Introduction

Chronic kidney disease is a severe and increasingly prevalent non-communicable disease, with a rising global incidence. Dialysis, a primary treatment modality, is essential for over 80% of patients with kidney failure, necessitating a growing number of skilled dialysis nurses. However, dialysis units are currently experiencing a critical shortage of nursing staff. Research indicates that, in the majority of dialysis centers, nurses are responsible for administering dialysis to multiple patients per shift, a practice that exceeds the recommended guidelines1. Furthermore, nurses are tasked with providing comprehensive care to vulnerable, clinically complex dialysis patients, with heavy workloads and extended working hours contributing to elevated job stress2. Additionally, they are frequently exposed to various occupational hazards, including chemical disinfectants, machine alarms signaling emergencies or malfunctions, and direct contact with patients’ bodily fluids3. These multifaceted challenges may lead to increased job burnout among dialysis nurses and a reduced willingness to remain in their roles4. These challenges underscore the urgent need to enhance nurses’ work environment and emotional well-being to sustain high-quality patient care5. Recent studies highlight psychological interventions improving dialysis patients’ physical and emotional health, which may indirectly influence nurses’ work-related flow and emotional engagement. For instance, Sadeghi et al.6,7 showed that acceptance and commitment therapy enhances clinical symptoms, treatment adherence, and pain control in dialysis patients, potentially reflecting the emotional challenges nurses face in high-stress settings8,9. Similarly, Torbati et al.10 demonstrated that psychoeducational interventions reduce patients’depression and anxiety, emphasizing the psychological burden on healthcare providers in comparable high-pressure contexts11. These findings highlight the critical interplay between patients’ and nurses’ emotional states, directly affecting care delivery efficacy and job satisfaction.

Flow, as defined by Csikszentmihalyi12, is “the holistic sensation that people feel when they act with total involvement.” It has been linked to key job outcomes, including improved performance10, reduced exhaustion13, and heightened engagement14. Work-related flow can be described as an optimal experience within an individual’s work routine. It integrates three core elements: absorption, work enjoyment, and intrinsic work motivation15. Absorption refers to a state in which an individual is deeply immersed in their work, concentrating fully on the current task; work enjoyment involves the cognitive and emotional evaluation of this immersive state, leading to a sense of satisfaction with the work; intrinsic work motivation is the internal sense of joy and fulfillment derived from the work itself, which motivates the individual to maintain interest and persist in exerting effort15. Work-related flow, characterized by a positive emotional state of deep engagement, self-forgetfulness, and enjoyment16,17, has been shown to enhance organizational spontaneity18, creativity19, communication effectiveness20, as well as engagement, performance, life satisfaction16, and well-being21,22,23. The importance of flow experiences in the workplace, as a positive phenomenon within organizational behavior, has recently attracted growing scholarly interest. Shreffler and Huecker22 developed a methodology to assess the flow state of physicians during their professional duties and examined the correlation between this flow and their levels of job burnout, job satisfaction, and overall well-being. Their findings indicated that enhanced flow experiences are associated with increased well-being and job satisfaction, alongside a reduction in job burnout. Martínez-Zaragoza et al.’s research24 further suggested that fostering flow could be a strategy to improve the health outcomes of hospital ward nurses. Zito et al.25 explored more complex dynamics, with their study investigating the mediating role of work flow in the relationship between job demands, job resources, and job burnout. Their findings indicated that job resources are essential in shaping work flow, and that work-related flow acts as a mediator in reducing job burnout, by buffering the effects of job demands. Furthermore, work flow directly impacts the reduction of job burnout. Additional studies have also examined the determinants of flow in the workplace. Previous research has shown that individual traits26,27 and positive emotions16,17 are also significant determinants of flow.

As defined by Krathwohl, Bloom, and Masia in 1964, the affective domain encompasses emotions, attitudes, values, and interests28. Russell29 proposed that interest, attitude, belief, value, self-esteem, morality, creativity, mental health, and self-development are intricately linked to the affective domain. This domain plays a crucial role in medical students’ holistic development and the sustained progress of medical education30. Its importance is equally evident in nursing, where the ability to apply emotions in practice is essential, including competencies in caring and emotional regulation31. Clive32 emphasizes that clinical nurses and nursing students must develop competencies across three key domains: cognitive, affective, and psychomotor skills, without prioritizing any single domain. An increasing number of nursing educators and professionals are focusing on the affective domain33,34. For example, Guo investigated the current status and influencing factors of nurses’ affective domain, exploring the relationships between nurses’ affective domain, organizational support, and social support34. This research found that factors such as age, marital status, professional title, monthly income, and departmental affiliation influence nurses’ affective domain. In contrast, Ji surveyed 600 nurses at a tertiary hospital and found that marital status did not influence nurses’ affective domain31. Despite these findings, research on the affective domain of dialysis nurses remains limited, and the results regarding the factors influencing these domains are inconsistent, suggesting ongoing debate.

Despite the critical role of dialysis nurses in delivering life-sustaining care amidst rising chronic kidney disease prevalence, there is a significant research gap concerning the factors influencing their emotional and professional engagement. Few studies have explored the interplay between work-related flow and affective domain in this population, which are pivotal for enhancing job satisfaction, reducing burnout, and improving patient care quality. This study addresses this gap by identifying key predictors of work-related flow and affective domain among dialysis nurses and examining their interrelationship. Furthermore, it investigates how demographic factors—such as years of experience, professional title, and employment status—shape these dynamics, offering a nuanced understanding to inform targeted interventions that bolster nurse well-being and optimize care delivery.

Methods

Design

This study employed a multi-site cross-sectional design. The STROBE guidelines for reporting cross-sectional studies were followed throughout the study.

Participants and setting

The study employed a convenience sampling method to recruit dialysis nurses from 14 blood purification centers across Fujian Province, China, ensuring representation of diverse hospital settings, including varying tiers, staffing levels, and regional contexts. This approach captured real-world practices in dialysis care. Inclusion criteria for participants were: (1) possession of a valid registered nurse license, (2) at least one year of experience in dialysis nursing, and (3) no history of mental illness or consciousness disorders. Exclusion criteria included: (1) student nurses or those currently undergoing training, and (2) nurses on sick leave or maternity leave at the time of the survey.

Sample size calculation

The sample size was determined using a guideline recommending 5 to 10 times the number of independent variables, a widely accepted approach in survey-based research. With 22 independent variables (15 demographic factors, 4 affective domain dimensions, and 3 work-related flow dimensions), the target sample size was calculated as 220 to 440 participants. To account for potential non-responses and incomplete data, the sample size was increased by 20%, yielding a minimum target of 275 participants (n = 22 × 10/(1–20%)). Additionally, the sample size was verified using the formula for finite populations:

$$n = \frac{{Z^{2} \times p(1 - p)}}{{e^{2} }}$$

where (n) is the required sample size, (Z) is the Z-score (1.96 for a 95% confidence level), (p) is the estimated proportion (0.5 for maximum variability), (e) is the margin of error (0.05), and (N) is the population size. This calculation, consistent with methodologies used in similar health-related survey studies, confirmed a minimum sample size of 275. The final sample of 460 valid responses, achieving a 91.6% response rate, ensures a robust and reliable dataset for analysis.

Instruments

Demographics questionnaire

The Demographics Questionnaire was developed specifically for this study through a systematic process to ensure its relevance and validity. Informed by a comprehensive literature review, the questionnaire encompasses 15 variables, including age, marital status, educational background, years of experience in dialysis nursing, and income, selected for their potential influence on work-related flow and affective domain. To enhance content validity, the questionnaire was reviewed by five senior dialysis nurses with extensive clinical experience, whose feedback was integrated to improve clarity and comprehensiveness. Additionally, a pilot test was conducted with a small sample of nurses to assess question clarity and respondent understanding, with subsequent refinements made prior to formal data collection. This rigorous development process ensures the questionnaire’s suitability for capturing relevant demographic data in the context of this study.

To clarify the demographic variables used in this study, a distinction is made between ‘professional title’ and ‘functional role’ based on the context of the Chinese healthcare system. ‘Professional title’ is a nationally standardized technical rank granted by the health authorities according to the National Classification Standard for Health Professionals. It is determined by factors including professional qualifications, years of experience, and comprehensive performance evaluation. The categories include Nurse, Senior Nurse, Nurse in Charge, and Deputy Chief Nurse and above. In contrast, ‘functional role’ refers to the specific job position or duties assigned within the dialysis unit, primarily distinguishing between clinical responsibilities (General Duty Nurse) and administrative responsibilities (Head Nurse). This classification criterion has been explicitly included in the demographic questionnaire to ensure accurate data collection.

Nurses’ affective domain evaluation scale

The Nurse Affective Domain Scale developed by Ji31 was used in this study. The scale consists of 25 items across four dimensions: perception of professional beliefs, evaluation of professional values, comprehension of professional connotations, and internalization of professional values. Each item was assessed on a 5-point Likert scale ranging from “completely inconsistent” (1 point) to “completely consistent” (5 points). The total scores ranged from 25 to 125, with higher scores indicating a higher level of affective domain. The overall Cronbach’s α coefficient for the scale was 0.976, with coefficients for each dimension being 0.897, 0.945, 0.946, and 0.910, respectively. And in this study, The overall Cronbach’s α coefficient for the scale was 0.991.

Work-related flow inventory (WOLF)

The Work-Related Flow Inventory (WOLF), developed by Bakker15, was used to measure work-related flow. The Chinese version of the WOLF was translated and validated by Zhu35 through cross-cultural adaptation. The scale consists of 13 items across three dimensions: absorption (4 items), work enjoyment (4 items), and intrinsic work motivation (5 items). A 5-point Likert scale was employed, with 1 representing “never” and 5 representing “always.” Higher total scores indicate more frequent work-related flow experiences. The Cronbach’s α for the Chinese version of the WOLF scale was 0.913 overall35. And in this study, the overall Cronbach’s α coefficient for the scale was 0.971.

Data collection

Data were collected using the online survey platform Sojump. The investigator requested the chairman of the Special Committee on Blood Purification to distribute the QR code of the Sojump questionnaire to head nurses of each dialysis center via a WeChat group. The group provided detailed information regarding the purpose, significance, and instructions for completing the survey. Within each center, the head nurse shared the QR code through their department’s WeChat group, allowing dialysis nurses to easily complete the survey by scanning the code. The duration of the online survey was around 15 min. Written informed consent was obtained through an electronic consent form embedded in the questionnaire platform. Participants were required to read the consent information and provide their consent before proceeding to the questionnaire. Each device was limited to one submission, and IP address verification was used to prevent duplicate responses.

Data analysis

Data were analyzed using IBM SPSS Statistics 26.0. Descriptive statistics were computed to summarize participants’ demographic characteristics, work-related flow, and affective domain. One-way analysis of variance (ANOVA) and independent samples t-tests were conducted to examine the effects of demographic variables on nurses’ work-related flow and affective domain. Tukey’s HSD post-hoc tests were applied for pairwise comparisons following significant ANOVA results. Pearson’s correlation analysis was used to explore the relationship between work-related flow and affective domain. Assumptions of normality and homogeneity of variances were verified before conducting ANOVA. All statistical tests were two-tailed, with significance set at P < 0.05.

Ethical considerations

This study was approved by the Ningde Normal University Affiliated Ningde Municipal Hospital Ethics Committee (NSYKYLL-2023-039). Participation was voluntary, and informed consent was obtained through the Sojump online survey platform. No personally identifiable information was collected, and confidentiality and anonymity were ensured for all respondents.

Results

Participants’ characteristics

A total of 502 questionnaires were administered in this study. Of these, 32 were excluded due to completion times of less than 100 s, and 10 were omitted for containing an excessive number of blank responses. As a result, 460 valid survey responses were included in the analysis, yielding an effective response rate of 91.6%.

The majority of valid respondents were married nurses (85.2%, n = 392). A significant proportion (52.6%, n = 242) held a junior college degree. Most blood purification centers (67.0%) employed fewer than 20 nurses. Among these nurses, the majority (63.9%, n = 294) had obtained specialized certification in blood purification. Additionally, 233 nurses (50.7%) were general nurses, and over four-fifths of the dialysis nurses (82.2%) had completed further studies at higher-level hospitals for more than three months. The demographic characteristics of the participants are presented in Table 1.

Table 1 Demographics characteristics of participants (N = 460).
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Scores of different demographic factors on work-related flow in dialysis nurses

As shown in Table 2, significant differences in nurses’ work-related flow scores were observed with respect to age (P = 0.022), hospital level (P = 0.002), years of experience in blood purification (P = 0.008), and income (P = 0.006).

Table 2 Comparison of work-related flow scores of dialysis nurses by different demographic factors \(({\overline{\text{x}}} \pm {\text{s)}}\)
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Scores of different demographic factors on affective domain of in dialysis nurses

As shown in Table 3, significant differences were associated with age (P = 0.001), hospital level (P < 0.001), number of dialysis machines (P = 0.039), number of nurses (P = 0.042), method of employment (P = 0.019), professional title (P = 0.007), functional role (P = 0.039), and income (P < 0.001).

Table3 Scores of different demographic factors on work-related flow of dialysis nurses \(({\overline{\text{x}}} \pm {\text{s)}}\)
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Score of dialysis nurses’ affective domain and work-related flow

As shown in Tables 4 and 5, the total score for the affective domain of 460 dialysis nurses was 112.42 ± 20.69, with an average score of 4.50 ± 0.83 per item. The scores for each dimension were as follows: perception of professional beliefs (22.62 ± 4.33), comprehension of professional connotations (31.28 ± 5.88), evaluation of professional values (27.33 ± 5.01), and internalization of professional values (31.19 ± 6.08).

Table 4 Scores of nurses’ affective domain.
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Table 5 Scores of nurses’ work-related flow.
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The total score for nurses’ work-related flow score was 49.55 ± 12.36, with an average score of 3.81 ± 0.95 per item. The scores for each dimension were as follows: absorption (15.98 ± 3.68), work enjoyment (15.64 ± 4.03), and intrinsic work motivation (17.92 ± 5.52).

Correlation analysis of dialysis nurses’ affective domain and flow at work

The Pearson correlation analysis presented in Table 6 reveals a significant positive correlation between the overall score for affective domain and the total score for work-related flow (r = 0.660, P < 0.001). Additionally, positive correlations were observed between the overall score for affective domain and the scores for each dimension of work-related flow (r = 0.550–0.697, P < 0.001).

Table 6 Correlation analysis between dialysis nurses’ affective domain and flow at work.
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Discussion

This research aimed to assess the extent of work-related flow and affective domain among dialysis nurses and to explore the relative importance of factors influencing these domain, as well as the correlation between them. The study involved a sample of dialysis nurses from 14 blood purification centers. The results indicated that dialysis nurses exhibited elevated levels of both affective domain and work-related flow, surpassing the average. Higher affective domain were positively correlated with stronger work-related flow. Given the relationship between work-related flow and affective domains, we recommend strategies such as increasing organizational support, improving nurse-patient ratios, and implementing targeted emotional well-being programs. These interventions could lead to improved nurse job satisfaction, reduced burnout, and better patient care outcomes.

In the current study, the total score for dialysis nurses’ work-related flow was 49.55 ± 12.36, placing it at a moderate level relative to the median score of 45.5. This score exceeded that reported by Yao et al.36, whose study in 2015 found a lower aggregate score for work-related flow among dialysis nurses (35.1 ± 10.4). This discrepancy may be attributed to the timing of Yao et al.’s study, which predates a period of significant research proliferation following the introduction of the work-related flow concept. As nursing managers increasingly recognize the advantages of fostering work-related flow, strategies to enhance this flow in the workplace have gained traction. In subscale analysis, absorption had the highest mean score, while intrinsic work motivation scored the lowest. This disparity can be attributed to the critical nature of hemodialysis procedures, where patients’ conditions can fluctuate due to hemodynamic changes and dialysis imbalances, requiring nurses to maintain a high level of focus and engagement. The lower score in intrinsic work motivation likely reflects the mismatch between work intensity and compensation, as lower salaries and insufficient social support contribute to diminished intrinsic motivation.

This study also revealed that demographic factors such as age, hospital rank, years of experience in blood purification, and income are positively correlated with stronger work-related flow. Nurses possessing these characteristics tend to have a long-standing sense of professional belonging, which enables them to fully acclimate to their work environment and undergo complete role transformation36. Additionally, salary increases can help alleviate the pressures that nurses face in balancing professional and personal lives37, reduce living expenses, and enhance their quality of life, fostering greater work-related flow.

The findings also show that the total score for the affective domain of dialysis nurses was 112.42 ± 20.69, surpassing the median score of 75.5, which aligns with results from Guo et al.34, indicating strong professional competence, passion for nursing, and appreciation of professional value. However, contrasting findings highlight variability in affective domain outcomes, Yang et al.38, reported lower affective domain scores among nurses in high-stress settings, such as emergency and intensive care units, where intense workloads and acute patient conditions may impair emotional competencies. Similarly, Ji31 found reduced scores for professional value internalization among nurses in demanding roles across diverse hospital departments, attributing this to excessive workloads and burnout. These discrepancies likely arise from differences in clinical environments and role expectations. Unlike our multi-center study focusing on dialysis nurses in a specialized, less acute setting, Yang et al. and Ji’s studies encompassed broader or more high-pressure contexts, suggesting that specialty-specific stressors influence emotional well-being. Additionally, our finding of a positive correlation between affective domain and work-related flow contrasts with Yang et al.’s38 and Ji’s31 observations that stress and burnout may weaken emotional competencies, potentially hindering work engagement. These contrasting results underscore the need for tailored interventions to bolster emotional competencies and work-related flow in dialysis settings, accounting for unique workplace dynamics. Once nurses grasp the nuances of their vocation, most adopt a positive perspective toward their work and understand its significance. Consistent with Guo et al.’s findings, the highest scores were observed in the assessment of professional values. Guo et al.'s participants came from nine distinct departments, while this study focused solely on dialysis nurses34. Regardless of their specialty, nursing staff recognize the essence of nursing, develop a love for their profession, and focus on its value, which helps them understand and appreciate their work39. However, the score for the internalization of professional values was the lowest across the four dimensions, consistent with findings from Guo, Ji, and Yang. This suggests that the internalization of professional values requires prolonged learning and a deeper understanding for these values to be fully embraced38,40.

This research also highlighted that the affective domain of dialysis nurses is influenced by various factors, including age, hospital tier, number of dialysis machines, staffing levels, employment status, professional title, responsibilities, and income. In terms of age, the findings of this study contrast with those of Yang et al.38, who found that older, more experienced nurses tend to exhibit superior emotional competencies. The contradiction may arise from the fact that older nurses, after years of service, may experience emotional burnout, diminished passion, and increased stress due to the balancing of family and professional responsibilities. In contrast, younger nurses may exhibit greater emotional competency due to fewer life pressures. Factors such as hospital tier, number of dialysis machines, nurse-to-patient ratios, employment status, and professional titles all serve as indicators of the work environment, which is crucial for mitigating job-related stress and helping nurses adjust to evolving professional roles. Additionally, higher wages can alleviate the strain of balancing work and personal life, reduce living costs, and improve overall quality of life, thereby fostering emotional well-being and work-related flow among nurses.

Finally, this study found a positive correlation between the total scores for the affective domain and work-related flow among dialysis nurses, consistent with the findings of Xu et al.41, suggesting that the affective domain influences work engagement. However, it is important to note that work engagement, although closely related, is distinct from work-related flow. Schaufeli & Bakker42 argue that work-related flow is a peak experience of engagement, and engagement leads to work-related flow. Similarly, Kahn43 contends that engagement is the root cause of work-related flow. This correlation may be due to the fact that nurses’ work-related flow is closely tied to positive emotional experiences, which enhance their cognitive, emotional, and attitudinal engagement44. When nurses are free from negative emotions and experience a sense of achievement, self-worth, and job satisfaction, they are more likely to become deeply immersed in their work. This work-related flow allows them to better appreciate the value of their nursing profession, manage job-related stress, develop stable professional emotions, and focus more on their nursing duties.

Clinical implications

Studies45 have indicated that a positive affective domain can enhance nurses’ work-related flow. It is recommended that managers pay closer attention to the emotional states and experiences of nurses and work toward creating a positive work environment. This could include offering welfare benefits, increasing nurses’ salaries, and optimizing nurse-to-patient ratios—measures that can stimulate nurses’ work-related flow. The allocation of human resources for dialysis nurses should be adjusted based on work demands to improve their job satisfaction and efficiency. In conclusion, nursing managers should proactively explore strategies to enhance the affective domain of dialysis nurses, aiming to stabilize their professional attitudes and emotions. By doing so, they can strengthen the personal job satisfaction of dialysis nurses, increase their work-related flow, and ultimately promote the sustainable and stable development of nursing work.

Limitations

The limitations of this study include the exclusive recruitment of participants from blood purification centers within general hospitals, excluding independent centers from the research scope. Future studies could expand the sample size to improve the generalizability of the findings. Additionally, the current sample size is considered insufficient, and subsequent studies should aim to increase it. Furthermore, this research only explored the preliminary correlation between emotional aspects and work-related flow within dialysis units, without examining potential mediating factors. Future research should integrate a broader range of indicators, investigate the intricate relationships between these factors in greater depth, and refine the experimental design to better explore the causal links between them.

Conclusion

The study revealed that nurses employed at 14 secondary and tertiary blood purification centers in Fujian Province exhibited a relatively high level of affective domain and a moderate level of work-related flow. It was found that demographic factors, including age, hospital ranking, years of experience in blood purification, and salary, were positively correlated with a stronger sense of work-related flow among dialysis nurses. Additionally, factors such as age, hospital tier, number of dialysis machines, staffing levels, employment status, professional title, job responsibilities, and earnings were found to influence the affective domain of dialysis nurses. It was observed that as the affective domain increased, the sense of work-related flow also improved. To enhance the performance of dialysis nurses, it is recommended that efforts be made to improve their affective domain.