The relationship between compulsory citizenship behavior and nurses’ silence: a cross-sectional study

The conservation of resources (COR) model offers a robust framework to investigate the relationship between nurses’ CCB and silence. The core premise of the model is that individuals strive to acquire, retain, and protect their resources to meet basic psychological and physiological needs [19, 20]. Excessive CCB depletes these resources—such as time, energy, and emotional well-being—causing heightened stress [5]. Power imbalances between nursing leaders and nurses exacerbate resource depletion, leading nurses to adopt cautious behaviors aimed at conserving their remaining resources [21]. As a result, silence often becomes a self-protective coping strategy, helping nurses avoid further resource loss and potential conflicts [7].

In public hospitals, nurses often face pressure from managers or colleagues to take on additional responsibilities, resulting in an involuntary burden known as CCB [6]. While studies revealed the negative effects of CCB on physical and mental health [21], its role in shaping silence among nurses—especially in high-stress healthcare settings—has not been sufficiently addressed. By applying the COR model, this study seeks to address this gap and provide actionable insights for healthcare leaders to reduce silence, and foster open communication.

This study aimed to assess the relationship between CCB and nurses’ silence.

The questions of this study were as follows:

This descriptive cross-sectional study was conducted at Yichang Central People’s Hospital located in Yichang City, Hubei Province, China. This facility is a comprehensive tertiary Grade-A healthcare institution integrating medical care, nursing, education, and scientific research. The institution employs over 5,000 staff members, including 3,018 nurses, and accommodates 3,880 beds.

Registered nurses from Yichang Central People’s Hospital in Hubei Province of China were selected as the study participants using the convenient sampling method. Inclusion criteria: (a) possessing a valid nursing license from the People’s Republic of China; (b) direct involvement in patient care; (c) having at least one year of work experience. Exclusion criteria included: (a) nurses in management positions; (b) assistant nurses; and (c) nurses on leave, studying, or training.

We estimated the required sample size using two approaches: power analysis and regression modeling. Power analysis, aimed at better estimating the population parameters, was conducted assuming a standard deviation of 10, a precision level of 2, and a two-sided significance level of 0.05, the sample size was calculated using the following formula: \(\:n={\left(\frac{Z1-\alpha\:/2\times\:\sigma\:}{\delta\:}\right)}^{2}={\left(\frac{1.96\times\:10}{2}\right)}^{2}=97\). After accounting for a 20% attrition rate, the adjusted sample size was 122. For the regression modeling approach, which aims to achieve higher statistical power, we followed the rule of thumb recommending 10–20 events per predictor variable. Anticipating 13 predictor variables, the required sample size was calculated as N=13*20=260. After adjusting for a 20% attrition rate, the final sample size was 325 [22]. To ensure sufficient statistical power and model reliability, we adopted the larger sample size of 325 participants. Ultimately, 402 eligible participants were recruited using a convenience sampling approach.

A pilot study was conducted to ensure the applicability and understandability of the instruments. Ten nurses participated in this pre-survey, which used an online questionnaire developed on the Wenjuanxing platform. Participants completed the questionnaire and evaluated the clarity of each item. Feedback from the pilot study confirmed that the questionnaire was straightforward, with clear items, simple options, and a manageable number of questions. No modifications were required based on this feedback.

The formal survey was conducted from October 10 to 17, 2023. The researcher initially contacted the nursing department director at the participating hospital, who facilitated recruitment by distributing the survey link to nurses via the hospital’s enterprise WeChat group. An invitation message was shared in the group, explaining the purpose of the study, the voluntary nature of participation, eligibility criteria, and the steps for completing the survey.

Upon accessing the link, participants were first presented with an electronic informed consent form and were required to click the “Agree” button to provide consent before proceeding to the questionnaire. The questionnaire consisted of three sections: general information, a CCB scale, and a nurses’ silence scale, each accompanied by specific instructions.

To support participants during the survey, the researcher provided contact information (email and phone) at the start of the survey and in the consent form, enabling participants to reach out with any questions. To ensure data accuracy and completeness, the system restricted submissions to one per IP address and required participants to complete the entire survey before submission.

Statistical analyses were conducted using IBM SPSS version 25.0. The demographic characteristics, nurses’ CCB, and silence scores were described using frequencies, percentages, means, and standard deviations. T-tests and ANOVA tests were used to analyze the relationships between general demographic characteristics and nurses’ CCB and silence. Correlation analysis was used to determine the relationship between CCB and nurses’ silence. Furthermore, linear regression analysis was used to investigate the effects of demographic characteristics and CCB on nurses’ silence. Hierarchical regression analysis was used to investigate further the impact of CCB on nurses’ silence.

This study was conducted strictly following ethical guidelines and was approved by the hospital’s ethics committee, with ethical approval number 2023-126-01. All participants provided informed consent before completing the survey, ensuring they were fully aware of the study’s purpose, procedures, and potential risks. To protect participants’ privacy and ensure anonymity, no identifying information such as names, employee IDs, or contact details was collected. Participants also retained the right to withdraw from the study at any time.

Out of 409 questionnaires collected online, data from 402 were included in the final analysis, with a response rate of 98.29%. Table 1 summarizes the socio-demographic characteristics of the participants. The majority were female (77.6%) and under 30 years old (42.3%). Most were married (61.7%) and held a bachelor’s degree or higher (60.0%). Nearly half had ≤ 5 years of work experience (47.0%), with 58.0% at the nurse or junior nurse level. In terms of income, 47.8% earned < 5,000 CNY, and 53.7% were permanent staff.

No significant differences in CCB scores were found across groups based on gender, age, marital status, educational level, professional title, average monthly income, or employment mode (P > 0.05). However, significant differences were observed among groups with different years of nursing experience (P < 0.05). Similarly, no significant differences in nurses’ silence scores were found across groups based on gender, age, marital status, educational level, professional title, or average monthly income (P > 0.05). Nevertheless, significant differences in nurses’ silence scores were identified based on years of nursing experience and employment mode (P < 0.05).

Table 2 details the prevalence of CCB and nurses’ silence. The mean score for CCB was 2.93 (0.8), indicating a moderate level overall. Concerning nurses’ silence, the mean score was 2.73 (0.69), indicating a moderate level. In this category, 47.8% of nurses demonstrated a moderate level, 31.6% a lower level, and 20.6% a higher level. Further analysis of the subscales for nurses’ silence showed that 49.8% of nurses exhibited a moderate level of acquiescent silence, 47.8% of defensive silence, and 45.8% of disregardful silence.

Table 3 presents the correlations between CCB and nurses’ silence, including its three subscales. The results of the Pearson correlation analysis revealed that CCB had a moderate positive correlation with silence (r = 0.524, p < 0.001), which was statistically significant. Similarly, a significant positive correlation exists between CCB and nurses’ silence subscales, with all correlations being statistically significant (p < 0.001 for each).

Table 4 presents a regression analysis examining the socio-demographic characteristics as predictors of CCB among nurses. The model explained 1.8% of the variance in CCB, with a significance level of α = 0.05 (F = 3.736, P = 0.025), indicating statistical significance. The results revealed that years of nursing experience significantly predicted CCB (P < 0.05), whereas other factors, including gender, age, marital status, education level, professional title, income, and employment type, were not significant predictors (P > 0.05). Specifically, nurses with ≥ 10 years of experience demonstrated significantly lower levels of CCB compared to those with < 5 years of experience (β = -1.399, SE = 0.518, P = 0.007). However, no significant differences were observed between nurses with 6–9 years of experience and those with < 5 years (β = -0.253, SE = 0.454, P = 0.578).

Table 5 employs socio-demographic characteristics and CCB as predictors in a regression modeling of three sub-scales of nurses’ silence. The models accounted for 22–27% of the variance at a significance level of α = 0.05 (F = 37.101, 28.077, and 33.000, respectively, all P<0.001), indicating statistical significance. In the prediction of acquiescent silence, the regression analysis revealed that nurses with 6–9 years of working experience demonstrated significantly lower levels of acquiescent silence compared to their counterparts with 1–5 years of experience (β = -0.726, SE = 0.300, P<0.05). Furthermore, CCB positively predicted acquiescent silence (β = 0.372, SE = 0.003, P<0.001). However, the mode of employment did not significantly predict acquiescent silence (P>0.05).

In predicting defensive silence, CCB emerged as a significant positive predictor (β = 0.334, SE = 0.034, P<0.001). Neither working experience nor mode of employment were significant predictors of defensive silence (P>0.05). Regarding disregardful silence, nurses with 6–9 years and over 10 years of working experience demonstrated significantly lower levels compared to those with 1–5 years of experience (β = -0.690, SE = 0.308, P<0.05; β = -1.029, SE = 0.372, P<0.05). Contract nurses showed higher levels than those with a permanent position (β = 0.697, SE = 0.034, P<0.05). Furthermore, CCB was positively associated with disregardful silence (β = 0.335, SE = 0.034, P<0.001).

Table 6 presents the multiple regression model results for clinical nurses’ silence, using demographic data and CCB as predictors. R² was employed to quantify the percentage of variance explained by the models. Initially, Model 1 was developed with nurses’ silence as the dependent variable, incorporating two significant demographic variables—working experience and employment mode—as independent variables. This model revealed that these variables predicted nurses’ silence, accounting for 5.7% of the variance. Subsequently, Model 2, an extension of Model 1, included CCB in addition to the previous variables. The results of this extended analysis demonstrated that, after controlling for working experience and mode of employment, CCB was a significant and positive predictor of nurses’ silence (β = 1.041, SE = 0.088, P<0.05). These three variables in Model 2 explained 30.3% of the variance in the model, marking an increase in R² of 24.6% from Model 1. This significant increase indicates that CCB accounts for an additional 24.6% of the variance in nurses’ silence, beyond the general demographic information.

Nurses in this study demonstrated moderate levels of CCB. This can be attributed to the hierarchical structure of the healthcare system and the demanding nature of the profession. Resource constraints in public hospitals, such as shortages of personnel, equipment, and budgets, often compel nurses to take on excessive responsibilities. Additionally, the hierarchical nature of the system limits nurses’ autonomy in decision-making, reinforcing a sense of obligation to comply with tasks beyond their formal roles. This lack of control, combined with intense job demands, fosters CCB as a coping mechanism or perceived professional duty.

Similar patterns have been observed in healthcare systems with similar organizational structures, such as Turkey [5, 6], where high job demands and limited autonomy are key factors driving CCB. Compared to non-healthcare sectors, such as education [21] and enterprises [26, 27], where moderate to high levels of CCB are also reported, the drivers in healthcare are distinct, shaped by specific job demands and systemic constraints inherent to the profession.

The CCB scale revealed notable differences in nurses’ responses, highlighting contrasting views on job expectations and unpaid overtime. Item 3, “I feel that I am expected to invest more effort in this job than I want to and beyond my formal job requirements,” scored the highest, suggesting that the demands of the public healthcare setting and complex patient needs create high expectations from superiors. Keykaleh et al. [28] observed that nurses are frequently called upon to deliver high-quality care, ensure patient safety, and manage emergencies, contributing to increased pressure and expectations regarding their dedication and responsibilities.

In contrast, item 2, “Working extra hours beyond the formal workload and without any formal rewards is common in our hospital,” received the lowest score, reflecting a generally negative attitude toward uncompensated overtime. This reluctance may be due to two main factors. First, work-related stress is prevalent in healthcare, and compulsory overtime can intensify this stress, making nurses hesitant to work extra hours. Second, maintaining a work-life balance is vital for many nurses, and mandatory overtime disrupts this balance, leading to a preference to avoid additional shifts. Yang et al. [29] found that the cumulative impact of work stress and reduced work-life balance from compulsory overtime may ultimately reduce career satisfaction, prompting nurses to prioritize job sustainability and personal well-being.

This study identified a moderate level of silence among nurses, aligning with findings from other studies conducted both within China and internationally. Two large-scale, multicenter surveys conducted in tertiary public hospitals in China also reported moderate levels of nurse silence [30, 31]. Globally, similar trends have been observed. For example, Farghaly Abdelaliem et al. [12] reported moderate silence levels among nurses in Saudi Arabia, while Sakr et al. [32] and Atalla et al. [33] found comparable levels in Egypt. In the Philippines, Labrague et al. [34] identified moderate levels of silence. The consistency of these findings across different settings highlights the widespread nature of this phenomenon among nurses, suggesting that silence may be a common response to workplace challenges in healthcare settings.

Among the three subscales of nurses’ silence, acquiescent silence was the highest, followed by defensive and disregardful silence, contrasting with the findings of Wang’s study [31]. Nurses’ silence has become widespread for three main reasons: (1) Worries and Concerns – Nurses often remain silent to preserve relationships and avoid conflicts with leaders and colleagues. (2) Reverence and Compliance – Silence frequently reflects respect for leadership and commitment to team dynamics. Nurses view adherence to instructions and norms as core professional duties, which discourages them from challenging authority. (3) Harmony and Courtesy – To foster a collaborative environment, nurses often choose silence to maintain harmony and courtesy. While this approach strengthens teamwork and minimizes discomfort, it can also limit the expression of individual opinions and concerns [35].

This study revealed notable differences in CCB among nurses with varying levels of work experience. Nurses with five years or less of work experience exhibited higher levels of CCB compared to those with ten or more years of experience. This finding contrasts with Baydin et al. [6], likely due to differences in respondent demographics, sample sizes, or other contextual factors. We infer that this pattern may be linked to the following factors: (1) Nurses new to the hospital or unit may feel heightened external pressures, prompting them to take on additional responsibilities and informal tasks to prove their value, thereby exhibiting higher levels of CCB. (2) Nurses with shorter work experience may face greater challenges, such as resource scarcity, insufficient support, or inadequate training. Under these circumstances, they may feel compelled to undertake extra work to compensate for these deficits and ensure task completion, leading to higher levels of CCB.

Work experience was found to significantly impact levels of silence, particularly acquiescent and disregardful silence, with shorter work experience linked to higher levels of silence. This finding aligns with studies by Labrague et al. [34] and De Los Santos JAA et al. [36]. From the researchers’ point of view, nurses with shorter tenures may lack the clinical experience and confidence needed for self-expression, leading them to choose silence to avoid mistakes or inappropriate actions. Additionally, new nurses may require time to adjust to work environments, team dynamics, and responsibilities. During this adaptation period, they often observe and learn rather than actively share opinions, as they are not yet fully familiar with the organizational culture.

Employment type also significantly affected nurses’ silence, with contract nurses exhibiting higher levels of silence and disregardful silence. These results are consistent with those of Yin et al. [37]. Based on our analysis, we propose that the higher levels of silence observed among contract nurses may be attributed to the following three factors: (1) Job Stability and Security – Unlike permanent nurses, contract nurses face greater job instability and risk of unemployment, making them hesitant to voice concerns; (2) Employment Relationship Inequality – Contract nurses often feel less empowered than permanent staff, which discourages them from questioning decisions within the organizational hierarchy; and (3) Professional Identity – As temporary employees, contract nurses may feel a diminished sense of professional identity and integration within the organization, leading to reduced participation and vocalization.

The findings of this study demonstrate that CCB significantly impacts nurses’ silence, including acquiescent, defensive, and disregardful silence. Higher CCB was also positively correlated with increased nurse silence, consistent with He’s findings [7]. Yam et al. [38] found that in nursing, CCB, typically involuntary, creates a gap between the effort invested by nurses and the recognition or compensation they receive. Often overlooked in formal compensation structures, this behavior can lead nurses to feel that their organizational contributions are undervalued, potentially fostering a sense of disempowerment and rationalizing counterproductive behaviors.

In public hospitals, where CCB is common, nurses frequently expend additional time and resources to maintain quality patient care. The healthcare setting’s pronounced power imbalance, reinforced by a hierarchical structure, suggests that assertive actions may negatively affect nurses’ career prospects. Consequently, nurses may adopt a more cautious, conservative approach, viewing silence as the safest option [7].

Although this study provides valuable insights, it has some limitations that should be acknowledged: (1) Potential selection bias: The study’s limited sample size and single-center design, combined with the voluntary involvement of participants and use of convenience sampling, may introduce selection bias. (2) Lack of causal inference: The cross-sectional design of this study, which involves observing and surveying participants at a single point in time, does not allow for the establishment of causal relationships. (3) Subjectivity and recall bias: Dependence on participants’ subjective recollections and memories in this study could lead to subjectivity and recall bias. (4) Challenge in controlling confounding variables: There may be a challenge in sufficiently controlling for confounding variables that affect CCB and silence among nurses, such as individual characteristics, work environment, and organizational culture. Not adequately addressing these variables could lead to confounding and misinterpreting results.

Based on this study’s findings, we propose the following strategies to address nurses’ CCB and silence. First, future studies should adopt longitudinal designs and integrate qualitative methods, such as in-depth interviews and observations, to better understand the dynamics of these behaviors among nurses. Second, nursing managers should optimize workload and resource allocation, foster psychologically safe environments, and implement fair performance evaluation systems to alleviate external pressures associated with CCB. Strategies like adequate staffing, effective communication channels, and sufficient rest periods can effectively enhance nurses’ autonomy and participation. Finally, targeted training for newly hired and contract-based nurses, combined with monitoring and adjusting motivational strategies, can help mitigate silence and foster a more open and communicative organizational culture.