The impact of psychological violence in the workplace on turnover intention of clinical nurses: the mediating role of job satisfaction

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.

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.

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.

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.

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.

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.

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.

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.

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.