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Workplace violence and turnover intention among Chinese nurses: the mediating role of compassion fatigue and the moderating role of psychological resilience

樱花视频 volume听24, Article听number:听2437 (2024) Cite this article

Abstract

Background

Workplace violence is a global public health issue and a major occupational hazard cross borders and environments. Nurses are the primary victims of workplace violence due to their frontline roles and continuous interactions.

Objective

The present study aimed to investigate the status of workplace violence, turnover intention, compassion fatigue, and psychological resilience among Chinese nurses, and explore the mediating role of compassion fatigue and the moderating role of psychological resilience on relationship between workplace violence and turnover intention among Chinese nurses.

Method

A cross-sectional study was conducted among a convenience sample of clinical registered nurses from public hospitals in Changsha, Hunan, China. Data was collected through an online questionnaire, which included a demographic information form, the Workplace Violence Scale (WVS), the Turnover Intention Questionnaire (TIQ), the Compassion Fatigue Scale (CF-CN), and the Connor-Davidson Resilience Scale (CD-RISC). Descriptive statistics and correlation analysis were employed to examine the relationships among the main variables. A moderated mediation analysis was further conducted using the PROCESS macro for SPSS (Model 4 and Model 8) to examine the mediating role of compassion fatigue and the moderating role of psychological resilience.

Result

The present survey recruited a convenience sample of 1,141 clinical registered nurses, who reported experiencing multiple types of workplace violence during the past year. Correlation analysis revealed significant positive correlations between workplace violence and turnover intention (r鈥�=鈥�0.466, P鈥�&濒迟;鈥�0.01) as well as compassion fatigue (r鈥�=鈥�0.452, P鈥�&濒迟;鈥�0.01), while negative correlation between workplace violence and psychological resilience (r=-0.414, P鈥�&濒迟;鈥�0.01). Moderated mediation analysis revealed that compassion fatigue mediated, while psychological resilience moderated, the positive relationship between workplace violence and turnover intention (all P鈥�&濒迟;鈥�0.05).

Conclusion

This study underscores the mediating effect of compassion fatigue and the moderating role of psychological resilience in the relationship between workplace violence and turnover intention among Chinese nurses. Future efforts should be undertaken to develop effective preventive measures and intervention strategies at individual, organizational, and national levels to mitigate workplace violence and foster supportive work environment.

Clinical trial number

Not applicable.

Peer Review reports

Introduction

Workplace violence refers to any type of acts, incidents, or behaviors where staffs are attacked, threatened, or humiliated in professional circumstances [1, 2], which takes in forms of physical violence and psychological violence. World Health Organization (WHO) has identified workplace violence towards healthcare workers as a significant concern within the healthcare systems [3]. Workplace violence is one of the most complex occupational hazards in healthcare environment around the world. An umbrella review of meta-analysis examined the prevalence of workplace violence against healthcare workers, which reported a prevalence of 58.7% for overall workplace violence, a prevalence of 20.8% for physical violence, a prevalence of 66.8% for verbal violence, and a prevalence of 10.5% for sexual harassment against healthcare workers [4]. Nurses is one of the professional groups most exposed to workplace violence due to the nature of their professions and the characteristics of their work environments [5,6,7]. The prevalence of workplace violence against nurses remains high around the world, and the estimate was 43% in United States (US) [8], 44% in Japan [9], and 67% in Italy [10]. In addition, a meta-analysis of cross-sectional studies examined the prevalence of workplace violence against Chinese nurses, which reported an incidence of 71% for overall workplace violence, an incidence of 63% for verbal violence, an incidence of 14% for physical violence, and an incidence of 6% for sexual harassment among these Chinese nurses during the last year [11]. International Council of Nurses (ICN) has issued a position statement to condemn all forms of workplace violence against nurses [12]. Nurses witnessing or experiencing workplace violence can threaten their health and safety as well as impair their work performance and professional attitudes [13, 14]. ICN has stated that workplace violence in the healthcare sectors can impair the delivery of patient services and the assurance of patient safety [15]. Specifically, a cross-sectional study indicated workplace violence as a major occupational hazard, since the experience of such violence impaired the health status and career satisfaction of victims [16]. Additionally, other study implicated workplace violence as the main cause of occupational stress, as the experience of such violence increased psychological stress and damaged health status of nurses [17].

Turnover intention refers to an employee鈥檚 tendency to leave the current profession and seek an alternative occupation within a certain timeframe [18]. Turnover intention represents the final stage of turnover perception, and can serve as an excellent indicator for actual turnover [18]. The turnover rates among nurses remain high around the word, reaching 18.7% in the US [19] and 12.3% in the United Kingdom (UK) [20]. The shortage of nurses is a prevalent challenge encountered by healthcare systems worldwide, with the WHO estimating a deficit of over 9听million nurses by 2030 [21]. China also faces high turnover rates among nurses, a cross-sectional survey of 12,291 nurses across 23 hospitals found that 9.82% of Chinese nurses exhibited strong turnover intention [22]. Studies have converged to examine the antecedents of turnover intention among nurses, with workplace violence emerging as a strong predictor of turnover intention [23]. For example, a longitudinal survey with data gathered from 2006 to 2010 examined the relationship between turnover intention and workplace violence among 1,515 Finnish physicians, revealed that workplace violence was positively associated with turnover intention [24]. In addition, a cross-sectional study investigated the relationship between turnover intention and workplace violence among Chinese nurses, which involved 1,761 nurses among 9 public tertiary hospitals across 4 provinces, indicated that workplace violence was positively associated with turnover intention [25]. Exposure to workplace violence can make nurses to doubt their own occupational value and professional status, which further causes nurses dissatisfaction with job and intention to leave job [26, 27]. While previous studies have primarily examined the occurrence rate and risk assessment of workplace violence, few studies have investigated the consequences and mechanisms of workplace violence on work outcomes [28]. Therefore, the present study aims to further explore the impacts of workplace violence on turnover intention, and uncover the mechanism behind this correlation among Chinese nurses.

Compassion fatigue refers to a state of physiological dysfunction and emotional exhaustion, which can induce emotional stress and psychological distress in affected individuals [29, 30]. Compassion fatigue is a synonymous term for various occupational stresses, encompassing dimensions of both occupational burnout and secondary traumatic stress. Occupational burnout is defined as a sense of exhaustion, frustration, and fatigue resulting from work pressure, while secondary traumatic stress is defined as a syndrome of intrusion, avoidance, and arousal stemming from indirect exposure to traumatic events. Nurses are recognized as the healthcare professionals who struggle the most with compassion fatigue, with reported prevalence ranging from 7.3 to 44.8% among this population [31]. Compassion fatigue is considered an occupational hazard within healthcare sectors, posing serious consequences for nurses, patients, and organizations alike. Studies have indicated that exposure to workplace violence can decrease compassion satisfaction and evoke compassion fatigue among victimized nurses [32]. Evidence has also implicated that the presence of compassion fatigue decreased the quality of occupational life and increased the risk of turnover intention among nurses [33]. Given the relationship between workplace violence and compassion fatigue as well as the association between compassion fatigue and turnover intention, compassion fatigue may act as a critical mediator through which workplace violence impacts turnover intention.

Psychological resilience represents a personality attribute which enables individuals to cope successfully with and recover quickly from adverse circumstances [34]. Psychological resilience constitutes a protective factor that helps nurses transform adverse events into positive experiences, thus enhancing retention intentions of nurses and stabilizing human resources of healthcare organizations. Previous studies have identified psychological resilience as a protective factor that can alleviate the adverse impacts of workplace violence on affected nurses [32]. Meanwhile, current evidence also demonstrated that psychological resilience constituted a personal resource to maintain positive professional attitudes and reduce turnover intentions among nurses [35]. In addition, previous studies have linked both compassion fatigue and psychological resilience to turnover intention, where higher level of compassion fatigue and lower level of psychological resilience predicted stronger turnover intention among nurses [36]. As psychological resilience can mitigate the negative impact of adverse events and foster professional growth after negative experiences, psychological resilience may act as a protective factor to moderate the impact of workplace violence on turnover intention.

Despite the recognized correlations among these variables, the underlying mechanisms driving these correlations merits further elucidations. Therefore, this study was performed to verify the correlations between these variables and to explore the mechanisms behind these correlations. The stressor-strain-outcome (SSO) model delineates a process between the stressors and the outcomes under the mediating role of strain, where stressors are environmental stimulus, strains are personal emotions, and outcomes are behavioral responses [37, 38]. The present study adopts the SSO model as the theoretical framework, where the stressor is workplace violence, the strains are compassion fatigue and psychological resilience, and the outcome is turnover intention. Thus, this study aims to examine the relationship between workplace violence and turnover intention, and to explore the mediating role of compassion fatigue and the moderating effect of psychological resilience in this relationship.

Method

The present study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies.

Design

A cross-sectional study was undertaken among a convenience sample of clinical registered nurses from public hospitals in Changsha, Hunan, China.

Participants

A convenience sampling method was adopted to recruit clinical registered nurses as study participants.

Inclusion criteria were set as: nurses who work in local public hospitals, obtained a Chinese registered nurse license, engaged in clinical patient care at least one year, and provided informed consent to participate.

Exclusion criteria were set as: nurse not employed by hospitals, such as training nurses and nursing interns.

Sample size

The equation n鈥�=鈥塟2伪/2笔(1-笔)/未2 was used to calculate the sample size. The type I error 伪 was set as 0.05, the Z伪/2 was set as 1.96, and the absolute error 未 was set as 0.03. With a reference prevalence of workplace violence set at 65.8% [39], the initial sample size was calculated to be 961. To account for a 10% allowance for invalid responses, the minimum required sample size was determined to be 1,058.

Recruitment

Wenjuanxing, the most popular online survey platform in China, was utilized to create the anonymous online questionnaires. WeChat, the largest social communication platform in China, was used to distribute the online questionnaire. The online questionnaire comprised four parts, the first part was an information sheet and the informed consent form, the second part was the inclusion and exclusion criteria, the third part was an instruction about questionnaire contents and response requirements, and the fourth part was the specific questionnaire items. The web link and a quick response听(QR) code for accessing the online questionnaire were then distributed to nurses through WeChat. Head nurses on each unit were asked to share the access information with the nurses on their respective units, allowing participating nurses to conveniently complete the survey using their mobile phones or computers. A rule was set as one internet protocol address could only submit the questionnaire once to avoid duplicate submissions.

The first part of the online questionnaire presented an information sheet and the informed consent form. Nurses were required to carefully review the relevant content and then click either 鈥淵es鈥� or 鈥淣o鈥� to indicate whether they fully understood the research details and were willing to provide their consent to participate. Only nurses who clicked 鈥淵es鈥� to signify their informed consent were then able to proceed to the next part of the survey. The second part of the online questionnaire presented the inclusion and exclusion criteria. Nurses were required to carefully review the relevant content and then click either 鈥淵es鈥� or 鈥淣o鈥� to confirm that they fully understood the participation requirements and met the eligibility criteria. Only nurses who clicked 鈥淵es鈥� to affirm their eligibility were then able to advance to the next part of the survey. The third part of the online questionnaire provided an instruction about questionnaire contents and response requirements. Nurses were required to carefully review this relevant information and then click either 鈥淵es鈥� or 鈥淣o鈥� to indicate their readiness to begin completing the questionnaire. Only nurses who clicked 鈥淵es鈥� to confirm their understanding and willingness to proceed were then able to advance to the next part of the survey. Nurses were then guided to the part of specific questionnaire items where they could complete the survey at their own pace. The confidentiality of questionnaire data was strictly maintained to guarantee the anonymity of participation.

Variables and measurements

Data was collected through an online questionnaire, comprising demographic information form, Workplace Violence Scale (WVS), Turnover Intention Questionnaire (TIQ), Compassion Fatigue Scale (CF-CN), and Connor-Davidsion Resilience Scale (CD-RISC).

Demographic information form

A demographic information form was constructed to collect general information, including gender, age, ethnicity, occupational department, and professional title. Gender was categorized as 鈥淢ale鈥� and 鈥淔emale鈥�. Ethnicity was categorized as 鈥淗an nationality鈥� and 鈥淥ther nationality鈥�. Occupational department was classified into 鈥淚nternal medicine department鈥�, 鈥淪urgery department鈥�, 鈥淓mergency medicine department鈥�, and 鈥淚ntensive care unit department鈥�. Professional title was divided into 鈥淧rimary title鈥�, 鈥淚ntermediate title鈥�, and 鈥淪enior title鈥�.

Workplace Violence Scale

The Chinese version of Workplace Violence Scale (WVS) was used to measure nurses鈥� experiences of workplace violence over the past year [40, 41]. The WVS has been widely utilized to assess workplace violence against healthcare workers in China, demonstrating favorable validity and reliability across diverse samples [42]. This scale consisted of 5 dimensions measuring physical assault (PA), emotional abuse (EA), threats (T), verbal sexual harassment (VSH), and sexual abuse (SA). Each item was rated on a 4-point scale ranging from 鈥�0鈥�=鈥塶one鈥� to 鈥�3鈥�=鈥塵ore than 3 times鈥�. The total score of the scale was the sum of the responses of each item, with higher scores indicating higher frequencies of workplace violences. A total score of 0 indicated that the nurse did not experience workplace violence, and a total score of 1鈥�15 indicated that the nurse experienced some level of workplace violence. The Cronbach鈥檚 伪 coefficient for the scale was 0.62, indicating acceptable internal consistency of this scale.

Turnover Intention Questionnaire

The Chinese version of Turnover Intention Questionnaire (TIQ) was used to measure nurses鈥� turnover intention [43, 44]. The TIQ has been widely applied to assess turnover intention among nurses, exhibiting high reliability and validity across different samples [45]. This scale consisted of 6 items across 3 dimensions, including the likelihood of quitting the current job (item 1 and 6), the motivation of finding another job (item 2 and 3), and the possibility of getting another job (item 4 and 5). Each item was rated on a 4-point scale ranging from 鈥�1鈥�=鈥塶ever鈥� to 鈥�4鈥�=鈥塧lways鈥�. The total score of the scale was the sum of the responses of each item (6鈥�24), with higher scores indicating greater turnover intention. The Cronbach鈥檚 伪 coefficient for the scale was 0.71, indicating favorable internal consistency of this scale.

Compassion fatigue scale

The Chinese version of the Compassion Fatigue Scale (CF-CN) was adopted to measure nurses鈥� compassion fatigue [46]. The CF-CN has been widely used and validated among healthcare professionals in China, supporting the reliability and validity of this scale in the current study context [47, 48]. This scale comprised 30 items across 3 dimensions, including compassion satisfaction (10 items), occupational burnout (10 items), and secondary traumatic stress (10 items). Each item was scored on a 5-point scale ranging from 鈥�1鈥�=鈥塶ever鈥� to 鈥�5鈥�=鈥塧lways鈥�, with items 1, 4, 15, 17, and 29 designated as reverse scoring questions. The present study used two subscales, occupational burnout and secondary traumatic stress, to measure compassion fatigue among nurses [47]. The test-retest reliability coefficients for each dimension ranged from 0.76 to 0.86, and the Cronbach鈥檚 伪 coefficients of each subscale ranged from 0.75 to 0.82, indicating acceptable reliability and internal consistency of the instrument.

Connor-davidsion resilience scale

The Chinese version of Connor-Davidson Resilience Scale (CD-RISC) was used to measure nurses鈥� psychological resilience [49]. The CD-RISC has been widely used and validated among healthcare professionals in China, supporting the reliability and validity of this scale in the current study context [50, 51]. This scale comprised 25 self-rated items across 3 dimensions, including optimism (4 items), strength (8 items), and tenacity (13 items). Each item was scored on a 5-point scale ranging from 鈥�0鈥�=鈥塶ot true at all鈥� to 鈥�4鈥�=鈥塼rue nearly all the time鈥�. The total score of the scale was the sum of the responses of each item, with higher scores indicating better resilience capacity. The Cronbach鈥檚 伪 coefficients of optimism subscale, strength subscale, and tenacity subscale was 0.60, 0.78, and 0.82, respectively. The CD-RISC exhibited high internal consistency, with a Cronbach鈥檚 伪 coefficient of 0.90 for the total scale in this study.

Data analysis

Data analyses were conducted using SPSS V.25.0 for Windows. The threshold for statistical significance was set at P鈥�<鈥�0.05 for all analyses. Descriptive analysis was performed to calculate means and standard deviations for quantitative variables as well as frequencies and percentages for categorical variables. The normality of the quantitative data distribution was assessed using the Shapiro-Wilk test or the Kolmogorov-Smirnov test. For quantitative data that followed a normal distribution, independent samples t-tests and one-way Analysis of Variance (ANOVA) were performed to determine differences in workplace violence and turnover intention across demographic characteristics. For quantitative data that did not follow a normal distribution, Wilcoxon Mann-Whitney (U-test) and Kruskal-Wallis H-tests were performed to determine differences in workplace violence and turnover intention across demographic characteristics. For quantitative data that followed a normal distribution, Pearson鈥檚 correlation coefficient was conducted to examine the relationships between the main variables. For quantitative data that did not follow a normal distribution, Spearman鈥檚 rank correlation coefficient was conducted to examine the relationships between the main variables.

A moderated mediation analysis was conducted using the PROCESS macro for SPSS (Model 4 and Model 8) to examine the mediating role of compassion fatigue and the moderating role of psychological resilience. Mediation analysis was performed using Model 4 in the PROCESS macro to examine whether compassion fatigue (mediator) mediated the relationship between workplace violence (independent variable) and turnover intention (dependent variable). Bias-corrected bootstrap confidence intervals (95%) were used to assess the statistical significance of the indirect effect. If the 95% CI did not contain 0, it indicated a significant mediating effect of compassion fatigue. Moderated mediation analysis was conducted using Model 8 in the PROCESS macro to investigate whether the mediating effect of compassion fatigue (mediator) varied depending on the level of psychological resilience (moderator). Bias-corrected bootstrap confidence intervals (95%) were used to assess the statistical significance of the conditional indirect effects at different levels of psychological resilience (-1 SD, mean, +鈥�1 SD). If the 95% CI did not contain 0, it indicated a significant moderated mediation effect, suggesting that the mediating effect of compassion fatigue was influenced by the level of psychological resilience.

Ethical considerations

This study obtained ethic approval from the institutional review board of the Third Xiangya Hospital, Central South University (Reference number: kuai 23773). All procedures were conducted in accordance with the provisions of the Declaration of Helsinki. The informed consent was obtained from all participants before they completed the questionnaire. As the questionnaire was distributed and collected anonymously online, this study did not collect handwritten informed consent forms from the participants. The submission of the completed questionnaire was considered as evidence of the participants鈥� informed consent and voluntary agreement to take part in the study.

Result

A total of 1,324 questionnaires were received, yielding 1,141 valid responses and achieving an effective response rate of 86.17%.

Demographic characteristics

Table听1 presents the demographic characteristics of the study participants. The sample was predominantly female, with 95.18% women and 4.82% men. The age of participants ranged from 21 to 54 years, with a mean age of 32.45鈥壜扁��6.80 years. With regard to ethnicity, the majority of participants (99.21%) identified as Han Chinese, while 0.79% belonged to other ethnic groups. In relation to occupational department, 53.46% of the participants were affiliated with the internal medicine department, 38.74% with the surgery department, 4.21% with the emergency medicine department, and 3.59% with the intensive care unit department. With respect to professional titles, 38.47% of the participants held a primary title, 36.54% held an intermediate title, and 24.99% held a senior title.

Table 1 The general characteristics of participants (n鈥�=鈥�1,141)
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Descriptive statistics

Table听2 presents the scores of the different variables measured for these nurses. The mean total score of the WVS was 1.43鈥壜扁��1.72, the mean total score of the TIQ scale was 10.65鈥壜扁��2.39, the mean score of the CF-CN was 41.69鈥壜扁��4.01, and the mean score of the CD-RISC was 64.01鈥壜扁��11.99.

Table听3 present the mean total score of the WVS and the TIQ across demographic characteristics. Given the non-normal distribution of the data, the Mann-Whitney test was used to compare two groups while the Kruskal-Wallis test was employed to compare multiple groups. The results indicated that there were no significant differences in the mean total scores of the WVS and the TIQ across gender, age, ethnicity, occupational department, and professional title (all P鈥�&驳迟;鈥�0.05).

Table 2 The score of main variables (n鈥�=鈥�1,141)
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Table 3 The score of the WVS and the TIQ across demographic characteristics (n鈥�=鈥�1,141)
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Correlation analysis

Table 4 presents the results of correlation analysis between different variables measured for these nurses. Spearman鈥檚 correlation analysis revealed significant positive correlations between workplace violence and turnover intention (r鈥�=鈥�0.466, P鈥�&濒迟;鈥�0.01), as well as compassion fatigue (r鈥�=鈥�0.452, P鈥�&濒迟;鈥�0.01), while negative correlations between workplace violence and psychological resilience (r=-0.414, P鈥�&濒迟;鈥�0.01)

Table 4 The correlation analysis for main variables
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Moderated mediation analysis

The PROCESS macro for SPSS was used to perform a moderated mediation analysis, Model 4 was used to examine the mediating role of compassion fatigue, and Model 8 was used to explore the moderating role of psychological resilience. The mediation analysis using Model 4 of the PROCESS macro examined the mediating role of compassion fatigue in the relationship between workplace violence (independent variable) and turnover intention (dependent variable). The direct effect of workplace violence on compassion fatigue was significant (尾鈥�=鈥�0.923, t鈥�=鈥�14.432), indicating that workplace violence significantly influenced the mediation variable compassion fatigue. The direct effect of workplace violence on turnover intention was also significant (尾鈥�=鈥�0.567, t鈥�=鈥�15.090), showing that workplace violence significantly influenced the dependent variable turnover intention. When the effects of both workplace violence and compassion fatigue were examined on turnover intention, the results showed that workplace violence (尾鈥�=鈥�0.165, t鈥�=鈥�6.015) and compassion fatigue (尾鈥�=鈥�0.436, t鈥�=鈥�37.238) both significantly influenced turnover intention. This suggested that compassion fatigue played a partial mediating role in the relationship between workplace violence and turnover intention. The bootstrap 95% confidence interval for the indirect effect of workplace violence on turnover intention through compassion fatigue did not include 0, further confirming the existence of this mediation effect (as shown in Tables听5 and 6).

Table 5 The mediation analysis of compassion fatigue
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Table 6 The effects of mediation role of compassion fatigue
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The moderated mediation analysis using Model 8 of the PROCESS macro examined the moderating role of psychological resilience on the mediating effect of compassion fatigue. At the low level of psychological resilience (-SD), the bootstrap 95% confidence interval did not include 0, indicating that compassion fatigue had a significant mediating effect with an effect size of 0.097. At the average level of psychological resilience (mean), the bootstrap 95% confidence interval did not include 0, indicating that compassion fatigue also had a significant mediating effect with an effect size of 0.071. At the high level of psychological resilience (+鈥塖D), the bootstrap 95% confidence interval included 0, indicating that compassion fatigue did not have a significant mediating effect. These results suggested that the mediating effect of compassion fatigue was contingent on the level of psychological resilience, with the mediating effect being stronger at lower levels of psychological resilience and being weaker at higher levels of psychological resilience. This finding demonstrated the moderating role of psychological resilience in the mediation process (as shown in Tables听7 and 8).

Table 7 The moderated mediation analysis of compassion fatigue and psychological resilience
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Table 8 The effect of moderated mediation role of compassion fatigue and psychological resilience
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Discussion

Workplace violence represents an occupational hazard cross borders, occupations, and cultures, drawing attention from organizations, researchers, and media [52]. Nurses, who constitute a majority of healthcare personnel, are recognized as the group most susceptible to workplace violence in healthcare circumstances [53]. The prevalence and seriousness of workplace violence against nurses highlight the characterization of consequences and mechanisms. Despite the established correlation between workplace violence and nurse outcome, the relationship and mechanism between workplace violence and turnover intention warrant further elaboration. Therefore, the present cross-sectional survey recruited a convenience sample of 1,141 nurses to examine the relationship between workplace violence and turnover intention, and to clarify the mediating role of compassion fatigue and the moderating effect of psychological resilience within this link.

Nurses face a high risk of workplace violence due to the nature of their occupation and the characteristics of their work environment. This study found that nurses experienced various forms of workplace violence in the past year, with emotional abuse and physical assault being the two most common types. The high prevalence of workplace violence observed in this study was similar to findings from previous studies conducted in China and other countries. For instance, a cross-sectional study involving 266 nurses from 165 hospitals in China observed that 64.7% of nurses experienced at least one type of workplace violence in the previous year, with verbal abuse being the most frequent form [54]. Furthermore, a cross-sectional study involving 599 mental healthcare nurses in Japan revealed that over 40% of nurses experienced workplace violence in the past year [9]. In addition, a cross-sectional study examining the prevalence of workplace violence among nurses in five European countries found that 54% experienced non-physical violence, 20% experienced physical violence, and 15% experienced both forms [55]. The types and incidences of workplace violence against nurses vary across geographic locations and hospital environments [56]; however, studies around the world converge to support a high prevalence of workplace violence against nurses. Notably, the rates of workplace violence against nurses remain underreported, as nurses often rationalize violent incidents as a regrettable part of their professions and accept violent events as an inevitable hazard of their occupations [57]. For example, a cross-sectional survey of 692 nurses in Slovenia concluded that only a portion of nurses reported violent incidents in formal written form, with the reporting rate being 6.5% for psychological violence and 10.9% for physical violence [58]. Furthermore, a whole-population survey of 411 nurses in the UK indicated that while 74.7% of nurses experienced workplace violence, only 18.2% of nurses reported all violent incidents [59]. Workplace violence is a professional hazard of nurses, inflicting not only physical injuries but also psychological harms on victimized nurses. The prevalence and seriousness of workplace violence against nurses underscore the urgency for healthcare institutions and systems to implement legislative measures and procedural frameworks preventing such occurrences and ensuring workplace safety. This study supports the prevalence of workplace violence against nurses and emphasize the characterization of consequence and mechanism of workplace violence among nurses.

Turnover intention refers to a behavioral tendency wherein staffs intend to leave their current professions. Turnover intention is a strong predictor of actual turnover, acting as both a proxy for and a predictor of actual turnover. This study was consistent with the results of previous studies, indicating the presence of turnover intention among significant proportion of nurses. For instance, a meta-analysis examining the prevalence of turnover intention among 37,672 primary health workers in China found that 30.4% of these primary health workers exhibited turnover intention to their current jobs [60]. Furthermore, a nationwide study of 11,942 nurses from 87 hospitals in China found that 22.93% of nurses exhibited strong turnover intention to their current positions [61]. Meanwhile, a cross-sectional study of 506 novice nurses from 5 hospitals in China reported an even higher prevalence of 51.9% for turnover intention among this population [62]. In addition, Dall鈥橭ra et al. (2015) investigated the prevalence of turnover intention among a sample of 31,627 registered nurses in 488 hospitals across 12 European countries, found that 33% of nurses demonstrated turnover intention to their current jobs [63]. Nurses, as the largest sector of healthcare workers, are the foundation and guarantee for the development and sustainability of hospitals. The presence of high turnover intention among nurses not only impairs the professional identity and growth of nurses but also affects the workforce and development of hospitals. The global shortage of nurses combined with the high rates of turnover intention emphasizes the imperative for healthcare institutions and systems to take implement prevention measures and intervention strategies bolstering organizational commitment and promoting occupational retention among nurses. This study indicates the presence of high turnover intention among nurses, which highlight the identification of antecedents of turnover intention among nurses.

This study identified a positive correlation between workplace violence and turnover intention among these nurses, implying that exposure to workplace violence increased turnover intention within this population. This finding was in line with previous studies, which observed that the experience of workplace violence decreased the quality of occupational life and induced the emergence of turnover intention among nurses [64]. Specifically, a cross-sectional survey of 1,024 nurses from 26 cities in China found that workplace violence was positively related to turnover intention among this sample [65]. Additionally, a cross-sectional study of 415 emergency nurses in China reported a positive association between workplace violence and turnover intention among this group [66]. This study aligned with previous studies support the adverse impact of workplace violence on turnover intention, underscoring the exploration of mechanisms behind this correlation. Evidence indicated that exposure to workplace violence provoked negative professional attitudes and decreased job satisfaction, thus impaired occupational commitment and elicited turnover intention among nurses [67].

This study revealed that compassion fatigue mediated the positive correlation between workplace violence and turnover intention among nurses. Nurses, who work on the frontlines of healthcare, face both physical challenges and emotional pressures in their daily duties. Compassion fatigue refers to a state of holistic exhaustion and deprivation, manifesting as physical decline in energetic endurance, emotional decline in empathetic ability, and spiritual decline in recovery capability [68, 69]. Compassion fatigue arisen from chronic exposure to patient distress, work pressure, occupational devotion, lack of personal-professional boundaries, and absence of self-care measures [68, 69]. The findings of this study suggested that the experience of workplace violence caused the presence of compassion fatigue, which further induced the emergence turnover intention among nurses. Exposure to workplace violence originates compassion discomfort, progresses to compassion stress, and culminates in compassion fatigue, ultimately eliciting job dissatisfaction, occupational burnout, and turnover intention among nurses. Numerous studies have demonstrated the detrimental consequences of compassion fatigue on nurse outcomes and the deleterious influences of workplace violence on compassion fatigue. This study was consistent with previous studies to confirm the mediating role of compassion fatigue in the link between workplace violence and turnover intention. Specifically, Chen et al. (2022) performed a cross-sectional survey of 4,520 psychiatrists among 41 tertiary psychiatric hospitals in China, found a positive relationship between workplace violence and turnover intention under the mediation effect of job burnout and occupational stress [70]. Additionally, Choi and Lee (2017) conducted a cross-sectional study among 358 nurses in Korea, found that workplace violence increased compassion fatigue, which in turn fueled turnover intention [64]. Evidence indicated that exposure to workplace violence caused compassion fatigue, which elicited job dissatisfaction, decreased organizational loyalty, and stimulated turnover intention among nurses [71]. Since mediating role of compassion fatigue proposed in this study, preventive measures and intervention strategies should aim to alleviate compassion fatigue and promote compassion satisfaction among nurses, mitigating the detrimental effects of workplace violence and preventing the emergence of turnover intention. Hospital administrators and nurse managers should formulate policies and provide opportunities for nurses to participate in group psychological debriefing or individual psychological counseling, thereby alleviating occupational burnout and traumatic stress.

This study identified that psychological resilience moderated the positive correlation between workplace violence and turnover intention among nurses. Resilience represents a personality attribute which enables nurses to cope with challenges, adaptation to adversity, and recover from setbacks [72, 73]. Resilience allows nurses to copy with pressure events and adapt to stressful environments, further enhance supportive systems and personal abilities [72, 73]. Resilience helps nurses to build professional relationships, enhance emotional insights, and achieve life spirituality, which enables nurses to buffer, mitigate, and resist the detrimental effects of workplace violence. Studies supported the protective effects of psychological resilience on nurse outcomes and the buffer roles of psychological resilience on workplace violence. While previous studies did not directly illustrate the moderating role of psychological resilience in the link between workplace violence and turnover intention, they have jointly indicated the negative impact of workplace violence on turnover intention and the protective effect of psychological resilience on turnover intention [74]. Other positive psychological indicators, similar to psychological resilience, have also been shown to play a moderating role in the relationship between workplace violence and turnover intention. For instance, a cross-sectional survey of 1,063 Chinese healthcare workers found that workplace violence was positively associated with turnover intention, and perceived social support and mental health mediated the relationship between workplace violence and turnover intention [75]. In addition, a longitudinal survey of 1,515 Finnish physicians found that workplace violence was positively associated with turnover intention, and job control moderated the relationship between workplace violence and turnover intention [26]. Evidence implicated psychological resilience as a psychological resources and personal attributes which enabled nurses to perceive workplace violence as a solvable problem and stimulate an adaptation process to workplace violence, thus buffered the fluctuation of job satisfaction and inhibited the emergence of turnover intention among nurses [76]. Given the moderating role of psychological resilience confirmed in this study, preventive measures and intervention strategies should aim to foster psychological resilience among nurses, alleviating the adverse effects of workplace violence and preventing the emergence of turnover intention. Preventive measures and intervention strategies should, therefore, focus on fostering psychological resilience among nurses to alleviate the adverse effects of workplace violence and mitigate the emergence of turnover intentions. Institutions or hospitals can implement positive psychology workshops and professional development programs to equip nurses with emotion regulation strategies and stress management techniques, thereby overcoming workplace violence and fostering occupational commitment.

Limitation

The present study has several limitations that should be acknowledged. First, the cross-sectional design of this study precluded any causal inferences about the relationships between the study variables. Future research should employ longitudinal designs to clarify temporal precedence necessary to infer causality. Second, the self-reported nature of this study introduced the potential for common method bias to inflate the observed relationships. Future research should incorporate objective measures, such as incident reports or observational data, to corroborate the findings. Third, the sample was drawn from public hospitals in a specific geographic region, which may limit the generalizability of the findings. Future research should replicate this study in more diverse samples to strengthen the external validity of the results.

Conclusion

Despite the promotion of 鈥渮ero tolerance鈥� policies, the incidence of workplace violence against healthcare workers, particularly nurses, remains a persistent issue [77]. The prevalence and seriousness of workplace violence against nurses underscore the characterization of consequence and mechanism behind this phenomenon. Therefore, this cross-sectional survey recruited a convenience sample of 1,141 nurses to examine the relationship between workplace violence and turnover intention, and further explore the mediating role of compassion fatigue and the moderating role of psychological resilience on this link among Chinese nurses. The findings of this study supported the mediating role of compassion fatigue and the moderating role of psychological resilience on relationship between workplace violence and turnover intention among Chinese nurses. Nurses represent the primary victims of workplace violence in healthcare sectors, facing a higher risk of such incidents than other types of healthcare staffs. Nurses witnessing and experiencing workplace violence not only impacts their health and safety but also impairs their work performance and job productivity [78, 79]. Various countries around the world have initiated coordinated strategies such as 鈥渮ero tolerance zone鈥� to prevent workplace violence in health sectors. National Health Commission of China established the 鈥渟afe hospital鈥� policy to build safe work environments and maintain medical orders in health institutions. Future research and practical efforts should be directed toward developing effective preventive measures and intervention strategies at the individual, organizational, and national levels to mitigate workplace violence and cultivate harmonious work atmosphere for nurses and other healthcare professionals. These efforts could mitigate the adverse effects of workplace violence and prevent the emergence of turnover intention by addressing compassion fatigue and fostering psychological resilience.

Data availability

Data that support the findings of this study are available from the corresponding author Xiaoli Liao upon reasonable request.

Abbreviations

WHO:

World Health Organization

ICN:

International Council of Nurses

WVS:

Workplace Violence Scale

TIQ:

Turnover Intention Questionnaire

CFS:

Compassion Fatigue Scale

CD-RISC:

Connor-Davidson Resilience Scale

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Acknowledgements

The authors would like to express their gratitude to all the participants and researchers involved in this study.

Funding

The authors did not receive any financial support for the research, authorship, or publication of this article.

Author information

Authors and Affiliations

  1. The First Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, China

    Miao Chen

  2. Nursing Department, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China

    Hao Xie

  3. School of Nursing, Sun Yat-sen University, Guangzhou, Guangdong, China

    Xiaoli Liao

  4. Hunan Traditional Chinese Medical College, ZhuZhou, Hunan, China

    Juan Ni

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Contributions

All authors have reviewed and approved the final manuscript. Miao Chen: Designed questionnaire, collected data, performed data reanalysis, revised the manuscript. Hao Xie: Collected data, and reviewed the manuscript.Xiaoli Liao: Conceptualized proposal, designed questionnaire, performed initial data analyses, and wrote the original manuscript draft.Juan Ni: Collected data, and reviewed the manuscript.All authors reviewed the manuscript.

Corresponding author

Correspondence to Xiaoli Liao.

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This study received ethical approval from the institutional review board of the Third Xiangya Hospital, Central South University (Reference number: kuai 23773). All procedures were conducted in accordance with the ethical standards established by the 1964 Declaration of Helsinki and its subsequent amendments. The informed consent was obtained from all participants before they completed the questionnaire.

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Chen, M., Xie, H., Liao, X. et al. Workplace violence and turnover intention among Chinese nurses: the mediating role of compassion fatigue and the moderating role of psychological resilience. 樱花视频 24, 2437 (2024). https://doi.org/10.1186/s12889-024-19964-y

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ISSN: 1471-2458

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