Does work stress & workplace incivility influence Employee Turnover Intentions? Mediating Role of Work-family Conflict


One of the largest industries in the world, contributing to the medical needs of billions of people (Arevalo, 2020). The demand for global healthcare services is tremendous. In 2018, the global healthcare sector was valued at $8.45 trillion. Globally spending on healthcare could exceed $10 trillion by 2022 (Allen, 2019). The global healthcare market industry is growing faster than GDP in most countries, according to the World Health Organisation (WHO, 2017). According to Arevalo (2020), the global healthcare industry generated $1.853 trillion in sales in 2018, an increase of 4.5% from the previous year. Manufacturing and provision of services and products related to health, opportunities for stable economic growth, and employment in economies around the world are affected by the employment of health workers, emerging technology, and capital invested in hospitals, clinics, and other healthcare infrastructure. In fact, these effects lead to improvement of population health (Mohammad & Wang, 2019). Current associations around the world need a workforce that focuses on the stable development and improvement of employers, staff members, and networks over the long way. General well-being is related to the healthcare industry (Ginter, Swayne, & Duncan, 2018). The healthcare sector serves the basic needs of the country and provides economic expansion potential (Mahmud & Parkhurst, 2007). Therefore, healthcare has drawn more attention worldwide and includes departments and properties such as financial, human resources, and physical organisations to provide health services to meet people's needs (Summer & Hoadley, 2014).

In the healthcare industry, nurses are the backbone of delivery services (Vahey, Alken, Sloane, Clarke, & Vargas, 2004). According to Qureshi et al. (2018), nurses have a primary job after doctors provide excellent medical care services. And benefits, especially when it comes to the treatment of patients for good quality patient consideration and the human services framework. In a similar manner, the turnover intention is essential in holding and pulling in qualified staff in healthcare with the goal that they can serve human services in their most ideal (Rad & Yarmohammadian, 2006).

In the Pakistani healthcare sector, almost two-thirds of 64% of nursing workers were unhappy with their prospects for development, low resources, and schedule of work. Most nurses showed an intention to change jobs due to a lack of adequate supervision (Malik & Sattar, 2019). Most of this increased turnover intention among nurses in the Pakistan healthcare sector (Nazir, Ahmed, Nawab, & Shah, 2016).

In developing economies such as Pakistan, due to the tremendous importance of retaining employees to reduce the turnover rate in the healthcare industry among nurses, it grew enormously. Addressing this issue (turnover intention) is essential and urgent since only a satisfied workforce would strive to remain part of the organization for a longer period, further leading to satisfying patients, and clients, contributing as the backbone in developing the financial system.

The issue of turnover intention In Ittefaq Hospital Lahore, Pakistan, the nurses’ turnover rate remains high, as reported by Naseer, Parveen, Afzal, Waqas, and Gillani (2017). Besides, this issue of turnover intention has been witnessed globally (Pang, Dan, Jung, Bae, & Kim, 2020). Along with this, Shin et al. (2020) reported turnover intention among nurses in Korean hospitals Higher nurse-to-patient ratios are the result, which has unfavourable effects.

Similarly, Pakistan is also experiencing a similar problem, as reported by Naseer et al. (2017), reported an issue of high turnover among nurses in Pakistan hospitals due to the high workload and shortage of nurses. In Pakistan, factors behind the high turnover intention of the public health sectors were also linked to a decrease in work productivity, inadequate working conditions, high absenteeism and low staff morale (Naveed, Tharani, & Alwani, 2010); along with this, inadequate resources, high workload, limited quality care (Ebrahimi, Hassankhani, Negarandeh, Jeffrey, & Azizi, 2017), work responsibility, shortage of professional and occupational nurses lack work, planning, and occupational stress (Naseer et al., 2017). However, these factors were found with high turnover intentions.

The healthcare sector of Pakistan, mainly Punjab, faces high turnover intention issues due to many reasons, such as Tasneem, Cagatan, Avci, and Basustaoglu (2018) suggested that increasing work stress among nurses at hospitals in Pakistan, uncivil behaviour (Laeeque et al. 2018). Furthermore, a high turnover intention was also observed among nurses in Punjab, Pakistan, due to WPI faced during work hours. Patients, physicians and patient attendants were reported to have been victims of harassment and incivility from nurses. Ineffective work performance, WFC, and depression were also documented. as reasons for increased turnover intention (Abrar, Bashir, Nureen, & Shahzadi, 2019).


Theoretical Perspective

Designed by Hobfoll, (1988), one of the stress models is the COR (conservation of resources) model. Psychological stress arises due to loss of actual resources, lack of gains in resources, investment in resources, and risk of loss of resources. The conservation of resources theory was designed to describe the core stress and coping process mechanisms (Hobfoll, 1989). COR theory states that loss of resources is the primary mechanism that creates stress reactions (Hobfoll, 1989).

Various studies used COR theory to test the relationship; current studies linked COR theory to work-family conflict and work stress. Lazarus and Folkman (1984) proposed transactional stress theory that defines stress as the difference between demands and resources and illuminates the procedure of stress assessment. The objective for selecting COR theory instead of other theories as a supporting framework is that the current study model talks about work stress and the conflict between family and work. WFC indicates a loss of resources because workers are unable to perform their jobs better. In line with these resource losses, it is expected that the current study model is justified by COR theory in a better way in comparison to other theories.

Based on COR theory, nurses are more involved in coping with challenges when they are feeling stressed at work and receiving more support from their workplace and will try to remain part of the organisation. On the contrary, more stress at work increases the intention to leave (turnover intention). In line with this idea, the present study shows that work stress can cause nursing staff to deplete their emotional and psychological reserves, resulting in occupational stress (work stress), which in turn leads to an intention to leave (turnover intention) the hospital.

Turnover Intention

Employee turnover, according to Basel and Fayza (2015), is a measure of the number of workers who quit and get replaced during a given time frame, such as a year. A percentage of the total workforce is expressed at the beginning of the period.

Work Stress and Turnover Intention

Since many years of empirical research on the relationship between WS (work stress) and turnover intention investigated, much of such literature evidence supported the idea of a positive association between the connection of WS with staff TI (Zunaidah, Nengyanti, & Hadjri 2019). Besides this influencing individual turnover intention, there are many different factors that affect TI. Similarly, work stress is an important factor that influences TI with a positive correlation (Lu Y et al., 2017).

The previous research in question was performed by Azlina and Mustapha (2012), who examined the connection between TI and WS of accounting staff. Job stress has a favourable relationship with the intention to leave a job. According to Haq (2014), an employee who is under much stress at work may want to leave. Shukla and Sinha (2017) also consider the psychological effects of demanding work environments. Workers who experience job-related stress, commonly known as stress at work, are forced to quit their current job. Individuals become exhausted when they experience stress from their jobs' diverse situations and are unable to manage them. In Guangdong Province, China, occupational stress is a factor that influences physicians' intentions to leave their profession. Reduced working hours, increased opportunities for career development and training, and encouragement and support for seniors and the administration can all help to reduce the likelihood of turnover (Lu Y et al., 2017). On the contrary, some studies have shown that WS has a favourable influence on TI (Kim & Kao, 2014; Ahmad et al., 2023).

This can be elaborated as work stress increases, it will increase the employee turnover intention; in another way, lowering the work stress, will be lower the employee turnover intention. According to Zunaidah, Nengyanti, and Hadjri (2019), work stress easily leads to frustrating workers’ turnover intention. In addition to this, Mahfooz, Arshad, Nisar, Ikram, & Azeem (2017) conducted a study in the healthcare sector that exposed that WS was positively related to TI. Based on the evidence from the literature cited above, the higher the work pressure, the higher the TI of the staff. Therefore, the current study has hypothesised that.

H1: Work stress has a positive effect on Turnover intention

Workplace Incivility and Turnover Intention

Since incivility is the sense of disrespect and uncivil behaviour expressed by spoken words, gestures, or actions, rude or uncivil acts, without regard to others, it is an indicator of disrespect and uncivil behaviour (Andersson & Pearson, 1999). Although Mobley et al. (1978) referred to TI as the intention of organisational members to quit their current work and seek other jobs due to job dissatisfaction, WPI can lead staff to leave as it is an important source of stress for individuals (Podsakoff, LePine & LePine, 2007) so it is assumed that incivility experienced leads employees to develop TI (Wilson & Holmvall, 2013) According to Lim and Teo (2009), they voiced concerns about rudeness at work and looked at how it influences workers' inclinations to leave their jobs. Additionally, Cortina et al. (2013) connected workplace misconduct to employees' desire to leave their jobs.

WPI potentially affects employees’ physical and psychological health (Heaphy & Dutton, 2008) Employee TI is the last step on which employees leave work. It starts with uncivil behaviour and ends with TI (Carpenter &Berry, 2015). According to various research, incivility at work due to employees' views and behaviours could lead to job replacement or job searching. For example, Mahfooz et al. (2017) revealed that due to WPI, employees often have less desire to keep their employment, and the research of colleagues and Lim, Cortina, and Magley (2008) additionally found that TI leads to victims of incivility. Consequently, if someone experiences incivility at work, there is a chance that he will become uninterested in it and eventually leave with the intention of changing his position (Riasat & Nisar, 2016).

Researchers have found that WPI is negatively related to productivity and job satisfaction and positively associated with nonattendance, desire, and tardiness to leave (Rahim and Cosby, 2016; Lim, Cortina, & Magley, 2008). Several studies provide important notes on the effects of WPI on TI (Sharma & Singh, 2016). Employees often put in less effort, work a shorter period, and do worse on the job because they have experienced being treated as a victim of WPI (Rahim & Cosby, 2016). That is, the greater the worker's perception of incivility in their workplace, the intention to leave or find new work is higher. So, based on the above-mentioned research, the hypothesis is developed as follows.

H2: Workplace Incivility has a positive effect on Turnover intention.

Work Stress and Work-family Conflict

Consequently, Byron (2005) highlighted that FWC and WFC are key facets of work stress perception. Due to the improvement in education in women, the number of employees in dual-income families is increasing. Therefore, it is mandatory to consider the dual roles of WF that generate stress in people (Armstrong, Atkin-Plunk, & Wells 2015). Additionally, Boyar, Maertz, Pearson, and Keough (2003) stated that when there is high employee demand at work, it increases work pressure, due to which employees become unable to play good family member roles. Based on cited literature review, the current study hypothesised the following relationship. Based on the evidence, the current study hypothesises.

H3: Work stress has a positive effect on work-family conflict.

Relationship of Workplace Incivility with Work-Family Conflict

According to Greenhaus and Beutell (1985), the degree to which employees' capacity to meet the family-to-work conflict is impacted by work-to-family conflict is known as the "work-to-family conflict." As mentioned earlier, WPI may reduce employee resources such as time, energy, and personal resources. When employees experience a reduction in these resources, their ability to fulfil family duties can be reduced. Specifically, Demsky, Fritz, Hammer, and Black (2018) stated that WPI goals are likely to require additional time and cognitive resources to understand their experiences even after their shift, given the ambiguous character of workplace incivility. As a result, they are less able to handle the requirements of their families, as they have limited time and cognitive resources. Additionally, targets of WPI are more possibly thinking about experiences related to working even after the actions (Demsky, Fritz, Hammer, & Black 2018; Ahmad, 2021). Employees will be less engaged in activities to gain resources, such as recovery activities. If they remain away from work, their resources can be reduced, making them less proficient in coping with family demands. Furthermore, people who face workplace incivility also experience negative emotions before quitting their job due to decreased resources, and such harmful effects can increase their time after work without appropriate resource regaining (Tremmel & Sonnentag 2018).

In the end, the conservation of resources (COR) theory of Hobfoll (1989) recommends that a shortage of resources can result in a protective attempt to safeguard the available remaining resources. Thus, when one experiences a loss of resources because of experiencing WPI, they try to save remaining resources by decreasing the investment of resources in the family domain, which creates WFC. Aligned with support to this case, Lim and Lee (2011) resulted in their study that WPI from supervisors positively predicted WFC, while rudeness from subordinates and co-workers did not, while Ferguson (2012) stated that workfellow vulgarity positively associated with WFC.

Lim and Lee (2011) found insignificant results of coworker rudeness and subordinate impoliteness towards WFC as their target audiences were from Singapore, and it is treated as a society of high-power distance (Avolio, Zhu, Koh, & Bhatia, 2004). The huge power gap between employee and supervisor creates workplace incivility from the supervisor more noticeable, which can also affect their nonwork domain; contrarily, incivility from subordinates and coworkers may not be assessed as harmful as compared to incivility from the supervisor, and it may not affect their behaviour and feelings outside of work.

Evidence shows that work-family conflict and different types of misbehaving are positively related. A study by Demsky, Ellis, and Fritz (2014) found that workplace violence was positively associated with WFC. Similarly, Carlson, Ferguson, Hunter, and Whitten (2012) have found that insulting supervision has a positive relationship with the WFC. Workplace incivility is a mixture of hostile and interpersonal actions that are antisocial, that is, full of shocking practices which can change the self-respect of victims and leave them exhausted physically and emotionally, due to which they become incapable of performing their responsibilities domestically (LaVan & Martin, 2008)

The emotion-centred model of the occupational stress method by Spector and Goh (2001) is also helpful in understanding the effects of WPI on WFC. According to Spector and Goh (2001), bullying and physical assault show strong negative emotions in victims. Psychological and physical problems are produced due to such negative emotions (Gallo & Matthews, 2003) and many long-lasting viruses (Begley, 1994), due to which victims do not fulfil family and work roles. Collectively, employees may have less or no resources to fulfil their work-family roles at a higher level of work behaviour. These individuals experience high levels of WFC as a result.

Contrarily, the low-power gap in Western culture, while studying both supervisor and coworker incivility, both have similar effects on employees such that influence from coworker incivility may also extend to the nonwork domain as supervisor discourtesy does (Ferguson, 2012; Ayenagbo, 2022). Although external vulgarity has not been be investigated in previous research work as a predictor of WFC, earlier literature showed that outsider mistreatment at work, such as daily mistreatment on a daily basis, also positively predicted WFC (Chi, Yang, & Lin, 2018).

Based on theoretical and empirical evidence, we assume that WPI from coworkers, outsiders, and supervisors can drain the resources of employees who expect WFC. In addition, the same patterns can be observed within individuals. Employees face more WPI, and their resources are depleted more compared to normal conditions; thus, employees face more WFC. Therefore, the relationship between workplace incivilities to work-family conflict has been hypothesised as follows:

H4: Workplace incivility has a positive effect on work-family conflict.

The Effect of Work-Family Conflict on Turnover Intention

TI is a dependent variable of work-family conflict; TI is defined as a regular change of workers in the employment market among organisations, careers, as well as between the terms of being employed full-time and being jobless (Kazi & Zedah, 2011). The literature shows that those individuals who assert work-family conflict usually leave their jobs. Different research work such as Asghar, Gull, Bashir, and Akbar (2018). Indicate a positive relationship between WFC and turnover intention. Based on Kahn's study, cited by Greenhaus and Beutell (1985), WFC occurs where the burden comes from work to family, which is opposed in a few terms, based on involvement in a work role (family) in such participation in family role (work) is made more complex. According to Isenhour et al. (2012), WFC arises when certain roles demand in one's life, namely the demand in family and work.

According to Netemeyer, Boles, and McMurrian (1996), WFC denotes work-related results, such as the intention of turnover and organisational loyalty. In addition to this, accounting professionals were found to increase the number of job cuts among employees, especially when different work activities conflict with family issues. Although some evidence from the literature, such as Armstrong, Atkin-Plunk, and Wells (2015), does not find such results. Kusumanegara (2018) has investigated the influence of WFC on TI with WS as an intervening variable. Basically, WS as an intervening variable is expected to bridge the effect of WFC on TI, which may affect TI positively.

Turnover intentions are most frequently discussed by scholars. Islam, Ahmad, Ahmed, and Ahmer (2019) showed some of the earlier research on the relationship between work-family conflict and turnover intention and found that work-family conflict substantially affects the working family. After this, Aboobaker and Edward (2020) also found an association between work-family conflict and turnover intention. Various empirical works, such as Harun, Mahmood, and Som (2020) and Chen, Brown, Bowers, and Chang (2015), have also reported positive relationships with TI in the WFC. Contrary to this, there is no link between WFC and TI, and WFC did not influence the intention of turnover (Han Han & Choi, 2015).

In addition, a study by Agustini, Queck and Specht (2008) additionally shows that there is no influence of WFC on intended turnover. 529 workers from the public accounting company in Jakarta and Bandung participated in this study. Because the respondents in this study are senior employees, there is very little chance that WFC will have an impact on their TI at their current employer. Furthermore, According to Yildiz, Yildiz, and Arda (2021), meta-analyses of the relationship between WFC and TI resulted in a reliable positive relationship between all forms of WFC and TI. For individuals facing conflict in their work role, their turnover intention tends to increase. However, there are still questions about why the scarce research on WFC is still affecting TI. Henceforth, following the empirical evidence cited earlier, the current study has been proposed as

H5: Work-family conflict is positively related to turnover intention.

Work-Family Conflict as a Mediator

Consequently, Du Prel and Peter (2014) studied the mediating effect of WFC in the association between WS and miserable signs. According to Blomme, Rheede and Tromp (2010), WFC was used in the study as a mediator between workplace flexibility and TI of staff working in the hospitality industry.

In the past, scholars have associated WFC as a mediating variable with the intention of turnover. Such as (Chen, Brown, Bowers, & Chang, 2015) found a mediating effect of WFC with TI 976 managers showed WFC has a significant negative impact on job satisfaction (Namayandeh, Juhari, & Yaacob, 2011) Similarly, they found a significant mediating role of workload and WFC, WFC mediated the effects of work stress on workplace behaviour (Ahmed & Omar, 2013). Based on the proof of the mediation of WFC, the current study has proposed mediating role of WFC in the relationship between workplace incivility and work stress with TI.

H6: Work-family conflict significantly mediates the relationship between work stress and turnover intention.

H7: Work-family conflict significantly mediates the relationship between workplace incivility and Turnover intention.

Figure 1.Research Framework


Sample Technique and Data Collection

The audience selected for this study was registered nurses working in the public health care sector in the Punjab province. In Punjab's public hospitals, there are a total of 64,848 registered nurses (Rafique & Nazir, 2018). Contact with the managing superintendent (MS) was officially made for the distribution of questionnaires. Being a self-administered approach, the district hospital participants were provided with reasonable time to complete and return the questionnaires. All the questionnaires have been pre-numbered serially to track the sent questionnaires.

The assessment of the measurement model (outer model) is the first step in PLS-SEM analysis. In model evaluation, the measurement model was undertaken to ensure the model's validity and reliability in line with the arguments of Salkind (2012), who gave the rule of thumb for outer loading. According to their rule of thumb, outer loading should be 0.5 and above. For the average variance extracted, it should be above 0.5. Based upon the following argument, all the items in outer loading which are below 0.5 should be deleted one by one with the lowest value, this technique is also validated by (Hair et al., 2016) because it improves the quality of data. The Likert scale was invented by Salkind (2012), who described this technique as measuring behaviour and attitudes. It has been widely used and validated in research studies in various fields of social sciences as the use of a rating scale lets the researcher evaluate the standard deviation and mean on variables and the mid-point of the scale (Sekeran & Bougie, 2016). In line with the original authors of workplace incivility, work-family conflict, work stress, and turnover intention will be measured through a 5-point Likert scale.

The quantitative approach was used to satisfy the research objectives. The quantitative study is the formal and methodological evaluation of the interactions and observes the variables' relationship (Ramayah et al., 2018). Salkind (2012) suggested sampling and stated that “If you are mailing out surveys or questionnaires, count on increasing your sample size by 40%-50% to account for lost mail and uncooperative respondents”. To maintain a suitable average response rate, at least 50% of additional questionnaires were distributed on a model size of 382, and a total number of 573 questionnaires were distributed among nurses concerning in order to assure generalization regarding an average response rate with earlier studies in the same context, Therefore, this study will apply the cluster sampling technique to divide the twenty-five districts covering government hospitals located in different countries geographical regions. In this study, the clusters will be considered 25 districts covering public hospitals in Punjab, Pakistan. When the research design considers many geographic clusters, cluster sampling is highly useful. Sekeran & Bougie (2016) argued that when the population is divided into groups, it requires the selection of cluster samples in order to study specific cases being shared within the cluster.


This section discusses the model assessment by two main approaches, assessment of the measurement model and assessment of the structural model through Smart PLS.

Demographic profile

The respondents were asked to provide their basic demographic details, including sex, age, marital status, hospital category, qualification, job position, work and experience. A comprehensive view is given in Table 1. Where most of the respondents were women, 383 (93.2%), while the male was only 28 (6.8%). In terms of age, about 211 respondents (51.3%) aged between 20-29 years, which fall under the age less than 30 years old, about 134 (32.6%) respondents with the age range between 30-39 years, while 52(12.65%) respondents are in the age of 40-49 years and followed by 14 respondents (3.41%) for the age ranged 50 and above. The finding of the marital status of the respondents revealed that out of the 411 respondents, 154 (37.47%) are single, and 257 (62.53%) are married. As revealed earlier, the respondents of this study are nurses working in 369(89.78%) district public hospitals of Punjab, while 36(8.76%) respondents are in general categories hospitals and followed by 6(1.46%) respondents belong to other category hospitals in the province of Punjab. Table 1 indicates that with respect to the education level, 371 (90.27%) have accomplished a nursing diploma, followed by 9 (2.19%) who have completed their bachelor, and 31 (7.54%) have achieved their Masters. With respect to the job position of the Respondents, the findings revealed that 260(63.26%) consist of staff nurses, followed by 93 (22.63%) ward manager nurses, and 58 (14.11%)) are other staff. The participants in the survey were also requested to provide their work experience in hospitals. Where 210(51.09%) were less than 5 years experienced; 132 (32.12%) had experienced between 5 to 10 years, 69 (16.79%) had experienced more than 10 years.

Category Frequency Valid %
Male 28 6.8
Female 383 93.2
20 to 29 211 51.3
30 to 39 134 32.6
40 to 49 52 12.7
50 above 14 3.4
Marital status
Married 257 62.5
Single 154 37.3
Hospital Category
District 369 89.78
General 36 8.76
Other 6 1.46
Nursing Diploma 371 90.27
Bachelor's degree 9 2.19
Masters 31 7.54
Job position
Staff Nurse 260 63.26
Ward Manager Nurse 93 22.63
other. 58 14.11
Less than 1 year 210 51.09
5 to 10 132 32.12
More than 10 years 69 16.79
Table 1.Demographic Characteristics of the Respondents Source: Calculated by the author.

Validity and Reliability

The reliability and validity of the measurement model were evaluated. The loading of 0.50 composite reliability scores above 0.70 and average variance scores of 0.50 were recommended (Hair et al., 2017). According to current research, all values are above the specified threshold. Table 2 shows the loading, CR and AVE. There are a few products with a low factor loading. These items were removed in order to maintain the recommended thresholds. The current study found that all scores were satisfactory and that the current research had sufficient reliability.

Construct Loading CR AVE
Work Stress 0.838 0.511
Ws2 0.773
Ws3 0.811
Ws4 0.555
Ws6 0.727
Ws8 0.681
Turnover Intention 0.838 0.634
ti1 0.842
ti2 0.836
ti3 0.702
Work-family Conflict 0.853 0.513
Wfc-1 0.718
Wfc-2 0.803
Wfc-3 0.836
Wfc-4 0.715
Wfc-5 0.803
Workplace Incivility 0.856 0.548
Wpi-1 0.732
Wpi-2 0.862
Wpi-3 0.790
Wpi-4 0.686
Wpi-5 0.604
Table 2.Validity and reliability assessmentNote: ws1, ws5, ws7, wfc6, wpi6 were deleted due to low factor loading.

Discriminant Validity

Current research also assessed discriminant validity by Fornell and Larcker (1981) criteria known as the square root of AVE (table 3) and HTMT scores (table 4). Based on square root AVE scores, all values were found to be higher than the corresponding scores. The bold values present the square root of AVE. Based on scores, the current study has found a sufficient level of discriminant validity in the current research model.

TI 0.796
WFC -0.093 0.716
WPI 0.201 0.282 0.740
WS 0.146 0.556 0.392 0.715
Table 3.The square root of AVESquare root of AVE Bold values

Henseler, Ringle, and Sarstedt (2015) have recommended HTMTinference to assess discriminant validity. The mentioned values for hTMT are HTMT 0.85 (Kline, 2023). In addition to this, Teo, Srivastava, and Jiang (2008) recommended HTMT 0.90. This means that if HTMT values lie below HTMT 0.85 or HTMT 0.90 shows the establishment of adequate discriminant validity. All HTMT values were found to be well below the recommended range. Based on the outcomes, it can be described that the current study established sufficient validity.

WFC 0.180
WPI 0.251 0.351
WS 0.302 0.616 0.505
Table 4.HTMT CriteriaSource: Calculated by the author

Variance in Endogenous Factor

Current research also evaluated the variance in endogenous variables through R-square values (Hair et al., 2016; Ramayah et al., 2018). Ong and Puteh (2017) recommended 0.10 and above R2 values. Current research has found a 9.6% variance in turnover intention and a 31.4% variance in work-family conflict. Therefore, there are satisfactory R2 values in the present research.

Construct R2 Adjusted R2
Turnover Intention 0.096 0.089
Work-Family Conflict 0.314 0.311
Table 5.R-square values R2Source: Calculated by the author

Effect size

Cohen (1988) recommended values for f square are 0.02, 0.15, and 0.35 showing small, medium, and large effects. The results on the effect size are presented in Table 6. Current research found that the medium effect of WFC on TI has a small effect. Workplace incivility on turnover intention and a small effect on work-family conflict Similarly, WS has a small effect on TI and a medium effect on work-family conflict.

Construct TI WFC WS Effect
Work-Family Conflict 0.055 Small
Workplace Incivility 0.034 0.007 Small
Work Stress 0.034 0.342 Small, Medium
Table 6.Effect size (f2)Source: Calculated by the author

Figure 2.Measurement model

Structural Model Assessment

Based on findings in the structural model, Table 7 represents findings on hypothesised relationships. A total of seven hypotheses were proposed, five hypotheses were accepted, and two hypotheses were rejected based on the p-value and t-value scores H1 between WFCTI (B= -0.270, t value = 4.165, p-value =0.000), H2 WPITI (B=0.190 t-value = 3.314p value = 0.001), H4: WSTI (B= 0.221, t- value = 3.261p value =0.001), H5: WS WFC (B= 0.527, t-value = 11.803p value = 0.000), were accepted during the direct relationship. H3: WPI WFC (B= 0.075, t -value = 1.520 p-value = 0.129) was rejected during the direct relationship. Although in the mediating effect, the work-family conflict was not mediated between WPI and TI (B= -0.020, t value = 1.345, p-value 0.179) and was rejected, WFC significantly mediated the relationship between WS and TI (B= -0.142, t value = 3.858, p-value 0.000) and accepted.

path Beta SD T- value P-value Decision
WFC TI -0.270 0.065 4.165 0.000 Accepted
WPI TI 0.190 0.057 3.314 0.001 Accepted
WPI WFC 0.075 0.049 1.520 0.129 Rejected
WS TI 0.221 0.068 3.261 0.001 Accepted
WS WFC 0.527 0.045 11.803 0.000 Accepted
WS WFCTI -0.142 0.037 3.858 0.000 Accepted
WPIWFCTI -0.020 0.015 1.345 0.179 Rejected
Table 7. Structural Model Assessment

Figure 3. Structural Model


The results were achieved through two main approaches, the measurement model and the structural model through Smart PLS. Current research proposed a positive significant effect of work stress on nurses' intention to turnover in the healthcare sector of Pakistan based on empirical evidence (Zunaidah, Nengyanti, & Hadjri 2019). Current research has found positive and significant effects of WS on TI (WSTI (B= 0.221, t -value = 3.261p- value = 0.001), Current study findings are also in line with empirical evidence in the literature supporting current study findings, such as those who have narrated the adverse effect of work stress that increases TI among nurses. According to Zunaidah, Nengyanti, and Hadjri (2019), work stress easily leads to frustrating workers’ turnover intention. Due to work stress, there are chances of delivering poor and delayed services by nurses, which may harm the organisation in both financial and non-financial aspects (Haq, 2014). Furthermore, there are chances that the effects of work stress show an adverse influence on nurses’ behaviour that ultimately increases the intention to leave the job (Haq, 2014).

Current research has proposed a positive significant effect of WPI on TI based on the evidence in the evidence in the existing literature Sharma and Singh (2016) and Hendryadi and Zannati (2018). When assessing the research model, the current research found a positive significant relationship between WPI and TI WPITI (B=0.190 t-value = 3.314p value = 0.001) as incivility is treated as harmful and disrespectful behaviour at work (Andersson & Pearson 1999), which indicate more toward burnout and exhaustion, directly towards TI. Therefore, based on evidence from the literature, this was a significant direct effect of WPI on TI.

To investigate the proposed relationship, the current study from collected data identified a positive significant connection between work stress and work-family conflict. WSWFC (B= 0.527, t- value = 11.803 p-value = 0.000), based on the findings, the hypotheses stated were supported. Employees, especially female staff in the current study (nurse), have to balance their work and life due to high demands at work, work pressure, deadlines, and family responsibilities (Duong, Hussain & Subramaniam, 2020). All these become stress creators at work in the form of work stress, which ultimately misbalances work and life, so in the end, a conflict is born between work and family (work-family conflict). Hence, organisations should set the best working environment and reduce the workload to a reasonable level. Along with this, special consideration should be given to working hours (Dodanwala, Santoso, & Shrestha 2022) so that work stress can be reduced to the minimum level to avoid work-family conflict. All these stated reasons give clear indications that there is a significant and positive relationship between WS and WFC.

Based on evidence from the literature (Chi, Yang & Lin, 2018), current research proposed a significant positive relationship between WPI and WFC. While evaluating the structural model to test the hypotheses based on the collected data, the current study found a positive insignificant association between workplace incivility and work-family conflict WPIWFC (B= 0.075, t -value = 1.520 p-value = 0.129),) Therefore, based on the findings of the current study, the proposed hypotheses were rejected. Lim and Lee (2011) found insignificant results of workfare and rudeness and subordinate discourteousness toward WFC as their target audiences were from Singapore, and it is treated as a society of high-power distance (Avolio, Zhu, Koh & Bhatia, 2004). The high-power distance between employee and supervisor creates workplace incivility from the supervisor more noticeable, which can also affect their nonwork domain; contrarily, incivility from subordinates and coworkers may not be assessed as harmful as compared to incivility from the supervisor, and it may not affect their behaviour and feelings outside of work.

Based on empirical evidence, such as Aboobaker and Edward (2020) and Harun, Mahmood, and Som (2020) have proposed a positive significant relationship between WFC and turnover intention. During the evaluation of the structural model based on the collected data, the current research found a negative but significant relationship between WFC and TI. WFCTI (B= -0.270,t-value = 4.165, p-value =0.000) Conflict increases when there is a conflict between work and family (Isenhour et al. 2012) due to these conflicts, workers, especially nurses, are overloaded due to a larger number of patients and a shortage of both resources (Maloney, 2018) and supporting staff Abdullah et al. (2014) due to which nurses start thinking of quitting from an existing job. In the long run, a negative relationship between the relationship of work-family conflict and TI is quite possible (Yildiz Yildiz & Arda 2021). Reasons can be several behind this, as nurses can become habitual in dealing with the work-life balance, and another reason could be that the current job of nurses is need-based and they do not see any other suitable option for new jobs, so they tend to show a negative association between WFC and TI.

While evaluating the mediating relationship in the current study, work-family conflict was introduced, and current research found negative but significant results in H6: WSWFCTI (TI (B= -0.142, t value = 3.858, p-value 0.000) and accepted. When assessing mediating hypotheses, the findings showed a higher level of significance in the mediating relationship, and based on the findings, the proposed hypotheses were accepted based on t and p values. The significant findings of the current study are also consistent with the literature, as Khan and Muhyuldeen (2020) discovered that WFC plays a significant mediating role between job stress and TI. According to current research, there is a high level of work stress, as well as a high rate of conflict. However, given the general state of the health industry in Pakistan, including a lack of resources and a shortage of staff, nurses may believe that the same situation will exist in other organisations. As a result, they avoid work-family conflict and try to stay with the same organisation as long as their current job meets their needs. As a result, they may be treating it negatively, which could explain why current research has discovered a significant negative mediating relationship of WFC between WS and TI (Helmle, Botero, & Seibold, 2014). Second, WFC was rejected because it did not mediate the relationship between WPI and TI (B= -0.020, t -value = 1.345, p-value 0.179). A disadvantage According to Gull et al. (2023), WFC is when there is a low level of supervisor support in terms of family life consideration, so this can be narrated that the level of significance depends on the level of supervisor support. According to current research, employees consider leaving their current job due to uncivil behaviour and lack of supervisor support. So, based on evidence, it can be stated that WFC has a negligible mediating effect on workplace incivility and turnover intention.


The findings of this study contribute to the body of knowledge on the impact of WS and workplace incivility on TI. Furthermore, current research adds to the literature on the important mediating role of WFC in WS, workplace incivility, and TI relationships. Current research has numerous theoretical implications in terms of resource conservation theory (COR). Workers who are under stress at work are more likely to leave, according to COR theory (Hobfoll, 2001) Thus, it would be difficult for workers, particularly nurses experiencing work stress, to remain in the same organisation, so they consider switching from their current job, resulting in an increase in turnover intention among nurses in the healthcare sector.

Furthermore, COR theory was chosen because it encompasses the overall framework. Work-family conflicts discuss the loss of resources, which causes workers to be unable to maintain a work-family balance, resulting in conflict between work and family (Kossek, Pichler, Bodner & Hammer, 2011). In addition to this COR theory, other employees stop caring about other employees in terms of civil or uncivil behaviour (Hobfoll, 2001). In the current research, there is a high level of uncivil behaviour in the form of workplace incivility (Khan, Gang, Fareed & Khan, 2020). Employees who face negative perceptions are expected to be dealing with a variety of unusual circumstances that affect their personal lives or survive in an environment in which they are losing various resources.

Apart from theoretical implications, current research has a number of practical implications. The findings of the current study will be useful for medical ruling bodies, such as the Pakistan Medical Council, in implementing strategies to address the severe issue of turnover intention. Based on the limited resources available to address the TI problem, this will be beneficial to the entire healthcare industry, particularly the Punjab Ministry of Health. Additionally, by applying current research findings, health professionals can learn to control workplace incivility, work-family conflicts, and work stress. Due to the lack of effective policies, relationships and work environments are a major concern. This study has implications for policymakers who want to create policies that are beneficial to the health industry and better for workers. Furthermore, the findings of the current study will provide valuable information for setting policies for general and special working styles to increase motivation among nurses, which will ultimately lead to a better healthcare sector in Pakistan, despite a shortage of workers.

To begin, current research focuses on healthcare nurses, but future research can cover a broad range of healthcare professionals. Future research can be expanded to include other industries. Second, while this study focused solely on nurses, future research could include leaders and other senior employees to obtain more concrete findings on the reasons for the intention to change jobs. Third, because this study was cross-sectional and only collected data once, future research can be performed longitudinally to measure the cause-and-effect relationship.


Currently, this study provides various perspectives that workers (nurse) in the healthcare industry experience high work stress workplace incivility, and work-family conflict while working. All these are due to a high workload shortage of staff and other supporting resources. In this study, nurses are facing uncivil behaviour from patients, attendants, and hospital staff. If nurses are not motivated and supported while performing their job in the health centre, this will certainly adversely affect the health industry with respect to the loss of valuable lives of patients, and heavy financial losses are expected in terms of loss of nursing staff due to their switching behaviour from the current job.