Abstract
Background:
COVID-19 pandemic has entered a normal stage in China. During this phase, nurses have an increased workload and mental health issues that threaten the sense of security. Poor sense of security may have a considerable impact on turnover intention through low work engagement. It was challenging to maintain the nurse workforce. Fewer studies have been conducted on the effect of nurses' sense of security on their turnover intention in that phase. This study aimed to investigate the interrelationship between nurses' sense of security, work engagement, and turnover intention during the normalization phase of the epidemic in China and to explore the impact of sense of security on turnover intention.
Methods:
A cross-sectional survey was conducted from September 2020 to May 2021 in Guangdong Province, China. Data were collected online using Sense of Security Scale for Medical Staff (SSS-MS), Utrecht Work Engagement Scale (UWES), and Turnover Intention Scale. Pearson's correlation analysis was used to assess the correlation between sense of security, work engagement, and turnover intention. The hypothesis model used multiple linear regression models and the bootstrapping procedure to analyze the relationship between these variables.
Results:
Data were collected from 2,480 nurses who met the inclusion criteria. Over half(64.5%) of nurses had a high and very high turnover intention. After controlling the demographic and working variables, sense of security (β = 0.291, P < 0.001) had a direct positive effect on work engagement. Sense of security (β = −0.447, P < 0.001) and work engagement (β = −0.484, P < 0.001) had a direct negative effect on turnover intention. Sense of security and all of its components were associated with turnover intention through the partially mediating effects of work engagement.
Conclusions:
Nurses' turnover intention was at a high level during the normalization phase of the epidemic. Sense of security and its components act as positive resources to reduce turnover intention by improving work engagement. Policy makers and managers may pay attention to the needs of nurses' sense of security, which may be a new perspective to help managers reduce their turnover intention and stabilize the nurse team.
Introduction
Nurses, as the largest health care professional grouping, play a critically significant role in the fight against the COVID-19 epidemic. The shortage of nurses in China remains a severe problem, and nurse turnover exacerbates shortages. Although the number of nurses in China is increasing yearly, the shortage of nurses due to the vast population base is a problem that cannot be ignored. According to the latest the latest WHO data (WHO NHWA Data Platform–January 2021 update), the density of nurses and midwives per 1,000 population in Europe and the Americas Region exceeds 8, and the average density of nurses and midwives per 1,000 population in 194 countries is 4.49 (). However, according to the statistical bulletin on China's health care development in 2021 released by the China Health Care Commission, there were only 3.56 registered nurses per 1,000 population (). Thus, the shortage of nurses has become a major health human resource problem to be solved urgently in China.
At the end of April 2020, China entered the phase of normalization of COVID-19 epidemic prevention and control. The goal was to strictly prevent imported cases, center on nucleic acid testing for risk prevention and control, and control the spread of the epidemic within 2 to 3 incubation periods (). The constant mutation of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) poses a considerable challenge to outbreak prevention and control (). Although the epidemic was not spreading or outbreaking on a large scale, unanticipated sporadic disseminated cases occurred from time to time. The work of many nurses has changed dramatically from the past. Due to the shortage of human resources in the community, nurses in general hospitals have been required to accept out-of-hospital nursing assignments in addition to clinical care in the hospital. For example, they were sent to the community or other places to participate in nucleic acid testing and vaccination (). Moreover, the change in workflow and shift patterns have also resulted in nurses working long hours, insufficient rest, and constant overtime (). The need for nurses in China has continued to increase during the normalization phase of the COVID-19 epidemic.
The COVID-19 epidemic contributed to an adverse working environment for healthcare workers. In the face of increased risk of infection, long work shifts, overload, and lifestyle changes may significantly affect healthcare workers' mental health, such as burnout, stress, depression and anxiety, insomnia, post-traumatic stress disorder, and insomnia (, ). Results from meta-studies during the COVID-19 epidemic reported that nurses demonstrated significantly worse mental health outcomes compared to other healthcare workers (, ). Since most nurses are women, they are more sensitive to the perceived emotional burden in the workplace (). Moreover, the occupational characteristics of nurses tend to more extended patient contact and follow-up, experiencing more workload and risk of infection (, ). Nurses also have a negative psychological impact during the normalization phase of the COVID-19 epidemic (). Increasing work stress and psychological stress made some of them opt to leave, but not in nursing, leading to an increased shortage (). The shortage may aggravate the burden on the healthcare system ().
Turnover intention is an employee's behavioral intention or attitude toward leaving his or her organization or unit, which is a psychological state or tendency before generating turnover behavior (). Moreover, it is a crucial antecedent variable for turnover behavior and can predict turnover behavior (). Research has previously observed that nurse turnover impacts the quality of care and generates many lost economic benefits (), rendering it an ongoing concern for administrators. Notably, nurses with higher turnover intention may not decide to engage in turnover behavior. However, high turnover intention were associated with absenteeism () and missed nursing care (). Thus, nurses' willingness to work may affect patients and their self-safety, especially caring for COVID-19 patients. Surveys such as that conducted by Nashwan have shown that nurses' turnover intention increased significantly during COVID-19 (from a mean score of 13.24 to 15.54) (). Therefore, the turnover intention of nurses under the normalization of the epidemic situation needs further research.
Previous studies have mentioned job insecurity as a predictor of turnover (). During COVID-19, many studies verified that insecurity was related to turnover intention (–). Insecurity is associated with physical and mental health well-being, and insecurity can contribute to the development of mental illness and somatic symptoms, and job burnout (–). However, due to medical professionals' professional and workplace characteristics, their security may be derived from their experiences at work, such as social media, doctor-patient relationships, medical work environment, and promotion system (, ). According to the work characteristics of medical personnel, the sense of security of medical personnel consists of five components: work environment, patient, self-competence, organizational management, and social support (). During the normalization of the COVID-19 epidemic, overload and nurse-patient conflicts also lead to a high incidence of anxiety and depression among nurses (, ). These psychological risks may threaten the nurse's sense of security during this period (), and the poor sense of security may increase the possibility of turnover. The association between insecurity and turnover intention among hotel employees () and corporate employees () during the COVID-19 pandemic has been identified. Nevertheless, has been scarce research on the relationship between nurse sense of security and turnover intention during the normalization of the COVID-19 epidemic.
Work engagement was defined as a positive, fulfilling psychological state characterized by vigor (i.e., abundant energy and resilience); dedication (i.e., a sense of meaning, pride, and challenge to the work); absorption (i.e., concentration on the work and readily absorbed in work) (). Since the rising of positive psychology, work engagement has received more and more attention. Previous studies have referred to work engagement as a protective factor for turnover intention (), which promotes job outcomes such as job satisfaction, job performance, and organizational citizenship behavior (, ).
The research was based on the job demands-resources model (JD-R Model) and the conservation of resources (COR) theory. The characteristics of any job could be divided into job demands and resources concerning the JD-R model (). Job demands refer to characteristics that require continuous physical or mental consumption. In contrast, job resources refer to characteristics that can support and help employees, reduce consumption, and motivate growth. Sense of security and work engagement help prevent burnout (, ). They belong to positive job resources. According to the positive process of the JD-R model, work engagement plays a vital role in acting as a bridge between available job resources and positive work outcomes (i.e., reduced turnover intention). An adequate sense of security could enable this positive path to reduce turnover intention by increasing work engagement. COR theory suggests that individuals tend to avoid the loss of resources (i.e., they have a tendency to retain, protect, and create resources) (). Sense of security and work engagement are significant job resources that individuals value. Thus, avoiding the loss of resources may lead individuals to choose to stay with the organization. Based on the above, this study proposes a conceptual model map, as shown in Figure 1. In addition, studies showed a correlation between sense of security and turnover intention. In this mediation model, however, we are unclear whether the components of sense of security contribute to it. Therefore, we considered different components of sense of security to bring into this research model to fill this gap in research.
Figure 1
The aim of this study is to examine the relationship between sense of security, work engagement, and turnover intention among Chinese nurses under the epidemic normalization of the COVID-19 epidemic. We propose four hypotheses as follows:
H1: Sense of security has a positive impact on work engagement (path a).
H2: Sense of security has a negative impact on turnover intention (path c).
H3: Work engagement negatively has a negative impact on turnover intention (path b).
H4: The effects of sense of security on turnover intention are partially mediated by work engagement (path c′).
Materials and methods
Design, setting and participants
A cross-sectional study was conducted between September 2020 and May 2021 using snowball and convenience sampling in Guangdong Province, China. The sample size was estimated based on Wu's () proposal that a sample size >200 is needed to construct a stable model. Therefore, we aimed to collect at least 200 valid questionnaires. Inclusion criteria: (1) Age ≥18, engaged in clinical work; (2) No mental or cognitive dysfunction; (3) Registered nurses who are qualified to practice; (4) Volunteer to participate in this study. Exclusion criteria: (1) Practice nurses and trainee nurses who have not obtained the practice qualification; (2) Nurses who did not work in the clinic during the survey period (such as studying abroad, not participating in the clinic while engaged in management work, asking for leave and being hospitalized).
Data collection
We sent the questionnaire to the members of the Guangdong Nursing Association through Wenjuanxing (a professional questionnaire website, https://www.wjx.cn). We explained the aim of the study and the principles of voluntary and anonymous participation. Then, the members forwarded the questionnaire to the head nurse of each nursing unit, who invited the nurses in each department to fill in the questionnaire.
Ethical considerations
The Ethics Committee has approved this study of Guangdong Provincial People's Hospital (NO. Ky2020-579-01). On the premise of strictly implementing the informed consent and voluntary principles, the research objectives, methods and significance was explained to the subjects on the title page of the questionnaire, and consent was obtained before the questionnaire could be filled out. We fully respect subjects' informed consent and privacy, and subjects can withdraw from the investigation to comply with their wishes.
Measurements
Demographic characteristics and working characteristics
We designed the demographic and working information questionnaire, including nine items: gender, age, marital status, education, professional title, work seniority, hospital level, employment status, and department. Based on past research on turnover intention (–), we set these variables as covariates to exclude potential confounding bias in examining mediation effects.
Sense of security
Sense of security was measured using the Sense of Security Scale for Medical Staff (SSS-MS), validated among the Chinese medical staff (). The scale was mainly composed of 5 dimensions and 22 items: environmental (4 items; e.g., “I am worried about the physical environment and occupational exposure in the hospital”;α = 0.843), patient (4 items; e.g., “The patient's distrust scares me at work”;α = 0.890), self (3 items; e.g., “I am worried that the lack of comprehensive ability leads to contradictions and inability to deal with emergencies”;α = 0.788), organizational management (7 items; e.g., “The lack of care and support from my superiors made me feel isolated and helpless”;α = 0.917), and social support (4 items; e.g., “The tense atmosphere of medical treatment reported by media reports upsets me”;α = 0.890). The scale was scored using the Likert 5-level method, ranging from 1 (absolutely agree) to 5 (absolutely disagree). The higher the score, the higher the sense of security. The scale has been shown to have good reliability among medical personnel. We calculated the average and the total scale score (α = 0.966).
Work engagement
Work engagement was measured by the Chinese version of the Utrecht Work Engagement Scale (UWES) (). The scale contained 3 dimensions and 16-item, vigor (6 items; e.g., “I feel strong and vigorous at work”;α = 0.902), dedication(5 items; e.g., “I am proud of my current job”;α = 0.953), and absorption (5 items; e.g., “When I am working all I think about is work”;α = 0.907). The scale was scored using the Likert 7-level method, ranging from 0 (never) to 6 (always). The higher the score, the greater the work engagement. We calculated the average and total scale scores (α = 0.962).
Turnover intention
To assess turnover intention, we used the Turnover Intention Scale (TI), translated and revised by LI Dongrong and LI Jingyuan (). This scale consisted of 6 items under three subscales: TII-the possibility of turnover (2 items; e.g., I am going to quit my present job'); TIII-the motivation to look for another job (2 items; e.g., I want to find another job of the same nature); TIIII-the possibility of obtaining another job (2 items; e.g., 'The likelihood that I will find a suitable position in another organization). The scale was scored using the Likert 4-level method, ranging from 1 (absolutely disagree) to 4 (absolutely agree). The higher the score, the greater the turnover intention. The higher the score, the greater the turnover intention. Nurses' turnover intention was classified as very low turnover intention ( ≤ 1), low turnover intention (>1, ≤ 2), high turnover intention (>2, ≤ 3), and very high turnover intention (>3). We calculated the average and total scale scores (α = 0.799).
Data analysis
IBM SPSS 26.0 and AMOS 24.0 were used for analysis. First, the data with the normal distribution of continuous variables were represented by mean and standard deviation. The categorical variables were described as frequency and percentage. Secondly, Pearson's correlation analysis was used to analyze the relationship between sense of security, work engagement, and turnover intention for normally distributed data. Finally, we used the PROCESS macro mediation model (model 4) () in SPSS. We set the sense of security as the independent variable, work engagement as the intermediary variable, and turnover intention as the dependent variable to estimate the size and significance of the mediation effect. The bootstrap method was used, with a sample size of 5,000 and a confidence interval of 95%. The mediation effect was considered significant if the confidence interval did not include zero. The same procedure was conducted to analyze five dimensions of sense of security to determine different components' effects ().
Results
Participants characteristics
A total of 2,554 nurses were distributed the online questionnaire, and 2,480 returned the survey (response rate: 97.1%). Participants were from 29 hospitals in Guangdong Province, including 14 tertiary hospitals, 8 secondary hospitals, and 7 primary hospitals. Most of them (89.9%) were female,51.5% were < 30 years old,60.0% were married,61.8% had junior college education,71.9% held the junior professional title, 34.0% had worked in hospitals for 6–10 years, 59.0% had worked in tertiary hospitals, and 64.6% were temporary. 26.5% of them were from the medicine unit. The characteristics of other participants are shown in Table 1.
Table 1
| Variable | Categories | n(%) |
|---|---|---|
| Gender | Male | 250(10.1) |
| Female | 2230(89.9) | |
| Age (years) | ≤ 30 | 1277(51.5) |
| 31-40 | 835(33.7) | |
| ≥41 | 368(14.8) | |
| Years of service (years) | ≤ 5 | 746(30.1) |
| 6–10 | 844(34.0) | |
| 11–20 | 555(22.4) | |
| ≥21 | 335(13.5) | |
| Professional title | Junior | 1782(71.9) |
| Intermediate | 602(24.3) | |
| Senior | 96(3.9) | |
| Marital status | Married | 1489(60.0) |
| Unmarried | 962(38.8) | |
| Divorce or widowed | 29(1.2) | |
| Education level | Secondary school | 18(0.7) |
| Junior college | 1532(61.8) | |
| Undergraduate or above | 930(37.5) | |
| Department | Intensive care unit | 173(7.0) |
| Medicine | 656(26.5) | |
| Surgery | 473(19.1) | |
| Obstetrics or gynecology | 298(12.0) | |
| Pediatrics | 173(7.0) | |
| Emergency | 264(10.6) | |
| Medical technology department | 281(6.5) | |
| Others | 162(17.8) | |
| Employment status | Temporary | 1603(64.6) |
| Permanent | 877(35.4) | |
| Hospital level | Primary hospital | 178(7.2) |
| Secondary hospital | 840(33.9) | |
| Tertiary hospital | 1462(59.0) | |
| Turnover intention | Very low turnover intention | 73(2.9) |
| Low turnover intention | 817(32.9) | |
| High turnover intention | 1147(46.3) | |
| Very high turnover intention | 443(17.9) |
Demographic characteristics of participants(N = 2480).
Descriptions and correlations of variables
Pearson's correlation coefficients of sense of security, turnover intention, and work engagement are shown in Table 2. Sense of security was positively correlated with work engagement. Turnover intention was negatively related to sense of security and work engagement.
Table 2
| Variables | Mean | SD | 1 | 2 | 3 | |
|---|---|---|---|---|---|---|
| 1 | Sense of security | 79.62 | 19.61 | 1 | ||
| 2 | Work engagement | 65.76 | 20.24 | 0.260*** | 1 | |
| 3 | Turnover intention | 14.13 | 4.28 | −0.390*** | −0.413*** | 1 |
Means, standard deviations (SD) and correlations among study variables (N = 2480).
***p < 0.001.
Test of the hypothesized model and associations among variable
Table 3 tabulates the results of the regression analyses examining the mediation hypothesis. The negative effect of sense of security on turnover intention was significant (β = −0.447, t = −24.522, p < 0.001), and the indirect negative effect of sense of security on turnover intention remained significant (β = −0.306, t = −18.923, P < 0.001) when the mediating variables were involved. Sense of security had a significant positive impact effect on work engagement (β = 0.291, t = 14.706, P < 0.001), and work engagement had a significant negative predictive effect on turnover intention (β = −0.484, t = −30.539, P < 0.001). As shown in Table 4, the association between sense of security and turnover intention was partly mediated by work engagement. As to its five dimensions, the relationship between environment, patient, self, organizational management, social support, and turnover intention was also partially mediated by work engagement.
Table 3
| Variable | Total effect of sense of security on turnover intention | Direct effect of sense of security on work engagement | Direct effects of sense of security on turnover intention and work engagement on turnover intention | |||
|---|---|---|---|---|---|---|
| Path c | Path a | Path c' and Path b | ||||
| β | t | β | t | β | t | |
| Sense of security | −0.447 | −24.522*** | 0.291 | 14.706*** | −0.306 | −18.923*** |
| Work engagement | – | – | −0.484 | −30.539*** | ||
| Gender | ||||||
| Male (ref) | ||||||
| Female | 0.021 | 1.175 | 0.023 | 1.165 | 0.033 | 2.097* |
| Age (years) | ||||||
| ≤ 30 (ref) | ||||||
| 31–40 | −0.031 | −1.144 | 0.066 | 2.253* | 0.001 | 0.046 |
| ≥41 | −0.023 | −0.514 | 0.007 | 0.155 | −0.019 | −0.508 |
| Years of service (years) | ||||||
| ≤ 5 (ref) | ||||||
| 6–10 | −0.03 | −1.299 | 0.104 | 4.162*** | 0.02 | 1.036* |
| 11–20 | −0.022 | −0.717 | 0.107 | 3.221** | 0.03 | 1.14 |
| ≥21 | −0.016 | −0.344 | 0.19 | 3.878*** | 0.076 | 1.979* |
| Professional title | ||||||
| Junior (ref) | ||||||
| Intermediate | 0.013 | 0.697 | 0.019 | 0.888 | 0.022 | 1.366 |
| Senior | 0.003 | 0.147 | 0.028 | 1.414 | 0.016 | 1.043 |
| Marital status | ||||||
| Married (ref) | ||||||
| Unmarried | −0.007 | −0.371 | −0.018 | −0.875 | −0.016 | −0.975 |
| Divorce or widowed | −0.003 | −0.174 | 0.02 | 1.026 | 0.006 | 0.427 |
| Education level | ||||||
| Secondary school (ref) | ||||||
| Junior college | −0.188 | −1.843 | −0.024 | −0.216 | −0.2 | −2.297* |
| Undergraduate or above | −0.118 | −1.156 | 0.027 | 0.24 | −0.105 | −1.21 |
| Department | ||||||
| Intensive care unit (ref) | ||||||
| Medicine | −0.018 | −0.548 | −0.001 | −0.026 | −0.019 | −0.66 |
| Surgery | 0.02 | 0.654 | −0.049 | −1.463 | −0.003 | −0.134 |
| Obstetrics or gynecology | 0.041 | 1.496 | −0.025 | −0.824 | 0.029 | 1.25 |
| Pediatrics | 0.009 | 0.372 | 0.004 | 0.156 | 0.011 | 0.533 |
| Emergency | −0.025 | −0.949 | −0.021 | −0.736 | −0.036 | −1.568 |
| Medical technology department | −0.008 | −0.299 | −0.064 | −2.144* | −0.039 | −1.67 |
| Others | 0.051 | 2.124* | 0.016 | 0.604 | 0.058 | 2.867** |
| Employment status | ||||||
| Temporary (ref) | ||||||
| Permanent | −0.026 | −1.283 | −0.088 | −4.007*** | −0.069 | −3.963*** |
| Hospital level | ||||||
| Primary hospital (ref) | ||||||
| Secondary hospital | −0.058 | −1.673 | 0.042 | 1.11 | −0.038 | −1.28 |
| Tertiary hospital | −0.102 | −2.905** | −0.014 | −0.364 | −0.109 | −3.637*** |
| Constant | 24.023 | 23.421*** | 37.637 | 7.147*** | 27.869 | 31.584*** |
| R2 | 0.247 | 0.113 | 0.454 | |||
| F | 34.939*** | 13.579*** | 85.044*** | |||
Results of the regression models testing the mediation hypothesis (N = 2480).
*P < 0.05, **P < 0.01, ***P < 0.001.
Table 4
| Effect | B | BootSE | 95%BootCI | |
|---|---|---|---|---|
| Lower | Upper | |||
| Sense of security → turnover intention | ||||
| Total effect | −0.097 | 0.004 | −0.105 | −0.090 |
| Direct effect | −0.067 | 0.005 | −0.075 | −0.058 |
| Indirect effect | −0.031 | 0.002 | −0.036 | −0.026 |
| Environment → turnover intention | ||||
| Total effect | −0.444 | 0.020 | −0.484 | −0.405 |
| Direct effect | −0.305 | 0.021 | −0.346 | −0.262 |
| Indirect effect | −0.139 | 0.012 | −0.162 | −0.115 |
| Patient → turnover intention | ||||
| Total effect | −0.410 | 0.020 | −0.450 | −0.371 |
| Direct effect | −0.276 | 0.021 | −0.317 | −0.234 |
| Indirect effect | −0.134 | 0.012 | −0.158 | −0.111 |
| Self → turnover intention | ||||
| Total effect | −0.539 | 0.028 | −0.595 | −0.484 |
| Direct effect | −0.345 | 0.029 | −0.403 | −0.286 |
| Indirect effect | −0.195 | 0.017 | −0.229 | −0.163 |
| Organizational management → turnover intention | ||||
| Total effect | −0.275 | 0.012 | −0.298 | −0.252 |
| Direct effect | −0.187 | 0.013 | −0.212 | −0.161 |
| Indirect effect | −0.088 | 0.007 | −0.102 | −0.074 |
| Social support → turnover intention | ||||
| Total effect | −0.423 | 0.019 | −0.461 | −0.385 |
| Direct effect | −0.287 | 0.021 | −0.327 | −0.246 |
| Indirect effect | −0.135 | 0.012 | −0.158 | −0.113 |
Direct and indirect effects of sense of security and its dimensions on turnover intention (N = 2480).
Discussion
This study constructed a hypothetical model based on theories to explore the relationship between nurses' sense of security and turnover intention during the normalization of the COVID-19 epidemic and with work engagement as a mediator in this relationship. We found that sense of security impacted positively and independently on work engagement and negatively and directly on turnover intention. Moreover, work engagement had a direct negative effect on turnover intention and partially mediated the relationship between sense of security and turnover intention among nurses. In addition, we examined the effects of the components of sense of security in this mediation model. All components of sense of security were negatively related to turnover intention. There were direct and indirect effects between the variables. It was shown that all components of sense of security (environment, patients, self, organizational management, and social support) may act as protective factors in reducing turnover intention and that work engagement partly mediated their relationship with turnover intention. This study may provide managers with new perspectives on sustaining the nursing team and developing nursing interventions during the normalization of the COVID-19 epidemic.
In the present research, the score of nurses' turnover intention was (14.13 ± 4.28), and nurses' turnover intention was at a high level during the normalization phase of the epidemic, which was higher than the findings of a previous survey of nurses in 23 hospitals in China before the epidemic (). We revealed that more than half of the nurses reported high turnover intention (46.3%) or very high turnover intention (17.9%). This may result from the changes that the epidemic has brought to work. In order to control sporadic epidemics, nurses were required to work overtime and accepted emergency assignments to do large-scale screening, increasing psychological problems and burnout (). One study noted that after the COVID-19 epidemic, the most reported predictors of nurses' turnover intention included fear of illness, stress, and anxiety (). Meanwhile, the psychological impact of the epidemic may be long-lasting after the epidemic (). All these reasons may lead to an increase in nurses' turnover intention.
Nurses' work engagement in this study was medium, consistent with previous studies under the COVID-19 epidemic (, ). During the normalized epidemic phase, despite the burnout of long-term epidemic prevention and control (), the role played by nurses in the epidemic is socially recognized as high, which is conducive to nurses' professional identity (). Higher work engagement could lead to higher self-efficacy and a sense of accomplishment in the workplace (), leading to more inclination to stay with the organization. Consistent with previous literature, work engagement was negatively associated with turnover intention ().
The study showed that nurses' sense of security tended to be on a high level, which indicates that nurses could feel supported and within control in the workplace during the epidemic normalization. The results showed that nurses' sense of security came most from organizational management, referring to hospital management and systems, leadership from superiors, and cooperation among colleagues, indicating that the participants indicated that the hospital was able to protect nurses' fundamental rights and interests (). The excellent atmosphere and cohesive team were so that nurses could obtain support and security from the organization, consistent with the previous study (, ).
Our study found that nurses' sense of security had a direct negative predictive effect on turnover intention and an indirect negative predictive effect on turnover intention through work engagement. The sense of security is a subjective feeling in the workplace and is the basic need of clinical nurses. Therefore, in this work environment, nurses could be satisfied and benefit from their work (). Furthermore, the five components of a sense of security were involved in the model. To some extent, work engagement partially mediated their association with turnover intention, indicating a positive process that reflected the JD-R model. It may be due to the open, inclusive and respectful work environment, nurse-patient relationship, and social support that allows nurses to speak up and generate positive creativity in their work, thus increasing their engagement and promoting commitment. In addition, in a well-managed organization, receiving recognition and praise from the team would provide positive feedback to promote engagement. When nurses feel protected by the organization, they feel satisfied with their work and are less likely to leave (). The self-factor is the nurse's resilience and ability to face an adverse event that affects the individual's perception and behavior toward the event. It is worth noting that their direct effects are all greater than the indirect effects. In the current period, measures to enhance the sense of security may be more effective in reducing turnover intention. Therefore, it is recommended that an improved external environment and organizational support be considered in intervention programs to promote a sense of security and that the training of nurses is increased to improve competency. However, it is not enough to rely on hospital administrators alone; it is also necessary to improve the health care system and laws and regulations that protect the rights and interests of nurses. It is vital to increase the confidence and positive affect of nurses, which contributes to the professional identity of nurses and is very important to stabilize the nursing team and reduce nurse turnover.
We revealed the relationship between work engagement and turnover intention. Work engagement as a protective factor for turnover intention was consistent with previous studies (, ). The reason probably was that nurses with work engagement would benefit from their work. First, nurses with high work engagement are full of energy and can recover quickly, even in difficult situations (). Secondly, nurses with high work engagement would have positive emotional and cognitive states and experience pleasure and immersion at work, as well as feel pride and inspiration at work (). Work engagement as a positive resource facilitates the improvement of negative affect. Therefore, there is a suggestion that managers may facilitate nurses' work engagement and thus reduce turnover intention. In the context of the normalization of the COVID-19 epidemic, nurses were involved in the fight against the epidemic more extensively, and more nurses were involved. Providing nurses with support and rewards that match the effort promotes nurses' sense of belonging to organizations. At the same time, social media during that period also provided robust support for medical staff, contributing to increased work engagement.
The current study verified the relationship between work engagement and sense of security and turnover intention and the mediating role of work engagement in the relationship between sense of security and turnover intention. The findings of this study may have considerable clinical implications. The implications are far-reaching in the event of a significant public safety event or a major incident such as an infectious epidemic. They may threaten the sense of security of health care system professionals (). The study was designed to enhance measures of sense of security and work engagement and may decrease nurses' turnover intention. It requires health systems, hospital administrators, and society to join together to increase investment in nursing and build a network of security to promote the sustainability of the nurse workforce. In addition, our study validated and supplemented JD-R Model and COR theory (, ). This study could be precious to fill the role of work engagement between sense of security and turnover intention in the Chinese context. Sense of security and work engagement as resources, primarily work engagement as an essential bridge between job resources and turnover intention, could help reduce turnover intention. The sense of security establishes an environment of mutual trust. A good sense of security would trigger individuals' tendency to avoid resource loss and motivation to create more work resources to dedicate more energy and effort input and increase their attachment to the organization, which provides a new perspective for reducing turnover intention.
Conclusion
This study found that sense of security and work engagement were negatively associated with turnover intention. Work engagement mediated the relationship between sense of security and turnover intention. The results suggest that managers should formulate policies and strategies to ensure and improve the interests and well-being of nurses and improve the practice environment to protect the sense of security of nurses, which is helpful to increase work engagement and reduce turnover intention. In addition, formulating strategies and measures to encourage and reward nurses in the work of expression and innovation, and improve work participation, will also help reduce the intention to leave, reduce the occurrence of turnover, and maintain the stability of the nurse team.
Limitation
Firstly, this study used a convenience sampling method considered simple, applicable, and appropriate for the study purpose. However, this method has the potential to produce sampling bias. Secondly, the subjects of this study are all nurses from hospitals at all levels in various regions of guangdong province, which can only represent the level of sense of security, work engagement, and turnover intention among nurses in Guangdong Province. Guangdong Province is a relatively developed province in China, and economic development may cause differences in different regions. Third, this sample was collected from September 2020 to May 2021, which may be biased. Finally, as this study was a cross-sectional survey, it cannot explain the causal relationship between relevant factors and turnover intention.
Funding
This work was supported by the Guangdong Basic and Applied Basic Research Foundation under (Grant No. 2021A1515012187), the Guangdong Health Economics Association Key Projects under (Grant No. 2022-WJZD-01), and Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences Project under (Grant No. 7197040908).
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Statements
Data availability statement
The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.
Ethics statement
The studies involving human participants were reviewed and approved by the Ethics Committee of Guangdong Provincial People's Hospital (No. Ky2020-579-01). The patients/participants provided their written informed consent to participate in this study.
Author contributions
H-gH: conceptualization. Q-xH: methodology. YT: software, formal analysis, and original draft preparation. S-bW and LD: writing—review and editing. All authors contributed to the article and approved the submitted version.
Acknowledgments
The authors would like to express sincerely gratitude to the 29 hospitals and nurses for participating in the study.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2022.1051895/full#supplementary-material
References
1.
World Health Organization. National Health Workforce Accounts Data Portal. (2022). Available online at:https://apps.who.int/iris/bitstream/handle/10665/331673/9789240003293-eng.pdf (accessed August 1, 2022).
2.
National Health Commission of the People's Republic of China. Statistical Bulletin of China in 2021. (2022). Available online at: http://www.gov.cn/xinwen/2022-07/12/content_5700670.htm (accessed: July 19, 2022).
3.
LiangWNLiuMLiuJWangYDWuJLiuX. [The dynamic COVID-zero strategy on prevention and control of COVID-19 in China]. Zhonghua Yi Xue Za Zhi. (2022) 102:239–42. 10.3760/cma.j.cn112137-20211205-02710
4.
JacobsJLHaidarGMellorsJW. COVID-19: Challenges of viral variants. Annu Rev Med. (2022). 10.1146/annurev-med-042921-020956
5.
MengZM. Study on the mechanism of community normalized epidemic prevention and control. Northwest Population. (2021) 42:62–70. Available online at: https://oversea.cnki.net/kns/detail/detail.aspx?FileName=XBRK202102006&DbName=CJFQ2021 (accessed July 23, 2022).
6.
LiuSWangCJiangYRenHYuTCunWet al. Nurse scheduling in COVID-19-designated hospitals in China: a nationwide cross-sectional survey. J Nurs Manag. (2022). 10.1111/jonm.13832
7.
AymerichCPedruzoBPerezJLLabordaMHerreroJBlancoJet al. COVID-19 pandemic effects on health worker's mental health: systematic review and meta-analysis. Eur Psychiatry. (2022) 65:e10. 10.1192/j.eurpsy.2022.1
8.
PappaSNtellaVGiannakasTGiannakoulisVGPapoutsiEKatsaounouP. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun. (2020) 88:901–7. 10.1016/j.bbi.2020.05.026
9.
DragiotiETsartsalisDMentisMMantzoukasSGouvaM. Impact of the COVID-19 pandemic on the mental health of hospital staff: an umbrella review of 44 meta-analyses. Int J Nurs Stud. (2022) 131:104272. 10.1016/j.ijnurstu.2022.104272
10.
VargheseAGeorgeGKondaguliSVNaserAYKhakhaDCChatterjiR. Decline in the mental health of nurses across the globe during COVID-19: a systematic review and meta-analysis. J Glob Health. (2021) 11:5009. 10.7189/jogh.11.05009
11.
AlbertPR. Why is depression more prevalent in women?J Psychiatry Neurosci. (2015) 40:219–21. 10.1503/jpn.150205
12.
GallettaMPirasIFincoGMeloniFD'AlojaEContuPet al. Worries, preparedness, and perceived impact of covid-19 pandemic on nurses' mental health. Front Public Health. (2021) 9:566700. 10.3389/fpubh.2021.566700
13.
ZhengLWangXZhouCLiuQLiSSunQet al. Analysis of the infection status of healthcare workers in wuhan during the COVID-19 outbreak: a cross-sectional study. Clin Infect Dis. (2020) 71:2109–13. 10.1093/cid/ciaa588
14.
WuQLiDYanMLiY. Mental health status of medical staff in Xinjiang Province of China based on the normalisation of COVID-19 epidemic prevention and control. Int J Disaster Risk Reduct. (2022) 74:102928. 10.1016/j.ijdrr.2022.102928
15.
ZhangSXChenJAfsharJAAlvarez-RiscoADaiHLiJet al. Succumbing to the COVID-19 pandemic-healthcare workers not satisfied and intend to leave their jobs. Int J Ment Health Addict. (2022) 20:956–65. 10.1007/s11469-020-00418-6
16.
KovnerC. COVID-19 and the supply and demand for registered nurses. Int Nurs Rev. (2022) 69:118–20. 10.1111/inr.12759
17.
HayesLJO'Brien-PallasLDuffieldCShamianJBuchanJHughesFet al. Nurse turnover: a literature review–an update. Int J Nurs Stud. (2012) 49:887–905. 10.1016/j.ijnurstu.2011.10.001
18.
PriceJLMuellerCW. A causal model of turnover for nurses. Acad Manage J. (1981) 24:543–65. 10.5465/255574
19.
ElangovanARKarASteinkeC. Meaningful moves: a meaning-based view of nurses' turnover. Health Serv Manage Res. (2021) 2021:16258. 10.1177/09514848211010427
20.
RafiMAHasanMTAzadDTAlamSFPodderVHossainSet al. Willingness to work during initial lockdown due to COVID-19 pandemic: Study based on an online survey among physicians of Bangladesh. PLoS ONE. (2021) 16:e245885. 10.1371/journal.pone.0245885
21.
ChaboyerWHarbeckELeeBOGrealishL. Missed nursing care: an overview of reviews. Kaohsiung J Med Sci. (2021) 37:82–91. 10.1002/kjm2.12308
22.
NashwanAJAbujaberAAVillarRCNazareneAAl-JabryMMFradelosEC. Comparing the impact of COVID-19 on nurses' turnover intentions before and during the pandemic in qatar. J Pers Med. (2021) 11:456. 10.3390/jpm11060456
23.
RichterAVanderETDe WitteH. Job insecurity and subsequent actual turnover: rumination as a valid explanation?Front Psychol. (2020) 11:712. 10.3389/fpsyg.2020.00712
24.
JungHSJungYSYoonHH. COVID-19: The effects of job insecurity on the job engagement and turnover intent of deluxe hotel employees and the moderating role of generational characteristics. Int J Hosp Manag. (2021) 92:102703. 10.1016/j.ijhm.2020.102703
25.
ChenCCZouSSChenMH. The fear of being infected and fired: Examining the dual job stressors of hospitality employees during COVID-19. Int J Hosp Manag. (2022) 102:103131. 10.1016/j.ijhm.2021.103131
26.
AlyahyaMAElshaerIASobaihA. The impact of job insecurity and distributive injustice post COVID-19 on social loafing behavior among hotel workers: mediating role of turnover intention. Int J Environ Res Public Health. (2021) 19:411. 10.3390/ijerph19010411
27.
SaquibJTalebMAlMeimarRAlhomaidanHTAl-MohaimeedAAlMazrouAet al. Job insecurity, fear of litigation, and mental health among expatriate nurses. Arch Environ Occup Health. (2020) 75:144–51. 10.1080/19338244.2019.1592093
28.
VirtanenMNybergSTBattyGDJokelaMHeikkilaKFranssonEIet al. Perceived job insecurity as a risk factor for incident coronary heart disease: systematic review and meta-analysis. BMJ. (2013) 347:f4746. 10.1136/bmj.f4746
29.
Dall'OraCBallJReiniusMGriffithsP. Burnout in nursing: a theoretical review. Hum Resour Health. (2020) 18: 41. 10.1186/s12960-020-00469-9
30.
HeQBaZZhanQYvXLiangYHuangHet al. Qualitative study on the influencing factors of job security of medical staff. Chin Nurs Manag. (2021) 21:754–8. Available online at: https://oversea.cnki.net/kns/detail/detail.aspx?FileName=GLHL202105026&DbName=CJFQ2021 (accessed June 18, 2022).
31.
BaZHeQZhanQYvXLiWHuangH. Qualitative research 0 n sense of security at work among clinical nurses. J Nurs Sci. (2020) 35:60–3. Available online at: https://oversea.cnki.net/kns/detail/detail.aspx?FileName=HLXZ202011021&DbName=CJFQ2020 (accessed July 21, 2022).
32.
BaZHeQZhanQYvXLiWHuangH. Development, reliability, and validity testing of the sense of security scaie for medical staff. Chin Occupat Med. (2021) 48:379–85. Available online at: https://oversea.cnki.net/kns/detail/detail.aspx?FileName=XYYX202104004&DbName=DKFX2021 (accessed June 30, 2022).
33.
YangXMiaoJFanWWangLSunSLiHet al. Analysis of psychological trends and policy recommendations of medical staff in northern china in the latter stages of the COVID-19 pandemic. Front Psychol. (2021) 12:747557. 10.3389/fpsyg.2021.747557
34.
JiangZWangSShenZZhaoXWangFChenYet al. Nurses' experience of work stress related to COVID-19 regular prevention and control in China: a qualitative study. J Nurs Manag. (2022) 30:375–83. 10.1111/jonm.13528
35.
PisanuEDi BenedettoAInfurnaMRRumiatiRI. Psychological impact in healthcare workers during emergencies: the italian experience with COVID-19 first wave. Front Psychiatry. (2022) 13:818674. 10.3389/fpsyt.2022.818674
36.
YilmazYUngurenETekinOAKacmazYY. Living with infection risk and job insecurity during COVID-19: the relationship of organizational support, organizational commitment, and turnover intention. Int J Environ Res Public Health. (2022) 19:48516. 10.3390/ijerph19148516
37.
Di StefanoGVenzaGAielloD. Associations of job insecurity with perceived Work-Related symptoms, job satisfaction, and turnover intentions: the mediating role of leader-member exchange and the moderating role of organizational support. Front Psychol. (2020) 11:1329. 10.3389/fpsyg.2020.01329
38.
SchaufeliWBSalanovaM. González-romá V, Bakker AB. The measurement of engagement and burnout: a two sample confirmatory factor analytic approach. J Happiness Stud. (2002) 3:71–92. 10.1023/A:1015630930326
39.
MoloneyWBoxallPParsonsMCheungG. Factors predicting registered nurses' intentions to leave their organization and profession: a job demands-resources framework. J Adv Nurs. (2018) 74:864–75. 10.1111/jan.13497
40.
BhattiMAMatNJuhariAS. Effects of job resources factors on nurses job performance (mediating role of work engagement). Int J Health Care Qual Assur. (2018) 31:1000–13. 10.1108/IJHCQA-07-2017-0129
41.
YildizBYildizT. A systematic review and meta-analytical synthesis of the relationship between work engagement and job satisfaction in nurses. Perspect Psychiatr Care. (2022). 10.1111/ppc.13068. [Epub ahead of print].
42.
DemeroutiEBakkerABNachreinerFSchaufeliWB. The job demands-resources model of burnout. J Appl Psychol. (2001) 86:499–512. 10.1037/0021-9010.86.3.499
43.
MorianoJAMoleroFLaguíaAMikulincerMShaverPR. Security providing leadership: a job resource to prevent employees' burnout. Int J Env Res Pub He. (2021) 18:12551. 10.3390/ijerph182312551
44.
DemeroutiEMostertKBakkerAB. Burnout and work engagement: a thorough investigation of the independency of both constructs. J Occup Health Psychol. (2010) 15:209–22. 10.1037/a0019408
45.
HobfollSE. Conservation of resources. A new attempt at conceptualizing stress. Am Psychol. (1989) 44:513–24. 10.1037/0003-066X.44.3.513
46.
RenYSongHLiSXiaoF. Mediating effects of nursing organizational climate on the relationships between empathy and burnout among clinical nurses. J Adv Nurs. (2020) 76:3048–58. 10.1111/jan.14525
47.
LeeJ. Nursing home nurses' turnover intention: a systematic review. Nurs Open. (2022) 9:22–9. 10.1002/nop2.1051
48.
MaYChenFXingDMengQZhangY. Study on the associated factors of turnover intention among emergency nurses in China and the relationship between major factors. Int Emerg Nurs. (2022) 60:101106. 10.1016/j.ienj.2021.101106
49.
YangHLvJZhouXLiuHMiB. Validation of work pressure and associated factors influencing hospital nurse turnover: a cross-sectional investigation in Shaanxi Province, China. Bmc Health Serv Res. (2017) 17:112. 10.1186/s12913-017-2056-z
50.
LiJXvBChenJ. The effect of organizational factors on job engagement. Chine J Appl Psychol. (2006) 176–81. Available online at: https://oversea.cnki.net/kns/detail/detail.aspx?FileName=YXNX200602011&DbName=CJFQ2006 (accessed June 2, 2022).
51.
HayesAF. Mediation, moderation, and conditional process analysis. In: Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach.New York: Guilford Publications (2013) p. 1:20.
52.
ZhangBLvXQiaoMLiuD. The full mediating role of loneliness on the relationship between social support and depression among rural family caregivers of persons with severe mental illness. Front Public Health. (2021) 9:729147. 10.3389/fpubh.2021.729147
53.
CaoJJiaZZhuCLiZLiuHLiFet al. Nurses' turnover intention and associated factors in general hospitals in China: a cross-sectional study. J Nurs Manag. (2021) 29:1613–22. 10.1111/jonm.13295
54.
FalatahR. The impact of the coronavirus disease (COVID-19) pandemic on nurses' turnover intention: an integrative review. Nurs Rep. (2021) 11:787–810. 10.3390/nursrep11040075
55.
Gonzalez MendezMJMaLAlvaradoRRamirezJXuKXuHet al. A multi-center study on the negative psychological impact and associated factors in Chinese healthcare workers 1 year after the COVID-19 initial outbreak. Int J Public Health. (2022) 176:4979. 10.3389/ijph.2022.1604979
56.
Rosas-PaezJCasillas-EspriellaJTinajero-SanchezJCMartinez-EncisoVD. Work engagement and burnout syndrome in a secondary care level during the COVID pandemic in Mexico, 2021. Rev Med Inst Mex Seguro Soc. (2022) 60:533–9. Available online at: https://europepmc.org/article/med/36048744 (accessed May 30, 2022).
57.
Gimenez-EspertMPrado-GascoVSoto-RubioA. Psychosocial risks, work engagement, and job satisfaction of nurses during COVID-19 pandemic. Front Public Health. (2020) 8:566896. 10.3389/fpubh.2020.566896
58.
MarraDSimonsMUSchwartzESMarstonEAHoelzleJB. Burnt out: rate of burnout in neuropsychology survey respondents during the COVID-19 pandemic, brief communication. Arch Clin Neuropsychol. (2022). 10.1093/arclin/acac081. [Epub ahead of print].
59.
LiLGaoXWangYZengCHouLXiQ. Professional identity and supporting willingness of nurses during the COVID-19 epidemic in China. Jpn J Nurs Sci. (2022) 19:e12487. 10.1111/jjns.12487
60.
OrgambidezABorregoYVazquez-AguadoO. Linking self-efficacy to quality of working life: the role of work engagement. West J Nurs Res. (2020) 42:821–8. 10.1177/0193945919897637
61.
ZhouLTetgoumKAXuXQuansahPEEpalleTMAmpon-WirekoSet al. COVID-19: The effects of perceived organizational justice, job engagement, and perceived job alternatives on turnover intention among frontline nurses. Front Psychol. (2022) 13:920274. 10.3389/fpsyg.2022.920274
62.
LiuSYangXMeiQ. The effect of perceived organizational support for safety and organizational commitment on employee safety behavior: a meta-analysis. Int J Occup Saf Ergon. (2021) 27:1154–65. 10.1080/10803548.2019.1694778
63.
VolevakhaIBKolomiietsNVKukharTV. Organizational factors of psychological safety in the workplace. Wiad Lek. (2021) 74:2789–93. 10.36740/WLek202111119
64.
AyalewEWorkinehY. Job satisfaction and associated factors among nurses in Bahir Dar city administrative, North West Ethiopia, 2017. BMC Res Notes. (2019) 12:319. 10.1186/s13104-019-4363-4
65.
FalatahRAlmuqatiJAlmuqatiHAltunbaktiK. Linking nurses' job security to job satisfaction and turnover intention during reform and privatization: a cross-sectional survey. J Nurs Manag. (2021) 29:1578–86. 10.1111/jonm.13279
66.
Ofei-DodooSLongMCBretchesMKruseBJHaynesCBachmanC. Work engagement, job satisfaction, and turnover intentions among family medicine residency program managers. Int J Med Educ. (2020) 11:47–53. 10.5116/ijme.5e3e.7f16
67.
ZhangWMengHYangSLiuD. The influence of professional identity, job satisfaction, and work engagement on turnover intention among township health inspectors in China. Int J Environ Res Public Health. (2018) 15:988. 10.3390/ijerph15050988
68.
SchaufeliWBTarisTWRhenenWV. Workaholism, burnout, and work engagement: three of a kind or three different kinds of employee well-being?Appl Psychol. (2010) 57:173–203. 10.1111/j.1464-0597.2007.00285.x
69.
KubotaKShimazuAKawakamiNTakahashiMNakataASchaufeliWB. Association between workaholism and sleep problems among hospital nurses. Ind Health. (2010) 48:864–71. 10.2486/indhealth.MS1139
70.
KhudaykulovAChangjunZObrenovicBGodinicDAlsharifHJakhongirovI. The fear of COVID-19 and job insecurity impact on depression and anxiety: an empirical study in China in the COVID-19 pandemic aftermath. Curr Psychol. (2022) 9:1–14. 10.1007/s12144-022-02883-9
Summary
Keywords
COVID-19, normalization, sense of security, work engagement, turnover intention, nurse
Citation
Tang Y, Dias Martins LM, Wang S, He Q and Huang H (2022) The impact of nurses' sense of security on turnover intention during the normalization of COVID-19 epidemic: The mediating role of work engagement. Front. Public Health 10:1051895. doi: 10.3389/fpubh.2022.1051895
Received
23 September 2022
Accepted
16 November 2022
Published
01 December 2022
Volume
10 - 2022
Edited by
Evangelos C. Fradelos, University of Thessaly, Greece
Reviewed by
Juan Jesús García-Iglesias, University of Huelva, Spain; Abdulqadir J. Nashwan, Hamad Medical Corporation, Qatar
Updates
Copyright
© 2022 Tang, Dias Martins, Wang, He and Huang.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Hui-gen Huang 13822221628@163.com
This article was submitted to Occupational Health and Safety, a section of the journal Frontiers in Public Health
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.