IJNHCR

Introduction

Nurses represent the largest and most critical professional group within healthcare organizations, as they spend the majority of their time providing direct patient care. Their contribution to service quality is undeniable, influencing healthcare efficiency, reducing medical errors, and ensuring positive patient outcomes [1]. Understanding the factors that affect nurses’ engagement, job satisfaction, and retention is therefore strategically important for the smooth operation and sustainability of healthcare systems.

Within this context, the phenomenon of quiet quitting has gained significant attention. It is not merely a behavioral choice but a complex psychological and organizational process. In healthcare, and particularly in nursing, quiet quitting is associated with chronic professional dissatisfaction, frustration, and psychological disengagement from work [2]. Manifestations include reduced professional initiative, lower empathy toward patients, decreased participation in interdisciplinary collaboration, and a general sense of detachment from professional growth [3]. Contributing factors, such as chronic understaffing, inadequate compensation, emotional exhaustion, and a lack of motivation, exacerbate the prevalence of this phenomenon.

Closely related to quiet quitting is turnover intention, defined as an employee’s conscious and deliberate intention to leave their current position within a specific timeframe [4]. In healthcare, turnover intention has critical implications, directly affecting organizational stability, service quality, and the sustainability of care systems. Nurses form the backbone of healthcare services, and their loss results in significant operational, social, and economic consequences [5,6].

Modern nursing roles are shaped by increasing ethical and professional challenges. Nurses face complex decisions that often extend beyond technical knowledge, including life-anddeath dilemmas, value conflicts, constraints in decision-making, and organizational pressures that may conflict with personal or professional ethics. Moral resilience has emerged as a key protective mechanism, enabling nurses to maintain professional integrity, mental well-being, and engagement. Defined by Rushton [7] as the capacity to sustain or restore moral integrity in the face of ethical challenges, moral resilience encompasses ethical competence, psychological strength, mindful reflection, and a commitment to core values such as justice, respect, empathy, and professional honesty [8].

Equally important is work engagement, a positive, motivational psychological state characterized by vigor, dedication, and absorption in work [9]. High engagement levels are associated with psychological well-being, protection against burnout, increased professional responsibility, improved patient care, and reduced turnover intention [10-13]. Nurses who demonstrate strong engagement and moral resilience are better equipped to navigate the demands of modern clinical practice, ensuring both their personal well-being and the delivery of high-quality, safe healthcare.

Subjects and Methods

Study Participants

The study population included a total of 1,012 individuals, representing all levels of nursing staff (Registered and Technical Nurses, Assistant Nurses, Nursing Assistants, and Orderlies). Data were collected from five hospitals within the 2nd Regional Health Authority of Piraeus and the Aegean. Data were collected using an appropriate questionnaire from January 20 to April 20, 2025.

Statistical Methods

Data analysis was conducted using IBM SPSS 30.0 (Statistical Package for the Social Sciences).

Categorical variables are presented as absolute (n) and relative (%) frequencies, while quantitative variables are summarized using mean, Standard Deviation (SD), median, interquartile range (IQR), minimum, and maximum values. Normality of quantitative variables was assessed using the Kolmogorov-Smirnov test and normality plots, with all dependent variables following a normal distribution.

Relationships between variables were examined using appropriate statistical tests: Student’s t-test for quantitative versus dichotomous variables, ANOVA for quantitative versus categorical variables with more than two groups, Spearman’s correlation for ordinal variables, and Pearson’s correlation for normally distributed quantitative variables. Variables with p<0.2 in bivariate analysis were included in multivariate linear regression using the backward stepwise method. Regression results are reported as beta coefficients (b), 95% confidence intervals, and p-values. The twotailed level of statistical significance was set at 0.05.

Dependent variables included scores on the three subscales of the quiet quitting questionnaire, the total quiet quitting score, and the overall turnover intention score.

Independent variables included scores on the four subscales of the moral resilience questionnaire, total moral resilience score, scores on the three subscales of the work engagement questionnaire, total work engagement score, and socio-demographic characteristics.

This analytical approach enabled a comprehensive examination of factors influencing quiet quitting and turnover intention among nursing staff, considering both moral resilience and work engagement as potential protective mechanisms.

Results

Demographic and work characteristics

The majority of participants were women (78.4%), with the largest age group being 41–50 years (39.4%). In terms of marital status, most were married (68.1%), and 71.1% reported having children. Regarding education, approximately one-third had completed secondary education (36.6%), while a similar proportion held a university or technical degree (35.9%). Employment status was predominantly permanent (81.1%), with 18.9% working under contract. The highest share of work experience fell within the 21– 30 years category (32.8%). In terms of income, over half earned €1,001–1,500 (56.3%). With respect to work departments, the majority were employed in ‘other departments’ (74.9%), though notable proportions worked in the ICU (11.3%) and Emergency Department (10.1%). Smaller shares were observed in Psychiatry (7.4%), the Emergency Department (7.0%), Outpatient Clinics (6.8%), and both the Operating Room and Surgical Department (4.5% each). Finally, the vast majority of participants (82.1%) reported working rotating shifts, while 17.9% did not.

Quiet Quitting

For the assessment of quiet quitting at work, the “Quiet Quitting Scale” (QQS) [14-16] was used. It consists of 9 items rated on a five-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The questionnaire comprises three subscales that address the following factors/dimensions: Detachment/ indifference, Lack of initiative, Lack of motivation.

The Cronbach’s alpha coefficient for the entire questionnaire was satisfactory (0.803).

Factor/Dimension	Average	SD	M	IQR	Min	Max
Distancing/indifference	1,94	0,74	1,75	0,75	1,00	5,00
Lack of initiative	2,25	0,73	2,00	1,00	1,00	5,00
Lack of motivation	2,82	0,90	3,00	1,50	1,00	5,00
Total quiet quitting score	2,24	0,61	2,22	0,78	1,00	5,00

Table 1: Descriptive results for the overall quiet quitting score and its three dimensions.

Figure 1: Descriptive results for the overall quiet quitting score and its three dimensions (n = 1.012)

Turnover intention

The measurement of turnover intention was carried out with the question: “How often have you seriously considered leaving your job?” and was scored on a valid 6-point Likert scale, from 1 (never) to 6 (very often) [17].

	Ν	%
How often have you seriously considered quitting your job?	3,6 (1,6)a	4,0 (2,8)b
Never	128	12,6
Rarely	125	12,4
Sometimes	246	24,3
Relatively often	155	15,3
Quite often	205	20,3
Very often	153	15,1
a SD b IQR

Table 2: Turnover intention (n = 1.012)

A significant proportion, nearly one in four (24.3%), reported that they consider leaving occasionally.

Moral Resilience

For the assessment of moral resilience, the Rushton Moral Resilience Scale-16 (RMRS) [18,19] was used, as it has been standardized in the Greek language. It consists of 16 items rated on a four-point Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree). The questionnaire comprises four subscales that address the following factors/dimensions: Response to moral adversity, Personal integrity, Relational integrity, and Moral efficacy.

The Cronbach’s alpha coefficient for the entire questionnaire was acceptable (0.764).

Figure 2: Mean scores for the dimensions of moral resilience and the overall moral resilience score. (n = 1.012).

Overall, personal integrity scored the highest (3.2–3.5), reflecting a strong sense of moral consistency. Response to moral adversity scored the lowest (2.2–2.7), indicating difficulty in managing the psychological effects of ethical dilemmas. Relational integrity showed moderate scores (2.2–3.4), suggesting some influence of interpersonal pressures, while moral efficacy was at a good level (3.0–3.3), demonstrating participants’ ability to understand and express their ethical positions.

Work Engagement

For the assessment of work engagement, the Utrecht Work Engagement Scale (UWES-9) [20,21] was used, as it has been standardized in the Greek language. It consists of 9 items rated on a seven-point Likert scale, ranging from 0 (never) to 6 (always/every day). The questionnaire comprises three subscales addressing the following factors/dimensions: Vigor, Dedication, and Absorption.

The Cronbach’s alpha coefficient for the entire questionnaire was excellent (0.927).

Figure 3: Mean scores for the dimensions of work engagement and the overall work engagement score. (n = 1.012)

The findings indicate that work engagement in the sample is expressed primarily through a sense of pride and dedication, and to a lesser extent through absorption in work.

Correlations between the dimensions of moral resilience and work engagement

The findings indicate that moral resilience is associated with work engagement, with stronger relationships observed between moral efficacy and the engagement dimensions, as well as between personal integrity and dedication. These results suggest that a sense of moral consistency and the ability to effectively apply ethical principles enhance vigor, dedication, and overall work engagement.

		Vigor	Dedication	Absorption	Total score of work engagement
Response to moral adversity	Pearson	0,151	0,157	0,077	0,139
	p-value	<0,001	<0,001	0,014	<0,001
Personal integrity	Pearson	0,185	0,203	0,17	0,197
	p-value	<0,001	<0,001	<0,001	<0,001
Relational integrity	Pearson	0,061	0,068	0,014	0,048
	p-value	0,054	0,030	0,654	0,126
Moral efficacy	Pearson	0,223	0,222	0,188	0,224
	p-value	<0,001	<0,001	<0,001	<0,001
Total score of moral resilience	Pearson	0,238	0,25	0,17	0,233
	p-value	<0,001	<0,001	<0,001	<0,001

Table 3: Correlations between the dimensions of moral resilience and work engagement (including their subscales).

Dependent variable: Overall score of quiet quitting

According to the results of the multivariate linear regression, the following emerged: Men had higher overall scores of silent resignations from work compared to women (p = 0.028). An increase in years of work experience was associated with a decrease in overall silent resignation scores (p = 0.015). An increase in the overall moral resilience score was associated with a decrease in overall silent resignation scores (p < 0.001). An increase in the overall work engagement score was associated with a decrease in overall silent resignation scores (p < 0.001).

Independent variable	b	95% confidence interval	p-value
Gender	-0,089	-0,169 to -0,010	0,028
Years of service	-0,043	-0,077 to -0,008	0,015
Total score of moral resilience	-0,459	-0,539 to -0,378	<0,001
Total score of work engagement	-0,116	-0,140 to -0,092	<0,001

Table 4: Multivariate linear regression with the overall score of quiet quitting as the dependent variable.

Dependent variable: Turnover intention score

According to the results of the multivariate linear regression, the following emerged: Employees without children had higher turnover intention scores compared to those with children (p = 0.029). An increase in educational level was associated with a decrease in turnover intention scores (p = 0.023). Employees with rotating shifts had higher turnover intention scores compared to those not working in rotating shifts (p = 0.035). An increase in the overall moral resilience score was associated with a decrease in turnover intention scores (p = 0.001). An increase in the overall work engagement score was associated with a decrease in turnover intention scores (p < 0.001).

Independent variable	b	95% confidence interval	p-value
Existence of children	0,230	-0,024 to -0,436	0,029
Educational level	-0,126	-0,234 to -0,018	0,023
Working on rotating hours	-0,267	-0,515 to -0,019	0,035
Total score of Moral resilience	-0,390	-0,617 to -0,163	0,001
Total score of Work engagement	-0,319	-0,386 to -0,251	<0,001

Table 5: Multivariate linear regression with Turnover intention as the dependent variable.