nurses.

The logistic regression analysis revealed a positive association between nurses' higher average monthly income and their classification as C3. The income of nurses is often associated with their level of seniority, job title, and position. High-income nurses are predominantly those in senior or managerial roles with extensive work experience. Consequently, they are more likely to engage in voice behavior. Moreover, economically developed regions with higher incomes tend to have a greater presence of high-earning nurses, particularly within hospitals that have stringent nurse recruitment requirements. As a result, the employed nurses in these hospitals may exhibit an elevated level of assertiveness and engagement in voice behavior.

The selection and guidance process for any job necessitates a comprehensive understanding of both the characteristics of the position and the personality traits, including selectors and applicants. Failure to do so may result in job-personality conflicts that can negatively impact an employee's performance, potentially jeopardizing the safety and well-being of others [18].

Logistic regression analysis revealed a significant positive association between the score of the personality traits and nurses' likelihood to enter the C3 group. This finding suggests that individual personality traits have an impact on nurses' voice behavior, with the openness trait exhibiting the highest score among those displaying high-voice behavior, followed by extraversion.

The proactive personality exerts a significant influence on voice behavior, both directly and indirectly through its impact on work engagement [19]. Open and extroverted nurses possess the attributes of a cheerful disposition, creativity, heightened empathy, and strong social skills. These qualities indicate their proficiency in critical thinking, fearlessness in exploration, and adeptness in communication with superiors and colleagues. Consequently, when confronted with potential obstacles that may impede organizational progress, they can employ critical thinking to tactfully identify issues without burdening interpersonal relationships. This approach allows for the presentation of possible solutions while avoiding any psychological strain caused by vocalizing concerns. Additionally, individuals with active and extroverted personalities often exhibit greater self-efficacy—a trait associated with increased propensity for expressing opinions [20].

The silence exhibited by employees reflects the organizational unfairness [21]. Enhancing the fairness within the organization is crucial for addressing and resolving the issue of organizational silence [21]. Therefore, managers should focus on fostering a fair atmosphere. The hospital needs to prioritize fairness and transparency in verification indicators, as well as ensure equitable distribution of staff performance evaluations. Additionally, creating a positive working environment and promoting healthy interpersonal relationships are essential steps towards strengthening nurses' sense of responsibility and awareness, ultimately leading to achieving the hospital's common goals and encouraging nurses' proactive voice behavior.

An inclusive and open team atmosphere serves as the cornerstone of organizational culture and voice behavior. The psychological safety of nurses within a team has a significant impact on team learning, work attitude, performance, and goal achievement [22]. By fostering an inclusive and relaxed communication environment, department managers can enhance nurses' interpersonal skills and abilities for effective group communication.

Self-efficacy is also a crucial determinant in influencing voice behavior. The higher the sense of self-efficacy, the more likely the nurse was to engage in voice behavior. The concept of self-efficacy refers to individuals' belief in their capacity to successfully accomplish specific tasks or work behaviors, and personal self-efficacy is closely associated with their subsequent behavioral patterns [23, 24].

The presence of strong self-efficacy is advantageous in fostering nurses' work enthusiasm, enhancing their ability to cope with pressure, and unleashing their passion for work [23, 24].

Nurses with elevated levels of self-efficacy demonstrate superior aptitude in managing diverse workplace emergencies. The hospital administrators can provide targeted training based on the professional level and management abilities of different nurses, in order to enhance their clinical management, scientific research, and innovation capabilities, as well as strengthen the self-efficacy of nurses.

This study aims to enhance nurses' understanding of improving their voice behavior capabilities, thereby promoting both their professional and personal development. It is recommended that hospital administrators focus on developing comprehensive skills among nursing staff and fostering a positive competitive environment within the hospital. Through the advancement of information systems, an appropriate platform for voice behavior can be established to encourage greater nurse participation. In nursing management, efforts should be directed towards cultivating open and outgoing personality traits among nurses, guiding them to fulfill their duties and promote proactive voice behavior. By creating an inclusive and relaxed communication environment, department managers can improve nurses' interpersonal skills and group communication effectiveness. The findings of this study can serve as a reference for hospital administrators in developing more reasonable night shift schedules, rest systems, salary structures, and promotion policies, ultimately enhancing nurses' voice suggestion capabilities and improving hospital management.

The interpretation of the findings from this study should consider several limitations. Firstly, the reliance on self-reported data from nurses may introduce subjective biases. Secondly, the exclusion of primary hospitals limits the generalizability of the results. Thirdly, the use of convenience sampling may compromise the representativeness of the sample. These factors collectively could introduce a degree of bias into the conclusions. Future research should aim to expand the sampling scope and employ more rigorous sampling methods to enhance the representativeness and reliability of the findings. Due to resource constraints, data for Qinghai, Xizang, and Neimenggu provinces were not collected. Consequently, the current analysis provides a general overview of nurses' voice behavior patterns across China without differentiating regional variations. In subsequent studies, we plan to gather additional statistical data from these three provinces to conduct a comprehensive analysis of regional disparities. To enhance external validity, data were collected from a diverse range of hospitals. Although confounding factors present certain limitations, the overall results remain broadly representative.