key: cord-0695027-52htv15k
authors: Irshad, Muhammad; Khattak, Sana Aroos; Hassan, Muhammad Mubbashar; Majeed, Mehwish; Bashir, Sajid
title: How perceived threat of Covid‐19 causes turnover intention among Pakistani nurses: A moderation and mediation analysis
date: 2020-08-10
journal: Int J Ment Health Nurs
DOI: 10.1111/inm.12775
sha: 425248f4ea54f3cba1a7cfbf24d0a0ac42ceb20c
doc_id: 695027
cord_uid: 52htv15k

The research on the psychological and behavioural consequences of the perceived threat of infectious diseases is still in its early stage. The current study aims to contribute to this line of research by (a) developing and validating a scale for the perceived threat of coronavirus (COVID‐19) and (b) investigating outcomes, the underlying mechanism and boundary condition of the perceived threat of COVID‐19 through the lens of conservation of resources theory. This study proposes that the perceived threat of COVID‐19 enhances turnover intention among nurses through psychological anxiety. The study further proposes an ideological contract as a buffer reducing turnover intention among nurses as a result of psychological anxiety. The current study data were collected with online questionnaires from Pakistani nurses (N = 117) treating COVID‐19 patients. The Model 4 specification of the process macros developed by Hayes. Introduction to mediation, moderation, and conditional process analysis: A regression‐based approach. New York, NY: The Guilford Press.) was utilized to test direct and indirect effects, while the Model 1 specification was used to test the moderation hypothesis. The results showed that the perceived threat of COVID‐19 enhances psychological anxiety (β = 0.30, P < 0.001) and turnover intention among nurses (β = 0.35, P < 0.001). The mediation hypothesis was also supported, as psychological anxiety playing an underlying role in the relationship between perceived threat of COVID‐19 and turnover intention (indirect effect = 0.13, LL = 0.05, UL = 0.23). The combined effect of psychological anxiety and ideological contract on turnover intentions was negative and significant (β = −.33, P < 0.001), confirming the moderation hypothesis. These results offer important implications for nursing managers. Limitations and future research directions are also discussed.

Due to the recent coronavirus pandemic, the world is witnessing unprecedented trends affecting the lives of millions of people around the globe (World Health Organization, 2020) . The World Health Organization (2020) has declared a global health emergency worldwide due to this pandemic. While COVID-19 shut down the entire world in a matter of days, healthcare workers bravely stepped forward to combat the pandemic (Misra, 2020 ). An exponential increase in the number of COVID-19 patients has enhanced the workload of healthcare workers, who are now working around the clock (Lucchini et al., 2020) . Due to the high demand and usage of personal protective equipment worldwide, many of these healthcare workers lack proper protective equipment, making them more vulnerable to COVID-19 (Wang, Zhou, & Liu, 2020) . Consequently, a large number of nurses has lost their lives to COVID-19 due to the lack of protective equipment, while others are still fighting the battle against this deadly disease (Chirico, Nucera, & Magnavita, 2020) . As a result, nurses perceive a high threat of catching COVID-19 (Ng et al., 2020) . Nurses not only face a constant threat of contracting COVID-19, they also see patients and even fellow nurses die every day, which is itself a harrowing experience (Chirico et al., 2020; Lancet, 2020) . Nurses' perceived risk, psychological strain, and feelings of helplessness have led some to revisit their career choices (Ranney, Griffeth, & Jha, 2020) . Turnover intentions refer to employees' intention to start thinking of leaving their current place of employment and looking for a new job (Cheng, Bartram, Karimi, & Leggat, 2016) . Most nurses treating COVID-19 patients in underdeveloped countries are at high risk of catching the virus due to a lack of proper protective equipment, which is leading to an increase in their intention to quit (Menon & Padhy, 2020) .

Hence, it is proposed: 1: Perceived threat of COVID-19 is positively associated with nurses' turnover intentions Although discussions on the psychological impact of COVID-19 among the general public have taken place, research on the psychological consequences of COVID-19 among nurses is still in its beginning (Montemurro, 2020) . Nurses are often seen as heroes, as they have become frontline soldiers in the war against COVID-19; however, they have to pay a very high price . Studies have reported that the threat of COVID-19 has created a wave of fear and anxiety among nurses, and they are worried about not only their health and lives but also the lives of their loved ones (Huang, Lin, Tang, Yu, & Zhou, 2020) . The continuous threat of becoming infected increases nurses' level of anxiety . Thus, nurses are not only affected physically, but they are also affected psychologically by the perceived threat of coronavirus (Kim & Su, 2020) . These negative emotions of fear and anxiety among nurses due to COVID-19 may lead to high turnover intentions (Barnett & Grabowski, 2020; Mo et al., 2020) . Hence, it is hypothesized: 2: Psychological anxiety mediates the relationship between perceived threat of COVID-19 and nurses' turnover intentions

As COVID-19 spreads, so too are the number of research studies, but even so, less scholarly attention has been given to nurses and the challenges they face . Nurses and other healthcare workers are our best hope during this public health emergency . In this time of dire need, the world cannot afford a shortage of nursing staff (Mo et al., 2020) . Hence, it is very important to find ways to reduce nurses' turnover intentions. There is no doubt that nursing is a very noble profession, and most people join this profession with the ideology of serving humanity. Thus, nurses are seen as having an ideological contract with their employer, obliging them to serve their patients to the best of their ability (Kaur, Kaur, & Kaur, 2019) . This contract of dedication to a specific cause might also stop them from developing turnover intentions (McCabe & Sambrook, 2013) . The ideological contract is a type of psychological contract in which the employment relationship is based on a cause and ideology, which motivates employees to remain within the organization (Bal & Vink, 2011) . Thus, employees might work for the organization under the belief that the organization is providing them with a platform to contribute to a significant cause (Krause & Moore, 2017) . Kim et al. (2018) referred to such jobs as having more task significance, which enhances employee motivation. Ideological currency is prevalent among doctors and nurses because the nature of their profession goes beyond mere transactions and relations (Griep et al., 2019) . Thus, contributing to a cause of serving humanity (ideological contract) might serve as nurses' actual motivation for sticking with the job, as it is suggested that psychological contract fulfilment lowers turnover intentions (Collins, 2010) . Hence, it is hypothesized: 3: Ideological contract moderates the relationship between psychological anxiety and nurses' turnover intentions such that the relationship between psychological anxiety and turnover intentions will be weaker among nurses with a high level of ideological contract than with a lower level of ideological contract.

To summarize, the current study aims to test the impact of perceived threat of COVID-19 on nurses' turnover intentions through the underlying mechanism of psychological anxiety. The study further aims to investigate the moderating role of an ideological contract on the relationship between psychological anxiety and turnover intention. The current study is rooted in the conservation of resources theory (Hobfoll, 1989; Hobfoll, Halbesleben, Neveu, & Westman, 2018) . This theory states that continuous exposure to stressors results in threat and actual loss of physical, psychological, and emotional resources; thus, people seek out different coping strategies to avoid the threat and actual loss of valuable resources (Hobfoll, 1989; Hobfoll et al., 2018) . Here, the threat of COVID-19 is a stressor that continuously depletes employees' valuable resources, and this loss of resources causes stress and anxiety among nurses. As a result, they should be more likely to think about quitting their job to avoid exposure to COVID-19, the stressor causing resource loss. Conservation of resources theory also states that people's existing resources not only help them offset the loss of resources due to stressors but also help them gain more resources (Hobfoll, 1989; Hobfoll et al., 2018) . In the case of the present study, nurses are exposed to a stressor in the form of threat of COVID-19, and their ideological contracts resulting from the nature of their noble profession help in offsetting this resource loss due to the perceived threat of COVID-19. Figure 1 shows the proposed model.

The current study is quantitative. Data for this causal study were collected through an online survey questionnaire among nursing staff treating COVID-19 patients in hospitals in Rawalpindi, Lahore, and Multan. This study is cross-sectional as data for all variables were collected at one point in time. The unit of analysis was individuals, as data for all variables were collected from a single source, that is, nurses. As the total population of nurses working in Pakistan is unavailable, we used a non-probability sampling technique. The snowball non-probability sampling technique was used for sample selection mainly because it was difficult to directly contact nurses treating COVID-19 patients. We followed Pernrod et al. 's (2003) recommendation to make sure that the final sample is diverse, as the effectiveness of the snowball sampling technique highly depends on the seed diversity. Kirchherr and Charles (2018) argue that the snowball sampling technique works best when seed diversity is ensured, and one way of doing so is to collect data among respondents from diverse backgrounds. To ensure seed diversity, all the authors separately chose nurses from their contact list and asked them to refer them to other nurses. At the end of each survey, the respondents were requested to provide the email address or mobile phone number of at least one and at most three other nurses who are treating patients affected with COVID-19. The authors then contacted the respondents through the provided email addresses.

Approval was obtained from the ethics committee of the author's university before starting the data collection process. A cover letter was attached to the survey in which the purpose of the study was explained, and the nurses were ensured that their confidentially would be maintained. The inclusion criterion for nurses was a minimum of six months of work experience and a nursing diploma. 62.4% of the total respondents were female, whereas the remaining 37.6% were male. 52.1% of the nurses were between 21 and 30 years of age, 34.2% were between 31 and 40 years of age, 10.3% were between 41 and 50 years of age, and the remaining 3.4% were above 50 years of age. 67% had a two-year nursing diploma, and 36% had a bachelor's degree in nursing (4-year programme).

To confirm the sample size's adequacy for the regression analysis, G*Power (version 3.1.9.4) designed by Faul, Erdfelder, Buchner, and Lang (2009) was employed. The number of predictors was set to two, and the other statistical parameters were set to their defaults (i.e. the medium effect size of 0.15, a level of 0.05, and high power of 0.95). The a priori sample size was computed to be 107, less than the actual sample size of 117. The post hoc power analysis value of 0.98 also lies above the recommended value of 0.80 (Cohen, 2013) .

So far, there is no measurement scale available to measure the threat of COVID-19. For the current study, items from the Perceived Threat of Terrorism Scale by Sinclair and LoCicero (2007) were modified to measure the perceived threat of COVID-19. Nurses were asked to report their perceived threat of COVID-19 with 13 items on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). All necessary tests were performed to assess items' interrelatedness through the corrected item-total correlation, dimensionality through exploratory factor analysis, reliability through Cronbach's alpha, and validity of the one-factor scale through confirmatory factor analysis. The corrected item-total correlations for all 13 items were within the acceptable range of 0.56 to 0.71 (see Table 1 ). Cronbach's alpha had a high value of 0.91 (see Table 2 ). Furthermore, the 13 items' loading onto one factor in the exploratory factor analysis proved the unidimensionality of the scale. Subsequently, confirmatory factor analysis was performed to confirm the loadings, which were found to be in the acceptable range (0.59 to 0.75). The model fit results for the one-factor model were satisfactory (v 2 = 87.09, df = 65, v 2 / df = 1.34, GFI = 0.90, CFI = 0.96, TLI = 0.96, RMR =0.06, RMSEA = 0.05) based on the recommended threshold values by Hair, Black, Babin, and Anderson (2014) . Thus, the perceived threat of COVID-19 can be appropriately measured through a 13-item scale (refer to Table 1), which yielded a good corrected item-total correlation, high reliability score, unidimensional factor loading, and good model fit results (see ,  Table 1 ). Wong, Gao, and Tam's (2007) 20-item scale to measure anxiety was used to measure nurses' anxiety during the current COVID-19 pandemic. A five-point Likert scale ranging from strongly disagree to strongly agree was employed to rate the responses. An example item is 'During COVID-19, I feel more nervous and anxious than usual'. Cronbach's alpha value was 0.89 for the current study. The scale for psychological anxiety is given in Appendix A.

Nurses' turnover intention due to COVID-19 was measured with a three-item scale by Vigoda (2000) . A fivepoint Likert scale ranging from 1 = strongly disagree to 5 = strongly agree was employed to rate the responses. Example items include (i) 'Due to the current situation, I often think about quitting'. (ii) 'Lately, I have taken an interest in job offers in the newspaper due to COVID-19'. (iii) 'Due to COVID-19, next year I will probably look for a new job outside this organization', Cronbach's alpha value was 0.77.

To measure nurses' ideological contract, a 9-item scale developed by Bingham (2006) was adopted. Responses were recorded on a five-point Likert scale ranging from 1 = not at all and 5 = to a great extent. An example item is 'During COVID-19, I feel I am obligated to contribute to the stated cause'. Cronbach's alpha value was 0.90. The scale for ideological contract is given in Appendix A.

Due to health emergencies in hospitals, it was not possible to collect multi-source and time-lagged data from nurses. Cross-sectional and single-source data have a common method bias problem. Confirmatory factor (Hair, Black, Babin, & Anderson, 2014) . The loadings of all items were well above .4, which is the acceptance criterion. Perceived threat of COVID-19 was positively related to psychological anxiety (r = 0.46, P < 0.001) and nurses' turnover intention (r = 0.47, P < 0.001). Psychological anxiety was also positively related to nurses' turnover intentions (r = 0.43, P < 0.001). Ideological contract was significantly negatively correlated with perceived threat of COVID-19 (r = À0.18, P < 0.05), psychological anxiety (r = À0.24, P < 0.01), and nurses' turnover intentions (r = À0.47, P < 0.001). The reliability of the variables was checked through Cronbach's alpha. All variables met the minimum cut-off criterion for reliability, with Cronbach's alpha exceeding 0.7. Table 3 reports the results for the direct effect of perceived threat of COVID-19 on nurses' turnover intentions and the indirect effect via psychological anxiety. Hayes' process macro for SPSS Model 4 was employed to test the direct and indirect hypothesized relationships (Hayes, 2013) . In line with H1, there was a significant positive direct effect of perceived threat of COVID-19 on nurses' turnover intentions (b = 0.35, P < 0.001). In the mediation analysis, path 'a' of perceived threat of COVID-19 on psychological anxiety (b = 0.30, P < 0.001) and path 'b' of psychological anxiety on nurses' turnover intentions (b = 0.44, P < 0.001) were both found significant. In line with Hypothesis 2, the indirect effect of the perceived threat of COVID-19 on nurses' turnover intentions via psychological anxiety was also found significant in 5000 bootstrapped samples (indirect © 2020 Australian College of Mental Health Nurses Inc.

effect = 0.13, LL = 0.05, UL = 0.23). Thus, Hypotheses 1 and 2 were confirmed. Table 4 represents results for the moderation analysis. Model 1 of Hayes' process macros was employed to test the moderating effect of ideological contract on the relationship between psychological anxiety and nurses' turnover intention. The combined effect of psychological anxiety and ideological contract on turnover intentions was found to be negative and significant (b = À0.33, P < 0.001). The slope test results indicated that the impact of psychological anxiety on nurses' turnover intention gets weaker as the value of the ideological contract rises. Furthermore, the moderation graph demonstrates that the relationship between psychological anxiety and nurses' turnover intention is steeper at low levels of ideological contract than at high levels. (see Fig. 2 ).

As per the World Health Organization (2020), the perceived threat of COVID-19 continues to affect the psychological health of people in general and of frontline workers in particular. This study contributes to the existing literature by taking into account the psychological and behavioural outcomes of the perceived threat of COVID-19. Nurses are giving of their sweat and blood to treat infected patients, cognizant of the professional risk involved. In doing so, they are pushing themselves beyond their limits, resulting in strain and anxiety. Anxiety has been observed as a progressive psychological response to stressors and is associated with both attitudinal and behavioural outcomes among healthcare workers, and predominantly nurses, who constitute around 60% of frontline workers (Wang, Zhou & Liu, 2020) . However, limited research has been conducted on this issue. It is important to understand the COVID-19 situation from the perspective of nurses, as only then can hospitals retain nurses during the pandemic.

This study proposed perceived threat of COVID-19 as an important predictor of turnover intentions among nurses. The results supported this relationship. This indicates that it is crucial to decrease perceived threat of infection among nurses to ensure their retention. Previous studies have also shown that fear and risk of catching the virus promote intention to quit among nurses (Ranney, Griffeth, & Jha, 2020) . Nurses' jobs require them to interact with patients, which makes them more prone to catching the infection. The feeling that they might also contract this deadly virus that does not yet have a proper treatment causes nurses to think about quitting, as staying in their job goes along with a higher risk and threat of COVID-19.

This study also proposed that perceived threat of COVID-19 leads to psychological anxiety among nurses, which leaves them with no other option than to consider quitting. We found support for anxiety as an underlying mechanism explaining how perceived threat of COVID-19 is cognitively absorbed by nurses and causes them to revisit their career choices (Menon & Padhy, 2020; Ranney et al., 2020) . These results show that perceived threat of COVID-19 causes negative psychological and behavioural outcomes for nurses in the form of anxiety and turnover intention. The results of the present study concur with other studies (Lin, Jiang, & Lam, 2013) , which see anxiety as the first stage of 'psychological withdrawal', which eventually results in turnover. Treating infectious diseases such as COVID-19 is always a stressful task for healthcare workers, as they are aware that they might also contract the infection. This is itself a frustrating experience that can lead nurses to switch jobs, as quitting seems to be the only option to prevent them from exposure to COVID-19 daily. Furthermore, this study proposed the ideological contract as an important factor that can minimize nurses' turnover intentions as a result of psychological anxiety. The psychological contract (Sheehan, Tham, Holland & Cooper, 2019 ) is a useful lens to study nurses' intention to stay or quit. Nurses are more likely to have an ideological contract, as most nurses join this profession to serve humanity, and this stops them from thinking about quitting despite facing anxiety and the threat of COVID-19 (Griep et al., 2019; Kim et al., 2018) . Consistent with this logic, the ideological contract was demonstrated to moderate the relationship between anxiety and turnover intentions, which suggest that fulfilment of the ideological contract, can lower turnover intentions among healthcare workers. These results show that what keeps nurses from thinking about changing jobs despite facing psychological anxiety is their ideological contract with their profession. When nurses are linked to the organization through a psychological contract, they push out psychological anxiety and keep doing their job despite the threat of contracting the infection.

This study only investigated the threat of COVID-19 as a predictor of turnover intention, when there might be several other factors as well. Future studies might investigate other factors, such as measures taken by hospitals against COVID-19, workload, stigma, and prejudice faced by nurses who treat patients suffering from infectious diseases. The current study only investigated the psychological and behavioural outcomes of perceived threat of COVID-19. However, performance-related outcomes are also crucial to study. Future studies may test the impact of perceived threat of COVID-19 on employee job performance and organizational productivity. Another limitation of this study is that it solely examined anxiety as a mental health outcome of the threat of COVID-19. Future studies might also investigate other mental health outcomes of perceived threat of infection, such as depression. The current study proposed a situational factor as a boundary condition. Future studies might also test the moderating role of personality dispositions, such as psychological capital. The current study used cross-sectional data, which is a further limitation. Future studies might wish to use a time-lagged or longitudinal research design. Another limitation of the current study is that it collected data from nurses only. Future researchers may wish to replicate this study with data from doctors or paramedics. It might also be fruitful to conduct similar studies in the banking and transport sectors, as employees of both of these sectors have continued to provide services despite the threat of contracting the infection. The current study did not test the antecedents of perceived threat of COVID-19. Future studies might also investigate factors that cause an increase in perceived threat of infection. One of these factors can be poor measures against the infection taken by organizations. Research on infection and its psychological as well as behavioural outcomes is scarce. This is one of the limited studies to investigate the causes of mental health issues and turnover intention among nurses in the context of infectious diseases. Thus, this study adds to the limited literature on infections and their psychological as well as behavioural outcomes for employees. Another theoretical contribution of this study is its investigation of the ideological contract as an important factor that can reduce turnover intention caused by anxiety among nurses.

Hospital management should arrange safety kits and protective equipment for all nurses who are treating COVID-19 patients so that they feel safe from the disease. The mental health of workers should be monitored both during and post-pandemic, and psychological interventions should be offered when the crisis subsides. This study's findings may help to inform preventative measures to retain nurses' mental health. Psychiatric and psychological counsellors should be deployed to help nurses. Crisis support systems such as peer support programmes should be established in which senior nursing staff are encouraged to provide support and guidance to young nurses regarding preventive measures against COVID-19. Various programmes aiming to reduce work-related stress among healthcare workers, such as Resilient in Stressful EVENTS (RISE) and Second Victim Experience and Support Tool (SVEST), are already in place (Burlison, Scott, Brown, Thompson, & Hoffman, 2017) . Hospital managers may use these programmes to reduce the perceived threat of COVID-19 among their staff. Nurses should also engage in self-care. It is never too late to seek social support from friends and family by talking out the struggles one is facing, particularly for nurses who have been serving in the COVID-19 pandemic. Hospital management should also employ interventions to develop an ideological contract with nurses to increase their devotion to serving humanity.

COVID-19 has potentially threatened humanity's survival. Nurses and other healthcare workers are our only hope in this difficult time, as they are risking their lives to save humanity. No country in the world can afford to lose nurses in this critical time. Hence, it is very important to ensure the safety and mental health of nurses so that they can continue saving people's lives without undue worry about their own.

Adapted Scale for Psychological Anxiety and Ideological Contract Psychological Anxiety Scale 1

During COVID-19, I feel more nervous and anxious than usual 2

During COVID-19, I feel afraid for no reason at all 3

During COVID-19, I get upset easily or feel panicky 4

During COVID-19, I feel like I'm falling apart and going to pieces 5

During COVID-19, I feel that everything is all right and nothing bad will happen 6

During COVID-19, My arms and legs shake and tremble 7

During COVID-19, I am bothered by headaches, neck and back pain 8

During COVID-19, I feel weak and get tired easily 9

During COVID-19, I feel calm and can sit still easily 10 During COVID-19, I can feel my heart beating fast 11 During COVID-19, I am bothered by dizzy spells During COVID-19, I contribute to the stated cause 2

During COVID-19, I commit resources toward advancing the stated cause 3

During COVID-19, I stand behind our corporate ideology, even if it requires a personal sacrifice 4

During COVID-19, I support opportunities for involvement in our cause 5

During COVID-19, I encourage employee involvement in the cause 6

During COVID-19, I act as a public advocate of the espoused cause 7

During COVID-19, I am dedicated to the organization's mission 8

During COVID-19, I help maintain company culture that promotes our corporate principles 9

During COVID-19, I help facilitate internal practices and policies that advance the organization's ideals

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The Bahria University Islamabad Pakistan has an Ethics Approval Committee. The Research Ethics Board at Faculty of Management Sciences Bahria University reviewed 'The Psychological Anxiety and Turnover Intention Among Nurses during COVID-19: Moderating Role of Ideological Contract' research proposal and considers the procedures, as described by the applicant, to conform to the University's ethical standards and guidelines. Clearance granted on 06/04/ 2020. Moreover, the participation in the survey was voluntary and study participants were first explained about the details of the project and it was assured to them that their responses will be kept in strict anonymity and will be reported as aggregate results.

Current research did not include formal financial funding and/or support. The author(s) declare that preparation of this manuscript was not supported by any external funding and is mere effort of the authors included.