Participants' characteristics
In our study, the nurses' ages ranged from 22 to 53 years with a mean age of 32.0±6.8 years, and most were female (92.8%). Regarding their educational level, those with bachelor's degrees were the majority (91.7%). The average length of work experience was 10.0±7.5 years, ranging from 1 to 41 years. Additionally, 38.4% worked in the department of internal medicine, 31.8% worked in surgery, 22.1% worked in the departments of obstetrics, gynecology, and pediatrics, and the rest were employed in outpatient clinics and emergency. See Table 1 for more details.
Table 1: Characteristics of the Sample (n=362)
Descriptive characteristics
|
N
|
%
|
Genger
|
|
|
Female
|
336
|
92.8
|
Male
|
26
|
7.2
|
Age, years (M±SD)
|
32.0
|
6.8
|
Experience in nursing profession, years (M±SD)
|
10.0
|
7.5
|
Education
|
|
|
Junior college
|
10
|
2.8
|
Undergraduate
|
332
|
91.7
|
Postgraduate or above
|
20
|
5.5
|
Professional title
|
|
|
Primary nurse
|
69
|
19.0
|
Nurse practitioner
|
135
|
37.3
|
Nurse-in-charge
|
156
|
43.1
|
Deputy director nurse
|
2
|
0.6
|
Department
|
|
|
Internal medicine
|
139
|
38.4
|
Surgery
|
115
|
31.8
|
Obstetrics and Gynecology
|
48
|
13.3
|
Pediatrics
|
32
|
8.8
|
Outpatient clinics and Emergency
|
28
|
7.7
|
Abbreviation: M ± SD: mean ± standard deviation.
Translation and adaptation
The most frequently mentioned issue by experts and the pilot was the semantic uncertainty involving the initial expressions like "save him/herself from shame" (scale item 5), "command" (scale item 7), "punish the entire unit" (scale item 14). For conforming to the Chinese terminology and cultural background, and making the items of C-ToxBH-NM smooth clear and coherent with no confusion, we have supplemented and modified some statements (see Table 2).
The behavior "my nurse manager lies to his/her employees to get his/her way" (scale item 24) sparked controversy over which dimension it belonged to. It was viewed by the expert committee as being under the self-promoting behavior category. Therefore, we paid attention to the dimensional attribution of scale item 24 in the course of subsequent data analysis.
According to the experts' assessments and the outcomes of the focus group discussions, the word "staff" in the original scale lacked specificity when it came to referring to the target of toxic behaviors. The general duty nurse is the major target of toxic leadership behaviors by nurse managers in Chinese hospitals. Therefore, we opted to change "staff" to "nurses" for concretization, which could adhere to Chinese expressions as well. According to the results of the pilot test, the participants stated there was no difficulty in comprehending items and spent about 4 min to finish the questionnaire, which indicated the number of items was appropriate.
Table 2 Modifications of cross-cultural adaptation
Items
|
ToxBH-NH
|
C-ToxBH-NH
|
4
|
"read" his/her temper
|
sense his/her words and expressions
|
5
|
save him/herself from shame
|
relieves his/her own sense of shame
|
7
|
command
|
influence
|
14
|
punish the entire unit
|
punish nurses throughout the unit
|
23
|
has a group of dedicated staff who
implement his/her orders
|
requires nurses to obey his/her orders at work
|
The whole scale
|
staff
|
nurses
|
Item analysis
The results of the critical ratio method showed that the CR values of each item of the C-ToxBH-NM ranged from 11.398 to 27.028 (p<0.001). And the item-total correlations of the 30 items C-ToxBH-NH ranged from 0.633 to 0.795, all of which were statistically significant (p<0.001) . If any item was removed, the Cronbach's α of the whole scale reduced or remained the same. Therefore, no items were removed (see Table 3).
Table 3 Item analysis results and reliability coefficients for the C-ToxBH-NH (n=362)
Items
|
Critical ratio (CR)
|
Item-total correlations
|
Cronbach's α if item deleted
|
Item-1
|
15.128***
|
0.722***
|
0.966
|
Item-2
|
14.908***
|
0.755***
|
0.966
|
Item-3
|
17.498***
|
0.772***
|
0.966
|
Item-4
|
14.978***
|
0.744***
|
0.966
|
Item-5
|
19.223***
|
0.795***
|
0.966
|
Item-6
|
18.183***
|
0.775***
|
0.966
|
Item-7
|
14.442***
|
0.716***
|
0.966
|
Item-8
|
16.716***
|
0.770***
|
0.966
|
Item-9
|
16.916***
|
0.766***
|
0.966
|
Item-10
|
16.551***
|
0.745***
|
0.966
|
Item-11
|
17.896***
|
0.771***
|
0.966
|
Item-12
|
16.846***
|
0.739***
|
0.966
|
Item-13
|
15.735***
|
0.769***
|
0.966
|
Item-14
|
15.905***
|
0.764***
|
0.966
|
Item-15
|
17.171***
|
0.764***
|
0.966
|
Item-16
|
13.195***
|
0.637***
|
0.967
|
Item-17
|
13.731***
|
0.700***
|
0.966
|
Item-18
|
14.764***
|
0.659***
|
0.967
|
Item-19
|
14.338***
|
0.695***
|
0.966
|
Item-20
|
13.463***
|
0.675***
|
0.966
|
Item-21
|
15.418***
|
0.691***
|
0.966
|
Item-22
|
12.835***
|
0.688***
|
0.966
|
Item-23
|
13.515***
|
0.660***
|
0.967
|
Item-24
|
12.617***
|
0.725***
|
0.966
|
Item-25
|
11.620***
|
0.685***
|
0.966
|
Item-26
|
11.467***
|
0.682***
|
0.966
|
Item-27
|
11.398***
|
0.633***
|
0.967
|
Item-28
|
12.894***
|
0.679***
|
0.966
|
Item-29
|
13.398***
|
0.675***
|
0.967
|
Item-30
|
12.409***
|
0.646***
|
0.967
|
***p <0.001.
Validity analysis
Content validity
The ages of seven experts invited to participate in the content validity evaluation ranged from 42 to 63, with a mean age of 51.1 ± 6.5 years. And the average length of work experience was 32 ± 8.5 years, ranging from 16 to 45. The I-CVI of the C-ToxBH-NM was 0.857 to 1.000, and the S-CVI/UA was 0.867 and the S-CVI/Ave was 0.981.
EFA
The Kaiser–Meyer–Olkin (KMO) coefficient was 0.967 and Bartlett's test of sphericity was significant (p≤0.001), which indicated it was effective to conduct factor analysis. EFA (181 individuals) used principal component analysis with varimax rotation to obtain a four-factor model (see Figure 1) with the four factors accounting for 72.020% of the total variance and eigenvalues>1.0 (17.417, 1.702, 1.293and 1.194). The "double loading" was observed for item 24. In order to maximize the retention of the original scale, item 24 was not excluded. The attribution of item 24 was determined by considering the experts' modifications and comparing the magnitude of its loadings on two different common factors. Finally, it was identified that item 24 belonged to common factor 3 "self-promoting behavior" (loadings on factor 3>loadings on factor 2).The factor loading of each item was between 0.443 and 0.803; the factor loading matrix is shown in Table 4.Therefore, all the items were retained.
Table 4 The factor loading values for every item in the C-ToxBH-NM (n=181)
Item
|
Factor content
|
F1
|
F2
|
F3
|
F4
|
Item-1
|
Intemperate Behavior
|
0.700
|
|
|
|
Item-2
|
|
0.687
|
|
|
|
Item-3
|
|
0.716
|
|
|
|
Item-4
|
|
0.703
|
|
|
|
Item-5
|
|
0.723
|
|
|
|
Item-6
|
|
0.728
|
|
|
|
Item-7
|
|
0.675
|
|
|
|
Item-8
|
|
0.744
|
|
|
|
Item-9
|
|
0.731
|
|
|
|
Item-10
|
|
0.718
|
|
|
|
Item-11
|
|
0.712
|
|
|
|
Item-12
|
|
0.626
|
|
|
|
Item-13
|
|
0.676
|
|
|
|
Item-14
|
|
0.733
|
|
|
|
Item-15
|
|
0.690
|
|
|
|
Item-16
|
Narcissistic Behavior
|
|
0.735
|
|
|
Item-17
|
|
|
0.716
|
|
|
Item-18
|
|
|
0.709
|
|
|
Item-19
|
|
|
0.583
|
|
|
Item-20
|
|
|
0.701
|
|
|
Item-21
|
|
|
0.747
|
|
|
Item-22
|
|
|
0.717
|
|
|
Item-23
|
|
|
0.752
|
|
|
Item-24
|
Self-Promoting Behavior
|
|
0.443
|
0.595
|
|
Item-25
|
|
|
|
0.768
|
|
Item-26
|
|
|
|
0.752
|
|
Item-27
|
|
|
|
0.756
|
|
Item-28
|
Humiliating Behavior
|
|
|
|
0.773
|
Item-29
|
|
|
|
|
0.803
|
Item-30
|
|
|
|
|
0.784
|
Explained variance (%)
|
|
30.242
|
20.027
|
11.448
|
10.303
|
Cumulative variance (%)
|
|
30.242
|
50.269
|
61.717
|
72.020
|
Note: Only factor loadings with an absolute value >0.40 are shown in the table.
CFA
We performed CFA (181 individuals) using the great likelihood method. After corrections to the primary model based on the modified indices, the adjusted indices were acceptable according to the goodness-of-fit indices of the model, which were consistent with the four-factor model of EFA (χ2 / df = 1.450; RMSEA = 0.050; GFI = 0.832; NFI = 0.845; ILI = 0.946; CFI = 0.945; see Table 5).
Table 5 The fit indices of models (n=181)
Fit indices
|
Good fita
|
Primary model
|
Adjusted model
|
χ 2 / df
|
<3.000
|
1.576
|
1.450
|
RMSEA
|
<0.080
|
0.057
|
0.050
|
GFI
|
>0.900
|
0.815
|
0.832
|
AGFI
|
>0.900
|
0.785
|
0.802
|
NFI
|
>0.900
|
0.830
|
0.845
|
IFI
|
>0.900
|
0.930
|
0.946
|
CFI
|
>0.900
|
0.929
|
0.945
|
aBased on fit indices of Fang et al.[34]
Reliability analysis
Internal consistency reliability was good in C-ToxBH-NH (n=362) samples with Cronbach's α being 0.967 for the whole scale, and 0.960 for the intemperate behavior subscale, 0.917 for the narcissistic behavior subscale, 0.868 for the self-promoting behavior subscale and 0.868 for the humiliating behavior subscale. Calculating the interclass correlation coefficients (ICC) found that the retest reliability of the scale was 0.948 and the retest reliability for each factor were 0.881, 0.804, 0.587, 0.529.