“ Staying strong ” : Human strength attributes in predicting nurses turnover intention

One of the medical personnel who have vital role in ensuring the continuity of quality and quantity of hospital services to patients are nurses. However, ironically there are many nurses who frequently make a turnover. This condition brings negative impact to the hospital. Aim of this research was to examine relationship between the attributes of human strength that exist within the individual, which are resilience, grit, and hardiness, with turnover intention and predict their contribution on turnover intention. This research was descriptive-analytic study with cross-sectional design. Population were all nurses in hospital X, Kediri, amounted to 60 nurses. Sample was collected by total sampling. Independent variables were resilience, grit, and hardiness. Dependent variable was turnover intention. Data were collected by offline questionnaires filled by the respondent and analyzed using regression. Based on regression analysis, variables that simultaneously and significantly related to turnover intention were resilience, grit, and hardiness (p<0,001). There was significant relationship between variables of resilience (p=0,001), grit (p=0,002), hardiness (p<0,001) with turnover intention. Resilience, grit, and hardiness as human strength attributes in individuals were predictors of turnover intention, both simultaneously and individually. It can be concluded that all of those three constructs were predictors for turnover intention among nurses in hospital.


INTRODUCTION
The performance of companies is related to their employees. One of the factors that have important role for the company development is the state of employees that worked in company (Albalawi et al., 2019). This situation does not only occur in industrial companies in general, but also in the context of health institution such as hospitals (Muhammad Azeem & Abdur Rahman, 2018). As the hospital human resources, there are employees in medical and nonmedical sectors. Employees in medical sector or called as medical personnel, have important role for the hospital development and existence (Mento et al., 2020). One of the medical personnel who have vital role in ensuring the continuity of the quality and quantity of hospital services to patients are the nurses.
Nurses have role related to hospital patient care and they become the day-to-day executor of doctor's mandatory for patients in outpatient and inpatient rooms (Toscos et al., 2020). Nurses bring important contribution for hospital to be noticed and realized by the hospital's management. Nursing staff make up most employees in a hospital, reaching 50% of the employees that work in the hospital (Shah et al., 2021). However, ironically there are many nurses who choose to frequently make a turnover from one hospital to another hospital (Yasin et al., 2020). This situation become more complicated by the Covid-19 pandemic existence (Labrague et al., 2020).
The high turnover of nurses in hospitals causes hospitals to experience a shortage of nursing personnel who perform their vital roles and functions in deliver service to patients. In ideal conditions, for example, for a type D hospital, the number of nurses in hospital is a ratio of 2:3, where 2 indicates the number of patient beds in hospital, while 3 indicates the number of nurses working in hospital. Which means that ideally, 2 nurses have responsibility to handle 3 patient beds (Peraturan Menteri Kesehatan Tentang Klasifikasi Dan Perizinan Rumah Sakit, 2014). However, the reality that happened was the number of nurses in the hospital did not match the ideal situation because of high turnover of nursing staff in the hospital. This can be seen through the turnover data record on nursing staff at hospital X in Kediri, East Java. During 2022 there were 24 nurses who made a turnover from hospital X in Kediri, East Java. In January there were 8 nurses who did turnover, in February there was 1 nurse who did the turnover, in March there were 4 nurses who did the turnover, in April there were 9 nurses who did the turnover, and in May there were 2 nurses who did the turnover.
Employees who make turnover from a company are triggered by several conditions such as wages, existing career opportunities, socio-demographic factors such as distance of living place and marital status (Luvi Christiani & Ilyas, 2018). Employees who are dissatisfied with their job in a company also tend to have intention to make a turnover (Lee & Kim, 2020). The psychological aspect also contributes to the emergence of turnover intention among employees in organization. Employees who feel that their psychological needs cannot be met by the organization tend to have intention to leave the organization. Various psychological pressures experienced by employees at work also contribute to employee turnover intentions (Gibson et al., 2012). Employees who do not posses character that includes several human strength attributes also tend to be more prone to have turnover intention (Seligman, 2019). Several human strength attributes that contribute to employees' work are resilience, grit, and hardiness (Sellers; Sobstad). Resilience serves as psychological protector or buffer for employees when experiencing difficult conditions related to their work. Resilience also helps employees to bounce back and grow and develop despite the stressful conditions they experience (Hartmann et al., 2019). Grit have contribution on employees as psychological attribute that help employees achieve and maintain optimal performance by fighting for their work goals diligently, persistently, and consistently (Southwick et al., 2019). With hardiness as attribute of internal psychological strength within employees, they will commit to live various experiences and worklife dynamics, whether pleasant or not, and able to believe that they have control in dealing with work-related problems (Setyawati, 2021).
Nurses turnover can cause dysfunction in hospitals, namely causing function disruption of hospital services, decreasing the quantity and quality of services provided to patients, disruption to hospital internal management, increasing the workload of other nurses in the hospital, and the number of patients who receive treatment. Rapid and frequent employees' turnover can bring variety of negative impacts for the hospital (Ladao et al., 2022). The important role and function of nurses in a hospital, especially during the Covid-19 pandemic, have made the hospital management to pay attention to the turnover issue of the nurses. Hospital management needs to know and pay attention to several things related to nurse turnover intentions. The turnover intention of nurses in hospitals is related to several things, including to several inner psychological factors, namely resilience, grit, and hardiness. These three constructs have important role in determining the turnover intention. However, from several previous studies regarding the turnover intention of hospital nurses, there have not been many studies that combine these psychological constructs such as resilience, grit, and hardiness as human strengths attributes with turnover intention. Based on this condition, it is necessary to do further research to examine the relationship between these variables. This study will examine the relationship between resilience, grit, and hardiness with turnover intentions, and predict the contribution of each variables both simultaneously and partially on nurses' turnover intentions in the hospital.

METHOD
This descriptive-analytic research was conducted with cross-sectional design. Research was conducted from December 2022 until February 2023. Population in this research were all nurses in hospital X, Kediri, East Java, amounted to 60 nurses. The sampling technique used in this research was saturated sampling. The independent variables in this research were resilience, grit, and hardiness. The dependent variable was turnover intention. Data were collected using questionnaires filled out by respondents and analyzed using regression at significance level of ɑ=0.05. Univariate data analysis was conducted to present the frequency distribution of variables, and multivariate data analysis was conducted to determine the association between each predictor and turnover intention among nurses in hospital X, Kediri, East Java, and to determine the prediction of dependent variable based on independent variables in this research.

RESULTS AND DISCUSSION
A company needs to be aware of, detect, understand, and follow up on situation which trigger their employees' intention to leave the company. Employees' intention to leave the company or what is called as turnover intention is predictor of real turnover. The high number of employees who have turnover intentions and later becoming the real turnover, has an impact on turnover rate of employees in the company, or in this case nurses in the hospitals. Hospital will experience several losses and disruption of performance, including the performance of services to patients when there is high or frequent turnover of incoming and outgoing nurses. Nurses who have turnover intentions are generally related to several things or conditions, namely internal conditions and externally conditions especially from the hospital management. Several conditions that were assumed to be related to turnover intention in this study were resilience, grit, and hardiness.  Table 1 presented about the demographic characteristics of respondents. The data showed that most respondents were nurses who had bachelor's degree education level (53.33%), were 25 years old (45.00%), and were female (80.00%). Table 1 also showed that most of respondents had been working as nurses in Hospital X for 3 years. There were previous researches that revealed similar results with this research. There were some research with quantitative approach stated that resilience, grit, and hardiness variables have a significant effect on turnover intention. Research conducted by Sellers and her team explained that all those constructs had significant contribution on nurses' turnover intention. The three constructs predicted turnover intention among nurses in rural areas. Nurses with those three human strength attributes lingered inside themselves tended to better able to make a comeback from negative experiences and to stayed in organization despite adversity encountered their job or work life (Sellers et al., 2019). The data analysis result in table 2 stated that simultaneously there was significant relationship between resilience, grit, and hardiness with turnover intention of nurses in the hospital (p<0.001). There was strong relationship between resilience, grit, and hardiness simultaneously with turnover intention by 76%. While the contribution of resilience, grit, and hardiness simultaneously to turnover intention was 51%, and the remaining 49% was influenced by variables not examined in this research. From the results of data analysis, predictions of turnover intention of nurses in the hospital could be made based on resilience, grit, and hardiness. Prediction through regression equation was Y = 60.526 -0.545 (X1 resilience) -0.484 (X2 grit) -0.549 (X3 hardiness). This meant that if variables of resilience, grit, and hardiness were considered constant, rate of turnover intention in nurses would be 60,526. Resilience, grit, and hardiness contribute to turnover intention simultaneously. The three constructs both produce positive and conducive impact related to work life for nurses in hospitals (Sellers et al., 2019;Søbstad et al., 2021). By experiencing those three qualities, nurses tend to stay and loyal to the organization. It can encourage nurses to stay with their jobs at the hospital because their intention to do turnover tends to be low. They tend to have no intention of leaving the hospital or looking for another job because they experienced positive psychological work life in the organization. Nurses also tend to be able to experience positive feeling related to their work in the hospital. In addition, they will also tend to experience conducive and good relationship with the hospital managements, experience increased work effectiveness and focus, and tend to be loyal to the hospital by displaying supportive and positive work attitudes and behaviours (Hung & Lam, 2020;Sellers et al., 2019).
Results of this research indicated that there was significant relationship between resilience and turnover intention of hospital nurses. Results of this research were in accordance with the results of study conducted by Cao and team in China, which stated that there was relationship between resilience and turnover intention. The research revealed that resilience directly and significantly affected turnover intention among nurses in China hospital (Cao et al., 2021). Resilience was a dynamic process encompassing positive adaptation within the context of adversity (Hartmann et al., 2019). Resilience helped individual handle adversity successfully in many aspects of their life, including work life aspect. Resilience would buffer the negative and destructive impact of difficulties and adversities through a resilience mechanism. Resilient employees tended to experience positive outcome related to their work, such as higher job satisfaction, lower burnout scores, or higher business success. Resilience also facilitated employees to perform optimally, to deal with stressful events at work, and to adopt a more positive mindset in the workplace. Resilience elicited employees' positive mental health, positive affects, lessened work burnout and emotional exhaustion related to work life. High resilient employees were predicted to be more loyal to the organization and had more work happiness rather than low resilient employees (Hartmann et al., 2019). This caused employees to stay longer in the organization.
Results of this research indicated that there was significant relationship between grit and turnover intention of nurses. Results of this research were in accordance with the results of research conducted by Lacap and team which stated that there was relationship between grit and turnover intention. The research revealed that grit significantly and negatively affect intention to quit (Lacap, 2020). Grit was psychological construct referring to disposition to pursue long-term goals with persistence and determination (Duckworth et al., 2007). Grit enabled employees to face challenges tirelessly, maintained determination despite failures and barriers. They were also became more positive toward job tasks and expectations. Grit helped employees to stay and treat disappointments and challenges as normal barriers in their ways to gain success. Individuals with grit tended to stay in the organization and finish their goals or targets related to work. They would do harder and bigger effort rather than quited and left the organization (Lacap, 2020).
Another study also stated similar results to this study, namely research conducted by Ginley which stated that grit could predict retention at workplaces. Grit even reduced turnover in hospitality. Grit itself was a combination of passion and perseverance, which means that individuals who had grit would do something they were passionate about in the long term, both persistently and consistently under normal or challenging circumstances. Gritty employees tended to be loyal on their job and were willing to work tenaciously and persistently, and continuously made improvements and increased their performance quality. They didn't give up easily and left their jobs even though they experienced difficulties in doing so. Gritty employees tended to be successful in overcoming work problems and made them stay longer in organization (Mcginley et al., 2020).
In addition to resilience and grit, what was also assumed to have relationship with nurses' turnover intentions in this study was hardiness. Hardiness was a personality trait characterized by feelings of commitment rather than alienation, control rather than powerlessness, and perceiving problems as challenges rather than threats (King, 2014). Hardiness produces tenacity in facing and adapting to stressful situations (Soni, 2021). Employee who had hardiness tend to experience changes in their perspective or behavior when faced with stressful situations in a more positive, more stable, more resilient, and more optimistic ways. Hardiness enabled employees to have positive coping behavior and low turnover intention (Søbstad et al., 2021). Hardiness influenced employees in perceiving, solving, and feeling when they managed stressful and demanding work situations, and tended to see things from positive point of views and sought coping behaviors that would influence employees' decision making to stay or leave from the organization (Setyawati, 2021). With this condition, nurses tend to stay in their jobs at the hospital rather than leave for another jobs. Hardiness facilitated nurses to being tied to the hospital, and more likely became responsible for their job.

CONCLUSIONS AND SUGGESTIONS
There was significant relationship between resilience, grit, and hardiness simultaneously with turnover intention of nurses in Hospital X, Kediri, East Java. In addition, it was also known that all those three constructs, partially had significant relationship with turnover intention of nurses. From the results it could be concluded that turnover intention could be predicted by resilience, grit, and hardiness as human based strength attributes of employees.
Suggestions that could be made based on results of this research where it was needed to do further research on turnover intention, resilience, grit, and hardiness in different contexts and approaches. It was necessary to design intervention and programs to solve the turnover intention problem among nurses in sustainable and practical ways, especially by considering factors of resilience, grit, and hardiness into the programs for nurses in hospital.

ETHICAL CONSIDERATIONS
Respondents were addressed before the survey about the study objectives and purposes, and verbal consent to participate in this study was taken from them.

Funding Statement.
No funding was received to assist with the preparation of this manuscript.