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Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention among Nurses at Veterans Administration Hospitals in Korea
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Asian Nursing Research xxx (2017) 1e7
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Research Article
Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention among Nurses at Veterans Administration Hospitals in Korea Q9
Hee-Yun Yim, RN, MSc, 1 Hyun-Ju Seo, RN, MPH, PhD, 2 Yoonhyung Cho, PhD, 3 JinHee Kim, RN, MPH, PhD 2, * 1 2 3
Q1
Nursing Department, Gwangju Veterans Administration Hospitals, Gwangju, South Korea Department of Nursing, College of Medicine, Chosun University, Gwangju, South Korea Department of Business Administration, College of Business, Chosun University, Gwangju, South Korea
a r t i c l e i n f o
s u m m a r y
Article history: Received 6 October 2015 Received in revised form 4 January 2017 Accepted 11 January 2017
Purpose: The aim of this study was to evaluate the mediating role of psychological capital (PCP) in the relationship between occupational stress and turnover intention in nurses. Methods: Data were collected from a sample of 447 nurses working at four Veterans Administration Hospitals throughout South Korea from July 1 to July 31, 2014. We collected data from the nurses using the following surveys: the Short Form Korean-Occupational Stress Scale, the Korean version of the Turnover Intention Scale, and the Korean version of the Psychological Capital Questionnaire. Multiple linear regression analysis was performed to examine the mediating role of PCP. Results: The level of occupational stress was 1.8 ± 0.2, the level of turnover intention was 3.3 ± 0.9, and the PCP level was 3.9 ± 0.5. There were significant correlations among the three variables (occupational stress, turnover intention, and PCP). PCP played a partial mediating role (b ¼ 0.216, p ¼ .008) in the relationship between occupational stress and turnover intention (p < .001) among nurses working at the Veterans Administration Hospitals. Conclusion: Based on the findings of this study, we recommend that South Korean hospitals offer occupational stress management programs that incorporate relevant programs in efforts to strengthen the overall components of PCP among nurses to reduce turnover intentions. Further studies are required to determine the most effective intervention programs for hospital settings. Copyright © 2017, Korean Society of Nursing Science. Published by Elsevier. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: nursing management occupational stress psychological turnover intention
Introduction Stress is defined as an individual perceiving external demands as being beyond his or her ability to cope with these demands [1]. More specifically, stress relates both to individuals' perceptions of the demands being made on them and to their perception of their capability to meet those demands [2]. Among health professionals, nurses experience the highest levels of occupational stress [3]. The occupational stress levels of nurses were reportedly 2.33e2.86 on a 4-point scale [4]. Major sources of stress for nurses are heavy workloads, leadership and management issues, interprofessional
* Correspondence to: JinHee Kim, RN, MPH, PhD, Department of Nursing, College of Medicine, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju, 501-759, South Korea. E-mail address: [email protected]
and intraprofessional conflicts, emotional demands of caring, lack of reward, role ambiguity, and shift work [5]. Research has demonstrated that occupational stress levels among nurses in Korea are particularly high when working durations exceed 3 years, when nurses work three different shifts, when salaries are high, and when nurses work on the general ward [4]. Occupational stress experienced by nurses can result in undesirable personal or organizational outcomes, including increased medical expenditures, burnout, increased accidents, and job dissatisfaction [6]. Among these negative outcomes, previous research has revealed a link between occupational stress and nurse turnover intention [7]. The turnover intentions of nurses were reportedly 3.28e3.51 on a 5-point scale [8]. General characteristics of nurses such as age, educational level, work status, marriage status, type of work, experience, salary, and so on are reportedly related to turnover intentions in Korea [9]. Nurse turnover is considered one factor that
http://dx.doi.org/10.1016/j.anr.2017.01.002 p1976-1317 e2093-7482/Copyright © 2017, Korean Society of Nursing Science. Published by Elsevier. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Yim H-Y, et al., Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention among Nurses at Veterans Administration Hospitals in Korea, Asian Nursing Research (2017), http://dx.doi.org/10.1016/ j.anr.2017.01.002
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negatively affects the quality of nursing care and patient outcome. Nurse turnover makes it difficult for human resources to maintain or build a quality staff and can often lead to high costs for hiring and training new nurses. The results of these effects leave organizations with tremendous losses. Nurses who quit increase the workload for other nurses, which can often lead to a greater number of health problems, emotional exhaustion, and accidents (e.g., needlestick injuries) [7]. Prevention of nurse turnover is a major challenge for human resource management in hospitals. Instead of addressing the inadequacies of employees, employers take an interest in cultivating positivity for employees to improve their work environment. Focusing on employees' positive qualities is not merely an attempt to recognize the importance of positivity; it is also an employer's attempt to adapt a more constructive approach and to deviate from the mainstream approaches focused primarily on negative aspects [10]. The positive organizational behavior approach is the study and application of positive human resource strengths and psychological capacities that can be measured, developed, and effectively managed to improve performance in today's workplace [11]. Positive organizational behavior and the increasing attention to employees' positive characteristics have promoted a growing interest in psychological capital (PCP) within the field of human resource management. PCP is defined as an individual's positive psychological state of development [11]. It has four components: efficacy, optimism, hope, and resilience [11]. Efficacy is based on Bandura's Social Cognitive Theory and is defined as “one's conviction (or confidence) about his or her abilities to mobilize the motivation, cognitive resources, or courses of action needed to successfully execute a specific task within a given context” [12,13]. According to Seligman [14], optimism is the way in which a person interprets and understands recent or past experiences. Snyder et al [15] defined hope as a “positive motivational state based on an interactively derived sense of successful agency (goal-directed agency) and pathways (planning to meet goals)”. Hope does not merely involve willpower or the drive to achieve set goals; it also involves waypower, the capacity to maneuver and work around challenges that stand in the way of achieving goals [10]. The last component, resilience, can be understood as an individual's capacity to adapt after he or she has experienced something negative or positive [11]. Efficacy affects how individuals perceive and interpret events. Most human stress is dominated by beliefs about dealing with efficacy [12]. An individual with a higher level of optimism is less likely to experience symptoms of stress in the workplace [10]. Hope provides individuals with a positive resource for stressful work situations. An individual's level of hope protects him/her against perceptions of uncontrollability, vulnerability, and unpredictability [16]. Resilience is the most important positive resource when navigating a turbulent and stressful workplace [10]. Resilient individuals are better equipped to cope with stressors in a workplace environment that continues to change. This is because these individuals are open to new experiences, respond flexibly to changing demands, and demonstrate emotional stability when faced with adversity [17]. PCP is negatively related to occupational stress, and decreased PCP, along with occupational stress, is thought to increase turnover intention [7,10]. Research has revealed that an increase in occupational stress results in a decrease in the overall PCP of employees, triggering consideration of turnover among nurses [10]. In the field of nursing workforce management, active management of occupational stress is required to prevent nurse turnover. Additionally, serious consideration of the use of PCP, a positive resource for combating employee turnover that has been receiving much interest in the field of workforce management, is needed. PCP has
been introduced as a positive resource in aiding nurses to overcome exhaustion and in helping to increase organizational commitment and customer orientation [18,19]. Although the feasibility of PCP is being assessed in the field of nursing workforce management, no research has focused on the relationships among occupational stress, PCP, and turnover intention. This study yielded basic data related to building a workforce management plan to decrease nurse turnover by identifying whether PCP plays a mediating role in the relationship between occupational stress and turnover intention. Objective The objective of this study was to evaluate the mediating role of PCP in the relationship between occupational stress and turnover intention in nurses. To investigate this relationship, we measured the levels of occupational stress, turnover intention, and PCP in a large sample of nurses. We believe our findings provide basic information for developing more successful nursing workforce management strategies that will ultimately reduce nurse turnover intention. Specifically, our study had three purposes: (a) to measure the levels of occupational stress, turnover intention, and PCP in nurses; (b) to explore the differences associated with each of these factors; (c) to investigate the relationships among occupational stress, turnover intention, and PCP in nurses; and (d) to identify whether PCP plays a mediating role in the relationship between occupational stress and turnover intention in nurses. Methods Design This was a cross-sectional descriptive study aimed at identifying the mediating role of PCP in the relationship between occupational stress and turnover intention in nurses. Participants and data collection The participants in this research were registered nurses working at four Veterans Administration Hospitals. South Korea has five Veterans Administration Hospitals, but we collected data only from the four that were willing to cooperate with data collection. Researchers visited the nursing department at each hospital to request participation, and to explain the purpose of this study and the contents of the questionnaires. A total of 553 instructional documents, along with consent forms and prepaid envelopes, were distributed to nurses with the help of the nursing department (three hospitals received 130 documents each; the other hospital received 163 documents). Nurses were informed of the purpose of the study and completed a written consent form prior to participation. Of the 553 distributed questionnaires, 457 were collected, for a return percentage of 82.6%. Of the three hospitals that received 130 questionnaires, one returned 103 (return percentage, 79.2%), one returned 103 (return percentage, 79.2%), and one returned 108 (return percentage, 83.1%). The hospital that received 163 questionnaires returned 143 questionnaires (return percentage, 87.7%). Of the returned questionnaires, 10 were excluded from this analysis due to various reasons: 6 questionnaires were missing answers for five or more variables; the other 4 questionnaires had fewer than five missing answers but included two or more with multiple responses. We believe that excluding these questionnaires, which were filled out with little sincerity, had no effect on the study results. All questionnaires were collected in a sealed envelope by mail or by the education head nurse with support from the division of nursing service. The data were collected from July 1st, 2014 to July 31st, 2014.
Please cite this article in press as: Yim H-Y, et al., Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention among Nurses at Veterans Administration Hospitals in Korea, Asian Nursing Research (2017), http://dx.doi.org/10.1016/ j.anr.2017.01.002
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Questionnaires and measurements Previously published and validated measures were used in this study. Questionnaires consisted of demographic questions (e.g., gender, age, marital status, educational level, occupational level, length of work experience as a nurse) and three scales that measured occupational stress, turnover intention, and PCP.
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guarantee the anonymity of nurses' identity, a prepaid envelope was provided with the questionnaire and only personal information absolutely necessary for this study was collected. Participants were informed that all information provided in the study would remain confidential and that all findings would be reported anonymously. Data analysis
Occupational stress Occupational stress was defined as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker [20]. To adjust to the South Korean context, occupational stress was measured using the Short Form Korean Occupational Stress Scale developed by Chang et al [21]. The scale is composed of 24 items from the following seven subscales: job demand, insufficient job control, interpersonal conflict, job insecurity, organizational system, lack of reward, and occupational climate. Each item is rated by a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). For this scale, high scores correspond to high levels of occupational stress. In the Chang et al [21] study, the Cronbach a score for occupational stress ranged from .51e.82. In this study, Cronbach a for occupational stress was .76. Turnover intention
Q3
Turnover intention was described as the process by which members of the nursing staff transfer or relinquish responsibilities within their organization [7]. The Korean version of the Turnover Intention Scale was used to assess turnover intention of nurses. The Turnover Intention Scale consists of four items, with each item on a 4-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). For this scale, a higher score corresponded to higher rates of turnover intention. The reported score was an average of the scores for all four items. According to a study conducted in South Korea by Kim and Lee, the Cronbach a for turnover intention was .87 [8]. In this study, the Cronbach a for turnover intention was .87.
Data were analyzed using the SAS statistical software, version 9.2 (SAS Institute, Cary, NJ, USA). First, general characteristics of participants were expressed in terms of frequencies and percentages. Means and standard deviations were calculated to determine the nurses' level of occupational stress, turnover intention, and PCP. To analyze differences in the levels of occupational stress, turnover intention, and PCP based on the respondent's general characteris's test were tics, a t test or one-way analysis of variance and Scheffe utilized. Pearson's correlation coefficient was used to examine the relationships among occupational stress, turnover intention, and PCP. To examine the mediating role of PCP in the relationship between occupational stress and turnover intention, we utilized the method of Baron and Kenny [23]. They suggested that a mediating role can be identified by using the following regression equations: (a) regressing the mediator on the independent variable, (b) regressing the dependent variable on the independent variable, and (c) regressing the dependent variable on both the independent variable and on the mediator. The following conditions must hold true to establish mediation from the results: (a) the independent variable must affect the mediator in the first equation, (b) the independent variable must affect the dependent variable in the second equation, and (c) the mediator must affect the dependent variable in the third equation. If these conditions all hold as predicted, then the effect of the independent variable on the dependent variable must be less in the third equation than in the second. Perfect mediation holds if the independent variable has no effect when the mediator is controlled. Partial mediation holds if the independent variable has an effect when the mediator is controlled. Results
PCP
Baseline characteristics of participants
PCP has been defined as an individual's positive psychological state [22]. The Korean version of the Pychological Capital Questionnaire was used to assess the PCP level of nurses. It consists of 24 items on the following four subscales: self-efficacy (6 items), hope (6 items), resilience (6 items), and optimism (6 items). Each item was measured through a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). Luthans et al [22] stated that the four components of PCP (efficacy, optimism, hope, and resilience) should not be examined separately but rather collectively, and that the factors have synergistic effects, which can yield stronger explanatory power. Luthans et al reported average scores from all 24 items, with higher scores signifying an increased level of positive PCP [22]. According to a study conducted in South Korea by Ko et al [18], the Cronbach a for PCP was .93. In this study, Cronbach a for PCP was .93.
Of the participants in this study, 98.7% were female, with the highest proportion in their 20s (43.6%), followed by those in their 30s (34.5%) and 40s (17.9%). Approximately half (51.7%) were married. In terms of educational level, the greatest proportion had a bachelor's degree (46.1%) and a slightly lower percentage had a 3year college degree (43.0%). With regard to the occupational level, general-duty nurse (85.2%) was the most common position, while head nurse (5.8%) was the least common position. Nurses with more than 5 years, but less than 10 years, of work experience (28.2%) were the most common, with having more than 15 years of experience (26.2%) being the next common. Nurses with less than 1 year of experience comprised 3.1% of the participants (Table 1).
Ethical considerations This study was approved by the Bohun Medical Center's Institutional Review Board (Human 2014-06-02). All participants provided informed consent prior to answering the questionnaires. To
Occupational stress based on participants' demographics For all nurses, the average level of occupational stress was 1.8 ± 0.2. Results showed that there were statistically significant differences in the level of occupational stress based on occupational level and length of job experience as a nurse (p ¼ .022, p ¼ .015). The general-duty nurses (1.8 ± 0.2) reported a higher level of occupational stress compared to that reported by head nurses (1.7 ± 0.2). Although there were statistically significant differences
Please cite this article in press as: Yim H-Y, et al., Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention among Nurses at Veterans Administration Hospitals in Korea, Asian Nursing Research (2017), http://dx.doi.org/10.1016/ j.anr.2017.01.002
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Table 1 Participant Demographics and Levels of Occupational Stress, Turnover Intention, and Psychological Capital (N ¼ 447). Variable
N
%
Occupational stress M ± SD
Total 447 100.0 Gender Male 6 1.3 Female 441 98.7 Age 20e29 (a) 195 43.6 30e39 (b) 154 34.5 40e49 (c) 80 17.9 50e59 (d) 18 4.0 Marital status Married 231 51.7 Unmarried 216 48.3 Educational level 3-yr college (a) 192 43.0 Bachelor's (b) 206 46.1 Master's or higher (c) 49 11.0 Occupational level General-duty nurse (a) 381 85.2 Supervising nurse (b) 40 8.9 Head nurse (c) 26 5.8 Length of job experience as a nurse (yrs) < 1 (a) 14 3.1 1, but < 3 (b) 54 12.1 3, but < 5(c) 69 15.4 5, but < 10 (d) 126 28.2 10, but < 15 (e) 67 15.0 15 (f) 117 26.2
F or t
Turnover intention p
1.8 ± 0.2 1.7 ± 0.4 1.8 ± 0.2
M ± SD
F or t
Psychological capital p
3.3 ± 0.9
M ± SD
F or t
p
3.9 ± 0.5
0.45
.673
3.6 ± 1.0 3.3 ± 0.9
0.83
.405
4.0 ± 0.6 3.9 ± 0.5
0.35
0.2 0.2 0.2 0.2
1.59
.192
3.4 3.4 3.0 2.6
± ± ± ±
0.8 0.8 0.9 1.0
9.97
< .001 a, b > c, d
3.8 4.0 4.2 4.5
± ± ± ±
0.5 0.5 0.5 0.3
25.21
< .001 a < c, d b < c, d
1.8 ± 0.2 1.8 ± 0.2
0.89
.376
3.3 ± 0.9 3.2 ± 0.9
1.49
.138
3.8 ± 0.5 4.1 ± 0.5
0.54
< .001
1.8 ± 0.3 1.8 ± 0.2 1.8 ± 0.2
2.00
.136
3.4 ± 0.8 3.2 ± 0.9 3.1 ± 1.1
3.65
.027
3.8 ± 0.5 4.0 ± 0.5 4.3 ± 0.5
19.39
< .001 a
1.8 ± 0.2 1.8 ± 0.2 1.7 ± 0.2
3.84
.022 a>c
3.4 ± 0.8 2.8 ± 0.8 2.6 ± 1.0
16.58
< .001 a > b, c
3.9 ± 0.5 4.3 ± 0.5 4.4 ± 0.4
25.28
< .001 a < b, c
± ± ± ± ± ±
2.86
.015
2.4 3.2 3.5 3.5 3.4 3.0
± ± ± ± ± ±
9.00
< .001 a < c, d, e c, d > f
3.8 3.8 3.8 3.8 4.0 4.3
± ± ± ± ± ±
15.75
< .001 a, b, c, d, e < f
1.8 1.8 1.8 1.7
1.6 1.8 1.8 1.8 1.8 1.8
± ± ± ±
0.2 0.2 0.3 0.2 0.2 0.2
in the level of occupational stress among groups based on their length of work experience, this study did not examine these differences in any further detail (Table 1). Turnover intention based on participants' demographics The average level of turnover intention for nurses was 3.3 ± 0.9. This study found statistically significant differences in the level of turnover intention among nurses based on their age, educational level, occupational level, and length of work experience as a nurse (p < .001, p ¼ .027, p < .001, p < .001, respectively). Nurses in their 20s and 30s had a higher level of turnover intention (3.4 ± 0.8) compared to nurses in their 40s (3.0 ± 0.9) and 50s (2.6 ± 1.0). Among all educational levels, there were statistically significant differences in the level of turnover intention; however, this study did not examine the contributing factors. The general-duty nurses (3.4 ± 0.8) had higher levels of turnover intention compared to that of nurses at all other occupational levels. In terms of the length of work experience as a nurse, those with 1e15 years of experience had a higher level of turnover intention than did those with less than 1 year of work experience (2.4 ± 0.5). Furthermore, those with 3e10 years of experience had a higher level of turnover intention compared to nurses with more than 15 years of work experience (3.0 ± 0.9) (Table 1). PCP based on participants' demographics The average PCP level was 3.9 ± 0.5. Nurses' level of PCP was significantly different across ages, marital status, educational levels, occupational levels, and length of work experience as a nurse (p < .001). Nurses in their 40s (4.2 ± 0.5) and 50s (4.5 ± 0.3) had a higher level of PCP than did those in their 20s (3.8 ± 0.5) and 30s (4.0 ± 0.5). Nurses who were unmarried (4.1 ± 0.5) had a higher level of PCP than did those who were married (3.8 ± 0.5). In terms of the impact of educational level on PCP, nurses who had earned more than one master's degree (4.3 ± 0.5) had the highest PCP,
0.5 0.8 0.9 0.8 0.8 0.9
0.5 0.5 0.5 0.5 0.5 0.5
.725
followed by nurses who had earned a bachelor's degree (4.0 ± 0.5) or those who had earned a 3-year college degree (3.8 ± 0.5). Nurses at higher occupational levels had higher levels of PCP compared to nurses at lower levels did. This observation is supported by the high levels of PCP reported by supervising nurses (4.3 ± 0.5) and head nurses (4.4 ± 0.4) compared with that of general-duty nurses (3.9 ± 0.5). In addition, nurses with more than 15 years of experience (4.3 ± 0.5) had higher levels of PCP than did those with less than 15 years of experience (Table 1). Correlations Occupational stress and turnover intention had a statistically significant, positive correlation (r ¼ .52, p < .001). Occupational stress and PCP had a statistically significant, negative correlation (r ¼ .47, p < .001). PCP also had a statistically significant, negative correlation with turnover intention (r ¼ .39, p < .001) (Table 2). Mediating role of PCP in relationship between occupational stress and turnover intention To examine the mediating role of PCP in the relationship between occupational stress and turnover intention, three regression analyses were conducted (Table 3) [23]. First, we observed a sta- Q4 tistically significant negative impact of occupational stress on PCP (b ¼ 0.984, p < .001). Second, we observed that occupational Table 2 Correlations among Occupational Stress, Turnover Intention, and Psychological Capital (N ¼ 447). Variable
OS TI PCP
OS
TI
PCP
r (p)
r (p)
r (p)
.52 (< .001) .47 (< .001)
1 .39 (< .001)
1
1
Note. OS ¼ occupational stress; PCP ¼ psychological capital; TI ¼ turnover intention.
Please cite this article in press as: Yim H-Y, et al., Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention among Nurses at Veterans Administration Hospitals in Korea, Asian Nursing Research (2017), http://dx.doi.org/10.1016/ j.anr.2017.01.002
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H.-Y. Yim et al. / Asian Nursing Research xxx (2017) 1e7 Table 3 Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention (N ¼ 447). Stepsa
b (p)
t
R2
1. OS / PCP 0.984 (< .001) 11.35 0.357 2. OS / TI 1.860 (< .001) 12.59 0.317 3. OS, PCP / TI 0.328 PCP / TI 0.216 (.008) 2.69 OS / TI 1.647 (< .001) 9.87
Adjusted R2
F (p)
0.350 0.310 0.319
48.96 (< .001) 40.92 (< .001) 35.78 (< .001)
Note. OS ¼ occupational stress; PCP ¼ psychological capital; TI ¼ turnover intention. a Values were adjusted for age, marital status, educational level, and occupational level.
stress had a statistically significant positive impact on turnover intention (b ¼ 1.860, p < .001). Lastly, a model that considered both occupational stress, as an independent variable, and PCP, as the mediator, revealed that PCP had a statistically significant negative impact on turnover intention (b ¼ 0.216, p ¼ .008) The model also indicated that the b value of occupational stress equaled 1.647, which was lower than the b value from the second analysis (1.860). Furthermore, this model highlighted the statistically significant impact of occupational stress on turnover intention (p < .001). Therefore, our results suggest that PCP plays a partial mediating role in the relationship between occupational stress and turnover intention. Discussion The chronic shortage of nurses in South Korea is a domestic and international issue. This research was conducted to demonstrate the importance of PCP by investigating its mediating role in the relationship between occupational stress and turnover intention and to provide fundamental information for the development of the nursing workforce management plan, which is essential in preventing nurse turnover. The levels of occupational stress reported by nurses in this study were lower than those reported previously [4]. The reason for this difference might be that nurses enrolled in this study were from Veterans Administration Hospitals, which tend to have more patients with chronic than with acute diseases. This affects the workload of nurses, as nurses at hospitals that have more patients with chronic diseases have lower workloads than those at hospitals having more patients with acute diseases. The results also revealed that general-duty nurses had higher levels of occupational stress than head nurses did, and that occupational stress differed by length of job experience. Because head nurses earn higher wages than general-duty nurses do, and wages increase with length of job experience, these findings appear to support previous research indicating that high annual wages (> $25,000) are related to high occupational stress levels [4]. Together, these results suggest that hospitals should provide occupational stress management programs for nurses, including head nurses, with more job experience. Study participants reported levels of occupational stress similar to those reported by workers in Korean conglomerates [24]. Overall, 15.2%e18.4% of Korean workers are exposed to high levels of occupational stress that can cause health problems, and the level of occupational stress reported by nurses is sufficient to affect their physical health [25]. Certain levels of stress are known to promote personal growth and increase productivity [10]. Alternatively, stress can have negative effects on both individual nurses and the organization (e.g., higher turnover, burnouts, increases in accidents). It is likely these errors occur when individuals are exposed to levels of stress that cannot be managed, or accumulate into a chronic condition [6].
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For these reasons, management of occupational stress should be an important aspect of the management of nurses. The nurses in this study reported levels of turnover intention similar to those reported in a previous study conducted in Korea [8]. However, the level of turnover intention among nurses in this study was higher than those reported by nurses within the United States and Europe, and among workers in various sectors in the United States [10,26,27]. This suggests that the level of turnover intention among Korean nurses is more likely to be higher than that in other developed countries. Turnover intention is a strong predictor of actual turnover in nurses [26]. The chronic shortage of nurses in South Korea because of high rates of nurse turnover is an important issue that must be addressed by the government. To tackle this problem, the Korean government has been helping in a number of ways, including expanding the number of nursing schools and finding work for unemployed registered nurses. Despite such efforts, the Korean government has failed to increase the number of practicing nurses. High staff turnover threatens the ability to secure quality human resources and leads to huge costs for recruitment and hiring. In addition, there is a decrease in the effectiveness and productivity of the organization [7]. Therefore, this is not only an issue that needs to be addressed by the government, but hospitals also need to play an active role in devising plans and strategies to prevent the loss of high-quality personnel. The results of this research revealed that turnover intention levels among nurses in their 20s and 30s were higher than those of nurses in their 40s and 50s, and also differed according to educational levels. Additionally, turnover intention was higher among general-duty nurses than among supervising nurses and head nurses, and those with less than 1 year of job experience as nurses had higher levels of turnover intention compared with those with more than 1 year of job experience. A review of turnover intention among Korean nurses identified the following factors affecting turnover intention level including age, educational level, work status, marriage status, type of work, level of experience, and salary [9]. These findings are similar to those of the current study, but the review did not clarify which values in terms of age, educational level, and so on were associated with the highest levels of turnover intention because the individual studies included in this issue were inconsistent, and the review could not directly compare the results. Therefore, it is difficult for us to directly compare our findings with that review. Research on turnover intention has been conducted for a long time within the Division of Nursing. In the future, it will be necessary to identify the characteristics of high-risk groups using systematic reviews and/or meta-analyses of previous research findings. Nurses in this study reported levels of PCP similar to those reported in previous studies [18]. However, the levels were lower than those reported in research that targeted physicians, as well as workers in various sectors, in the United States [10,28]. Collectively, Korean nurses appear to have lower PCP levels than do individuals in other occupations. PCP, which consists of efficacy, optimism, hope, and resilience, is positively associated with employees' exhibiting desirable attitudes (satisfaction, commitment, well-being), behaviors (citizenship behavior), and performance. It is negatively associated with undesirable attitudes (cynicism for change, stress, anxiety, turnover intention) and behaviors. Efficacy may derive from mastery experience, modeling, social persuasion, and physiological/psychological arousal [12]. Optimism is amenable to development through a three-step process, including leniency toward the past, appreciation for the present, and opportunity seeing for the future [14]. Hope can be built and supported via training interventions that focuses on designing goals, creating pathways, and overcoming obstacles [16]. Resilience may be built using positive emotions and
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altering the relative levels of perceived risk and personal assets [10]. Avey et al [10] proposed that combining the positive resources of efficacy, optimism, hope, and resilience could help with the development of practical guidelines for managing and better understanding the stress epidemic plaguing the workplace. To increase desirable attitudes, behaviors, and performance among employees, an intervention program that strengthens all components of PCP must be developed and implemented. The analysis of the relationships among occupational stress, turnover intention, and PCP revealed a moderate negative relationship between PCP and occupational stress, and a low negative relationship between PCP and turnover intention. These findings are consistent with those of prior research, and are related to PCP's role as a partial mediator in the relationship between occupational stress and turnover intention [10]. A previous study demonstrated that organizational commitment partially mediated the relationship between PCP and customer orientation, and also yielded the same findings regarding relationships [18]. Analysis of the mediating effects of PCP in the relationship between nurse occupational stress and turnover intentions verified that PCP had a partial mediating effect. Thus, increased nurse occupational stress levels result in indirectly and directly lowered levels of PCP and increases in turnover intention. Therefore, one important result of this study is the suggestion that, because PCP plays a partial mediating role between occupational stress and turnover intention, efforts must be made to increase PCP levels, specifically, occupational stress management programs to lower turnover intention. Previous research has demonstrated that individual-level programs for occupational stress management using cognitivebehavioral intervention and relaxation techniques are more effective than are organizational-level programs [29]. Furthermore, a team approach, including workers, health administrators, and managers is more effective than individual-approach programs. Luthans et al [30] developed instructions for strengthening the components of PCP using a Web-based intervention program. The intervention program includes two parts. The first develops and enhances resilience and efficacy by defining the concepts of resilience and efficacy and then presenting ways to implement them in the workplace. Afterward, subjects consider personal work-related situations in their own organization and carry out self-reflection exercises. The second part is intended to improve hope and optimism by helping workers to identify realistic, challenging goals and to break this goal into smaller goals to increase the capacity for hope. As goals appear more feasible, expectations of success in the applicable areas increase, ultimately influencing levels of optimism and hope. Based on the findings of these previous studies, occupational stress management programs should incorporate personal-level team approaches using cognitive-behavioral intervention and/or relaxation techniques as the main strategy for reducing nurse turnover intention [29,30]. This kind of program should also incorporate the PCP component-strengthening program suggested by Luthans et al [30]. Finally, this merged program should be assessed to verify its effectiveness. Currently, research on PCP within the division of nursing is in the initial stages. More research is needed to investigate the causal relationship and to explore the application and effects of PCP in lowering nurse turnover intention so as to produce concrete evidence for incorporating PCP into nursing workforce management plans. The results of this study demonstrated that the PCP has mediating effects in the relationship between nurse occupational stress and turnover intention. The findings are significant with regard to the importance of PCP in workforce management strategies to lower nurse turnover intention. However, the study has several
limitations. First, this study asked nurses employed in four of the five Veterans Administration Hospitals in Korea to participate, and so was considered a convenience sample. For this reason, it may be difficult to make generalizations about all clinical nurses from our findings. Second, this was a cross-sectional study, meaning that it was unable to account for alternative explanations of the order of variables. To understand the interactions between variables fully, a longitudinal study that accounts for the chronological context to determine the cause-and-effect relationships among occupational stress, PCP, and turnover intention is needed. Lastly, relationships between variables may be overstated due to the use of a selfreported questionnaire, which can lead to social desirability bias. These limitations must be considered when interpreting the results of this study. Conclusion To develop nurse workforce management strategies that reduce nurse turnover intention, this study measured levels of PCP, occupational stress, and turnover intention among nurses, and identified the mediating role of PCP in the relationship between occupational stress and turnover intention. Our results indicated that nurses working in Korea experience high levels of occupational stress and turnover intention and low levels of PCP compared with those in other occupations. Statistically significant associations were observed among all three variables, and PCP was shown to have a partial mediating role in the relationship between occupational stress and turnover intention. Based on the results of this study, we recommend that South Korean hospitals operate occupational stress management programs as the main program and incorporate accompanying programs that strengthen the overall components of PCP among nurses to reduce turnover intention. Further studies are required to determine the most effective intervention programs for implementation in hospital settings. Conflict of interest No conflict of interest has been declared by the authors. Acknowledgment
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Research Article
Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention among Nurses at Veterans Administration Hospitals in Korea Q9
Hee-Yun Yim, RN, MSc, 1 Hyun-Ju Seo, RN, MPH, PhD, 2 Yoonhyung Cho, PhD, 3 JinHee Kim, RN, MPH, PhD 2, * 1 2 3
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Nursing Department, Gwangju Veterans Administration Hospitals, Gwangju, South Korea Department of Nursing, College of Medicine, Chosun University, Gwangju, South Korea Department of Business Administration, College of Business, Chosun University, Gwangju, South Korea
a r t i c l e i n f o
s u m m a r y
Article history: Received 6 October 2015 Received in revised form 4 January 2017 Accepted 11 January 2017
Purpose: The aim of this study was to evaluate the mediating role of psychological capital (PCP) in the relationship between occupational stress and turnover intention in nurses. Methods: Data were collected from a sample of 447 nurses working at four Veterans Administration Hospitals throughout South Korea from July 1 to July 31, 2014. We collected data from the nurses using the following surveys: the Short Form Korean-Occupational Stress Scale, the Korean version of the Turnover Intention Scale, and the Korean version of the Psychological Capital Questionnaire. Multiple linear regression analysis was performed to examine the mediating role of PCP. Results: The level of occupational stress was 1.8 ± 0.2, the level of turnover intention was 3.3 ± 0.9, and the PCP level was 3.9 ± 0.5. There were significant correlations among the three variables (occupational stress, turnover intention, and PCP). PCP played a partial mediating role (b ¼ 0.216, p ¼ .008) in the relationship between occupational stress and turnover intention (p < .001) among nurses working at the Veterans Administration Hospitals. Conclusion: Based on the findings of this study, we recommend that South Korean hospitals offer occupational stress management programs that incorporate relevant programs in efforts to strengthen the overall components of PCP among nurses to reduce turnover intentions. Further studies are required to determine the most effective intervention programs for hospital settings. Copyright © 2017, Korean Society of Nursing Science. Published by Elsevier. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: nursing management occupational stress psychological turnover intention
Introduction Stress is defined as an individual perceiving external demands as being beyond his or her ability to cope with these demands [1]. More specifically, stress relates both to individuals' perceptions of the demands being made on them and to their perception of their capability to meet those demands [2]. Among health professionals, nurses experience the highest levels of occupational stress [3]. The occupational stress levels of nurses were reportedly 2.33e2.86 on a 4-point scale [4]. Major sources of stress for nurses are heavy workloads, leadership and management issues, interprofessional
* Correspondence to: JinHee Kim, RN, MPH, PhD, Department of Nursing, College of Medicine, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju, 501-759, South Korea. E-mail address: [email protected]
and intraprofessional conflicts, emotional demands of caring, lack of reward, role ambiguity, and shift work [5]. Research has demonstrated that occupational stress levels among nurses in Korea are particularly high when working durations exceed 3 years, when nurses work three different shifts, when salaries are high, and when nurses work on the general ward [4]. Occupational stress experienced by nurses can result in undesirable personal or organizational outcomes, including increased medical expenditures, burnout, increased accidents, and job dissatisfaction [6]. Among these negative outcomes, previous research has revealed a link between occupational stress and nurse turnover intention [7]. The turnover intentions of nurses were reportedly 3.28e3.51 on a 5-point scale [8]. General characteristics of nurses such as age, educational level, work status, marriage status, type of work, experience, salary, and so on are reportedly related to turnover intentions in Korea [9]. Nurse turnover is considered one factor that
http://dx.doi.org/10.1016/j.anr.2017.01.002 p1976-1317 e2093-7482/Copyright © 2017, Korean Society of Nursing Science. Published by Elsevier. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
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negatively affects the quality of nursing care and patient outcome. Nurse turnover makes it difficult for human resources to maintain or build a quality staff and can often lead to high costs for hiring and training new nurses. The results of these effects leave organizations with tremendous losses. Nurses who quit increase the workload for other nurses, which can often lead to a greater number of health problems, emotional exhaustion, and accidents (e.g., needlestick injuries) [7]. Prevention of nurse turnover is a major challenge for human resource management in hospitals. Instead of addressing the inadequacies of employees, employers take an interest in cultivating positivity for employees to improve their work environment. Focusing on employees' positive qualities is not merely an attempt to recognize the importance of positivity; it is also an employer's attempt to adapt a more constructive approach and to deviate from the mainstream approaches focused primarily on negative aspects [10]. The positive organizational behavior approach is the study and application of positive human resource strengths and psychological capacities that can be measured, developed, and effectively managed to improve performance in today's workplace [11]. Positive organizational behavior and the increasing attention to employees' positive characteristics have promoted a growing interest in psychological capital (PCP) within the field of human resource management. PCP is defined as an individual's positive psychological state of development [11]. It has four components: efficacy, optimism, hope, and resilience [11]. Efficacy is based on Bandura's Social Cognitive Theory and is defined as “one's conviction (or confidence) about his or her abilities to mobilize the motivation, cognitive resources, or courses of action needed to successfully execute a specific task within a given context” [12,13]. According to Seligman [14], optimism is the way in which a person interprets and understands recent or past experiences. Snyder et al [15] defined hope as a “positive motivational state based on an interactively derived sense of successful agency (goal-directed agency) and pathways (planning to meet goals)”. Hope does not merely involve willpower or the drive to achieve set goals; it also involves waypower, the capacity to maneuver and work around challenges that stand in the way of achieving goals [10]. The last component, resilience, can be understood as an individual's capacity to adapt after he or she has experienced something negative or positive [11]. Efficacy affects how individuals perceive and interpret events. Most human stress is dominated by beliefs about dealing with efficacy [12]. An individual with a higher level of optimism is less likely to experience symptoms of stress in the workplace [10]. Hope provides individuals with a positive resource for stressful work situations. An individual's level of hope protects him/her against perceptions of uncontrollability, vulnerability, and unpredictability [16]. Resilience is the most important positive resource when navigating a turbulent and stressful workplace [10]. Resilient individuals are better equipped to cope with stressors in a workplace environment that continues to change. This is because these individuals are open to new experiences, respond flexibly to changing demands, and demonstrate emotional stability when faced with adversity [17]. PCP is negatively related to occupational stress, and decreased PCP, along with occupational stress, is thought to increase turnover intention [7,10]. Research has revealed that an increase in occupational stress results in a decrease in the overall PCP of employees, triggering consideration of turnover among nurses [10]. In the field of nursing workforce management, active management of occupational stress is required to prevent nurse turnover. Additionally, serious consideration of the use of PCP, a positive resource for combating employee turnover that has been receiving much interest in the field of workforce management, is needed. PCP has
been introduced as a positive resource in aiding nurses to overcome exhaustion and in helping to increase organizational commitment and customer orientation [18,19]. Although the feasibility of PCP is being assessed in the field of nursing workforce management, no research has focused on the relationships among occupational stress, PCP, and turnover intention. This study yielded basic data related to building a workforce management plan to decrease nurse turnover by identifying whether PCP plays a mediating role in the relationship between occupational stress and turnover intention. Objective The objective of this study was to evaluate the mediating role of PCP in the relationship between occupational stress and turnover intention in nurses. To investigate this relationship, we measured the levels of occupational stress, turnover intention, and PCP in a large sample of nurses. We believe our findings provide basic information for developing more successful nursing workforce management strategies that will ultimately reduce nurse turnover intention. Specifically, our study had three purposes: (a) to measure the levels of occupational stress, turnover intention, and PCP in nurses; (b) to explore the differences associated with each of these factors; (c) to investigate the relationships among occupational stress, turnover intention, and PCP in nurses; and (d) to identify whether PCP plays a mediating role in the relationship between occupational stress and turnover intention in nurses. Methods Design This was a cross-sectional descriptive study aimed at identifying the mediating role of PCP in the relationship between occupational stress and turnover intention in nurses. Participants and data collection The participants in this research were registered nurses working at four Veterans Administration Hospitals. South Korea has five Veterans Administration Hospitals, but we collected data only from the four that were willing to cooperate with data collection. Researchers visited the nursing department at each hospital to request participation, and to explain the purpose of this study and the contents of the questionnaires. A total of 553 instructional documents, along with consent forms and prepaid envelopes, were distributed to nurses with the help of the nursing department (three hospitals received 130 documents each; the other hospital received 163 documents). Nurses were informed of the purpose of the study and completed a written consent form prior to participation. Of the 553 distributed questionnaires, 457 were collected, for a return percentage of 82.6%. Of the three hospitals that received 130 questionnaires, one returned 103 (return percentage, 79.2%), one returned 103 (return percentage, 79.2%), and one returned 108 (return percentage, 83.1%). The hospital that received 163 questionnaires returned 143 questionnaires (return percentage, 87.7%). Of the returned questionnaires, 10 were excluded from this analysis due to various reasons: 6 questionnaires were missing answers for five or more variables; the other 4 questionnaires had fewer than five missing answers but included two or more with multiple responses. We believe that excluding these questionnaires, which were filled out with little sincerity, had no effect on the study results. All questionnaires were collected in a sealed envelope by mail or by the education head nurse with support from the division of nursing service. The data were collected from July 1st, 2014 to July 31st, 2014.
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Questionnaires and measurements Previously published and validated measures were used in this study. Questionnaires consisted of demographic questions (e.g., gender, age, marital status, educational level, occupational level, length of work experience as a nurse) and three scales that measured occupational stress, turnover intention, and PCP.
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guarantee the anonymity of nurses' identity, a prepaid envelope was provided with the questionnaire and only personal information absolutely necessary for this study was collected. Participants were informed that all information provided in the study would remain confidential and that all findings would be reported anonymously. Data analysis
Occupational stress Occupational stress was defined as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker [20]. To adjust to the South Korean context, occupational stress was measured using the Short Form Korean Occupational Stress Scale developed by Chang et al [21]. The scale is composed of 24 items from the following seven subscales: job demand, insufficient job control, interpersonal conflict, job insecurity, organizational system, lack of reward, and occupational climate. Each item is rated by a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). For this scale, high scores correspond to high levels of occupational stress. In the Chang et al [21] study, the Cronbach a score for occupational stress ranged from .51e.82. In this study, Cronbach a for occupational stress was .76. Turnover intention
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Turnover intention was described as the process by which members of the nursing staff transfer or relinquish responsibilities within their organization [7]. The Korean version of the Turnover Intention Scale was used to assess turnover intention of nurses. The Turnover Intention Scale consists of four items, with each item on a 4-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). For this scale, a higher score corresponded to higher rates of turnover intention. The reported score was an average of the scores for all four items. According to a study conducted in South Korea by Kim and Lee, the Cronbach a for turnover intention was .87 [8]. In this study, the Cronbach a for turnover intention was .87.
Data were analyzed using the SAS statistical software, version 9.2 (SAS Institute, Cary, NJ, USA). First, general characteristics of participants were expressed in terms of frequencies and percentages. Means and standard deviations were calculated to determine the nurses' level of occupational stress, turnover intention, and PCP. To analyze differences in the levels of occupational stress, turnover intention, and PCP based on the respondent's general characteris's test were tics, a t test or one-way analysis of variance and Scheffe utilized. Pearson's correlation coefficient was used to examine the relationships among occupational stress, turnover intention, and PCP. To examine the mediating role of PCP in the relationship between occupational stress and turnover intention, we utilized the method of Baron and Kenny [23]. They suggested that a mediating role can be identified by using the following regression equations: (a) regressing the mediator on the independent variable, (b) regressing the dependent variable on the independent variable, and (c) regressing the dependent variable on both the independent variable and on the mediator. The following conditions must hold true to establish mediation from the results: (a) the independent variable must affect the mediator in the first equation, (b) the independent variable must affect the dependent variable in the second equation, and (c) the mediator must affect the dependent variable in the third equation. If these conditions all hold as predicted, then the effect of the independent variable on the dependent variable must be less in the third equation than in the second. Perfect mediation holds if the independent variable has no effect when the mediator is controlled. Partial mediation holds if the independent variable has an effect when the mediator is controlled. Results
PCP
Baseline characteristics of participants
PCP has been defined as an individual's positive psychological state [22]. The Korean version of the Pychological Capital Questionnaire was used to assess the PCP level of nurses. It consists of 24 items on the following four subscales: self-efficacy (6 items), hope (6 items), resilience (6 items), and optimism (6 items). Each item was measured through a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). Luthans et al [22] stated that the four components of PCP (efficacy, optimism, hope, and resilience) should not be examined separately but rather collectively, and that the factors have synergistic effects, which can yield stronger explanatory power. Luthans et al reported average scores from all 24 items, with higher scores signifying an increased level of positive PCP [22]. According to a study conducted in South Korea by Ko et al [18], the Cronbach a for PCP was .93. In this study, Cronbach a for PCP was .93.
Of the participants in this study, 98.7% were female, with the highest proportion in their 20s (43.6%), followed by those in their 30s (34.5%) and 40s (17.9%). Approximately half (51.7%) were married. In terms of educational level, the greatest proportion had a bachelor's degree (46.1%) and a slightly lower percentage had a 3year college degree (43.0%). With regard to the occupational level, general-duty nurse (85.2%) was the most common position, while head nurse (5.8%) was the least common position. Nurses with more than 5 years, but less than 10 years, of work experience (28.2%) were the most common, with having more than 15 years of experience (26.2%) being the next common. Nurses with less than 1 year of experience comprised 3.1% of the participants (Table 1).
Ethical considerations This study was approved by the Bohun Medical Center's Institutional Review Board (Human 2014-06-02). All participants provided informed consent prior to answering the questionnaires. To
Occupational stress based on participants' demographics For all nurses, the average level of occupational stress was 1.8 ± 0.2. Results showed that there were statistically significant differences in the level of occupational stress based on occupational level and length of job experience as a nurse (p ¼ .022, p ¼ .015). The general-duty nurses (1.8 ± 0.2) reported a higher level of occupational stress compared to that reported by head nurses (1.7 ± 0.2). Although there were statistically significant differences
Please cite this article in press as: Yim H-Y, et al., Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention among Nurses at Veterans Administration Hospitals in Korea, Asian Nursing Research (2017), http://dx.doi.org/10.1016/ j.anr.2017.01.002
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Table 1 Participant Demographics and Levels of Occupational Stress, Turnover Intention, and Psychological Capital (N ¼ 447). Variable
N
%
Occupational stress M ± SD
Total 447 100.0 Gender Male 6 1.3 Female 441 98.7 Age 20e29 (a) 195 43.6 30e39 (b) 154 34.5 40e49 (c) 80 17.9 50e59 (d) 18 4.0 Marital status Married 231 51.7 Unmarried 216 48.3 Educational level 3-yr college (a) 192 43.0 Bachelor's (b) 206 46.1 Master's or higher (c) 49 11.0 Occupational level General-duty nurse (a) 381 85.2 Supervising nurse (b) 40 8.9 Head nurse (c) 26 5.8 Length of job experience as a nurse (yrs) < 1 (a) 14 3.1 1, but < 3 (b) 54 12.1 3, but < 5(c) 69 15.4 5, but < 10 (d) 126 28.2 10, but < 15 (e) 67 15.0 15 (f) 117 26.2
F or t
Turnover intention p
1.8 ± 0.2 1.7 ± 0.4 1.8 ± 0.2
M ± SD
F or t
Psychological capital p
3.3 ± 0.9
M ± SD
F or t
p
3.9 ± 0.5
0.45
.673
3.6 ± 1.0 3.3 ± 0.9
0.83
.405
4.0 ± 0.6 3.9 ± 0.5
0.35
0.2 0.2 0.2 0.2
1.59
.192
3.4 3.4 3.0 2.6
± ± ± ±
0.8 0.8 0.9 1.0
9.97
< .001 a, b > c, d
3.8 4.0 4.2 4.5
± ± ± ±
0.5 0.5 0.5 0.3
25.21
< .001 a < c, d b < c, d
1.8 ± 0.2 1.8 ± 0.2
0.89
.376
3.3 ± 0.9 3.2 ± 0.9
1.49
.138
3.8 ± 0.5 4.1 ± 0.5
0.54
< .001
1.8 ± 0.3 1.8 ± 0.2 1.8 ± 0.2
2.00
.136
3.4 ± 0.8 3.2 ± 0.9 3.1 ± 1.1
3.65
.027
3.8 ± 0.5 4.0 ± 0.5 4.3 ± 0.5
19.39
< .001 a
1.8 ± 0.2 1.8 ± 0.2 1.7 ± 0.2
3.84
.022 a>c
3.4 ± 0.8 2.8 ± 0.8 2.6 ± 1.0
16.58
< .001 a > b, c
3.9 ± 0.5 4.3 ± 0.5 4.4 ± 0.4
25.28
< .001 a < b, c
± ± ± ± ± ±
2.86
.015
2.4 3.2 3.5 3.5 3.4 3.0
± ± ± ± ± ±
9.00
< .001 a < c, d, e c, d > f
3.8 3.8 3.8 3.8 4.0 4.3
± ± ± ± ± ±
15.75
< .001 a, b, c, d, e < f
1.8 1.8 1.8 1.7
1.6 1.8 1.8 1.8 1.8 1.8
± ± ± ±
0.2 0.2 0.3 0.2 0.2 0.2
in the level of occupational stress among groups based on their length of work experience, this study did not examine these differences in any further detail (Table 1). Turnover intention based on participants' demographics The average level of turnover intention for nurses was 3.3 ± 0.9. This study found statistically significant differences in the level of turnover intention among nurses based on their age, educational level, occupational level, and length of work experience as a nurse (p < .001, p ¼ .027, p < .001, p < .001, respectively). Nurses in their 20s and 30s had a higher level of turnover intention (3.4 ± 0.8) compared to nurses in their 40s (3.0 ± 0.9) and 50s (2.6 ± 1.0). Among all educational levels, there were statistically significant differences in the level of turnover intention; however, this study did not examine the contributing factors. The general-duty nurses (3.4 ± 0.8) had higher levels of turnover intention compared to that of nurses at all other occupational levels. In terms of the length of work experience as a nurse, those with 1e15 years of experience had a higher level of turnover intention than did those with less than 1 year of work experience (2.4 ± 0.5). Furthermore, those with 3e10 years of experience had a higher level of turnover intention compared to nurses with more than 15 years of work experience (3.0 ± 0.9) (Table 1). PCP based on participants' demographics The average PCP level was 3.9 ± 0.5. Nurses' level of PCP was significantly different across ages, marital status, educational levels, occupational levels, and length of work experience as a nurse (p < .001). Nurses in their 40s (4.2 ± 0.5) and 50s (4.5 ± 0.3) had a higher level of PCP than did those in their 20s (3.8 ± 0.5) and 30s (4.0 ± 0.5). Nurses who were unmarried (4.1 ± 0.5) had a higher level of PCP than did those who were married (3.8 ± 0.5). In terms of the impact of educational level on PCP, nurses who had earned more than one master's degree (4.3 ± 0.5) had the highest PCP,
0.5 0.8 0.9 0.8 0.8 0.9
0.5 0.5 0.5 0.5 0.5 0.5
.725
followed by nurses who had earned a bachelor's degree (4.0 ± 0.5) or those who had earned a 3-year college degree (3.8 ± 0.5). Nurses at higher occupational levels had higher levels of PCP compared to nurses at lower levels did. This observation is supported by the high levels of PCP reported by supervising nurses (4.3 ± 0.5) and head nurses (4.4 ± 0.4) compared with that of general-duty nurses (3.9 ± 0.5). In addition, nurses with more than 15 years of experience (4.3 ± 0.5) had higher levels of PCP than did those with less than 15 years of experience (Table 1). Correlations Occupational stress and turnover intention had a statistically significant, positive correlation (r ¼ .52, p < .001). Occupational stress and PCP had a statistically significant, negative correlation (r ¼ .47, p < .001). PCP also had a statistically significant, negative correlation with turnover intention (r ¼ .39, p < .001) (Table 2). Mediating role of PCP in relationship between occupational stress and turnover intention To examine the mediating role of PCP in the relationship between occupational stress and turnover intention, three regression analyses were conducted (Table 3) [23]. First, we observed a sta- Q4 tistically significant negative impact of occupational stress on PCP (b ¼ 0.984, p < .001). Second, we observed that occupational Table 2 Correlations among Occupational Stress, Turnover Intention, and Psychological Capital (N ¼ 447). Variable
OS TI PCP
OS
TI
PCP
r (p)
r (p)
r (p)
.52 (< .001) .47 (< .001)
1 .39 (< .001)
1
1
Note. OS ¼ occupational stress; PCP ¼ psychological capital; TI ¼ turnover intention.
Please cite this article in press as: Yim H-Y, et al., Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention among Nurses at Veterans Administration Hospitals in Korea, Asian Nursing Research (2017), http://dx.doi.org/10.1016/ j.anr.2017.01.002
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H.-Y. Yim et al. / Asian Nursing Research xxx (2017) 1e7 Table 3 Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention (N ¼ 447). Stepsa
b (p)
t
R2
1. OS / PCP 0.984 (< .001) 11.35 0.357 2. OS / TI 1.860 (< .001) 12.59 0.317 3. OS, PCP / TI 0.328 PCP / TI 0.216 (.008) 2.69 OS / TI 1.647 (< .001) 9.87
Adjusted R2
F (p)
0.350 0.310 0.319
48.96 (< .001) 40.92 (< .001) 35.78 (< .001)
Note. OS ¼ occupational stress; PCP ¼ psychological capital; TI ¼ turnover intention. a Values were adjusted for age, marital status, educational level, and occupational level.
stress had a statistically significant positive impact on turnover intention (b ¼ 1.860, p < .001). Lastly, a model that considered both occupational stress, as an independent variable, and PCP, as the mediator, revealed that PCP had a statistically significant negative impact on turnover intention (b ¼ 0.216, p ¼ .008) The model also indicated that the b value of occupational stress equaled 1.647, which was lower than the b value from the second analysis (1.860). Furthermore, this model highlighted the statistically significant impact of occupational stress on turnover intention (p < .001). Therefore, our results suggest that PCP plays a partial mediating role in the relationship between occupational stress and turnover intention. Discussion The chronic shortage of nurses in South Korea is a domestic and international issue. This research was conducted to demonstrate the importance of PCP by investigating its mediating role in the relationship between occupational stress and turnover intention and to provide fundamental information for the development of the nursing workforce management plan, which is essential in preventing nurse turnover. The levels of occupational stress reported by nurses in this study were lower than those reported previously [4]. The reason for this difference might be that nurses enrolled in this study were from Veterans Administration Hospitals, which tend to have more patients with chronic than with acute diseases. This affects the workload of nurses, as nurses at hospitals that have more patients with chronic diseases have lower workloads than those at hospitals having more patients with acute diseases. The results also revealed that general-duty nurses had higher levels of occupational stress than head nurses did, and that occupational stress differed by length of job experience. Because head nurses earn higher wages than general-duty nurses do, and wages increase with length of job experience, these findings appear to support previous research indicating that high annual wages (> $25,000) are related to high occupational stress levels [4]. Together, these results suggest that hospitals should provide occupational stress management programs for nurses, including head nurses, with more job experience. Study participants reported levels of occupational stress similar to those reported by workers in Korean conglomerates [24]. Overall, 15.2%e18.4% of Korean workers are exposed to high levels of occupational stress that can cause health problems, and the level of occupational stress reported by nurses is sufficient to affect their physical health [25]. Certain levels of stress are known to promote personal growth and increase productivity [10]. Alternatively, stress can have negative effects on both individual nurses and the organization (e.g., higher turnover, burnouts, increases in accidents). It is likely these errors occur when individuals are exposed to levels of stress that cannot be managed, or accumulate into a chronic condition [6].
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For these reasons, management of occupational stress should be an important aspect of the management of nurses. The nurses in this study reported levels of turnover intention similar to those reported in a previous study conducted in Korea [8]. However, the level of turnover intention among nurses in this study was higher than those reported by nurses within the United States and Europe, and among workers in various sectors in the United States [10,26,27]. This suggests that the level of turnover intention among Korean nurses is more likely to be higher than that in other developed countries. Turnover intention is a strong predictor of actual turnover in nurses [26]. The chronic shortage of nurses in South Korea because of high rates of nurse turnover is an important issue that must be addressed by the government. To tackle this problem, the Korean government has been helping in a number of ways, including expanding the number of nursing schools and finding work for unemployed registered nurses. Despite such efforts, the Korean government has failed to increase the number of practicing nurses. High staff turnover threatens the ability to secure quality human resources and leads to huge costs for recruitment and hiring. In addition, there is a decrease in the effectiveness and productivity of the organization [7]. Therefore, this is not only an issue that needs to be addressed by the government, but hospitals also need to play an active role in devising plans and strategies to prevent the loss of high-quality personnel. The results of this research revealed that turnover intention levels among nurses in their 20s and 30s were higher than those of nurses in their 40s and 50s, and also differed according to educational levels. Additionally, turnover intention was higher among general-duty nurses than among supervising nurses and head nurses, and those with less than 1 year of job experience as nurses had higher levels of turnover intention compared with those with more than 1 year of job experience. A review of turnover intention among Korean nurses identified the following factors affecting turnover intention level including age, educational level, work status, marriage status, type of work, level of experience, and salary [9]. These findings are similar to those of the current study, but the review did not clarify which values in terms of age, educational level, and so on were associated with the highest levels of turnover intention because the individual studies included in this issue were inconsistent, and the review could not directly compare the results. Therefore, it is difficult for us to directly compare our findings with that review. Research on turnover intention has been conducted for a long time within the Division of Nursing. In the future, it will be necessary to identify the characteristics of high-risk groups using systematic reviews and/or meta-analyses of previous research findings. Nurses in this study reported levels of PCP similar to those reported in previous studies [18]. However, the levels were lower than those reported in research that targeted physicians, as well as workers in various sectors, in the United States [10,28]. Collectively, Korean nurses appear to have lower PCP levels than do individuals in other occupations. PCP, which consists of efficacy, optimism, hope, and resilience, is positively associated with employees' exhibiting desirable attitudes (satisfaction, commitment, well-being), behaviors (citizenship behavior), and performance. It is negatively associated with undesirable attitudes (cynicism for change, stress, anxiety, turnover intention) and behaviors. Efficacy may derive from mastery experience, modeling, social persuasion, and physiological/psychological arousal [12]. Optimism is amenable to development through a three-step process, including leniency toward the past, appreciation for the present, and opportunity seeing for the future [14]. Hope can be built and supported via training interventions that focuses on designing goals, creating pathways, and overcoming obstacles [16]. Resilience may be built using positive emotions and
Please cite this article in press as: Yim H-Y, et al., Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention among Nurses at Veterans Administration Hospitals in Korea, Asian Nursing Research (2017), http://dx.doi.org/10.1016/ j.anr.2017.01.002
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altering the relative levels of perceived risk and personal assets [10]. Avey et al [10] proposed that combining the positive resources of efficacy, optimism, hope, and resilience could help with the development of practical guidelines for managing and better understanding the stress epidemic plaguing the workplace. To increase desirable attitudes, behaviors, and performance among employees, an intervention program that strengthens all components of PCP must be developed and implemented. The analysis of the relationships among occupational stress, turnover intention, and PCP revealed a moderate negative relationship between PCP and occupational stress, and a low negative relationship between PCP and turnover intention. These findings are consistent with those of prior research, and are related to PCP's role as a partial mediator in the relationship between occupational stress and turnover intention [10]. A previous study demonstrated that organizational commitment partially mediated the relationship between PCP and customer orientation, and also yielded the same findings regarding relationships [18]. Analysis of the mediating effects of PCP in the relationship between nurse occupational stress and turnover intentions verified that PCP had a partial mediating effect. Thus, increased nurse occupational stress levels result in indirectly and directly lowered levels of PCP and increases in turnover intention. Therefore, one important result of this study is the suggestion that, because PCP plays a partial mediating role between occupational stress and turnover intention, efforts must be made to increase PCP levels, specifically, occupational stress management programs to lower turnover intention. Previous research has demonstrated that individual-level programs for occupational stress management using cognitivebehavioral intervention and relaxation techniques are more effective than are organizational-level programs [29]. Furthermore, a team approach, including workers, health administrators, and managers is more effective than individual-approach programs. Luthans et al [30] developed instructions for strengthening the components of PCP using a Web-based intervention program. The intervention program includes two parts. The first develops and enhances resilience and efficacy by defining the concepts of resilience and efficacy and then presenting ways to implement them in the workplace. Afterward, subjects consider personal work-related situations in their own organization and carry out self-reflection exercises. The second part is intended to improve hope and optimism by helping workers to identify realistic, challenging goals and to break this goal into smaller goals to increase the capacity for hope. As goals appear more feasible, expectations of success in the applicable areas increase, ultimately influencing levels of optimism and hope. Based on the findings of these previous studies, occupational stress management programs should incorporate personal-level team approaches using cognitive-behavioral intervention and/or relaxation techniques as the main strategy for reducing nurse turnover intention [29,30]. This kind of program should also incorporate the PCP component-strengthening program suggested by Luthans et al [30]. Finally, this merged program should be assessed to verify its effectiveness. Currently, research on PCP within the division of nursing is in the initial stages. More research is needed to investigate the causal relationship and to explore the application and effects of PCP in lowering nurse turnover intention so as to produce concrete evidence for incorporating PCP into nursing workforce management plans. The results of this study demonstrated that the PCP has mediating effects in the relationship between nurse occupational stress and turnover intention. The findings are significant with regard to the importance of PCP in workforce management strategies to lower nurse turnover intention. However, the study has several
limitations. First, this study asked nurses employed in four of the five Veterans Administration Hospitals in Korea to participate, and so was considered a convenience sample. For this reason, it may be difficult to make generalizations about all clinical nurses from our findings. Second, this was a cross-sectional study, meaning that it was unable to account for alternative explanations of the order of variables. To understand the interactions between variables fully, a longitudinal study that accounts for the chronological context to determine the cause-and-effect relationships among occupational stress, PCP, and turnover intention is needed. Lastly, relationships between variables may be overstated due to the use of a selfreported questionnaire, which can lead to social desirability bias. These limitations must be considered when interpreting the results of this study. Conclusion To develop nurse workforce management strategies that reduce nurse turnover intention, this study measured levels of PCP, occupational stress, and turnover intention among nurses, and identified the mediating role of PCP in the relationship between occupational stress and turnover intention. Our results indicated that nurses working in Korea experience high levels of occupational stress and turnover intention and low levels of PCP compared with those in other occupations. Statistically significant associations were observed among all three variables, and PCP was shown to have a partial mediating role in the relationship between occupational stress and turnover intention. Based on the results of this study, we recommend that South Korean hospitals operate occupational stress management programs as the main program and incorporate accompanying programs that strengthen the overall components of PCP among nurses to reduce turnover intention. Further studies are required to determine the most effective intervention programs for implementation in hospital settings. Conflict of interest No conflict of interest has been declared by the authors. Acknowledgment
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Please cite this article in press as: Yim H-Y, et al., Mediating Role of Psychological Capital in Relationship between Occupational Stress and Turnover Intention among Nurses at Veterans Administration Hospitals in Korea, Asian Nursing Research (2017), http://dx.doi.org/10.1016/ j.anr.2017.01.002
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