Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s2):13564 Relationship between workload and organizational citizenship behavior in community nursing service management in Indonesia Miftahul Munir,1 Karyo Karyo,2 Umu Qonitun3 1Department of Public Health; 2Department of Nursing; 3Department of Midwifery, Nahdlatul Ulama Institute of Health Sciences, Tuban, Jawa Timur, Indonesia Abstract The management of community nurse services is essential for enhancing public health. Factors such as workload, organizational support, and job satisfaction influence organizational citizenship behavior (OCB), which impacts the quality of nursing gover- nance. This research investigated the relationship among work- load, OCB, and community nurse management using a quantita- tive correlational approach with 171 community nurses from health service centers in Tuban Regency, Indonesia. Simple ran- dom sampling was used to ensure equal representation of the par- ticipants. Data were collected using structured questionnaires that measured workload, OCB, and nurse governance. Spearman’s cor- relation test was used to analyze the relationships between these variables. The findings indicated that 46.7% of respondents exhib- ited high OCB, while 45.8% rated community nurse governance as good. Regarding workload, 50% of respondents reported a moderate workload. Statistical analysis revealed a significant cor- relation among workload, OCB, and nurse governance (p<0.05). Higher OCB levels were associated with better governance, while a moderate workload contributed to more effective nurse manage- ment. Balancing workloads and fostering OCB is crucial to enhancing nursing governance and healthcare service quality. Strengthening organizational support, implementing targeted training programs, and improving nurse management strategies can contribute to more effective community health services. Future research should consider psychosocial stress and emotional burden when developing a comprehensive workload assessment model. Introduction A critical issue in community nursing management worldwide is the shortage of nursing personnel, particularly in underserved areas.1 This shortage exacerbates nurses’ workloads owing to the additional burden of administrative responsibilities. Limited infrastructure and health resource support, including medical equipment and training, result in significant challenges in deliver- ing optimal healthcare services. These challenges have become even more pronounced with the increasing complexity of public health issues, such as non-communicable diseases, mental health disorders, and infectious disease outbreaks.2 Addressing these challenges requires strategic workforce planning, resource alloca- tion, and effective management approaches to support communi- ty-based health care. The Village Health Service Center is a vital primary health- care service designed to enhance public health at the village level. It provides essential health services, especially in rural communi- ties with limited access to comprehensive healthcare facilities.3 However, its implementation faces various challenges, including nurse shortages, inadequate facilities, and unbalanced work sched- ules.4 Additionally, the lack of coordination among Village Health Service Centers, local governments, and health centers hampers service operations and case management.5 Administrative ineffi- ciencies, such as ineffective medical records and reporting, further increase nurses’ workload.6 These factors collectively affect the Correspondence: Miftahul Munir; Department of Public Health, Ilmu Kesehatan Nahdlatul Ulama Tuban Institute, Jawa Timur, Indonesia. E-mail: munir.stikesnu@gmail.com Key words: community nurse; organizational citizenship behavior; workload. Contributions: MM, conceptualization, data curation, formal analysis, methodology, validation, visualization, resources, investigation, writing – original draft, writing – review & editing; KK, conceptualization, investigation, methodology, validation, resources, supervision, writing – original draft, writing – review & editing; UQ, conceptualization, methodology, formal analysis, validation, resources, investigation, writ- ing – original draft, writing – review & editing. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: the Health Research Ethics Committee at IIKNU Tuban granted ethical approval with number 60/0084223523/LEPK.IIKNU/XII/2023 in December 2023, with a valid- ity period of one year. Subsequently, permission was obtained from the Tuban District Government, specifically from the Investment and Integrated One-Stop Service Office (PTSP). The research was then con- ducted meticulously, in alignment with its established ethical objectives. Consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgements: we express our gratitude to all the nurses willing to participate in this study, who played an essential role in its success. We also extend our thanks to all the lecturers at the Nahdlatul Ulama Institute of Health Sciences for their support. Received: 31 December 2024 Accepted: 3 March 2025 Early view: 28 May 2025 This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 12(s2):13564 doi:10.4081/hls.2025.13564 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13(s2):13564] [page 7] service quality and well-being of healthcare professionals. Furthermore, low recognition and insufficient incentives con- tributed to a decrease in motivation and commitment among nurs- es.7 Therefore, improving organizational management is essential for enhancing service quality and ensuring the well-being of nurs- es, ultimately supporting national health development goals.8,9 In East Java, the expansion of Village Health Service Centers from their inception in 2010 to the end of 2020 saw a 72.3% increase in facilities, with 3213 nurses operating in 4413 sub-districts across 27 cities and regencies.10,11 This expansion significantly improved healthcare accessibility, particularly in rural areas, highlighting the need for further optimization of primary healthcare services. An initial survey conducted on September 12, 2023, through interviews with nurses in Tuban Regency, revealed that 55% of respondents exhibited moderate Organizational Citizenship Behavior (OCB), while 45% effectively managed administrative and managerial tasks, achieving 100% of the expected targets. Since 2010, the East Java Provincial Government has implemented the Village Health Service Center program to enhance access to healthcare in rural areas.12 These centers provide essential health- care services, including immunization, maternal and child health, noncommunicable disease management, and health education. They also facilitate early disease detection and public health pro- motion, thereby reducing disparities between urban and rural healthcare access in East Java.13 Individual performance is the cornerstone of an organization’s overall success. When each member performs effectively, it enhances overall productivity and contributes to achieving organi- zational goals.14-17 Skilled and motivated personnel are crucial in meeting healthcare standards and operational targets. Effective performance management not only improves workplace efficiency but also fosters a supportive and productive environment.18,19 Organizations that invest in training, motivation, and efficient management foster synergy and long-term sustainability.20,21 Prior research has found that fairness and employee engagement signif- icantly improve OCB, positively impacting overall productivi- ty.22,23 However, existing studies have not extensively explored the mediating role of work engagement in linking organizational jus- tice with OCB, particularly in healthcare settings.5,24 This study differs from previous research in that it focuses on the relationship between OCB and workload among community nurses. Specifically, it explores how OCB, such as assisting col- leagues and providing services beyond primary responsibilities, is influenced by the workload in community nursing. Previous stud- ies have primarily examined this relationship in hospital settings, neglecting the unique challenges faced by community nurses, such as limited healthcare accessibility and resource constraints.25-27 Furthermore, research on the correlation between high workload and OCB in developing countries, such as Indonesia, remains lim- ited.28,29 A more comprehensive approach is required to examine cultural factors, specific workload dimensions, and practical inter- ventions to enhance OCB in community nursing.30 Encouraging OCB among nurses fosters a supportive work environment, enhances team productivity, and improves healthcare service deliv- ery.31-33 Given these considerations, this study aimed to investigate the relationship between OCB and nurse workload in the Village Health Service Center in Tuban Regency, providing insights into strategies to enhance nursing performance despite high workloads.34 Materials and Methods Research design This study utilized a correlational quantitative design to ana- lyze the relationship between workload, organizational citizenship behavior, and community nurse governance in the Tuban Regency. The workload perceived by community nurses and the OCB they exhibit are expected to impact nurses’ governance in delivering health services to the community. The study population consisted of all community nurses employed at the Village Health Service Center in Tuban Regency, where they play a vital role in delivering preventive and promotive health services to the community. Population, sample, sampling The total population in this study consisted of 171 respondents, who were community nurses working at the Village Health Service Center in the Tuban Regency. The inclusion criteria were nurses who had worked for at least one year, were willing to participate as respondents, and were not on leave or work permits during the study. Simple random sampling was used, ensuring that every member of the population had an equal chance of being selected. The sample size was determined using the Slovin formula with a confidence level of 95% and a margin of error of 5%, resulting in 120 respondents. The sample size was sufficient to ensure the research results were representative and valid. Variables Three variables were analyzed in this study. The independent variables were the workload and OCB. Workload refers to the level of burden perceived by community nurses, which includes factors such as the number of tasks, working hours, and pressure experi- enced in performing their tasks. OCB refers to nurses’ behavior beyond their formal responsibilities, encompassing dimensions such as altruism, conscientiousness, sportsmanship, courtesy, and civic virtue. The dependent variable was community nurse gover- nance, which evaluates nurses’ performance in carrying out their duties in accordance with the established standard operating proce- dures, as the quality of services provided to the community. Instruments OCB was measured using a questionnaire based on Organ’s (1988) theory, which included the dimensions of altruism, conscien- tiousness, sportsmanship, courtesy, and civic virtue. The dependent variable, i.e., community nurse governance, was assessed using a performance checklist based on community health service standards in Indonesia. The research instruments included a workload ques- tionnaire, which used a Likert scale ranging from 1 to 5. Before implementation, the questionnaire underwent validity and reliability testing through statistical analysis, including construct validity test- ing using methods such as Exploratory Factor Analysis (EFA) or Confirmatory Factor Analysis (CFA), as well as reliability testing using Cronbach’s alpha. All the questionnaires that met the validity and reliability criteria were deemed suitable for further research. Data collection This study was conducted in Tuban in December 2023. Before participating, the respondents signed an agreement with the researcher stating their willingness to participate by completing an informed consent form. Data collection was conducted using sev- eral methods, including the direct distribution of questionnaires to community nurses at the Village Health Service Center, structured interviews to explore factors influencing nurse governance, and Pathways of Change, Part II [page 8] [Healthcare in Low-resource Settings 2025;13(s2):13564] performance observation using a checklist based on community health service standards. This process was implemented to ensure that the obtained data provided a clear and comprehensive under- standing of the factors affecting community nurse governance. Analysis The collected data were statistically analyzed to derive mean- ingful conclusions from the responses. Univariate analysis was conducted to describe the characteristics of the respondents, including demographic factors such as age, education level, years of service, and other relevant background information. This analy- sis also examined the distribution of the research variables and provided an overview of the dataset before further examination. Bivariate analysis was performed to explore relationships between two variables at a time. To determine the strength and direction of these relationships, Pearson’s correlation (for normally distributed data) or Spearman’s correlation (for non-normally distributed data) was applied, depending on the nature of the data. Ethical clearance This research was approved by the Health Research Ethics Commission of the Nahdlatul Ulama Institute of Health Sciences, Tuban, ensuring compliance with ethical standards and guidelines for conducting research involving human participants. Approval was granted under the reference number 60/0084223523/ LEPK.IIKNU/XII/2023. During data collection, the researcher ensured the confidentiality of data and respondents’ identities. All information provided was used solely for research purposes and not disclosed to any third party without permission. An anonymity procedure was applied, ensuring respondents’ personal identities were neither recorded nor linked to the collected data. This approach protected respondents’ privacy and ensured they felt safe providing honest and open responses. Results Table 1 presents the characteristics of research respondents, highlighting key demographic and professional attributes. Most respondents were aged 37-42 (66, 38%), followed by those aged 31-36 (60, 35%). Most respondents were female (93, 55%) and held a professional nursing degree (Profesi Ners) (96, 56%). Regarding OCB, nearly half of the respondents (56, 46.7%) exhib- ited high OCB, indicating strong engagement in behaviors that support their organization. In terms of community nurse manage- ment, the majority (55, 45.8%) perceived governance in their area as good. Additionally, half of the respondents (60, 50%) reported experiencing a moderate workload, suggesting a balanced distribu- tion of responsibilities among community nurses. Table 1 indicates that most community nurses in the area expe- rience a balanced workload, which may influence their ability to manage tasks and responsibilities efficiently. Table 2 illustrates the cross-tabulation of OCB and community nurse management. Among respondents with moderate OCB, most rated their community nurse management as good, with 28 respon- dents representing the largest subgroup in that category. In con- trast, among those with high OCB, the majority perceived their community nurse management as moderate, with 29 respondents comprising the largest subgroup in that row. These majority trends underscore a significant association between the levels of OCB and the perceptions of nurse management, as supported by the Spearman correlation test result of 0.002. Table 3 presents the relationship between workload and com- munity nurse management. The majority of respondents with a moderate workload (30, 25%) perceived their community nurse management as moderate, indicating a balanced distribution of responsibilities. Meanwhile, among those with a high workload, the largest proportion (32, 27%) rated their community nurse man- agement as good, suggesting that despite increased work demands, these nurses maintained effective governance. The Spearman cor- relation test result of 0.001 indicates a significant relationship between workload and community nurse management. This sug- gests that nurses with higher workloads may develop better man- agement capabilities, possibly influenced by experience, skills, and organizational support. Discussion This study investigated the relationship between workload and organizational citizenship behavior in community nursing manage- ment. The findings of this study indicated a significant relationship between OCB and workload with community nursing manage- ment, as evidenced by a p-value <0.05 in the Spearman test. This relationship reflects the influence of individual factors and work- load on nurses’ management of community nursing services. OCB, which represents proactive attitudes, commitment, and initiative at work, has been shown to contribute to the improvement of commu- nity management quality. Meanwhile, a high workload, which is generally perceived as a burden on performance, is correlated with increased effectiveness in community management. Nurses with high OCB had better community nursing management, with 45.8% classified as good, whereas those with low OCB were entirely clas- sified as poor. This suggests that strong OCB enhances commit- ment, efficiency, and effectiveness of community healthcare ser- vices. These findings align with previous research emphasizing Pathways of Change, Part II Table 1. Characteristics of research respondents. Characteristics n % Age 25-30 years 45 27 31-36 years 60 35 37-42 years 66 38 Gender Male 78 45 Female 93 55 Education Level 3 diploma in nursing 75 44 Bachelor's degree in nursing 96 56 Organizational citizenship behavior Low 10 8.3 Moderate 54 45.0 High 56 46.7 Community nurse management Low 14 11.7 Moderate 51 42.5 Good 55 45.8 Workload Low 5 4.2 Moderate 60 50 High 55 45.8 Source: primary data of researchers in 2023. [Healthcare in Low-resource Settings 2025;13(s2):13564] [page 9] that well-managed community nursing improves nurses’ roles, optimizes resources, and fosters collaboration in integrated health- care.35-37 Effective governance enhances resource allocation, work environment, and public health outcomes.38-40 According to Alex et al. (2024), good governance plays a crucial role in achieving pub- lic health goals, such as reducing disease prevalence, increasing healthcare access, and strengthening community health systems.41 Through structured management, community nurses can improve health program efficiency, reduce costs through preventive care, and enhance community engagement. Strengthening OCB and management strategies is essential for improving service quality and ensuring the sustainability of healthcare interventions.42 These findings strengthen the vital role of OCB and effective manage- ment in enhancing the quality of community nursing services and ensuring the long-term sustainability of healthcare interventions. Altruism emerged as the most influential factor in this study as it fostered collaboration and strengthened community-based nursing services. Nurses who demonstrate high levels of altruism are more likely to support their colleagues and patients, thereby contributing to a positive and cohesive healthcare environment.43 Jepma et al. highlight that altruistic nurses offer assistance without expecting personal gain, promoting teamwork and mutual trust.44 These behaviors enhance cooperation in delivering healthcare services and increase commitment to patient welfare, even in challenging situations. Nurses prioritizing altruism go beyond formal job responsibilities, offering voluntary support that benefits their orga- nization and the broader healthcare system.45-47 Consequently, altruism positively influences health care outcomes by improving service quality and efficiency.48,49 This study identified a signifi- cant relationship between workload and community nursing man- agement, with nurses experiencing high workloads demonstrating better management performance (27%) than those with moderate (19%) or low workloads (0%). This suggests that high workloads may drive nurses to develop better adaptation mechanisms and enhance task management efficiency. Supporting research indi- cates that when effectively managed, high workloads improve time management, decision-making, teamwork, and innovation use.50-52 Studies by Sibilio et al. and Park et al. highlighted that nurses in demanding roles develop superior prioritization skills, resource allocation strategies, and adaptability, ultimately improving ser- vice quality and public health outcomes.53-56 However, this study is limited by its workload measurement, which primarily focuses on work quantity rather than psychological factors such as stress, emotional burden, and psychosocial challenges.57-60 Additionally, assessing OCB remains challenging due to reliance on subjective evaluations, which may impact measurement accuracy in commu- nity nursing practice.61-63 Future research should adopt a more holistic approach by incorporating psychological dimensions into workload assessments, providing a more accurate understanding of their impact on nursing performance, mental health, and behav- ioral indicators of commitment and care quality in community nursing.64-66 Therefore, while the findings of this study indicate a positive relationship between high workload and effective commu- nity nursing management, it remains essential to implement poli- cies that promote work-life balance for nurses. Institutional sup- port, including time management training, improved workplace facilities, and equitable task distribution, can help nurses maintain productivity without experiencing excessive work-related stress. Overall, this study confirms that both OCB and workload play sig- nificant roles in shaping community nursing management, empha- sizing the need for strategies that foster OCB among nurses and optimize workload distribution. Healthcare institutions and policy- makers can leverage these findings to design targeted training pro- grams and implement evidence-based work policies that enhance nurses’ effectiveness, ultimately ensuring sustainable delivery of high-quality community healthcare services. Conclusions This study highlights the positive impact of effective commu- nity nurse management on nurses’ roles, collaboration, and health- care quality. Altruism fosters collaboration and trust, whereas ele- Pathways of Change, Part II [page 10] [Healthcare in Low-resource Settings 2025;13(s2):13564] Table 2. Cross tabulation of organizational citizenship behavior and community nurse management. Community nurse management Organizational citizenship behavior Low Moderate Good Total Low 10 (8%) 0 (0%) 0 (0%) 10 (8%) Moderate 4 (3%) 22 (18%) 28 (23%) 54 (45%) Good 0 (0%) 29 (24%) 27 (22%) 56 (46%) Total 14 (11%) 51 (42%) 55 (45%) 120 (100%) Spearman test = 0.002 Source: primary data of researchers in 2023. Table 3. Cross tabulation of workload and community nurse management. Community nurse management Workload Low Moderate Good Total Low 4 (3%) 1 (1%) 0 (0%) 5 (4%) Moderate 7 (5%) 30 (25%) 23 (19%) 60 (50%) High 3 (0.2%) 20 (16%) 32 (27%) 55 (45%) Total 14 (11%) 51 (42%) 55 (45%) 120 (100%) Spearman test = 0.001 Source: primary data of researchers in 2023. vated workloads can enhance management when balanced with effective strategies, including time and resource management. These findings provide valuable insights into strengthening rural healthcare by optimizing collaboration and resource utilization. Implementing targeted strategies and providing nurses with the necessary support and training can enhance healthcare delivery, particularly in resource-limited areas. References 1. World Health Organization. Nursing and Midwifery [Internet]. 2024 [cited 2024 May 1]. Available from: https://www.who.int/ n e w s - r o o m / f a c t - s h e e t s / d e t a i l / n u r s i n g - a n d - midwifery#:~:text=The%20largest%20needs-based%20short- ages,midwives%20by%20the%20year%202030 2. Wong NWM. Exploring the motivations behind environmental volunteering and the development of environmental citizenship in Taiwan. Soc Sci Humanit Open 2024;10:100986. 3. Davis JM, Agrawal D, Austin R. Fostering security-related citi- zenship through the employee-supervisor relationship: An examination of supervisor security embodiment. Comput Secur 2024;142:103896. 4. Al-shami SA, Al mamun A, Rashid N, Cheong CB. Happiness at workplace on innovative work behaviour and organisation cit- izenship behaviour through moderating effect of innovative behaviour. Heliyon 2023;9:e15614. 5. Rahman MHA, Karim DN. Organizational justice and organiza- tional citizenship behavior: the mediating role of work engage- ment. Heliyon 2022;8:e09450. 6. Liu Z, Chen C, Cui H, Hu Y. The relationship between nurses’ social network degree centrality and organizational citizenship behavior: The multiple mediating effects of job satisfaction and work engagement. Heliyon 2023;9:e19612. 7. Subongkod M, Sinlapasawet W, Lalaeng C, Hongsakul B. The Relationship Between Organizational Politics and Organizational Citizenship Behavior in The Management Perspective: Evidence in Thailand. Procedia Comput Sci 2024;237:819–26. 8. Alqhaiwi ZO. A bright side to unethical pro-organizational behavior: Improving work performance by satisfying psycho- logical needs. J Bus Res 2024;184:114879. 9. Efendi F, Aurizki GE, Pradipta RO. Nursing beyond borders: The Indonesian diaspora. Nursing Beyond Borders: The Indonesian Diaspora. 2024, pp. 1-110. 10. Efendi F. Transforming Health in Indonesia: A Pathway to Sustainable Development. Gac Med Caracas 2023;131. 11. Jin M, Qian R, Wang J, et al. Influencing factors associated with mental workload among nurses: A latent profile analysis. Int J Nurs Sci 2024;11:330–7. 12. Croushore A. A Chronic Pain Management Nurse Practitioner Brings Her Skills to Community Clinics. Pain Manag Nurs 2024;25:e160–1. 13. Alex J, Ramjan LM, Ferguson C, et al. Development and psy- chometric evaluation of the catheter assessment, management and performance (CAMP) scale for nurses. Nurse Educ Pract 2024;80:104122. 14. Love S, Cunningham N, Reid M, Adler M. Training Michigan School Providers (Nurses And Mental Health Specialists) In Pediatric Pain Management Strategies: Increasing Access To Care In Rural Communities. J Pain 2023;24:89. 15. Noor S, Nursalam N, Sukartini T. Determinants of organisation- al commitment on nurse’s performance. Int J Innov Creat Chang 2020;13:235–48. 16. Wilandika A, Pandin MGR, Yusuf A. The roles of nurses in sup- porting health literacy: a scoping review. Front Public Heal 2023;11. 17. Wijaya D, Supriyanto S, Yusuf A. Organisational Citizenship Behaviour (OCB) Model in Hospital Nurses in Indonesia. Malaysian J Med Heal Sci 2023;19:165–72. 18. Komppa J, Eronen K, Korpela E. Work community support in professional language learning among culturally and linguisti- cally diverse nurses : Implementation of action research in a hos- pital setting. Lang Heal 2024;2:100033. 19. Dewi YS, Danasari TM, Sudarmaji WP, et al. Critical Cultural Competence of Nurses in Intensive Care Unit: A Review. Malaysian J Med Heal Sci 2023;19:173–9. 20. Diriba D. IDF21-0155 Effectiveness of a nurse-led community- based self-management program among adults with diabetes- family dyads in Ethiopia. Diabetes Res Clin Pract 2022;186:109478. 21. Kenwright M, Fairclough P, McDonald J, Pickford L. Effectiveness of community mental health nurses in an integrat- ed primary care service: An observational cohort study. Int J Nurs Stud Adv 2024;6:100182. 22. Dauvergne JE, Bruyneel A, Caillet A, et al. Workload assess- ment using the nursing activities score in intensive care units: Nationwide prospective observational study in France. Intensive Crit Care Nurs 2024. 23. Sánchez-Sánchez MM, Campos-Asensio C, Arias-Rivera S. Workloads of intensive care nurses. Validity of their estimation using mobile applications and comparison with Nursing Activities Score. Systematised review of the literature. Enfermería Intensiva (English ed) 2024;35:229–41. 24. Gunawan DR, Eliyana A, Anggraini RD, et al. Organizational citizenship behavior in correctional institutions: Does meaning of work matter? Kybernetes. 2024. 25. Bayadsi J, Drach-Zahavy A, Cohen M, Srulovici E. Unraveling the impact of subjective and objective workload on patient expe- rience: Mediation and moderation by missed nursing care assessments in a nested multisource diary design. Int J Nurs Stud 2025;161:104919. 26. Sallach T, Mönke FW, Schäpers P. Cybervetting of organization- al citizenship behavior Expectations: Profile summary as a Key in LinkedIn-based assessments. Comput Human Behav 2024;154. 27. Sembiring MJ, Eliyana A, Papian M, et al. Antecedents of orga- nizational citizenship behavior of marketing and supply chain employees. Probl Perspect Manag 2023;21:255–66. 28. Thomas G, Albishri NA. Driving employee organizational citi- zenship behaviour through CSR: An empirical study in the con- text of luxury hotels. Acta Psychol (Amst) 2024;245:104231. 29. Hsieh CC, Li HC, Liang JK, Chiu YC. Empowering teachers through principals’ emotional intelligence: Unlocking the poten- tial of organizational citizenship behavior in Taiwan’s elemen- tary schools. Acta Psychol (Amst) 2024;243:104142. 30. Schlindwein LF, Montalvo C. Energy citizenship: Accounting for the heterogeneity of human behaviours within energy transi- tion. Energy Policy 2023;180:113662. 31. Chant K, Meek J, Hayns-Worthington R, et al. Live stream web- cams on the neonatal unit: ‘An additional responsibility’ for nursing workload? J Neonatal Nurs 2024;30:33–7. 32. Agbejule OA, Ekberg S, Hart NH, Chan RJ. Supporting cancer- related fatigue self-management: A conversation analytic study of nurse counsellor and cancer survivor consultations. Eur J Pathways of Change, Part II [Healthcare in Low-resource Settings 2025;13(s2):13564] [page 11] Oncol Nurs 2024;73. 33. Mcbride M. The role of community and district nurses. Clin Integr Care 2019;27:100231. 34. Choi S, Jeong KS, Park SR. ESG activity recognition enhances organizational commitment and service-oriented organizational citizenship behavior among insurance call center staff. Heliyon 2024;10:e31999. 35. Lo Presti A, Ambrosino G, Barattucci M, Pagliaro S. Good guys with good apples. The moderating role of moral competence on the association between moral disengagement and organization- al behaviours. Rev Eur Psychol Appl 2023;73:100891. 36. Kamil NLM, Idris MA. The Effect of Proactive Personality as a Buffer Mechanism on Organisational Citizenship Behaviour: The Role of Contextual Factors and Work Engagement. Saf Health Work 2022;13:S301–2. 37. Karupaiah V, Idris MA. The effects of organizational justice and stressors on organizational citizenship behavior and health among employees in Malaysia: A Multilevel Approach. Saf Health Work 2022;13:S304. 38. Li YX, Chen CH. The impact of employee-perceived CSR on organizational citizenship behavior - evidence from China. Asia Pacific Manag Rev 2023;28:487–500. 39. Hermanto YB, Srimulyani VA, Pitoyo DJ. The mediating role of quality of work life and organizational commitment in the link between transformational leadership and organizational citizen- ship behavior. Heliyon 2024;10:e27664. 40. Sridadi AR, Eliyana A, Gunawan DR, et al. The mediating role of work engagement: A survey data on organizational citizen- ship behavior. Data Brief 2022;42:108243. 41. Tear MJ, Reader TW. Understanding safety culture and safety citizenship through the lens of social identity theory. Saf Sci 2023;158:105993. 42. Alex J, Ferguson C, Ramjan LM, et al. Development and evalu- ation of a spaced eLearning intervention for nurses in enhancing urinary catheter management - A co-design study in partnership with research end-users. Nurse Educ Today 2025;144:106448. 43. Jiang W, Zhang Y, Yan F, et al. Effectiveness of a nurse-led mul- tidisciplinary self-management program for patients with coro- nary heart disease in communities: A randomized controlled trial. Patient Educ Couns 2020;103:854–63. 44. Jepma P, Eijk R, Bos AAE, et al. International Journal of Nursing Studies Advances Feasibility of a new transmural care pathway for advance care planning for older persons : A qualita- tive study into community care registered nurses’ perspectives. Int J Nurs Stud Adv 2024;7:100264. 45. Liu WI, Liu CH, Liao CY, et al. Mobile community learning programme’s effectiveness in case management for psychiatric nurses: A preliminary randomised controlled trial. Nurse Educ Today 2020;85:104259. 46. Arefadib N, Cooklin A, Nicholson J, Shafiei T. Postnatal depres- sion and anxiety screening and management by maternal and child health nurses in community settings: A scoping review. Midwifery 2021;100:103039. 47. Bozzetti M, Soncini S, Bassi MC, Guberti M. Assessment of Nursing Workload and Complexity Associated with Oncology Clinical Trials: A Scoping Review. Semin Oncol Nurs 2024;40:151711. 48. Moore LD, Arbogast JW, Robbins G, et al. Drastic hourly changes in hand hygiene workload and performance rates: a multicenter time series analysis. Am J Infect Control 2024;52:1371–6. 49. Landry V, Kilpatrick K. Essential Elements of a Workload Measurement Instrument for Nurse Practitioners. J Nurse Pract 2024;20. 50. Thumm EB, Smith D, Giano Z. Evaluating the roles of workload and practice climate in workforce retention across the midwifery career lifespan: A latent profile analysis of early-, mid-, and late- career US midwives. Women and Birth 2024;37:101833. 51. Hess LM, Das S, Asaithambi R, et al. Impact of EHR on Realism, Skills, and Workload in Sepsis Simulation. Clin Simul Nurs 2024;93:101560. 52. Reguera-Carrasco C, Barrientos-Trigo S. Instruments to mea- sure complexity of care based on nursing workload in intensive care units: A systematic review. Intensive Crit Care Nurs 2024;84:103672. 53. Sibilio S, Zaboli A, Parodi M, et al. Objective assessment of nursing workload in an intermediate care unit: A prospective observational study. Intensive Crit Care Nurs 2025;86:103767. 54. Park S, Yoo J, Lee Y, et al. Quantifying emergency department nursing workload at the task level using NASA-TLX: An exploratory descriptive study. Int Emerg Nurs 2024;74:101424. 55. Lashley M. Unleashing the Power to Serve: Engaging Nurses in the Community. J Radiol Nurs 2024. 56. Johnson HL, Cruthirds DF, Taylor LA, et al. Redefining faculty workload metrics: A data-driven approach. J Prof Nurs 2024;55:112–8. 57. Pohl S, Battistelli A, Djediat A, Andela M. Emotional support at work: A key component for nurses’ work engagement, their quality of care and their organizational citizenship behaviour. Int J Africa Nurs Sci 2022;16:100424. 58. Qalati SA, Zafar Z, Fan M, et al. Employee performance under transformational leadership and organizational citizenship behavior: A mediated model. Heliyon 2022;8. 59. Jiang C, He L, Xu S. Relationships among para-social interac- tion, perceived benefits, community commitment, and customer citizenship behavior: Evidence from a social live-streaming plat- form. Acta Psychol (Amst) 2024;250:104534. 60. Mulaudzi FM, Cur M, Littet Phil D, Gundo R. The views of nurses and healthcare users on the development of Ubuntu com- munity model in nursing in selected provinces in South Africa: A participatory action research. Nurs Outlook 2024;72:102269. 61. Su L, Cheng X, Zarifis A. Passengers as defenders: Unveiling the role of customer-company identification in the trust-cus- tomer citizenship behaviour relationship within ride-hailing con- text. Tour Manag 2025;107. 62. Wang M, Armstrong SJ, Li Y, et al. The influence of leader-fol- lower cognitive style congruence on organizational citizenship behaviors and the mediating role of trust. Acta Psychol (Amst) 2023;238:103964. 63. Ross P, Sheldrake J, Ilic D, et al. An exploration of intensive care nurses’ perceptions of workload in providing extracorporeal membrane oxygenation (ECMO) support: A descriptive qualita- tive study. Aust Crit Care 2024;37:585–91. 64. Vauhkonen A, Saaranen T, Cassar M, et al. Professional compe- tence, personal occupational well-being, and mental workload of nurse educators – A cross-sectional study in four European countries. Nurse Educ Today 2024;133. 65. Lawrence PR, Spratling R. Resources, Workload, and Care Coordination Hours Predict Depressive Symptoms in Parents of Children with Medical Complexity. J Pediatr Heal Care 2024;38:781. 66. Ditlopo P, Rispel LC, Van Bogaert P, Blaauw D. The impact of the nurse practice environment, workload, and professional sup- port on job outcomes and standards of care at primary health care clinics: A structural equation model approach. Int J Nurs Stud Adv 2024;7:100241. Pathways of Change, Part II [page 12] [Healthcare in Low-resource Settings 2025;13(s2):13564]