Review of nursing turnover research, 1977–1996

PII:

Soc. Sci. Med. Vol. 47, No. 12, pp. 1905±1924, 1998 # 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain S0277-9536(98)00333-5 0277-9536/98/$ - see front matter

REVIEW OF NURSING TURNOVER RESEARCH, 1977±1996 TERESA WAI CHI TAI,1* SHERRY I. BAME2,3 and CHESTER D. ROBINSON4 Department of Health Management, Quinnipiac College, Hamden, CT, U.S.A., 2Department of Urban Planning, Texas A&M University, College Station, TX, U.S.A., 3Department of Family and Community Medicine, Texas A&M University, College Station, TX, U.S.A. and 4Institute of Medical Economics, Bryan, TX, U.S.A.

1

AbstractÐTurnover represents a major problem for health care services in terms of cost and quality of care given. As a result, turnover has been the subject of a large number of investigations. However, the variety of study populations, research methodologies, and inconsistent de®nitions and measurements of turnover lead to diculties when attempting to compare studies. The purpose of this paper is to present: (1) a summary of turnover study methods and procedures, and (2) a summary of socio-demographic, organizational, and social support factors associated with turnover of nursing sta€. # 1998 Elsevier Science Ltd. All rights reserved Key wordsÐnursing turnover, sta€ demographics, organizational characteristics, social support, quality of work life

INTRODUCTION

Sta€ turnover in health facilities reduces both the e€ectiveness and the productivity of delivering care and adds to labor costs of operating facilities (Price and Mueller, 1986). Ineciencies of incoming employees, of co-workers, of the position while vacant, and of the departing employee, while dicult to estimate, are detrimental to the quality and cost-e€ectiveness of patient care (Phillips, 1990). Turnover has a negative impact on the cohesiveness of the work unit (Mueller and Price, 1989). In addition, the additional burden put on the remaining sta€ during the transition period until a new person is hired and trained may create a stressful climate fostering further turnover (Abelson, 1986). These factors may undermine a health care organization's survival in a highly changing and uncertain environment (Sofaer and Myrtle, 1991). Sta€ socio-demographic characteristics, personality, and professionalism have been proven signi®cantly associated with turnover behavior within health care organizations. However, less is known about how sta€'s perceptions and use of social support, as well as how the organization itself, a€ects turnover. The purpose of this paper is to present: (1) a review of nursing turnover studies over the twenty year period from 1977 to 1996; and (2) a summary of associations of turnover behavior with nursing employees' socio-demographic factors, facility organizational characteristics, and social support characteristics (see Table 1). This paper provides a concise examination of turnover studies of particular interest to health care *Author for correspondence.

providers. First, this literature review will alert researchers about the variation in turnover measurement and encourage use of a consistent measurement of turnover in future studies. Second, this review highlights organizational factors a€ecting turnover and demonstrates the importance of social support to reduce turnover; thus, opening the way for administrative intervention of the work support climate and programs to reduce turnover. The variables that we identify as signi®cant predictors of turnover will hopefully encourage management practices of health services providers that actively and creatively manage turnover problems. We suggest several possible management strategies: i.e., employee assistance programs, positive o€ered climate, strengthen supervisory support and training programs, enhance communication feedback and opportunities for advancement within the organization to retain the high turnover risk group, and create a stable work environment and bene®t packages for their longer tenure employees. Third, with the diculty of measuring hidden and indirect cost, and balancing negative and positive consequences of turnover, we hope this review will stimulate future studies to identify an optimal level of turnover. The following paper will brie¯y review the problem of turnover, its confounding variables (sta€ socio-demographic factors and facility organizational characteristics) and explanatory variables (social support at home and at work, and quality of work life). A model modi®ed from Mobley et al.'s (Mobley et al., 1978) conceptualization, which summarizes the associations of turnover with demographics, organizational factors, support systems, and quality of work life, is presented in Fig. 1.

1905

Cavanagh (1990)

Bloom et al. (1992)

. 669 full and part-time RN and LVNs, PCTs and NPCTs, clerical, admin. Sta€ of 55 dialysis facilities responded (83.3% unit response rate) . eastern and central Texas, U.S.A.

Bame (1993)

. unknown # of hospitals (100±650 beds) . survey: questionnaires

. 124 non-pro®t hospital nurses (79 sta€ nurses and 45 managers), 108 for-pro®t hospital nurses (70 sta€ nurses and 38 managers) responded (38.5% response rate) . Los Angeles, U.S.A.

. survey: questionnaires

. unidenti®ed # full-time RNs (59.9% response rate) . U.S.A. . 435 hospitals (no size reported)

. 55 dialysis facilities (4±50 treatment stations each) . survey: questionnaires and interview

. 669 full and part-time RNs, LVNs, PCTs, NPCTs, social workers, dietitians, clerical, and admin. of 55 dialysis facilities responded (83.3% unit response rate) . eastern and central Texas (rural and urban), U.S.A. . 55 dialysis facilities (5±62 sta€ each, 1±52 full-time and 2±10 part-time sta€ each) . survey: questionnaires and interview

(2) mean non-pro®t (nurses, 20%; managers, 20%), mean for pro®t (nurses, 33%, managers, 30%)

(1) voluntary leaver

(1) voluntary RN leaver from 1/1/80± 12/13/80 (2) mean, 26%

(2) mean: nursing, 31%; technician, 32%; clerical, 36%; admin., 12%

(1) # current sta€ new to facility a year before survey

(2) median (overall, 28%; ranged from 0±54%)

(1) # of new sta€ hired within the previous per total # sta€ working in the unit, excluding physicians

(2) 29% overall (5% in-voluntary, 16% avoid and 8% unavoidable)

. rural, unknown country

. 5 nursing homes (120±242 beds) . survey: questionnaires

(1) stayers, unavoidable and avoidable leavers obtained from nursing director

(2) turnover rate

. study location, country . facility type (size) . type of research

. 191 RNs, LVNs and aides responded (>95% response rate)

(1) de®nition

Turnover

. study subjects (response rate)

Study population

Bame and Bettenhausen (1992)

Abelson (1987)

Author

not reported

. tenure (inverse)

not reported

not reported

. tenure (NS)

. age (NS)

socio-demographic

not reported

. workload (direct) . location (urban has more turnover) . owner (NS)

. size (direct)

. owner (NS)

. years of operation (inverse) . location (NS)

. size (NS)

. owner (NS)

. years of operation (inverse) . location (NS)

. size (direct for part-time)

not reported

organizational

not reported

not reported

not reported

not reported

job tension (higher tension for avoidable leavers than stayers)

job tension

not reported

not reported

not reported

Ðcontinued

. promotion opportunity (inverse)

not reported

not reported

not reported

. job opportunity (NS)

not reported

not reported

support at work and quality of work life

support at home

Relationship with turnover (NS = not statistically signi®cant for p-value>0.05)

Table 1. Summary table of turnover research

1906 T. Tai et al.

Gray and Phillips (1994)

George (1979)

Ferris and Rowland (1987)

Distefano (1988)

Decker (1985)

Chappell and Novak (1992)

Author

. 288761 nursing sta€ (7837 nurse managers, 148303 RN, 37315 enrolled nurses, 15466 midwives, 79840 other nursing sta€), 53131 non-nursing sta€ (7072 physiotherapists, 4907 radiographers, 6166 laboratory scienti®c ocers, and 34986 clerical ocers) participated (not reported response rate) . England

. 15 long term care nursing homes (20±360 beds) . survey: questionnaires

. Central North Carolina, U.S.A.

. 81 RNs of day shift responded (100% response rate) . mid-western, U.S.A. . 1 hospital (medium size) . survey: questionnaires . 463 RNs, LPNs and aides responded (76% response rate)

. survey: questionnaires

. 245 nursing assistants responded (78% response rate) . Winnipeg, Canada . 26 long-term care institutions for seniors (not reported size) . survey: interview . 483 sta€ nurses responded (80% response rate) . eastern U.S.A. . 1 major university teaching hospital (no size reported) . survey: questionnaires . 180 newly hired psychiatric aides responded (100% response rate) . not reported country . 2 state hospitals (not reported size)

Study population

(2) 13.6% all sta€ (nurse manager, 10.1%; RN, 14.1%; enrolled nurse, 11%; midwives, 11.1%; other nursing sta€, 13.6%; physiotherapists, 15.6%; radiographers, 12.9%; LSOs; 13.3%; clerk, 15.9%)

(1) leavers vs stayers, measured annually

(2) mean full-time (RN, 55%; LPN, 61%; aides; 65%). mean part-time (RN, 67%; LPN, 74%; aides, 145%)

(1) estimated length of stay; voluntary quit

(2) not reported

(1) intent to leave

(1) voluntary leaver, follow up 1 year of new hires (2) total, 34%; voluntary, 23%

(2) not reported

(1) propensity to leave

(2) not reported

(1) not reported

Turnover

. tenure (inverse)

. job (LPNs had higher turnover than RNs) . age (inverse)

. tenure (direct)

. race (NS)

. age (direct)

. tenure (inverse)

. gender (NS) . race (white more likely to quit) . education (NS)

. age (inverse)

not reported

not reported

socio-demographic

not reported

. owner (more LPNs turnover in for pro®t homes only)

not reported

not reported

not reported

not reported

organizational

not reported

not reported

not reported

not reported

not reported

not reported

job tension

not reported

not reported

not reported

not reported

not reported

not reported

support at home

not reported

Ðcontinued

. promotion opportunity (inverse)

not reported

not reported

. promotion opportunity (inverse)

not reported

support at work and quality of work life

Relationship with turnover (NS = not statistically signi®cant for p-value>0.05)

Turnover literature review 1907

Knapp and Missiakoulis (1983)

Jolma (1990)

Hom and Gri€eth (1991)

. 3041 ocers in charge, 3215 deputies, 2332 care sta€ responded (not reported response rate)

(1) propensity to leave: proportion of sta€ who left during 1976±1977

(2) mean turnover intent, 4 (1 = not all likely to 7 = extreme likely)

. Arizona, U.S.A.

. not reported # and size of acute care hospitals . survey: questionnaires

(1) turnover intent

(2) sample 1: 12% voluntary quit; sample 2: 21% voluntary quit

(1) Intention to quit

(2) ranged from 60% to 200%

(1) not reported

(2) not reported

. 123 medical surgical RNs responded (50% response rate)

. sample 1: 1 hospital; sample 2: another hospital . survey: questionnaires

. sample 1: 244 nurses responded (78.7% response rate); sample 2: 190 new RNs responded (not reported response rate) . Cleveland, U.S.A.

Helmer and McKnight . 429 RNs represented by the Hawaii (1989) Nurses Association Collective Bargaining Organization responded (over 30% response rate) . Honolulu, U.S.A. . 5 acute care hospitals (not reported size) . survey: questionnaires

. south-eastern U.S.A. . 8 critical units of a large tertiary care ctr . survey: questionnaires

. job (LPN/ LVNs higher turnover than RNs)

. age (inverse)

not reported

not reported

not reported

not reported

. unit size and intent to leave (direct) . Work load and Intent to leave (Direct)

not reported

not reported

not reported

. owner (NS)

. size (direct for RN only)

organizational

not reported

not reported

not reported

not reported

not reported

not reported

job tension

not reported

not reported

not reported

not reported

not reported

not reported

support at home

not reported Ðcontinued

. job opportunity (direct)

. job opportunity (direct)

not reported

. intra and inter unit interaction and turnover (inverse)

not reported

support at work and quality of work life

Relationship with turnover (NS = not statistically signi®cant for p-value>0.05) socio-demographic

(1) nurse stability: length of time hired not reported in a study unit

(2) mean unskilled nurse aide, 68%; LPN/LVN, 51%; RN, 36%

. North Carolina, U.S.A.

. 122 nursing homes (not reported size) . survey: questionnaires

(1) voluntary quit full and part-time nursing personnel

Turnover

. unidenti®ed full and part-time nursing personnel (65% response rate)

. >100 district health authorities (DHA) . data collected from DHA

Study population

Hart and Moore (1989). 119 critical care sta€ RNs responded (52.2% response rate)

Halbur (1983)

Author

1908 T. Tai et al.

(1) intention to resign (2) not reported

. Louisiana, U.S.A. . 21 hospitals (<100 to >200 beds) . survey: questionnaires

(1) Intention to leave (2) not reported

. 755 RNs responded (48.2%)

. 21 hospitals (<100 to >200 beds) . survey: questionnaires

. 755 RNs responded (48.2%) . Louisiana, U.S.A.

(1) stayers vs leavers Lowery and Jacobsen . 276 full-time nurses hired from (1984) 1971±1981 who stayed >1.5 years responded (not reported response rate) . a large metro. area, unknown (2) 33% of those hired between 1979± country 1981 . 1 teaching hospital (not reported size)

Lane et al. (1990)

Lane et al. (1988)

. unidenti®ed # and size of community and urban hospitals and medical centers . survey: interview

(2) not reported

(1) Leaver

(2) median (magnet hospitals, 9%; non-magnet hospitals, not reported; national picture, 16%)

. U.S.A.

. 16 unidenti®ed magnet hospitals, unidenti®ed # non-magnet hospitals (not reported size) . survey: questionnaires

(1) not reported

(2) propensity to leave (ocers in charge, 9%; deputies, 12%; care sta€, 15%)

Turnover

. 939 sta€ nurses from magnet hospitals resoonded (69% response rate), 808 sta€ nurses from nonmagnet hospitals responded (53% response rate)

. 2000 nursing homes (not reported size) . survey: questionnaires

. England and Wales

Study population

Landstrom et al. (1989). 26 RNs who left less than 18 months prior to study responded (not reported response rate) . Illinois, U.S.A.

Kramer and Schmalenberg (1991)

Author

. age (inverse)

. marital status (NS) . tenure (NS)

. education (NS) . marital status (NS) . tenure (NS)

not reported

not reported

. gender (NS)

socio-demographic

not reported

. location (NS)

. size (NS)

. size (NS) . location (NS)

not reported

not reported

organizational

not reported

not reported

not reported

not reported

not reported

job tension

not reported

not reported

not reported

not reported

not reported

support at home

not reported

Ðcontinued

. job opportunity (NS)

not reported

. con¯ict between nurse and manager motivates turnover . lack of co-worker support motivates turnover

. job satisfaction on organization structure, prof'l practice, management, leadership, prof'l development and turnover (magnet hospital sta€ more satis®ed and less turnover)

support at work and quality of work life

Relationship with turnover (NS = not statistically signi®cant for p-value>0.05)

Turnover literature review 1909

Price and Mueller (1986)

(1) voluntary and involuntary leaver (2) overall voluntary, 18%; overall involuntary, 2%

. U.S.A.

(2) overall, 12% resigned

(1) stayer and leavers

. 1748 hospital employees responded

Prestholdt et al. (1987) . initial sample: 441 nurses; holdback sample: 426 nurses responded (47.3% response rate) . Louisiana, U.S.A. . 21 hospitals (100±200 beds) . survey: questionnaires

. RNs of 492 hospitals responded (1) voluntarily leaver during 4/1/80 to (59.9% response rate) 3/31/81 . U.S.A. (2) overall, 22% . 492 hospitals from 1981 AHA nursing personnel survey (10±750 RNs each) . survey: questionnaires

(2) 11%

. metro. area, U.S.A. . 1 hospital (large size) . survey: questionnaires

Pfe€er and O'Reilly (1987)

(1) voluntary termination from personnel record, 1 year after survey

. 307 RNs and LVNs responded (44% response rate)

Parasuraman (1989)

. gender (NS)

. age (inverse)

not reported

not reported

. age (inverse correlation, NS in regression) . job (inverse)

(1) intention to resign in the next not reported . 327 supervisory sta€: pt-care and 6 months assistant pt-care coordinators responded (not reported response rate) . metro. area, U.S.A. (2) mean intention to resign, scale unknown (primary and team care both 2.2; 1st/2nd/3rd shift, 2.3/2.2/2.0) . 1 large hospital (not reported size) . survey: questionnaires

. gender (NS) . tenure (positive correlated) . education (NS)

(2) ranged 0% to 50% (mean, 4%)

Parasuraman et al. (1982)

. age (NS)

. age-tenure and intention to quit (inverse)

. age and actual turnover (NS)

not reported

not reported

not reported

not reported

not reported

not reported

not reported

. owner (NS)

not reported

not reported

not reported

job tension

. Work load and Intent to quit (Direct)

. size and Unit turnover (Direct)

not reported

organizational

not reported

not reported

not reported

not reported

not reported

not reported

not reported

support at home

. job opportunity (direct) . promotion opportunity (inverse) Ðcontinued

. job opportunity (direct)

not reported

not reported

not reported

not reported

not reported

support at work and quality of work life

Relationship with turnover (NS = not statistically signi®cant for p-value>0.05) socio-demographic

(1) unit turnover rate (leavers vs. stayers) from hospital record, Jan. to Aug.

(1) voluntary termination and nontermination collected 47 weeks after initial survey (2) 10%

Turnover

. 115 work units such as ER, admissions, pediatrics, payroll, and radiology responded (63% response rate) . a western state, U.S.A. . 5 voluntary short term general hospital (not reported size) . survey: questionnaires

. 1 hospital (medium size) . survey: questionnaires

. survey: questionnaire and personal ®les of employees . 203 full-time service, technical, clerical and nursing sta€ responded (over 90% response rate) . south-eastern urban area, U.S.A.

Study population

Mueller and Price (1989)

Mobley et al. (1978)

Author

1910 T. Tai et al.

. study 1: 7 LPNs and 77 nurses' aides from 6 months or less of service, study 2: 271 nursing sta€ with 7± 60 months of service responded (67.5% response rate) . Florida and Texas, U.S.A. . 25 nursing homes (not reported size) . survey: questionnaires, cohort study

. unidenti®ed RNs of 111 hospitals responded (46.4% response rate) . north central U.S.A. . 111 short term, general care hospitals (50±>1000 beds)

Spencer (1986)

. Detroit metro. area, U.S.A. . 1 hospital (560 beds) . survey: questionnaires

. 102 RNs, 120 LPNs, 66 aides responded (77.4% response rate)

. survey: questionnaires

. Salt Lake City, U.S.A. . 1 university hospital (310 beds)

. 212 RNs and LPNs responded (not reported response rate)

(1) voluntary turnover 1 year before survey (2) mean, 21%

(1) voluntary job termination during 6 months period after initial survey; (2a) study 1: 51%; (b) Study 2: 30.2%

(1) voluntary termination (exclude voluntary retire, dismissal, leave/ absence due to medical/ed. reasons) (2) 19%

(1) leavers vs. stayers, within one year after initial survey from hospital records (2) 42%

(2) 18% (overall head RN, 12%; sta€ RN, 16%; LPN/LVN, 27%; PCT, 24%; NPCT, 12%; clerical, 24%; admin., 4%)

. eastern and central Texas (rural and urban areas), U.S.A.

. 42 chronic, outpatient hemo-dialysis facilities (15±330 patients each) . survey: questionnaires

(1) leavers vs. stayers, follow up 10 months after initial survey

Turnover

. 53 head RNs, 61 sta€ RNs, 47 LVN/LPNs, 107 PCTs, 59 NPCTs, 43 clerical, 27 admin., 21 unidenti®ed job responded (62.3% response rate)

. survey: questionnaires

. 5 hospitals

Study population

Sheridan (1985)

Sheridan and Vredenburgh (1978)

Seybolt et al. (1978)

Robinson (1995)

Author organizational

not reported

not reported

. age (inverse)

. marital (NS) . tenure (leaver had shorter tenure)

. size (NS)

not reported

not reported

. family income (inverse) . education (NS). . job (higher turnover in prof'l train nurse) . size (NS) . age (inverse); . gender (NS); . race (white more likely to quit); . family income (inverse) . education (NS). . work load (NS) . marital (NS) . tenure (inverse) . job (higher turnover likelihood in LPN/LVNs) . years of operation (inverse) . location (NS); . owner (less turnover in public and national chains) . education (NS) not reported

socio-demographic

not reported

not reported

not reported

not reported

not reported

job tension

not reported

not reported

not reported

not reported

not reported

support at home

not reported

Ðcontinued

. group cohesion and turnover (inverse)

not reported

not reported

. quality of work life (inverse)

support at work and quality of work life

Relationship with turnover (NS = not statistically signi®cant for p-value>0.05)

Turnover literature review 1911

. survey: questionnaires

Study population

Turnover

. not reported location . 1 public psychiatric hospital (not reported size) . survey: questionnaires

. 56 nursing sta€ responded (66.7% response rate)

. 42 chronic, outpatient hemodialysis facilities (15±330 patients each) . survey: questionnaires

. 53 head RNs, 61 sta€ RNs, 47 LVN/LPNs, 107 PCTs, 59 NPCTs, 43; clerical, 27 admin., 21 unidenti®ed job responded (62.3% response rate) . eastern and central Texas (rural and urban areas), U.S.A.

(1) termination from hospital personnel ®les, 6 months after initial survey (2) 20% after 6 months

not reported

. education (NS) . marital (NS) . tenure (inverse) . job (higher turnover likelihood in LPN/LVNs) not reported

. owner (Less turnover in public and national chains)

. location (NS)

. years of operation (inverse)

. gender (NS)

(2) 18% overall (head RN, 12%; sta€ RN, 16%; LPN/LVN, 27%; PCT, 24%; NPCT, 12%; clerical, 24%; admin., 4%) . race (white more likely to quit) . family income (inverse)

. Work load (NS)

. age (inverse)

. location (Less turnover in rural) . owner (For pro®t units has more turnover)

organizational

(1) leavers vs stayers, follow up 10 months after initial survey

socio-demographic

stressful event (direct)

not reported

not reported

job tension

not reported

emotional support for concerns (inverse)

not reported

support at home

not reported

. supervisor support (less turnover for more support)

. administrator's experience (NS)

. administrator's age (NS) . administrator's education (NS)

support at work and quality of work life

Relationship with turnover (NS = not statistically signi®cant for p-value>0.05)

RN = registered nurse, LVN = licensed vocational nurse; LPN = licensed practical nurse, PCT = patient care technician, NPCT = non-patient care technician, admin. = administration, metro. = metropolitan).

Zatura et al. (1986)

Tai (1996)

. 110 nursing homes (not reported size) . survey: questionnaires

Stryker-Gordon (1979) . unidenti®ed nursing assistants (1) full and part-time separations in responded (not reported response rate) 1976 . Minnesota, U.S.A. (2) ranged from <40% (61 units) to >80% (10 units).

Author

1912 T. Tai et al.

Turnover literature review

1913

Fig. 1. Turnover model LITERATURE REVIEW METHOD

Methods used to locate published studies of nurse turnover from 1977 to 1996 included searching the computerized indexes of research literature in the disciplines of nursing, medical, health services administration and management, psychology, and social science related to demographics, organizations, job tension, job satisfaction, support systems, and quality of work life. Previous literature reviews were also reviewed for studies not identi®ed through the computer search. A computer search of dissertation abstracts was also conducted to ®nd dissertation studies. Over 200 studies were considered for inclusion. To be considered, the studies had to report analyses *The nursing workforce in both the United States and England is composed of two levels of quali®cation: a ``practical'' quali®cation with limited career opportunities (enrolled nurse in England; licensed practical or vocational nurse in the US) and a professional quali®cation with full career development potential (registered general nurse or equivalent in England; registered nurse in the US).

of quantitative data from samples of nurses between the published year of 1977 and 1996. From the quantitative studies, only those that met the following criteria were included in this review: (a) the study was written in English, because translators were not available to authors of this paper; (b) the study was a quantitative analysis of empirical data for comparison of turnover rates from studies; (c) the sample included nurses* (registered nurse, licensed vocational nurse, and licensed practical nurse) as employees engaged in patient care, because nurses were the main subjects of interest in this turnover review; (d) the study had to report a measure of sta€ turnover as it was the dependent variable of this review paper; and (e) bivariate analysis between turnover and other independently measured variables had to be reported to demonstrate existence of consistent relationships between turnover and each confounding and independent variable over studies. Quantitative measures are needed to summarize if there are signi®cant relationships between turnover and each confounding and independent variable. For results to be statistically signi®cant, the p-value has to be 0.05 or less.

1914

T. Tai et al.

Thirty-seven articles met these criteria for inclusion. Two of the studies reported separate statistics for two samples. Five studies did not identify size of study population; another three did not identify number of health care facilities analyzed. Individual sample sizes ranged from 26 to 2332 nursing sta€. Geographically, 34 studies were conducted in the United States, two in England, and one in Canada. Hospitals were the most common work sites (n = 25 studies), followed by nursing homes (n = 7 studies), and out-patient dialysis facilities (n = 4 studies). One study did not report the work site of nurses. Nurses known to be employed in hospitals comprised 66.4% of the total studies reviewed.

THE PROBLEM OF TURNOVER

Turnover rates Nursing has historically had a high turnover rate. The American Nurses' Association (1962) reported a turnover rate in excess of 40% annually in the late 1950s. In 1980, the national full time equivalent (FTE) registered nurse (RN) turnover in hospitals was down to 30% (National Association for Health Care Recruitment, 1992). By 1992, this annual hospital nursing turnover rate had dropped to 14% nationally (National Association for Health Care Recruitment, 1992). Although hospital nursing sta€ turnover rates have been decreasing, Price and Mueller (1981) reported nursing turnover rates were more than double the rates reported for professionals of comparable education and gender. This problem of turnover in health services is detrimental to the delivery of quality health care (George, 1979; Hart and Moore, 1989; Jones, 1990b), and is expected to become more acute as the aging baby boomers demand for health care services increases (Burner et al., 1992). Turnover costs The nationwide nursing shortage has been of serious concern to many hospital administrators, nursing directors, and personnel directors both in the private and public sector (Ihaza, 1986). The loss of work group eciency and the disruption of organizational performance caused by an employee separation plus the recreating, hiring and training of a replacement are major consequences of turnover (Cavanagh, 1989). The ®nancial costs incurred to obtain a replacement may vary widely by location and time, and according to which components are included in the cost estimates. The National Association for Health Care Recruitment (1992) estimated the direct costs of recruiting and hiring a nurse at $2396 in 1992, up 13% in 1991 after an increase of 8% in 1990. This may be due to the fact that recruiting cost is only a portion of turnover costs and that indirect costs are usually

not estimated, as Jones (1990a,b) indicated in her study of four metropolitan hospitals. Jones estimated that recruitment costs were more than $10,000 per nurse termination; this included the costs of un®lled positions, hiring costs, orientation and training costs, and low new nurse productivity. However, even this amount may be underestimated as indirect and hidden turnover costs account for 80% or more of the total cost of replacing a professional employee (Phillips, 1990). Taking these factors into account, Johnston (1991) estimated that turnover costs may exceed $25,000 per nurse, unadjusted for in¯ation. Turnover consequences Turnover may be stressful for the remaining sta€ who must constantly adjust to newcomers (Mobley, 1982). Price (1977) contends that turnover reduces consensus, increases con¯icts, and reduces satisfaction among stayers. The loss of valued individuals disrupts communication patterns and the social order of an organization (Price, 1977). As turnover increases, communication is likely to become less accurate (Bluedorn, 1982). This can a€ect group cohesiveness, performance, and morale (Cavanagh, 1989). The e€ects of lower morale can be particularly pervasive on the stayers. Staw (1980) claimed that turnover may stimulate further worker turnover. Employees who had no previous intent to ®nd new work may consider leaving due to the increased stress of work and decreased work morale as a result of a colleague's departure. Turnover may adversely impact interaction and integration among stayers (Price, 1977). As turnover increases, close and continuing social relationships or integration at work become more dicult. Despite the focus on the negative consequences of turnover, some researchers have recognized and explored the positive aspects of turnover on individuals and the organization (Ritti, 1970; Pettman, 1973; Pfe€er, 1976; Staw, 1980; Bluedorn, 1982; Abelson and Baysinger, 1984). Abelson and Baysinger (1984) summarized potential positive bene®ts of turnover as better person±job matches, sta€ing ¯exibility, salary and fringe-bene®t savings, and infusion of new ideas into the organization. Pfe€er (1976) contended that turnover can increase the e€ectiveness of an organization; employee mobility is important for the development of innovation by permitting organizations to become more ¯exible and adaptable to change. Similarly, hospitals which employ and promote sta€ from the outside encourage the introduction of new practices and standards of care (Cavanagh, 1989). Pettman (1973) showed that the probability of people changing jobs increased as their educational level increased. This may be partly explained by the existing market performance, but also by con¯ict situations occurring within the workplace. This belief was supported by a study conducted by Price

Turnover literature review

and Mueller (1981) of 1101 nurses which found that the education level of nurses was one of the statistically signi®cant variables correlated with turnover behavior; nurses with bachelor degrees were associated with a higher turnover rate. Ritti (1970) suggested that turnover actually bene®ts society by providing a mechanism for individuals to obtain employment for which they are best suited. Furthermore, individuals with high perception of promotional opportunity were less likely to turnover. On the other hand, turnover may be a consequence when sta€ perceive that opportunities for advancement within the organization are few. Besides agreeing that turnover may open opportunities for hospitals to weed out non-productive employees and bring in new ideas, skills, and talents, Prescott and Bowen (1987) suggest that turnover per se does not necessarily signal poor working conditions or poor administration. A nurse's term of employment in a well-managed work environment can lead him or her into promotion elsewhere, to return to school or to a di€erent kind of work experience which will capitalize upon competencies gained. Turnover de®nitions The traditional turnover perspective assumes that people leave organizations for either voluntary or involuntary reasons (Price, 1977; Bluedorn, 1978). Reasons for voluntary turnover include: better pay elsewhere, better working conditions or organizations to work for elsewhere, problems with a supervisor or the administration, a spouse move to another location, mid-career change, stay home to care for a dependent, or not returning after pregnancy leave (Abelson, 1987). Involuntary turnover includes: dismissal, layo€, forced retirement, medical disability, or death. Dalton et al. (1981) suggest that examining avoidable and unavoidable turnover, in addition to the conventional voluntaryinvoluntary turnover, could improve understanding and prediction of turnover behavior. Abelson and Baysinger (1984) also contend that voluntary turnover rates may be a poor guide to understanding certain aspects of employee turnover in complex organizations. The avoidable departure of some employees through voluntary separation may be merely a convenient substitute for terminating employees which the organization would prefer to lose, and would be functional for the organization. Dysfunctional turnover, on the other hand, is the unavoidable separation of employees whom the organization prefers to retain (Abelson and Baysinger, 1984). Researchers have not used a consistent de®nition of turnover. Some de®ned turnover as quitters vs non-quitters; others de®ned it as leavers vs stayers, new sta€ vs old sta€, intention to quit vs intention to stay, or vacant positions vs positions already ®lled (see Table 1 for a summary of turnover de®-

1915

nitions and measures according to author). This inconsistency should be taken into account when comparing studies or generalizing across studies. In addition, reliability of turnover varies according to record-keeping methods used, the de®nition and accuracy of the reason for turnover, and the degree of consistency in maintaining personnel records of turnover. TURNOVER AND INDIVIDUAL SOCIO-DEMOGRAPHIC CHARACTERISTICS

The socio-demographic characteristics of sta€ are not usually considered explanatory variables in a turnover model. Nevertheless, research indicated certain age, race, income, tenure, and job categories of sta€ increase or predispose turnover risk. With the exception of gender and education, clear di€erences in turnover have been shown to exist for these widely used correlates. The associations between sta€ socio-demographic characteristics and turnover are summarized in Table 1. Age There has been considerable investigation into the relationship between turnover and age, indicating a consistent pattern of inverse relationship with health care facility sta€ turnover. Gray and Phillips (1994) found that turnover rates were signi®cantly higher among nursing sta€ of younger age groups than older age groups. George (1979) found that age was positively correlated with the estimated nursing home sta€ length of stay on the job. Also, Lowery and Jacobsen (1984) found an inverse relationship between age and turnover for hospital nurses. Knapp and Missiakoulis (1983) also reported that age was a signi®cant predictor of turnover propensity, in which the propensity to leave decreases with age up to age ®fty-nine. Mobley et al. (1978) reported that ``age-tenure'', a composite of the standardized age and tenure variables, was inversely correlated to hospital employees' intention to quit, but not with actual turnover. Parasuraman (1989) found that age was inversely related to job termination of hospital nurses; however, age showed a similar but not signi®cant relationship with job termination in the multiple regression analysis. Both the studies of Robinson (1995) and Tai (1996) of dialysis sta€ turnover also showed that older employees had signi®cantly lower likelihood of turnover than younger ones, even when controlling for tenure; the likelihood of turnover decreased 7% with each added year of age. A similar hospital employee turnover-age relationship was also found by Sheridan and Vredenburgh (1978) when social power indicators were used. Although age was not signi®cantly related with turnover in a study by Abelson (1987) of sta€ in nursing homes, the pattern was similar. Mueller and Price (1989) reported that age was not signi®-

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T. Tai et al.

cantly related to unit turnover rates in their study hospitals. Gender In the health care work place the majority of the workers are female; thus, with this homogeneity, one would expect that gender should not in¯uence the likelihood of turnover. The research supported this hypothesis. The studies of Distefano (1988) of hospitals' employees, Knapp and Missiakoulis (1983) of nursing homes employees, Mueller and Price (1989) of hospital unit turnover, Price and Mueller (1986) of hospital employees, and both Robinson (1995) and Tai (1996) of dialysis employees reported that turnover was not signi®cantly related to employee gender. Thus, gender showed a consistent non-signi®cant relationship with sta€ turnover in both health care and non-health care organizations. Race Minority employees may be less likely to change jobs than whites, perhaps because of less job mobility or opportunity. Research examining the associations between race and turnover has shown that whites have higher turnover than minorities (Distefano, 1988; Robinson, 1995; Tai, 1996). Also, the white unemployment rate is typically lower than the unemployment rate for other racial or ethnic groups (Robinson, 1995). For these reasons, whites may be more likely to change jobs than are minority groups. Distefano (1988) found that black psychiatric aides had lower turnover rates than white psychiatric aides. Robinson (1995) and Tai (1996) reported that minority (i.e., black, Hispanic, and Asian) employees had signi®cantly less turnover than white sta€ in dialysis facilities. However, in a study of nursing homes employees, George (1979) found no signi®cant correlation between race and estimated length of stay on the job. Thus, except for George's (1979) study, race showed a consistent relationship with sta€ turnover in health care facilities, in which whites have higher turnover than minorities. Income More a‚uent individuals may have less need or motivation to change jobs in order to improve their income status (Robinson, 1995). This hypothesis was supported by the Price and Mueller (1986) study of hospital employees; they found a signi®cant inverse relationship between turnover and both family and individual income. Both the studies of Robinson (1995) and Tai (1996) of dialysis employees reported a signi®cant inverse bivariate relationship between family income and turnover behavior of dialysis sta€. However, because age, tenure, job, and race were collinear with income, income was not a signi®cant predictor of likelihood of turnover in the multivariate analyses of these dialysis sta€.

Education The personal needs or career ambitions of most health care employees may be directly related to educational level. Therefore, one may expect that individuals with more education may be more likely to quit in order to seek career advancement if there are limited opportunities in their current organization. However, studies have shown that turnover and education are not related. For example, the studies of Distefano (1988) of hospital psychiatric aides, Lane et al. (1988) of hospital nurses, Mueller and Price (1989) of hospitals' units, Price and Mueller (1986) of hospitals' employees, both Robinson (1995) and Tai (1996) of dialysis employees, and Seybolt et al. (1978) of hospital nursing sta€ showed turnover behavior was independent of educational level in health care settings. Marital status In a study of Canadian female professionals with managerial responsibilities and clerical employees, Aston and Lavery (1993) found that employees who had no support external to work reported lower quality of life and physical well-being. In their study, satisfaction with support was strongly correlated with self-esteem in married respondents. Fewer non-married respondents who had external social support reported depressed moods. Also, better quality of life and physical well-being were reported by both married and non-married respondents. Their study also showed that increased spousal support was related to higher self-esteem, less depressed mood, and better quality of life of female clerical workers. Support from family members had a signi®cant in¯uence on the quality of life of female non-married managerial respondents. Support from friends was related to the quality of life of the non-married managerial group, and to the physical well-being of both non-married managerial and clerical groups. Thus, one may expect that di€erences in marital status may in¯uence likelihood of turnover. Single employees may have higher turnover than married sta€ because they might be more mobile, not having to consider moving family members when switching jobs. Contrary to what has been found in non-nursing professions, research has shown that marital status and nursing turnover was not signi®cantly related. For example, the studies of Lane et al. (1988, 1990) of hospitals' employees, Robinson (1995) and Tai (1996) of dialysis employees, and Seybolt et al. (1978) of hospital nurses, showed no signi®cant relationship between turnover behavior and marital status. Tenure There has been considerable evidence of an inverse relationship between turnover and tenure. Longer tenured employees have more human capi-

Turnover literature review

tal invested in the organization; thus, they may be more reluctant to leave an organization than those with less tenure (Abelson, 1986). Gray and Phillips (1994) found that turnover rates were signi®cantly higher among nursing sta€ of shorter length of service than those with longer years of service. Bloom et al. (1992) found that length of tenure was inversely related to hospital nurse turnover. The study of Ferris and Rowland (1987) of hospital nurses found increased tenure was a signi®cant moderator of intention to leave; however, absenteeism may be a confounding factor. Their study indicated that lowtenured nurses who were absent more frequently tended to be less inclined to leave, whereas hightenured nurses who were absent more tended to have stronger intent to leave. The study of George (1979) of nursing home employees found tenure was positively correlated with estimated length of stay on the job. Mobley et al. (1978), in a study of hospital employees, indicated that age-tenure had a signi®cant inverse relationship with intention to quit and intention to search for an alternative job, but did not show a signi®cant relationship with actual turnover. Mueller and Price (1989) found that tenure and unit turnover rates were directly correlated. Robinson (1995) and Tai (1996) showed a signi®cant inverse relationship between dialysis employee tenure and the likelihood of turnover. Seybolt et al. (1978) found that hospital nurses who left had a signi®cantly shorter tenure than the stayers. Although the mean of tenure was not signi®cantly di€erent by stayers, avoidable leavers, and unavoidable leavers in a study by Abelson (1987) of nurses in nursing homes, the pattern was similar. Using intention to leave as a turnover measure, Lane et al. (1990, 1988) found tenure was not signi®cantly related to intention to leave of hospital nurses. Job category Job category was included in several studies because there were signi®cant variations in turnover among di€erent occupations and levels of responsibility (Price, 1977). Price and Mueller (1986) reported that professionally trained nurses had a stronger aliation with the nursing profession than to the speci®c employer. Similarly, managerial employees may have a higher job satisfaction, work autonomy, and stronger organizational commitment than do others; thus, their likelihood of turnover would be lower than others. Parasuraman (1989) found that hospital nurse turnover had a signi®cant inverse relationship with job levels. Within the six job levels of nursing sta€ hierarchy, ranging from LPN to assistant director, the higher the job level within the organization, the lower the likelihood of quitting. He concluded that LVNs/LPNs would be more likely to quit than RNs because the jobs of LVN/LPNs were less speci®c and they had less opportunities for career advancement. Also, they

1917

may look elsewhere for better pay or better working conditions. In the study of George (1979) of nursing homes, the mean turnover rates of both full-time and parttime RNs (55.3%/67.3%) were lower than both LPNs (61.1%/74.3%) and nurse aides (65.2%/ 145.1%). In similar health care settings, Halbur (1983) also found that the mean turnover rate was much lower for RNs (36%) than for LVN/LPN (51%) or unskilled nurse attendants (68%). Robinson (1995) and Tai (1996) found that the likelihood of LVN/LPN turnover was over ®ve times higher than other job categories. Thus, job category showed a consistent relationship with sta€ turnover in health care facilities, with higher turnover in low rank direct patient care job categories. TURNOVER AND FACILITY'S ORGANIZATIONAL CHARACTERISTICS

Organizational characteristics may in¯uence turnover behavior because of di€ering personnel policies, practices, and organizational climate. A similar set of organizational characteristics and administrative strategies associated with turnover patterns of various types of job category would reinforce the concept of a common predisposing climate for turnover (Bame, 1993). For example, facility size, work load, years of operation, location, and ownership type may a€ect sta€ turnover. Location may in¯uence turnover because of di€erent job market opportunities in large metropolitan cities vs smaller towns or rural areas. The associations between facility organizational characteristics and turnover are summarized in Table 1. Size Considerable attention has been devoted to understanding the relationship between health facility organizational size and turnover. Price and Mueller (1986) showed that size was directly related to supportive services and programs for nursing personnel sta€. This, in turn, should increase job satisfaction and reduce motivation for turnover. Halbur (1983) reported that both nursing aide-attendant and RN turnover rates in nursing homes increased as organizational size increased; however, this relationship was not signi®cant for LPNs. Jolma (1990) indicated that unit size was positively correlated with hospital nurses' intent to leave their jobs. Mueller and Price (1989) also found that intra-hospital unit turnover rates correlated signi®cantly with unit size. However, this relationship with size may not hold in small health facilities, such as small nursing homes, outpatient clinics, and dialysis facilities, which can provide only modest employee support programs. A small number of turnover studies in hospital settings (Spencer, 1986; Lane et al., 1988) found that size was not signi®cantly related to turnover.

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T. Tai et al.

Bame and Bettenhausen (1992) reported a signi®cant positive correlation between size (number of patients and number of treatment stations) and turnover of part-time dialysis sta€; however, this relationship was not found in overall sta€ turnover nor turnover of full-time sta€. Bame (1993) found that organizational size was not associated with dialysis sta€ turnover. Bloom et al. (1992) presented that organizational sta€ size was a powerful predictor in the multivariate analyses; hospitals with larger sta€ size have higher turnover. Robinson (1995) found that the bivariate relationship between dialysis facility size and employee turnover was not signi®cant. Unfortunately, the various turnover studies did not use a consistent de®nition of facility size; hospitals and large nursing homes normally used the number of sta€ed beds, whereas number of patients or number of visits has been used as a measure in outpatient settings. Further research is needed to verify the relationship between turnover and unit size as ®ndings reported in these studies were inconsistent. Work load Patient±sta€ work load may a€ect turnover; a heavy workload may increase job tension and decrease job satisfaction, which in turn, may increase the likelihood of turnover. Bloom et al. (1992), using RN per number of beds set up and sta€ed for use as stang ratio, found that higher ratios were signi®cantly related to increased hospital employee turnover. Mobley (1982) summarized a number of studies that suggested the importance of scale of operations of work units as a determinant of turnover. Parasuraman et al. (1982) found that hospital nurses who had ``thoughts about quitting the present job'' reported signi®cantly higher ``work overload''. The study of Jolma (1990) of hospital nurses found that the relationship between nurses' perceived role and overload was signi®cantly related to his or her intent to leave the position. In turn, Price and Mueller (1986) demonstrated a strong association between hospital nursing turnover intent and actual turnover. However, patient±stang work load was not a signi®cant predictor of likelihood of turnover in dialysis employees (Robinson, 1995; Tai, 1996). Thus, work load of hospital nurses a€ected turnover intent or behavior, but work load in outpatient dialysis facilities was not a predictor of actual turnover behavior. This may be due to di€erences in settings or to other di€erences in turnover de®nition and analysis. Years of operation One would expect that the longer a facility is owned by the same organization, the stronger and more mature the organizational culture and environment. This in¯uence may enhance employee job satisfaction and organizational commitment, and thus, may reduce the likelihood of turnover.

Bame and Bettenhausen (1992) and Bame (1993) found that turnover, measured as proportion of new sta€, was inversely related with years of operation of the dialysis facilities. Robinson (1995) and Tai (1996) found that years of operation of dialysis facilities were inversely related to turnover in the bivariate analysis but not in the multivariate analysis. Thus, length of operation showed a consistent inverse pattern with sta€ turnover but was not signi®cant when analyzed with other confounding organizational characteristics. Location One would speculate that rural areas generally had limited job opportunities and corresponding lower turnover rates than urban areas. StrykerGordon (1979) reported that nursing homes with lower turnover rates were more likely to be located in communities with population less than 25,000. Bloom et al. (1992) found that hospitals located in urban areas have signi®cantly higher turnover. In contrast, Lane et al. (1990) did not ®nd hospital location (rural and urban) to be signi®cantly related to intention to resign of hospital nurses. However, the ®ndings of Lane et al. may not be comparable to the other studies because resign intention is a di€erent measure from actual turnover behavior. In the analyses of sta€ at 55 dialysis facilities (Bame and Bettenhausen, 1992; Bame, 1993) and sta€ at 42 dialysis facilities in Texas (Robinson, 1995; Tai, 1996), researchers did not ®nd a signi®cant relationship between sta€ turnover rates and facility location. Further research is needed to test this relationship in other types of health care settings. Type of ownership Di€erent ownership types were expected to have di€erent locus of personnel policy-making and scope of employment practices. This, in turn, may a€ect organizational culture and management style which may in¯uence sta€ turnover. Publicly owned facilities are funded and operated under city, county, or federal auspices, and generally have personnel policies and employment practices determined by centralized decision-making bodies. Similarly, national ownership of a chain of facilities would more likely have centralized personnel policy-making and employment practices. Therefore, national chain-owned and public facilities may have personnel policy-making and employment practices that are very di€erent from facilities locally owned by private groups. Sta€ at locally owned facilities would more likely be involved in determining and implementing their own facility policies and practices. On one hand, perhaps sta€ more involved in their organization's policy-making would be more committed to the organization and less likely to leave. On the other hand, sta€ in public facilities or large chains may have better personnel training programs, fringe bene®ts and promotional opportu-

Turnover literature review

nities available because of the economies of scale of a larger organization, and thus, be more motivated to stay. The ®ndings on the relationship between turnover and ownership were mixed. George (1979) reported higher turnover of LPNs in proprietary nursing homes than in non-pro®t homes, but the relationship was reversed among full-time nursing aides. Bloom et al. (1992) and Pfe€er and O'Reilly (1987) found that the relationship with ownership type was not a signi®cant predictor of turnover of hospital employees in the multivariate analyses, nor did Bame and Bettenhausen (1992) and Bame (1993) ®nd a signi®cant relationship between proportion of new sta€ and dialysis facility ownership. Halbur (1983) also found that this relationship was not signi®cant in the turnover of employees in 122 nursing homes in North Carolina. The ®ndings of Bloom et al. may be biased because for-pro®t organizations represented only 7% of the total hospitals studies. Stryker-Gordon (1979) reported that higher turnover was associated with proprietary nursing homes. Robinson (1995) and Tai (1996) also found that national chain ownership of dialysis facilities was marginally signi®cant in predicting sta€ turnover (p = 0.06). Further research focusing on the e€ect of bene®t programs, training and promotion opportunities is needed to verify the relationship between turnover and facility ownership as ®ndings reported in these studies were inconsistent. TURNOVER AND EMPLOYEES' FAMILY AND FRIENDS SOCIAL SUPPORT SYSTEMS

A main focus of research in the study of turnover has been to determine what motivates nurses to leave their organizations (Price, 1989). Support at work has been shown to a€ect work satisfaction and turnover, but the direct relationship between family support and nursing turnover is unknown except for the recent work of Tai (1996). Social support from friends and family, as a moderator of physical and psychological well-being, is well documented in the literature. However, no references were found on the relationship between family support and turnover. Thus, this review of turnover literature was expanded to include the in¯uence of social support on employee stress, job tension, and burnout; all of which have been found related to turnover (Zatura et al., 1986; Abelson, 1987; Klenke-Hamel and Methieu, 1990). Social support was de®ned by House (1981) as resources helping individuals to cope with work stress through three types of e€ect: (1) a direct reduction in levels of job-related stress, (2) a direct improvement in emotional and physical well-being, and (3) an indirect, moderating e€ect on the job stress±strain relationship. The associations between social support from family/friends and turnover are summarized in Table 1.

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Support from family and friends for emotional concerns signi®cantly predicted employee's turnover behavior in dialysis facilities, adjusting for sta€ socio-demographics and for organizational characteristics (Tai, 1996). The turnover rate was 2.5 times higher for sta€ who reported no social support for emotional concerns (43% turnover), compared to that of sta€ who reported any emotional support from family and friends (17% turnover). Other aspects of family support, i.e., emergency support, housekeeping support, ®nancial support, and listening support, were not signi®cant predictors of turnover. Chappell and Novak (1992) reported that having family to talk to about work problems signi®cantly reduced work pressure of nursing assistants in nursing homes; psychological support from family and friends had a bu€ering e€ect on burnout. Their ®ndings showed that support from family and friends was signi®cantly related to lower burnout measured as emotional exhaustion, low personal accomplishment, and depersonalization. In a study of female welfare workers, Davis-Sacks et al. (1985) found that spousal support increased a feeling of personal accomplishment and self-esteem, and reduced depersonalization, anxiety and depression. Their study suggested that social support, particularly from supervisors and spouses, was associated with low levels of both burnout and mental health problems resulting from job stress. In contrast, Russell et al. (1987) reported that burnout in Iowa public school teachers during the ®nal month of the school year was unrelated to support from spouse, friends, and family. TURNOVER AND EMPLOYEES' WORK-PLACE SOCIAL SUPPORT SYSTEMS, QUALITY OF WORK LIFE, AND JOB TENSION

Research has shown that an increased perceived personal and work-group support climate reduced the likelihood of turnover. Health care employees who had personal support from other sta€ and supervisors were more likely to have higher job satisfaction than others; which in turn was associated with lower turnover rates. Similarly, a favorable work-group climate that promotes job satisfaction and member cohesiveness may reduce the likelihood for turnover. The relationship between social support at work and turnover is summarized in Table 1. The study of Tai (1996) of sta€ in 42 dialysis facilities showed that supervisor support signi®cantly predicted the likelihood of employee turnover although other aspects of social support at work (co-worker support and work-group support climate) did not a€ect turnover behavior. The 16% turnover rate for those who reported supervisor support was almost half that of the 27% turnover rate of those who perceived no support from their supervisor.

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T. Tai et al.

Hart and Moore (1989) found a signi®cant di€erence in RN sta€ stability measured as length of time employed in the unit, according to the nurse's perception of intra-unit patterns of interaction with the unit-level manager and division-level nurse manager. However, the degree of support to sta€ RNs from non-nursing departments (such as housekeeping, messenger services, and social workers) and other health care professionals (such as laboratory, pharmacy, respiratory therapists, dietitians, and physical therapists) were not signi®cantly related to nurse stability. Helmer and McKnight (1989) reported that having an administrator who would listen to hospital nurses, as well as a strong, supportive nursing administration were the two highest priorities ranked by sta€ nurses. Landstrom et al. (1989) reported that con¯ict between a hospital nurse and the nursing manager was the most common source of con¯ict (85%) in the initial stage of turnover. Lack of co-worker cohesiveness and support was noted by 42% of those who quit as a major source of con¯ict in the initial stage of turnover. However, none of the administrator's demographic factors, i.e. age, sex, education, years in long-term care, years on present job, previous occupation, and outside professional activities, were associated with nursing turnover in 110 nursing homes (Stryker-Gordon, 1979). Kramer and Schmalenberg (1991) studied the experience of sta€ nurses from magnet hospitals that ``successfully attracted and retained nurses, were good places to work, and delivered quality nursing care''. The median turnover rate of nurses in the 16 magnet hospitals was 9% in 1990, nearly half the national turnover rate (16%) reported in 1990 by the National Association for Health Care Recruitment Survey (National Association for Health Care Recruitment, 1992). Nurses from magnet hospitals reported higher satisfaction on ®ve job satisfaction factors ± organizational structure, professional practice, management style, quality of leadership, and professional development ± than those who worked in non-magnet hospitals. Nurses from magnet hospitals were three times more likely to be very satis®ed with the management style, de®ned as ``the way in which the organization and nursing department was run-style, climate, milieu, participative management, visibility and accessibility of leaders''. Quality of leadership was de®ned as attributes and characteristics of leader behavior such as administrative support, responsiveness and expectations of leaders, quality of nurse-managers, formal and informal interaction opportunities. Nurses from magnet hospitals were three times more likely to report that they were very satis®ed with the quality of leadership than those from non-magnet hospitals. Thus, Kramer and Schmalenberg's study (1991) provides evidence that these aspects of support climate at work and quality

of work life were important factors associated with the signi®cantly lower turnover rates of nurses in magnet hospitals. Sheridan (1985) found that group cohesion (i.e., how frequently the employee felt that co-workers were congenial and cooperated with each other in providing care to all the patients in the nursing home unit) was signi®cantly related to nursing home employee turnover among newly hired patient care sta€, but not signi®cantly related to turnover for those who worked in the nursing homes for more than six months. These ®ndings support the hypothesis that hospital nursing employees' propensity to leave jobs declined signi®cantly as job tenure and group cohesion increased (Price and Mueller, 1981). Hence, work-group support climate can be regarded as a signi®cant factor in sta€ retention, particularly for those newly hired. Research has focused on internal social support at work (from co-workers, supervisors, and administrators) associated with physical and psychological well-being, and burnout. A break down by occupation and marital status of Canadian professional and clerical sta€ studied by Aston and Lavery (1993) showed no signi®cant e€ects of co-workers and supervisor support, with the exception of a negative relationship between co-worker support and quality of life in the unmarried clerical group. Aston and Lavery suggested that interactions at work may put a strain on spousal relations. Overall, unmarried women, especially in the managerial group, seemed to bene®t from internal support systems at work. Davis-Sacks et al. (1985) found that internal social support, particularly from supervisors, was associated with lower levels of burnout and mental health problems resulting from job stress. These and several other studies concluded that sta€ support signi®cantly reduced role ambiguity, role con¯icts, and work load, and improved physical and psychological well-being (Davis-Sacks et al., 1985; Russell et al., 1987). Jayaratne et al. (1988) indicated that perceived increased sta€ support was a signi®cant moderator of role ambiguity, role con¯ict, anxiety, depression, irritability, somatic, depersonalization, and emotional exhaustion. Russell et al. (1987) found that supervisor support was signi®cant moderator of teacher burnout. Teachers with supportive supervisors reported less emotional exhaustion, more positive attitudes toward students, and greater personal accomplishment. Ross et al. (1989) found that counseling sta€ who had greater ``social integration'', provided by relationships in which persons had shared interests and concerns, had signi®cantly less emotional exhaustion and depersonalization. However, the study ®ndings on sta€ support are not consistent; suggesting a di€erence that support used rather than support perceived may be more important to the physical and psychological well-

Turnover literature review

being of employees. For example, Jayaratne et al. (1988) found perceived sta€ support was not signi®cantly related to either ``work load'' or ``personal accomplishment'' of social workers. Nor, in the same study, was perceived supervisor support signi®cantly related to ``work load'', ``personal accomplishment'', or ``depersonalization''. Aston and Lavery (1993) also found supervisor's support was not signi®cantly related to physical or psychological well-being of female professional and clerical sta€. An individual's perceived low probability of promptly ®nding a better job may suppress a desire to seek other employment and thus reduce the likelihood of turnover behavior. Price and Mueller (1986), Prestholdt et al. (1987), Jolma (1990), and Hom and Gri€eth (1991) found that turnover increased as external job opportunities increased. However, Abelson (1987) and Lane et al. (1990) reported that the relationship was not signi®cant. While external employment opportunities may be attractive, the pay di€erential or other rewards may not be sucient to make a change worthwhile. No literature references were found which addressed the issue of turnover relative to the pay o€ered by prospective employers. Dialysis employees' quality of work life and turnover were signi®cantly related in the study of Robinson (1995). Quality of work life was de®ned as one's perception of promotional opportunity, job security, interesting work, and supervisor's technical skills. There were no speci®c references relating the quality of work life of health care sta€ to turnover. However, several investigators reported that turnover and promotional opportunities were inversely related (George, 1979; Decker, 1985; Price and Mueller, 1986; Cavanagh, 1990). Others found that supervisory employees had lower rates of turnover than did non-supervisory employees (Seybolt et al., 1978; Decker, 1985; Volk and Lucas, 1991). None of the references reported on possible correlation between turnover and either job security or perceptions that the work was interesting. SUMMARY AND CONCLUSION

Sta€ turnover has serious rami®cations for employers, patients, funding agencies, and the nursing profession itself. Numerous attempts have been made to understand why individuals leave their jobs. The con¯icting results obtained from simple bivariate analyses underscored the complexity of turnover behavior. Rigorously controlled investigations are now being used to better understand a health care employee's decision to leave his or her job. From the many research studies investigating why nurses leave their jobs, some variables are beginning to emerge as signi®cant predictors of turnover behavior. Studies on turnover in hospitals and nursing homes have shown that older sta€,

1921

minorities, those with higher income, or longer tenure were associated with lower actual or intended turnover. Job satisfaction and tension, organizational commitment, perceived job possibilities, and supervisor's behavior were other factors that may lead to turnover. Tai (1996) found that increased emotional support from family/friends and supervisor support at work predictably reduced the likelihood of turnover in dialysis facilities. For this reason, it is recommended that health care providers may want to consider implementing employee assistance programs. Such programs have been shown in business and industrial settings to provide increased social support for employees and, in turn, improve their retention rate. Also, future turnover research should include an expanded turnover model which includes both social support at home and at work. The meta-analysis of Blegen (1993) of data from 48 studies, with a total of 15,048 registered nurses engaged in patient care, indicated that job satisfaction was most strongly correlated with stress and organizational commitment (r>0.50), followed by communication with supervisor, autonomy, recognition, routinization, communication with peers, fairness, and locus of control (0.20 < r < 0.50). On the other hand, variables frequently included in these studies, such as education, age, tenure, and professionalism, had correlation of less than 0.20. In a study of 1597 nursing sta€ from urban and rural hospitals, Hinshaw et al. (1987) indicated that actual turnover was predicted by anticipated turnover for medical/surgical nurses and baccalaureateprepared registered nurses, but not for diploma-prepared nurses and critical care nurses; anticipated turnover was in¯uenced by organizational, professional/occupational job satisfaction, group cohesion, and initial expectation of tenure. Their ®ndings suggested that e€ective retention strategies need to be targeted speci®cally to particular conditions of the nursing sta€ such as educational preparation and the clinical service on which sta€ are working. The meta-analysis of Irvine and Evans (1995) of data from 11 turnover studies indicated a strong positive relationship between behavioral intention and turnover; a strong negative relationship between job satisfaction and behavioral intention, and between job satisfaction and turnover. Of the variables related to nurse job satisfaction in their meta-analysis, work content and work environment variables had a stronger relationship with satisfaction than either economic or individual di€erence variables. Their ®ndings suggested that administrators and nurse managers have more control over work content variables through job design, or work environment variables through appropriate leadership support and human resource management practices, than they have over external labor market factors or sta€'s individual characteristics.

1922

T. Tai et al.

This review explores an organizational analysis of turnover and demonstrates the importance of social support to reduce turnover; thus opening the way for administrative intervention on work support climate and programs to reduce turnover. One direction for future research is to expand the model to include other organizational and managerial variables not captured in this model, for example work autonomy. One limitation of the current review is the use of single time studies. Thus, future research to test the model longitudinally could guide decisions and management practices towards improved sta€ social support at work. Other directions for research are to consider: (1) testing the turnover model according to avoidable, voluntary turnover vs involuntary turnover; (2) measuring turnover consistently; (3) including market wage and fringe bene®t as well as their interactions with seniority in the model; and (4) testing the model for predicting turnover in other types of health facilities. A fourth direction for research is to consider the turnover costs imposed on the institution and patients. Also, follow-up interviews regarding reasons of turnover, for example, moving, returning to school, vs stressful or poor work conditions, are recommended. Another limitation of this review was its geographically circumscribed area of facilities that volunteered to participate; it was unknown whether non-participating facilities had di€erent turnover pictures. Future research in expanding study population in other health facilities and other international locations is needed. Lastly, di€erent types of support measurement, especially the use of employee assistance programs, positive work climate and supervisor support, are recommended to validate ®ndings. Socio-demographics and turnover Age, tenure, race, and job status of a nurse were the consistently signi®cant socio-demographic factors which predictably increased the likelihood of turnover in this turnover review. Thus, active recruitment of quali®ed, older individuals and minorities may help to reduce turnover likelihood. Management should examine existing orientation programs or develop new programs to enhance employee communication and promote supervisory feedback regarding work-related support. As appropriate, management could enhance existing support programs, career ladders, communication, and training programs to make the work climate more attractive, especially to the high-turnover-prone group of younger, newer sta€. Management should seek ways to recognize and reward sta€ who stay longer than ®ve years. Routine communications, feedback, and training sessions may help make health care employment more attractive to younger, newer sta€ and increase their human capital investment in the current organization. Further, manage-

ment should work more closely with patient care sta€ who have little or no work-related support network. However, equally important, continued support should be given to longer tenure employees in order to reinforce a stable, reliable workforce. Facility's organization and turnover Employees of large-scale chains are less likely to turnover than are employees of other types of organizations. National chain facilities may enjoy economies of scale and extensive resources because of their size; thus, they may o€er more generous employee bene®ts and greater opportunities for promotion. Health care facilities should implement employee assistance programs (EAPs) tailored to the needs of their employees, such as work support programs, supervisor communication training, and better work climate. Larger facilities, with the economics of scale, may prefer the more successful inhouse administered EAPs which are more sensitive to the particular needs of their employees. However, smaller facilities can also bene®t from EAPs; they may contract with an outside agency to design and con®gure an EAP to meet their needs. Family/friends social support and turnover Examining social support from family and friends adds new facts to sta€ turnover, as employees who had greater emotional support from family and friends were signi®cantly less likely to turnover (Tai, 1996). This relationship was consistent with studies that examined stress and turnover. Routine communication, debrie®ng, and feedback sessions may help create an emotionally supportive work climate for those who may not have adequate support at home. Although family support for sta€ is not under the control of health care administrators, EAPs which help employees and their family with personal problems, ®nancial troubles, or family discord may be a management solution to health care employers. In general, these programs identify troubled employees, motivate them to resolve their troubles, and provide access to counseling or treatment as needed. EAP referrals access professional care, either in-house or from community-based agencies, for such problems as alcoholism, emotional diculties, stress, drug dependence, ®nancial troubles, legal complications, and family discord. Akabas and Akabas (1982) reported that organizations which successfully used EAPs decreased turnover rates, unemployment and insurance costs, and use of sick time. Work support and turnover Supervisor support has been shown to signi®cantly reduce turnover. Support programs at work and a positive work climate, factors directly in¯uenced by administrators, reduce individual turnover. Further research is needed to validate the relationship between work support climate and turnover as

Turnover literature review

®ndings reported in these studies were inconsistent. Supervisors should be particularly attentive to the support needs of employees of high potential turnover, i.e., the patient care sta€ (LVN/LPNs and aides), and the younger, or shorter service employees. As appropriate, management should implement new programs or enhance existing support programs at work, i.e., career ladders, communication and training programs, to make the work climate more attractive, especially to the high potential turnover groups.

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