The effect of inclusive leadership on turnover intention of intensive care unit nurses: the mediating role of organization-based self-esteem and interactional justice

The concept of inclusive leadership was pioneered by foreign researchers. In 2006, Nembhard and Edmondson first proposed the concept of inclusive leadership, formally introducing “inclusivity” into leadership research [18]. They believe that inclusive leadership can recognize subordinates’ contributions to the organization, and accept their viewpoints and opinions, thus making subordinates feel valued by others [18]. Then, Carmeli et al. proposed on their basis that inclusive leadership is characterized by openness, effectiveness, and accessibility [19].

Currently, research has shown that inclusive leadership can inspire employees’ innovative work behavior, enhance job engagement and self-efficacy [20], strengthen organizational belonging [11, 21]. However, existing research primarily focuses on the field of business management. There is limited research on the relationship between inclusive leadership and turnover intentions among ICU nurses, who constitute a special group. Based on this, we propose Hypothesis 1.

Social exchange theory posits that the relationship between employees and organizations is a reciprocal one. When employees perceive support and fair treatment from the organization, they develop certain psychological obligations to the organization. These obligations are manifested through changes in attitudes such as trust and commitment, ultimately leading to behaviors that fulfill the expectations of the organization [22].

OBSE primarily refers to employees’ perception of their own value and their perception of organizational values. The openness and approachability of inclusive leadership can enable employees to perceive support and respect from the organization. Research by Kong et al. suggests that inclusive leadership is associated with employees’ levels of OBSE [22]. Additionally, studies by Ghosh et al. have found that employees with high levels of OBSE are more willing to engage in behaviors that benefit the organization [23]. Based on this, we propose Hypothesis 2.

According to affective events theory, employees react emotionally to events in the workplace, and these reactions influence their job performance and job satisfaction. Positive emotions accumulation can lead to positive work attitudes, while negative emotions accumulation manifests as lower affective commitment or a tendency to leave the organization [24].

Interactional justice refers to whether individuals are treated fairly and respectfully in the process of interaction with leaders, and whether individuals receive information that should be conveyed as parties on the other hand. Inclusive leadership facilitates the creation of an environment characterized by openness in information sharing and encouragement of communication and expression [25]. Existing research suggests that benevolent leadership, ethical leadership, and servant leadership are associated with interactional justice [26], and interactional justice positively influences employees’ job satisfaction and job performance [27]. Based on this, we propose Hypothesis 3.

Settoon et al. argue that the essence of social exchange is a cooperative relationship of mutual benefit between employees and leaders or organizations [22]. When employees perceive support from the organization and recognition of their own worth, they trust the organization, reciprocate, and establish good social exchange relationships with the organization [22, 28]. Relevant research indicates that employees with high levels of OBSE are more inclined to foster a positive negotiation atmosphere with others and establish good interpersonal relationships, aiming to contribute to the organization [29]. Based on this, we propose Hypothesis 4.

Based on the above discussion, the theoretical model constructed in this study is illustrated in Fig. 1.

The current study adopted a cross-sectional design and adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines (see Supplementary File 1).

This study employed a convenience sampling method to select four general hospitals in northern China for the survey. A comprehensive survey was conducted among all full-time nurses working in the intensive care units of these hospitals, totaling 495 nurses. The inclusion criteria for the participants were as follows: [1] holding the nurse certificate and being registered; [2] officially employed and independently performing clinical work in the ICU; [3] voluntarily participating in the study with informed consent. Exclusion criteria included: [1] ICU nurses who withdrew from the study midway; [2] ICU nurses unable to participate in the study due to special circumstances occurring during the investigation period.

Under the guidance of well-trained research assistants, participants provided information related to demographic characteristics, inclusive leadership, OBSE, interactional justice, and turnover intention. Before the survey, researchers contacted the nursing management departments of various hospitals, upon obtaining consent, confirmed details such as survey timing, location, and participant numbers. During the survey, researchers explained the purpose, procedures, and potential risks of the study to participants. After participants were informed and consented, they began filling out the questionnaires. Data collection occurred from November to December 2023.

During the survey period, 5 nurses were unable to participate due to specific circumstances. Ultimately, a total of 490 individuals participated in the survey. A total of 490 questionnaires were distributed in this survey. After excluding 8 questionnaires with incomplete personal information and 22 questionnaires with incomplete answers, 460 valid questionnaires were collected, resulting in an effective completion rate of 93.9%. Previous studies have shown that SEM analysis is suitable when the sample size is ≥ 200 [30]. Therefore, the sample size of this study meets the basic requirements for model validation.

In this study, SPSS 27.0 and AMOS 25.0 were utilized for data analysis and model construction. First, descriptive statistics were used to analyze the demographic characteristics of the participants. Next, a normality test was conducted on the continuous variables. When the Kolmogorov-Smirnov test result is P > 0.05, the data is considered to follow a normal distribution [36]. If the continuous variables followed a normal distribution, Pearson correlation analysis was used to examine the relationships among the four variables and their dimensions. If not, Spearman correlation analysis was employed. When 0 < r/rs < 0.2, the correlation is very weak or negligible; 0.2 < r/rs < 0.4 indicates a weak correlation; 0.4 < r/rs < 0.6 represents a moderate correlation; and r/rs ≥ 0.6 denotes a strong correlation [37]. Finally, the structural equation model (SEM) was employed to test the mediating role of OBSE and interactional justice between inclusive leadership and turnover intention [31].

Based on previous research on the SEM item parceling, we adopted the " item-to-construct balance " to parcel items for interactional justice and OBSE [38]. To assess the model’s fit, the following indices were used: χ²/df, GFI, AGFI, CFI, IFI, RMSEA, and 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 [31]. To assess the influence of inclusive leadership on turnover intention, the bias-corrected percentile Bootstrap method was utilized to estimate the 95% confidence interval (CI) of the mediating effect by extracting 5000 Bootstrap samples. If the 95% CI does not include 0, it is considered statistically significant [39].

This study strictly adhered to Declaration of Helsinki. Before distributing the questionnaires, we obtained informed consent from the hospital’s nursing management department and thoroughly explained the purpose and significance of the study to all potential participants. All participants voluntarily signed the informed consent form after fully understanding the study’s content. Since this study does not involve any unethical behavior and does not include human or animal experiments, the Ethics Committee of Kaifeng Central Hospital confirmed that this study is exempt from the ethical review process in accordance with national laws and regulations(https://​www.​gov.​cn/​zhengce/​zhengceku/​2023-02/​28/​content_​5743658.​htm).

Among the surveyed participants, females accounted for 92.8%, while males accounted for only 7.2%. The majority of participants were aged between 25 and 35 years old (62.2%), and over half were married (62.6%). Most ICU nurses held a bachelor’s degree (86.1%), and more than half of them had been working for over 6 years (58.7%). Table 1 presents detailed demographic information of the participants.

The results are presented in Table 2. The individual average scores for inclusive leadership were (4.51 ± 0.70), while those for OBSE were (4.15 ± 0.63). The individual average scores for interactional justice were (4.27 ± 0.68), and for turnover intention were (2.05 ± 0.67). Pearson correlation analysis showed that inclusive leadership was positively correlated with OBSE (r = 0.488, P < 0.01) and interactional justice (r = 0.607, P < 0.01), respectively. It was significantly negatively correlated with turnover intention (r=-0.467, P < 0.01). OBSE (r=-0.527, P < 0.01) and interactional justice (r=-0.527, P < 0.01) were negatively correlated with turnover intention, respectively. OBSE was positively correlated with interactional justice (r = 0.752, P < 0.01).

The results, as shown in Fig. 2, indicate that inclusive leadership positively predicts both OBSE and interactional justice (β = 0.48, P < 0.001; β = 0.33, P < 0.001). OBSE positively predicts interactional justice (β = 0.60, P < 0.001). Moreover, inclusive leadership, OBSE, and interactional justice each negatively predict turnover intention (β=-0.27, P < 0.001; β=-0.29, P < 0.001; β=-0.18, P < 0.05), respectively. The Hypothesis 1 was valid.

In order to examine the influence of the independent variable on the dependent variable through intermediary variables, we calculated a 95% CI of percentile bootstrapping and bias-corrected percentile bootstrapping through 5000 bootstrap samples. The results show that OBSE and interactional justice play a mediating role in this relationship, with a total indirect effect size of -0.25. As shown in Table 3. The intermediary effect consists of indirect effects produced by three paths: The indirect effect of inclusive leadership → OBSE → turnover intention was − 0.137. Bootstrap 95%CI: (-0.226, -0.063), P < 0.001. The Hypothesis 2 was valid. The indirect effect of inclusive leadership → interactional justice → turnover intention was − 0.058. Bootstrap 95%CI: (-0.140, -0.028), P < 0.01. The Hypothesis 3 was valid. Inclusive leadership → OBSE → interactional justice → turnover intention, indirect effect − 0.051, Bootstrap 95%CI: (-0.095, -0.020), P < 0.01, Hypothesis 4 was valid.

As presented in Table 4. The χ²/df = 2.705, GFI = 0.956, AGFI = 0.929, NFI = 0.975, RFI = 0.965, IFI = 0.984, TLI = 0.978, CFI = 0.984, RMSEA = 0.061 and SRMR = 0.026. The model fit results indicate that the model is acceptable.

The results of this study indicate that inclusive leadership has a significant negative predictive effect on ICU nurses’ turnover intention, which is consistent with the findings of Zeng et al. and Hall et al. [11, 40]. ICU nurses, as a specialized group of nurses, are confronted with complex and critically ill patients for extended periods. They have greater work pressure and complex nursing tasks, and are more likely to have job burnout than ordinary nurses, which affects job satisfaction and increases turnover intention [5, 15]. What’s more, it affects the quality of nursing care and endangers the life safety of critically ill patients. The leadership style of ICU nurse managers is not only closely related to the outcome of nursing care, but also affects the stability of the nursing team. Inclusive leadership, as an open, effective, and approachable leadership style, can effectively reduce turnover intention. When nursing managers exhibit open behavior, they can create a work environment that is equal, inclusive, and open. This, in turn, enables ICU nurses to achieve a higher sense of organizational identity and belonging [5]. Secondly, when the nursing manager shows effective behavior, ICU nurses feel the care and work support, and will give back to the organization with a more positive attitude and increase work input. Lastly, when nursing managers are approachable, it facilitates the establishment of high-quality leader-member exchange relationships, thereby stimulating proactive behaviors in ICU nurses [12].

In the management of intensive care units, medical institutions and nurse managers should be aware of the importance of inclusive leadership. Healthcare institutions should encourage nurse managers to develop or enhance their capacity for inclusive leadership. Nursing managers should pay attention to adjusting their leadership styles appropriately, treating nurses from different backgrounds equally, and meeting the diverse needs of subordinates. This enhances subordinates’ sense of connection and attachment to the organization, thereby increasing their emotional commitment to the organization, reducing turnover intentions, improving nursing quality, and ultimately promoting improvements in patient health outcomes. It also fosters the long-term stable development of the nursing team.

OBSE encompasses two aspects: the extent to which individuals believe in their own value, usefulness, and effectiveness, and the extent to which they believe their organization is valuable, useful, and effective. Facing critically ill ICU patients and intricate nursing tasks, ICU nurses may worry about making mistakes that could lead to tension in doctor-patient relationships. Long-term exposure to various pressures from medical institutions, leaders, and patients’ families can easily demoralize ICU nurses’ enthusiasm for work. When nursing managers exhibit openness and approachability, actively listen to the voices of ICU nurses, and consider their needs in decision-making and daily management, ICU nurses perceive respect and attention, and their psychological needs are also met. ICU nurses will feel that they are valuable and useful to the organization, thereby enhancing their own level of OBSE. When nursing managers demonstrate characteristics of effectiveness, they can guide ICU nurses in handling work errors that arise in high-pressure environments and provide assistance to nurses at any time. ICU nurses can also discuss emergent work issues with nursing managers and enhance their job competence under the professional guidance of nursing managers. Undoubtedly, in such situations, ICU nurses will feel that their organization is valuable and useful, and the level of OBSE will be elevated. This finding aligns with the research conducted by De et al. and Randel et al. [41, 42]. Chen et al. pointed out in their study that employees with high levels of OBSE tend to have increased intentions to stay, while those with low levels of OBSE are more likely to experience job burnout and a decrease in willingness to work hard [16]. The results of this study also confirm that OBSE acts as a mediator variable, exhibiting a negative correlation with turnover intention.

The implication for medical institutions and nurse managers is that the OBSE of ICU nurses should be improved by various means. For example, first, continue to pay attention to the voice and emotional needs of ICU nurses, and establish an equal and effective communication mechanism. Second, if conditions permit, the treatment and further study opportunities should be appropriately tilted to ICU nurses, so as to improve the job satisfaction and organizational commitment. Third, it is crucial to establish a people-oriented management philosophy. Given the current shortage of nurses, it is important to allocate nursing workload reasonably and allocate human resources according to the characteristics of ICU work.

As a mediating variable, interactional justice exhibits a negative correlation with turnover intention, which is consistent with the findings of the research conducted by Su et al. [5]. Inclusive leadership, with its inclusive attitude, listens to the opinions of ICU nurses from different backgrounds. This inclusive and respectful behavior directly impacts ICU nurses, prompting them to adopt an inclusive approach when communicating with colleagues and other departments, as well as with patients and their families, thereby fostering a fair and open organizational atmosphere. Such an organizational atmosphere contributes to positively reinforcing ICU nurses’ sense of interactional justice with colleagues and leaders, inspiring them to approach complex nursing tasks with a positive work attitude [20, 43].

In China, the subordinate very respect for authority. ICU nurses’ perception of their work is also affected by the words and actions of nurse managers. This requires nurse managers to display open, effective and approachable behaviors timely in their daily work, master the skills of equal interaction with nurses.

In addition to the results already demonstrated, another finding of this study is that OBSE and interactional justice are related, and they play a chain mediating role between inclusive leadership and turnover intention. Because ICU nurses with high levels of OBSE feel confident and valuable, they are more willing to participate in the management of daily affairs, and establish good interpersonal relationships with leaders and colleagues [16, 25, 27].

Medical institutions and nursing managers should continuously promote the improvement of performance management systems to ensure a close linkage between ICU nurses’ performance and their value. This contributes to enhancing ICU nurses’ OBSE and also helps establish a positive organizational atmosphere.