A Pathway for Nurses From Work Strain to Anger: Mediation of Social Intelligence

doi:10.21203/rs.3.rs-4011084/v1

Background

This study aimed to determine the mediating role of social intelligence in the effect of nurses' work-related strain on trait anger and anger expressions. The challenging working conditions for nurses often result in increased strain and anger. Social intelligence could help to manage anger.

Methods

This cross-sectional, descriptive study was conducted with 446 nurses at a public hospital in Türkiye between April and May, 2021. The questionnaire consisted of nurse demographics, Trait Anger and Anger Expression Inventory, Tromso Social Intelligent Scale, and Work-Related Strain Inventory. Descriptive statistics and Pearson's correlation coefficient were conducted using SPSS (v.26) and mediation analysis was conducted using PROCESS macro (Hayes, model 4).

Findings:

Social intelligence played a mediating role in the effect of work-related strain on trait anger, anger-in, anger-out, and anger-control (β = .105, β = .100, β = .131, β=-.136, respectively). Social intelligence reduced the effect of work-related strain on trait anger and anger in/out expressions, while increasing anger control.

Conclusion

The findings of this study show that social intelligence could be used to manage anger of nurses. Nurse managers could implement initiatives aimed at managing nurses' anger and anger expressions through the decreasing of work-related strain and increasing of nurses’ social intelligence.

Anger

anger expressions

mediation

nurses

social intelligence

work-related strain

Approximately 18% of nurses have experienced anger at their work [1]. Nurses are faced with difficult working conditions such as conflicts with team members, lack of support from the managers and colleagues, exposing to violent situations, over workload, work with patients with a poor prognosis, lack of salary [2]. Moreover, previous studies have shown nurses inadequately express themselves, usually remain silent and suppress, denial when they are angry [2–3].

Nurse anger adversely impacts nurses, patients, and organizational outcomes [4, 5, 6]. Some studies conducted with nurses found a negative relationship between anger and both physical and mental health [3–7]. In particular, nurses who experience high levels of anger and/or use inappropriate anger management styles such as anger in/out are at increased risk of mental distress and burnout [5]. Increased anger in/out expressions as inappropriate expression styles lead to a decrease in organizational commitment, job satisfaction, organizational performance and quality of nursing care [3]. Moreover, it was found that being in a anger traits or expressing anger in/out increases interpersonal problems [4–8, 9], makes nurses feel inadequate [3], and increases the likelihood of making mistakes in patient care and treatment [4]. Therefore, this seems an important issue.

1.1 | Background

Anger is a natural emotion that may vary from a slight feeling of irritation or discomfort to more intense anger and rage [10]. When cognitive processes were examined, anger was associated with irrational thoughts, and when examined within the scope of social aspects, it was related to the inability to cope with environmental stress [11]. Spielberger et al. classified the concept of anger as either experiential or expressionistic [10]. The experience of anger is emotional experiences accompanied by physiological reactions. It includes both situational and trait anger. Situational anger is a sudden, negative, and subjective reaction to changing circumstances, while trait anger is the basic feeling of anger that persists steadily and continuously, regardless of specific situations or timing. The expression of anger, on the other hand, refers to the styles of expression adopted by individuals to cope with anger. It consists of three types of anger expressions: anger-in (suppression), anger-out, and anger-control. Anger-in and anger-out are considered inappropriate (uncontrolled/maladaptive/unregulated) ways of expressing anger, while anger-control is an appropriate expression [3].

Nurses at the forefront in terms of work-related strain [5]. In a study, it was stated that anger states and anger characteristics of nurses were closely related to work strain and stress [7]. In addition, studies have shown that work-related strain had an adverse impact on nurses’ physical and mental health, thereby reducing their level of motivation, job performance, and job satisfaction [12] as well as the quality of patient care and safety [13], leading to high turnover rates. Work-related strain was also found to adversely affect team climate, social support, and coping negativity that could be related to social intelligence [14].

Coping with work-related strain and keeping in control are desirable but could be hard to achieve. The way a nurse has learnt to coping with strain and stress is often adopted in a family and social groups. Those nurses who are lacking in social intelligence may not deal with angry situations that getting more anger. Nurses need to think critically what type of relationship they develop with other individuals [15]. According to the Theory of Social Intelligence [16], it refers to an individuals' ability to build successful relationships [17, 18]. Individuals who have high social intelligence are capable of understanding and appropriately responding to social environments [19]. Social intelligence allows them to perceive social cues, predict human behavior within a particular context, and react appropriately [20]. Lepore and Kliewer emphasized that high social intelligence, on the other hand, may reduce the severity of conflict through various strategies such as negotiation, humor, withdrawal, or self-expression [21]. Moreover, they noted that social intelligence increases resilience through effective coping mechanisms and regulates emotional responses to negativity. Previous studies found that nurses with high social intelligence are successful in understanding and correctly interpreting the behaviours of patients, relatives, and team members, allowing them to cope with possible negative situations and manage emotions [18–21, 22, 23]. Bayram and Elevli reported that individuals with low social intelligence engage in damaging behaviors in interpersonal relationships, resulting in a tense emotional climate [22]. Based on these study results, social intelligence can be effective in providing anger management.

2.1 | Aim

The aim of this study was to determine the mediating role of social intelligence in the effect of nurses' work-related strain on trait anger and styles of anger expression.

The study tested four hypotheses: Social intelligence plays a mediating role in the effect of nurses' work-related strain; on trait anger (H1), on anger-in behavior (H2), on anger-out behavior (H3), and on anger-control behavior (H4) (Fig. 1).

INSERT FIGURE 1

2.2 | Study design and participants

The study was conducted using a cross-sectional and descriptive survey design. The data were collected between April and May, 2021. The research universe consisted of 652 nurses who involved in direct care in a public hospital in Istanbul, Türkiye. All nurses were invited to participate to the study and 446 of them fully completed the survey. The participation response rate was 68.4%.

2.3 | Measurement and data collection

2.3.1 | Socio-demographic and work-related variables

The data were obtained taking into account demographics including age, gender, marital status, status of having children, educational background, current unit, length of service in the current hospital, length of service in the current unit, average weekly working hours, and perceived workload. Nurses' demographics and work-related variables are shown in Supplemental Table 1.

2.3.2 | Trait Anger (T-Anger) and Anger Expression Inventory (AngerEX)

The inventory was developed by Spielberger et al. [24] and adapted to Turkish culture by Özer [25]. It includes two scales named T-Anger and AngerEX which are 4-point Likert-type. The scale is scored ranging from “almost never” (1 point), “sometimes” (2 points), “most of the time” (3 points), to “almost always” (4 points).

The T-Anger scale consists of items that express how individuals generally feel or how often they experience anger. The T-Anger scale consists of 10 items (10 to 40 points).

AngerEX is consisted of three subscales, 24 items. and 8 items (8 to 32 points) in each subscale. The style of expression of anger is how often the individuals are usually mentioned they expresses that they behaving in a manner. These subscales are classified as Anger-in, Anger-out, and Anger-control. Anger-in means suppress thoughts and feelings, Anger-out shows aggressive behaviors, and Anger-control reflects the ability to control the thoughts and feelings [25]. Sample items of the T-Anger, Anger-in, Anger-out and Anger-control subscales include: “I lose my temper when a task that I have completed is evaluated badly,” “When I am angry, I stamp with rage without showing it,” “When I am angry, I hurt others by being sarcastic,” and “When I am angry, I control my actions.” In the reliability analyses of the original and Turkish versions of the T-Anger scale in different groups, the reliability coefficient was found to be .82-.90 and .67-.91 for the overall scale, .60-.73 and .60-.77 for the Anger-in subscale, .72-.83 and .69-.91 for the Anger-out subscale, and .80-0.86 and .81-.90 for the Anger-control subscale, respectively [25, 24]. In this study, Cronbach's alpha coefficients of the T-Anger and AngerEX scale were found to be over .70.

2.3.3 | Tromso Social Intelligent Scale (TSIS)

The Social Intelligence Scale developed by Silvera et al., [26] was adapted to Turkish culture by Doğan and Çetin [23]. The scale is a Likert-type scale consisting of 21 items. It includes three subscales: social knowledge process, social skills, and social awareness. Sample items of these subscales include: “I understand other people’s feelings,” “I fit in easily in social situations,” and “I am often surprised by others’ reactions to what I do.” The scores assigned to the items are as follows: “1- Not Suitable at All,” “2- Not Suitable,” “3- Somewhat Suitable,” “4- Suitable,” and “5- Completely Suitable.” Items 1, 2, 3, 4, 7, 8, 10, 11, and 13 are reverse coded. The scale score is calculated with the average score. Higher scores indicate higher levels of social intelligence. The Cronbach's alpha coefficient for the Turkish version of the scale was .82, while it was found to be .86 in the current study.

2.3.4 | Work-Related Strain Inventory (WRSI)

The original scale was developed by Revicki et al., [27], and was adapted to Turkish culture by Aslan et al. [28]. The scale was developed in order to determine the level of work-related strain and stress in health professionals. The one-dimensional, 4-point Likert-type scale consists of 18 items. The items are scored ranging from "Not suitable at all = 1 point" to "Completely suitable = 4 points.” Items 2, 4, 8, 9, and 11 are reverse scored. The lowest possible score is 18, while the highest possible score is 72 [28]. Higher scores indicate higher levels of work-related strain. Sample items include: “It seems like I cannot get the recognition that I deserve” and “I feel guilty when I cannot completely understand my patients or clients.” The original scale was tested in different groups, and the Cronbach's alpha coefficient was found to range between .85 and .90 [27]. The Cronbach's alpha for the Turkish version was .87, while it was found to be .74 in the current study.

2.3.5 | Data collection

The researchers distributed the questionnaire to the nurses in person and explained the purpose of the study before obtaining written consent. Participants were asked to return the forms, in sealed boxes placed in units, within one week. The boxes were monitored and collected by the head nurse, who then returned them, still sealed, to the researchers.

2.4 | Ethical consideration

Ethical approval was obtained from the Scientific Research and Publication Ethics Committee of a state university. Permission was obtained from the authors of the scales. Informed consent was obtained from all participants in the study. The first page of the data collection tool included the necessary informational text indicating the purpose and scope of the study, as well as ethical considerations.

2.5 | Statistical analysis

Statistical Packages for Social Sciences (SPSS) for data analysis 26.0 and the PROCESS macro [29] SPSS v3.5 were used in this study. It was determined that the Skewness and Kurtosis values of the scales ranged between − 1 and + 1, indicating a normal distribution (Table 1). Number, percentage, mean, and standard deviation, as well as Pearson's correlation analysis, were used for the descriptive statistics. Hayes' Model 4 and 5000 bootstrap samples were used in the mediating variable analysis [29, 30]. The confidence interval was adjusted to 95%, not including zero, and the effect was statistically significant at p < .05.

3.1 | Descriptive statistics and correlation for the study’s variables’ scores

Descriptive statistics and correlation for variable scores are shown in Table 1. There was a negative relationship between the WRSI score and the TSIS and Anger-control score, while the relationship between the T-Anger, Anger-in, and Anger-out was positive and significant (p < .001). There was a negative relationship between the TSIS score and the T-Anger, Anger-in, and Anger-out scores, and a positive and significant relationship between the Anger-control score (p < .001).

Table 1

Descriptive statistics and correlation for the study variables’ scores (N = 446)
	1	2	3	4	5	6
1. State-trait	1	.580*	.678*	− .251*	− .398*	.400*
2. Anger-in		1	.625*	− .046	− .385*	.384*
3. Anger-out			1	− .269*	− .434*	.327*
4. Anger-control				1	.415*	− .236*
5. TSIS					1	− .392*
6. WRSI						1
Mean score (SD)	19.45 (5.43)	16.01 (4.32)	14.73 (3.94)	22.77 (4.80)	74.44 (10.05)	46.20 (7.23)
Min-max score	10–39	8–30	8–30	8–32	46–105	27–68
Cronbach alpha	.851	.779	.790	.849	.856	.737
Skewness	.708	.447	.817	− .095	.345	− .115
Kurtosis	.421	− .214	.653	− .510	.132	− .131
TSIS: Tromso Social Intelligence Scale, WRSI: Work-Related Strain Inventory r: Pearson correlation & p < .001*

INSERT Table 1

3.2 | Mediation analysis

Mediation analysis results are shown in Fig. 2 and Table 2. The standardized direct effect of WRSI on the TSIS and T-Anger scores was β= − .38 and β = .28, respectively (p < .001). The standardized direct effect of TSIS on T-Anger was β=-.28 (p < .001) (Fig. 2a). The indirect effect of WRSI on T-Anger with the mediating effect of the TSIS was .105 (Table 2), with a model R² value of .17 (F: 8.0798 p < .001). The standardized direct effect of WRSI on TSIS and Anger-in was β=-.38 and β = .31, respectively (p < .001). The standardized direct effect of TSIS on Anger was β=-.27 (p < .001) (Fig. 2b). The indirect effect of WRSI on Anger-in with the mediating effect of the TSIS was .100 (Table 2), with a model R² value of .18 (F: 8.8240, p < .001). The standardized direct effect of WRSI on TSIS and Anger-out was β=-.38, and β = .20, respectively (p < .001). The standardized direct effect of TSIS on Anger-out was β=-.35 (p < .001) (Fig. 2c). The indirect effect of WRSI on Anger-out with the mediating effect of the TSIS was .131 (Table 2), with a model R² value of .24 (F: 11.6122, p < .001). The standardized direct effect of WRSI on TSIS and Anger-control was β=-.38 (p < .001) and β=-.10, respectively (p < .05). The standardized direct effect of TSIS on Anger-control was β = .36 (p < .001) (Fig. 2d). The indirect effect of WRSI on Anger-control with the mediating effect of TSIS was − .136 (Table 2), with a model R² value of .09 (F: 4.0884, p < .001).

Table 2

Indirect effects of exploratory variables on responsive variables (N = 415)
			Effect	SE	LLCI	ULCI
WRSI ->	TSIS ->	Anger-trait	.105	.025	.059	.157
WRSI ->	TSIS ->	Anger-in	.100	.023	.059	.148
WRSI ->	TSIS ->	Anger-out	.131	.024	.088	.179
WRSI ->	TSIS ->	Anger-control	− .136	.023	− .183	− .092
TSIS: Tromso Social Intelligence Scale, WRSI: Work-Related Strain Inventory
p < .001

INSERT Table 2

INSERT FIGURE 2 (a,b,c)

The current study determined the mediating role of social intelligence in the effect of nurses' work-related strain on trait anger and anger expression styles. All hypotheses were confirmed. Social intelligence was found to increase anger-control behavior and decrease trait anger, anger-in, and anger-out behavior associated with work-related strain. Therefore, the Theory of Social Intelligence was supported.

Nurses' work-related strain were moderate, although higher than previous results obtained before the pandemic [6–31]. The results of another study conducted during the pandemic were also consistent with the current findings [32]. The findings may have been influenced by nurses’ increased workloads, material and equipment shortages, nurses’ experience of social isolation, fear of death, insufficient managerial support, feelings of uncertainty, changing workflows, and lack of properly defined roles during the pandemic [33].

In addition, it was determined that nurses' trait anger and anger in/out expressions were at a moderate level, while their level of anger control was high. These results are consistent with results obtained from previous studies conducted in Türkiye [34, 35, 36, 37, 38]. According to a study conducted in the United Kingdom, nursing was among the three most stressful occupational groups [39]. Nurses are the only health professionals who provide uninterrupted health care, especially in inpatient services, and they can be reached most easily by patients and relatives. Thus, they are likely to experience trait anger in the face of this difficult and exhausting responsibility [38]. According to this study’s results, anger-control was the highest among the anger expression styles of nurses. This result can be explained by the professional philosophies and values nurses must adopt in response to their intense work pace, as well as the training in interpersonal relations they received as part of their education. It might also partially be explained by certain cultural values, since anger is both an individual and social phenomenon in terms of its causes/consequences and is influenced by cultural norms [5–7]. Harmonious relations and collective human values are very important in Türkiye as in other Asian countries. In South Korea, for example, nurses are expected to be extremely respectful and polite to patients, relatives, and colleagues and therefore have higher anger-in scores [40]. It should be noted that intense and prolonged anger-in and anger-control expressions may lead to negative situations [5]. It is therefore recommended that nursing managers carefully identify, monitor, and analyze strategies aimed at ensuring nurses’ anger-control through individual approaches. In addition, management approaches toward nurses' decision-making processes and their existing autonomy can promote effective anger-control strategies.

According to this study’s results, nurses' social intelligence were moderate to high. These results are consistent with those found in previous studies [41, 42]. Moreover, the results showed that social intelligence led to a decrease in trait anger and anger in/out behavior and an increase in anger-control, even in cases of work-related strain in current study (H₁, H₂, H₃, H₄). Taştan [43] found that social cohesion reduced individuals’ anger behaviors. Akbarian & Mazraehshadi [41] revealed a positive relationship between social intelligence and social capital, the latter of which includes friendship, trust, communication, and support at work. Rezaei & Mousanezhad Jeddi [44] found that social intelligence increased regulation and internal control, while reducing stress. Studies related to social intelligence indicated that coping levels and positive thinking [18–21, 22, 23] may reduce anger in/out behavior, while increasing anger-control [45]. Considering that social intelligence is an improvable phenomenon [46], it may be concluded that strategies aimed at improving social intelligence may be employed to create healthier and more productive work environments.

Limitations

The cross-sectional design of this study did not allow us to conclude causal inferences. Therefore, future longitudinal studies may assess the causal relationships between the variables. In addition, all variables were evaluated using simultaneous and self-reported tools, which may have caused bias, thereby affecting the reliability of the results. This study was conducted only for nurses working at one public hospital in Türkiye, the study results can’t be generalized in other regions and cultures.

Social intelligence reduced the effect of work-related strain on trait anger and anger in/out, while increasing anger-control expressions. Therefore, the Theory of Social Intelligence and all assumptions were confirmed. These conclusions point to the importance of fostering nurses' social intelligence to control their anger.

Considering the difficulties of the current working conditions of nurses, these results may show that social intelligence could decrease trait anger, anger in/out expressions even if increased work-strain. In addition, when nurses’ social intelligence is improved, their anger could be controlled. So it could provide anger management. Future studies on the mechanisms underlying anger and anger expressions could focus on different frameworks associated with social intelligence. Improvement of social intelligence not only reduces anger, but also improves anger control. Therefore, nurse managers should pay more attention to nurses with high work-strain, and low social intelligence. This study indicates that the effect of work-related strain on nurses' trait anger and anger expressions can be altered through their social intelligence. Nurse managers can implement initiatives aimed at managing nurses' anger and anger expressions through the reduction of work-related strain and the improvement of social intelligence.

Ethics approval: The study was approved by the ethics committee of the Osmaniye Korkut Ata University. Decision no: 06/03/2020, Number: E.7235. Uploaded to the system as Ethical Approval.

Consent to participate: Not applicable. Consent was obtained from all participants in the study. It could not be uploaded to the system.

Consent for publication: Not applicable

Data Availability Statement: Not applicable.

Competing interests: The authors declare that they have no competing interests

Fundings: No financial support has been received.

Publication approval: All authors have signed the transfer of publication rights form for the article. The signed publication right transfer (Copyright Transfer Statement) form has been uploaded to the system.

Authors' contributions:

HTS. Study conception and design, form data collection, data analysis and interpretation, writing and original draft

ET. Study conception and design, data analysis and interpretation, writing and original draft

HKK. Study conception and design, data collection, data analysis and interpretation, writing and original draft

DY. Data collection, writing and original draft

Acknowledgements: We thank all the participants for their contribution in this study.

Authors' information

¹Hanife TIRYAKI SEN, PhD, RN,

Department of Nursing Administration, Hamidiye Faculty of Nursing, University of Health Sciences, Istanbul, Türkiye

e-mail address: [email protected]

https://orcid.org/0000-0003-3350-1701

²Emine TÜRKMEN, RN, PhD, Assoc. Prof,

Istinye University, Faculty of Health Sciences, Nursing Department, Istanbul, Türkiye

e-mail: [email protected]

https://orcid.org/0000-0002-3356-5871

^3*Hilal KUŞCU KARATEPE, RN, PhD, Asst. Prof,

Osmaniye Korkut Ata University, Faculty of Health Sciences, Nursing Department, Osmaniye, Türkiye

e-mail: [email protected]; [email protected]

https://orcid.org/0000-0001-9237-2714

⁴Demet YURTSEVER, RN,

Kanuni Sultan Süleyman Education and Research Hospital, Health Care Patient Services Manager, Istanbul, Türkiye

e-mail: [email protected]

https://orcid.org/000-0002-0980-1088

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No competing interests reported.

SuplementalTable.docx

A Pathway for Nurses From Work Strain to Anger: Mediation of Social Intelligence

Status:

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Abstract

Background

Methods

Findings:

Conclusion

Figures

1 INTRODUCTION

1.1 | Background

2 METHODS

2.1 | Aim

2.2 | Study design and participants

2.3 | Measurement and data collection

2.3.1 | Socio-demographic and work-related variables

2.3.2 | Trait Anger (T-Anger) and Anger Expression Inventory (AngerEX)

2.3.3 | Tromso Social Intelligent Scale (TSIS)

2.3.4 | Work-Related Strain Inventory (WRSI)

2.3.5 | Data collection

2.4 | Ethical consideration

2.5 | Statistical analysis

3 RESULTS

3.1 | Descriptive statistics and correlation for the study’s variables’ scores

3.2 | Mediation analysis

4 DISCUSSION

CONCLUSIONS

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1