WORKFORCE CSIRO PUBLISHING
Australian Health Review, 2014, 38, 425–431 http://dx.doi.org/10.1071/AH13204
Impact of organisational characteristics on turnover intention among care workers in nursing homes in Korea: a structural equation model Jong Goon Ha1 , PhD Candidate Ji Man Kim2 PhD, Assistant Professor Won Ju Hwang3 RN, PhD, Assistant Professor Sang Gyu Lee4,5,6 MD, PhD, MBA, Associate Professor 1
Department of Public Health, Graduate School, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, South Korea. Email: [email protected] 2 Department of Health Business Administration, Woosong University, 171 Dongdaejeon-ro, Dong-gu, Daejeon 300-718, South Korea. Email: [email protected] 3 College of Nursing Science, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul 130-701, South Korea. Email: [email protected] 4 Graduate School of Public Health, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, South Korea. 5 Institute of Health Services Research, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, South Korea. 6 Corresponding author. Email: [email protected]
Abstract Objective. The aim of the present study was to analyse the impact of organisational characteristics on the turnover intention of care workers working at nursing homes in Korea. Methods. Study participants included 504 care workers working at 14 nursing homes in Korea. The variables measured were: high-performance work practices, consisting of five subfactors (official training, employment stability, autonomy, employee participation and group-based payment); organisational commitment, consisting of three subfactors (affective, normative and continuance commitment); organisational support; and turnover intention. The inter-relationship between high-performance work practices, organisational support, organisational commitment and turnover intention and the fit of the hypothetical model were analysed using structural equation modelling. Results. According to our analysis, high-performance work practices not only had a direct effect on turnover intention, but also an indirect effect by mediating organisational support and commitment. The factor having the largest direct influence on turnover intention was organisational commitment. Conclusions. The results of the present study suggest that to improve health conditions for frail elderly patients at nursing homes, as well as the efficiency of nursing homes through the continuance of nursing service and enhancement of quality of service, long-term care facilities should reduce the turnover intention of care workers by increasing their organisational commitment by actively implementing high-performance work practices. What is known about the topic? Considerable studies have shown that the adoption of high-performance work practices is related to an organisation’s performance and job satisfaction. In addition, previous studies found that job satisfaction is inversely related to the turnover intention of employees. What does this paper add? This paper identified that high-performance work practices are closely related to the turnover intention of care workers in nursing homes. These findings could improve our understanding of the factors that impact on labour management in nursing homes. What are the implications for practitioners? The turnover of care workers is one of the major managerial challenges for nursing home managers. The findings of this study suggest that managers should be focused on high-performance work practices to improve the efficiency of their organisations. Additional keyword: nursing assistants. Received 28 October 2013, accepted 3 March 2014, published online 29 May 2014 Journal compilation AHHA 2014
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Introduction In Korea, the aging population is growing faster than anywhere else in the world. The proportion of people aged 65 years exceeded 7% in 2000, and this number is expected to be >14% in 2018. Furthermore, this percentage is expected to be >20% by 2026, a value indicative of a super-aged society.1 This 26-year time span from an aging society to a super-aged society is very fast compared with the 36, 94 and 154 years predicted for Japan, the US and France, respectively.2 The Korean government implemented long-term care insurance on 1 July 2008 as a social insurance similar to that in Japan and Germany. Through this insurance, older people who cannot maintain their daily activities due to their old age or chronic disease are provided nursing service benefits. This nursing service is provided primarily at nursing home facilities. Before the introduction of this insurance, in June 2008, there were 1332 nursing homes in Korea; by December 2010, this number had nearly doubled to 2429.3 Most services at Korean nursing homes are performed by care workers. Over 100 000 care workers currently work at nursing homes and account for over 80% of nursing home employees.4 However, because wages are low, the work environment is poor and the services provided are labour-intensive and considered suitable for unskilled workers, care workers face mental and physical difficulties and experience a high level of stress and turnover.5 Studies carried out in the USA and Israel have also reported very high turnover rates for care workers. These studies reported turnover rates between 74% and 100% per year overall and a record 400% at some nursing homes.6 Turnover intention is one response to job satisfaction that is characterised by a desire to switch from the current company to another company.7 Job satisfaction is inversely related to turnover intention.8 Factors that affect turnover intention include jobrelated factors, work groups and human resource management systems. Accumulating research suggests that the adoption of high-performance work practices (HPWPs) is related to an organisation’s performance.9 HPWPs include incentive
compensation, training, employee participation, selectivity and flexible work arrangements.10 These practices increase employees’ knowledge, skills and abilities (KSAs), empower employees to leverage their KSAs for organisational benefit and increase employees’ motivation to do so.11,12 The result is greater job satisfaction, lower employee turnover and higher productivity, all of which help improve organisational performance.13 The turnover of care workers has a direct negative effect on the health of frail elderly residents at nursing homes, as well as on the efficiency of nursing home services in general.14 Research on nurses has shown that turnover among nurses increases their colleagues’ workload and stress, and has an adverse impact on the amount and quality of nursing care due to a shortage of nurses. At the organisational level, administrative costs are increased because of expenses associated with the recruitment and training of new employees.15 Therefore, reducing the turnover of care workers is very important in managing the health of elderly residents as well as in effectively managing nursing facilities. Thus, the present study was designed to analyse the organisational factors, especially HPWPs, affecting the turnover intention of care workers at Korean nursing homes using a structural equation model. Unlike more advanced Western countries that are in the mature phase of long-term care system development, Korea is in the initial stages. As such, Korea’s experiences can provide valuable information for many developing countries that will have to contend with an aging society in the near future. Materials and methods Data collection We chose a random sample of 14 nursing homes in Seoul and Gyeonggi Province, Korea, with a capacity of more than 50 elderly residents and whose administrators agreed to participate in the study. We asked the administrators to distribute the questionnaire to their care workers. The structured questionnaire survey was conducted from 2 to 16 April 2010. Of the 656
Table 1. Operational definitions and measurement of study variables Variable Turnover intention Employment stability Formal training Autonomy Group-based payment
Employee participation Organisational support Organisational commitment
Operational definition Assessment of the possibility of employees voluntarily leaving their current organisations in the near future The degree of employees’ sense of stability about maintaining their jobs in their organisations Scope of opportunities for broad education and training provided by organisations to employees The degree of influence employees have on their work Whether organisations offer group-based incentives related to their achievement or run profit-sharing systems Having an opportunity to participate in decision making and provide suggestions for improvement Support or help related to tasks offered to members by their organisations Determination of members to work hard for their organisations and remain as members of their organisations based on positive beliefs in their organisations’ goals and values
Measurement tool 16
Price
Akhtar et al.17 and Delery and Doty18 Delery and Doty18 Price16 Akhtar et al.17
Delery and Doty18 Price16 and Kim19 Mowday et al.20 and Allen and Meyer21
Scale Five-point Likert scale
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care workers across the 14 nursing homes, 504 consented to participate in the study. Study variables Based on previous studies,16–21 organisational characteristics affecting turnover intention were selected and reflected in the questionnaire. The operational definitions of the study variables and the tools used to measure them are summarised in Table 1. Turnover intention, which is defined as the extent to which an employee plans to discontinue working for their current employer, was measured using the questionnaire developed by Price16 and scored on a five-point Likert scale. The measure of HPWPs, the main independent variable, consisted of five scales, namely Employment stability,17,18 Formal training,18 Autonomy,16 Group-based payment17 and Employment participation18. In addition, organisational support16,19 and organisational commitment20–21 were measured. Hypothetical model and hypothesis The hypothetical model used in this study is shown in Fig. 1, and the hypotheses (H) applied to the model were as follows: H1: HPWPs will have a positive effect on the organisational support perceived by care workers H2: HPWPs will have a positive effect on the organisational commitment of care workers H3: Organisational support will have a positive effect on the organisational commitment of care workers H4: Organisational support will have a negative effect on the turnover intention of care workers
H5: Organisational commitment of care workers will have a negative effect on turnover intention H6: HPWPs will have a negative effect on turnover intention Statistical analysis To investigate general characteristics of the participants, descriptive statistics were examined. Reliability and validity tests were performed for each question in the survey and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were undertaken to check the suitability of the data. Based on the results, correlations among HPWPs, organisational support, organisational commitment and turnover intention and the fitness of the hypothetical model were analysed using a structural equation model. All statistical analyses were conducted using SPSS 12.0 for Windows (SPSS, Chicago, IL, USA) and AMOS 18.0 (SPSS). Results General characteristics of participants and distribution of variables The general characteristics of the study participants and the distribution of variables are given in Table 2. Of the 504 participants, 485 (96.2%) were female. Mean care worker age was 50.4 years, with most being aged in their 40s (302; 59.9%). With regard to educational status, the largest proportion of care workers had graduated from high school (302; 59.9%). Most participants had worked at the nursing home for 1–2 years (169; 33.5%), with the mean duration of service engagement being 3.2 years. Most
Employment stability
Continuous commitment
Affective commitment
Normative commitment
Formal training
autonomy
H2
HPWPs
Employee participation
H5
Organisational commitment
Turnover intention
H1 H3
Group-based payment
427
H4
Organisational support
H6
Fig. 1. Hypothetical model. Six hypotheses were evaluated: H1, high-performance work practices (HPWPs) will have a positive effect on the organisational support perceived by care workers; H2, HPWPs will have a positive effect on the organisational commitment of care workers; H3, organisational support will have a positive effect on the organisational commitment of care workers; H4, organisational support will have a negative effect on the turnover intention of care workers; H5, organisational commitment of care workers will have a negative effect on turnover intention; H6, HPWPs will have a negative effect on turnover intention.
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Table 2. Characteristics of the study participants and distribution of study variables n (%)
Turnover intention
Organisational support
Organisational commitment
Formal training
High-performance work practices Employee Employment Autonomy participation stability
Group-based payment
Gender Female Male
485 (96.2) 19 (3.8)
2.84 2.57
3.24 3.30
3.13 3.10
3.68 3.69
3.43 3.36
3.50 3.24
3.26 2.51
3.89 3.63
Marital status Unmarried Married Other
52 (10.3) 445 (88.3) 7 (1.4)
2.74 2.55 2.88
3.23 3.30 3.32
3.07 3.11 3.32
3.67 3.70 3.64
3.67 3.70 3.64
3.38 3.23 3.07
2.89 2.50 2.71
3.85 3.62 3.71
Duration of service engagement 7 years 34 (6.7)
2.54 2.55 2.57 2.62 2.67 2.47
3.38 3.31 3.36 3.25 3.21 3.11
3.01 3.08 3.05 3.12 3.18 3.46
3.81 3.77 3.73 3.67 3.35 3.70
3.34 3.50 3.38 3.24 3.20 3.20
3.18 3.31 3.20 3.31 3.06 3.54
2.42 2.54 2.51 2.57 2.63 2.70
3.74 3.82 3.54 3.76 3.69 3.64
Education Elementary school Middle school High school Junior college College Other
22 (4.4) 90 (17.9) 302 (59.9) 46 (9.1) 43 (8.5) 1 (0.2)
2.57 2.52 2.55 2.68 2.73 3.50
3.42 3.23 3.30 3.24 3.44 3.25
3.20 3.19 3.08 3.11 3.08 2.88
3.58 3.81 3.68 3.74 3.49 4.25
3.20 3.46 3.33 3.43 3.36 3.00
3.23 3.30 3.21 3.42 3.27 1.50
2.52 2.46 2.49 2.71 2.94 1.75
3.57 3.46 3.66 3.93 3.63 3.00
Employment status Permanent Temporary
185 (36.7) 319 (63.3)
2.70 2.51
3.18 3.37
3.21 3.04
3.86 3.60
3.50 3.28
3.55 3.07
2.71 2.44
3.68 3.62
504
2.58 ± 0.53
3.30 ± 0.90
3.10 ± 0.48
3.69 ± 0.72
3.36 ± 0.71
3.25 ± 0.90
2.54 ± 0.83
3.64 ± 0.89
Total
participants (445; 88.3%) were married. Of the 504 participants, 319 (63.3%) and 185 (36.7%) were temporary and permanent employees, respectively.
commitment on the influence of work practices on turnover intention was also significant at –0.369 (P < 0.01). The established structural equation model explained 45.6% of the total variance of turnover intention (Table 5).
Test of study models The CFA of variables established the suitability of the data. The structural model was tested based on these variables and its fitness was found to be satisfactory (Table 3). Because the test of the hypothetical model also revealed satisfactory fitness (c2 = 70.57, Q = 2.19, Root Mean Square of Residuals (RMSR) = 0.05, Normed Fit Index (NFI) = 0.93, Comparative Fit Index (CFI) = 0.96, Adjusted Goodness of Fit Index (AGFI) = 0.90), the model was used without revision. Results of hypothesis testing The results of hypothesis testing are given in Table 4. There were significant positive correlations between HPWPs and organisational support (H1), between HPWPs and organisational commitment (H2) and between organisational support and organisational commitment (H3). In contrast, there were significant negative correlations between organisational support and turnover intention (H4), between organisational commitment and turnover intention (H5) and between HPWPs and turnover intention (H6). Indirect effects were also evaluated to verify the effect of organisational support on the influence of work practices on turnover intention; the effect was found to be significant at –0.260 (P < 0.01). Moreover, the effect of organisational
Discussion There have been no accurate statistics published relating to the turnover rate of care workers in Korea because the long-term care system for older people was instituted only 5 years ago. However, the situation is expected to be similar to that in other countries in the mature stage of the system. In the US, most nursing services for frail elderly patients at nursing homes are performed by care workers.22 A high turnover rate of care workers has been found to have a direct negative effect on the continuity of nursing services, as well as on the quality of services for the aged.23 In addition, employee turnover leads to additional costs associated with the recruitment and training of new employees, contributing to inefficiencies in management.24 In a meta-analysis of 92 studies investigating the effects of HPWPs on organisational performance, Combs et al. found that the use of HPWPs is positively related to organisational performance and that this relationship is larger for HPWPs systems than for individual practices.10 The Society for Human Resource Management (SHRM) assesses employment stability as one of the most critical factors, following income and benefits packages.25 Employment stability improves job satisfaction by reducing the stress that accompanies unemployment.
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Table 3. Results of confirmatory factor analysis HPWPs, high-performance work practices; Q, model parameter; RMSR, Root Mean Square of Residuals; NFI, Normed Fit Index; CFI, Comparative Fit Index; GFI, Goodness of Fit Index; AGFI, Adjusted Goodness of Fit Index; TLI, Trucker-Lewis Index
HPWPs Organisational support Organisational commitment Turnover intention
c2
Q
RMSR
NFI
CFI
GFI
AGFI
TLI
Delta2
1855.84 455.23 145.35 55.44
2.06 2.01 2.02 2.03
0.040 0.042 0.022 0.032
0.903 0.902 0.901 0.902
0.911 0.913 0.913 0.934
0.926 0.931 0.934 0.941
0.895 0.915 0.913 0.929
0.921 0.924 0.923 0.921
0.903 0.903 0.902 0.902
Table 4. Results of path analysis for hypotheses tested HPWPs, high-performance work practices. *P < 0.05, **P < 0.01 Hypothesis
Estimate
Critical ratio
H1: HPWPs !organisational support 0.429** H1: HPWPs !organisational commitment 0.638** H3: Organisational support !organisational 0.165* commitment H4: Organisational support !turnover intention –0.134* H5: Organisational commitment !turnover –0.369** intention H6: HPWPs !turnover intention –0.148*
0.667 1.382 11.231 8.467 –4.564 0.627
Table 5. Effects of factors on turnover intention HPWPs, high-performance work practices; SMC, squared multiple comparisons. *P < 0.05, **P < 0.01 Turnover intention
HPWPs
Organisational support
Organisational commitment
Direct effect Indirect effect
–0.148* –0.260**
–0.134* –0.024*
–0.369**
Total effect
–0.408*
–0.158*
–0.369**
SMC
0.456
Participation in decision making is related to bosses’ leadership and abilities, given that democratic bosses will allow their subordinates to participate in decision making. However, although participation in decision making is correlated with job satisfaction, some studies have found no correlation26; thus, it is difficult to reach a conclusion about the relationship. Moreover, bosses’ leadership style can affect employees’ autonomy. If bosses exhibit an authoritative or bureaucratic leadership style, employees would have little autonomy over their work. Previous studies conducted with employees in other industries27,28 have found similar findings for the relative importance of the use of HPWPs. The basis of these work practices should involve competency development, motivation and increased opportunities for contributing to organisational performance. By improving these practices, nursing homes can reap potential benefits in the form of both improved health of frail elderly residents and enhanced management efficiency. Work practices perceived by care workers were also found to have an indirect effect on turnover intention by mediating organisational commitment and organisational support, as well as having a direct effect.29,30 A study by Lee5 showed that organisational commitment decreased turnover intention and found that organisational commitment had the largest direct influence on turnover intention. These findings suggest that nursing homes should make an
effort to improve the organisational commitment for care workers because increased organisational commitment is expected to enhance the quality of service at nursing homes. According to several other previous studies that looked at the relationship between turnover intention of care workers and organisational factors, the potential of professional growth, involvement in work-related decisions and supervision are considered important factors influencing turnover intention or the actual turnover of care workers.31–34 A study by Kim and Kim35 also reported that job satisfaction and organisational commitment of care workers affected the quality of service for the elderly at nursing homes. Moreover, Lee5 proposed that the expertise of care workers should be strengthened and organisational support should be offered to prevent turnover. A study by Lee and Lee36 revealed a close correlation between recognition and rewards from nursing homes with the job satisfaction of care workers. In agreement with the results of these previous studies, care workers participating in the present study perceived the work practices of nursing homes, especially HPWPs, as organisational support for them and subsequently evaluated this category positively. As a result of supportive practices, the employees were more committed to the nursing homes emotionally and morally (and not just of economic necessity); consequently, their turnover intention declined. However, the present study has some limitations. First, our data came from a limited number of facilities in Seoul and Gyeonggi Province, Korea, and this may limit the generalisability of the results. Second, we used turnover intention as an antecedent variable of actual turnover. The relative difference between them in a single model cannot be determined if both are not examined simultaneously. Therefore, it is somewhat difficult to accept that higher turnover intention is expected to be associated with higher actual turnover. However, because statistics for the actual turnover of care workers were not available at the time in Korea, turnover intention was unavoidably used as a dependent variable. Turnover intention is a variable that explains actual turnover as well, and studying it is more accurate and more effective in terms of cost than evaluating turnover itself. In addition, studying turnover intention has the advantage of preventing actual turnover by improving the factors affecting turnover intention. As such, turnover intention has been recognised as an optimal variable to predict actual turnover.37–39 Third, the cross-sectional design of the study was another limitation. Because the study investigated both exogenous and endogenous variables at the same time with a single questionnaire, there could be a bias in that the actual responses affected the endogenous variables. However, the structural equation model used in this study verified the reliability and validity of the measures through CFA, so the bias typically
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observed in studies using cross-sectional data is considered to be offset to some degree. Conclusions This study revealed that the turnover intention of care workers is closely related to how they perceive work practices at their respective nursing homes. In addition, organisational support and organisational commitment were found to be critical parameters in the correlation between work practices, especially HPWPs, and turnover intention. These results imply that nursing homes should actively apply HPWPs for care workers to enhance their emotional and moral commitment to the workplace. As a result, these practices will contribute to the health of the elderly in these facilities, as well as to efficient workplace management, by improving the continuity of nursing care and the quality of service as a result of a reduction in the turnover intention of care workers. Competing interests The authors declare they have no competing interests. References 1
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15
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Australian Health Review, 2014, 38, 425–431 http://dx.doi.org/10.1071/AH13204
Impact of organisational characteristics on turnover intention among care workers in nursing homes in Korea: a structural equation model Jong Goon Ha1 , PhD Candidate Ji Man Kim2 PhD, Assistant Professor Won Ju Hwang3 RN, PhD, Assistant Professor Sang Gyu Lee4,5,6 MD, PhD, MBA, Associate Professor 1
Department of Public Health, Graduate School, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, South Korea. Email: [email protected] 2 Department of Health Business Administration, Woosong University, 171 Dongdaejeon-ro, Dong-gu, Daejeon 300-718, South Korea. Email: [email protected] 3 College of Nursing Science, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul 130-701, South Korea. Email: [email protected] 4 Graduate School of Public Health, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, South Korea. 5 Institute of Health Services Research, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, South Korea. 6 Corresponding author. Email: [email protected]
Abstract Objective. The aim of the present study was to analyse the impact of organisational characteristics on the turnover intention of care workers working at nursing homes in Korea. Methods. Study participants included 504 care workers working at 14 nursing homes in Korea. The variables measured were: high-performance work practices, consisting of five subfactors (official training, employment stability, autonomy, employee participation and group-based payment); organisational commitment, consisting of three subfactors (affective, normative and continuance commitment); organisational support; and turnover intention. The inter-relationship between high-performance work practices, organisational support, organisational commitment and turnover intention and the fit of the hypothetical model were analysed using structural equation modelling. Results. According to our analysis, high-performance work practices not only had a direct effect on turnover intention, but also an indirect effect by mediating organisational support and commitment. The factor having the largest direct influence on turnover intention was organisational commitment. Conclusions. The results of the present study suggest that to improve health conditions for frail elderly patients at nursing homes, as well as the efficiency of nursing homes through the continuance of nursing service and enhancement of quality of service, long-term care facilities should reduce the turnover intention of care workers by increasing their organisational commitment by actively implementing high-performance work practices. What is known about the topic? Considerable studies have shown that the adoption of high-performance work practices is related to an organisation’s performance and job satisfaction. In addition, previous studies found that job satisfaction is inversely related to the turnover intention of employees. What does this paper add? This paper identified that high-performance work practices are closely related to the turnover intention of care workers in nursing homes. These findings could improve our understanding of the factors that impact on labour management in nursing homes. What are the implications for practitioners? The turnover of care workers is one of the major managerial challenges for nursing home managers. The findings of this study suggest that managers should be focused on high-performance work practices to improve the efficiency of their organisations. Additional keyword: nursing assistants. Received 28 October 2013, accepted 3 March 2014, published online 29 May 2014 Journal compilation AHHA 2014
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Introduction In Korea, the aging population is growing faster than anywhere else in the world. The proportion of people aged 65 years exceeded 7% in 2000, and this number is expected to be >14% in 2018. Furthermore, this percentage is expected to be >20% by 2026, a value indicative of a super-aged society.1 This 26-year time span from an aging society to a super-aged society is very fast compared with the 36, 94 and 154 years predicted for Japan, the US and France, respectively.2 The Korean government implemented long-term care insurance on 1 July 2008 as a social insurance similar to that in Japan and Germany. Through this insurance, older people who cannot maintain their daily activities due to their old age or chronic disease are provided nursing service benefits. This nursing service is provided primarily at nursing home facilities. Before the introduction of this insurance, in June 2008, there were 1332 nursing homes in Korea; by December 2010, this number had nearly doubled to 2429.3 Most services at Korean nursing homes are performed by care workers. Over 100 000 care workers currently work at nursing homes and account for over 80% of nursing home employees.4 However, because wages are low, the work environment is poor and the services provided are labour-intensive and considered suitable for unskilled workers, care workers face mental and physical difficulties and experience a high level of stress and turnover.5 Studies carried out in the USA and Israel have also reported very high turnover rates for care workers. These studies reported turnover rates between 74% and 100% per year overall and a record 400% at some nursing homes.6 Turnover intention is one response to job satisfaction that is characterised by a desire to switch from the current company to another company.7 Job satisfaction is inversely related to turnover intention.8 Factors that affect turnover intention include jobrelated factors, work groups and human resource management systems. Accumulating research suggests that the adoption of high-performance work practices (HPWPs) is related to an organisation’s performance.9 HPWPs include incentive
compensation, training, employee participation, selectivity and flexible work arrangements.10 These practices increase employees’ knowledge, skills and abilities (KSAs), empower employees to leverage their KSAs for organisational benefit and increase employees’ motivation to do so.11,12 The result is greater job satisfaction, lower employee turnover and higher productivity, all of which help improve organisational performance.13 The turnover of care workers has a direct negative effect on the health of frail elderly residents at nursing homes, as well as on the efficiency of nursing home services in general.14 Research on nurses has shown that turnover among nurses increases their colleagues’ workload and stress, and has an adverse impact on the amount and quality of nursing care due to a shortage of nurses. At the organisational level, administrative costs are increased because of expenses associated with the recruitment and training of new employees.15 Therefore, reducing the turnover of care workers is very important in managing the health of elderly residents as well as in effectively managing nursing facilities. Thus, the present study was designed to analyse the organisational factors, especially HPWPs, affecting the turnover intention of care workers at Korean nursing homes using a structural equation model. Unlike more advanced Western countries that are in the mature phase of long-term care system development, Korea is in the initial stages. As such, Korea’s experiences can provide valuable information for many developing countries that will have to contend with an aging society in the near future. Materials and methods Data collection We chose a random sample of 14 nursing homes in Seoul and Gyeonggi Province, Korea, with a capacity of more than 50 elderly residents and whose administrators agreed to participate in the study. We asked the administrators to distribute the questionnaire to their care workers. The structured questionnaire survey was conducted from 2 to 16 April 2010. Of the 656
Table 1. Operational definitions and measurement of study variables Variable Turnover intention Employment stability Formal training Autonomy Group-based payment
Employee participation Organisational support Organisational commitment
Operational definition Assessment of the possibility of employees voluntarily leaving their current organisations in the near future The degree of employees’ sense of stability about maintaining their jobs in their organisations Scope of opportunities for broad education and training provided by organisations to employees The degree of influence employees have on their work Whether organisations offer group-based incentives related to their achievement or run profit-sharing systems Having an opportunity to participate in decision making and provide suggestions for improvement Support or help related to tasks offered to members by their organisations Determination of members to work hard for their organisations and remain as members of their organisations based on positive beliefs in their organisations’ goals and values
Measurement tool 16
Price
Akhtar et al.17 and Delery and Doty18 Delery and Doty18 Price16 Akhtar et al.17
Delery and Doty18 Price16 and Kim19 Mowday et al.20 and Allen and Meyer21
Scale Five-point Likert scale
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care workers across the 14 nursing homes, 504 consented to participate in the study. Study variables Based on previous studies,16–21 organisational characteristics affecting turnover intention were selected and reflected in the questionnaire. The operational definitions of the study variables and the tools used to measure them are summarised in Table 1. Turnover intention, which is defined as the extent to which an employee plans to discontinue working for their current employer, was measured using the questionnaire developed by Price16 and scored on a five-point Likert scale. The measure of HPWPs, the main independent variable, consisted of five scales, namely Employment stability,17,18 Formal training,18 Autonomy,16 Group-based payment17 and Employment participation18. In addition, organisational support16,19 and organisational commitment20–21 were measured. Hypothetical model and hypothesis The hypothetical model used in this study is shown in Fig. 1, and the hypotheses (H) applied to the model were as follows: H1: HPWPs will have a positive effect on the organisational support perceived by care workers H2: HPWPs will have a positive effect on the organisational commitment of care workers H3: Organisational support will have a positive effect on the organisational commitment of care workers H4: Organisational support will have a negative effect on the turnover intention of care workers
H5: Organisational commitment of care workers will have a negative effect on turnover intention H6: HPWPs will have a negative effect on turnover intention Statistical analysis To investigate general characteristics of the participants, descriptive statistics were examined. Reliability and validity tests were performed for each question in the survey and exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were undertaken to check the suitability of the data. Based on the results, correlations among HPWPs, organisational support, organisational commitment and turnover intention and the fitness of the hypothetical model were analysed using a structural equation model. All statistical analyses were conducted using SPSS 12.0 for Windows (SPSS, Chicago, IL, USA) and AMOS 18.0 (SPSS). Results General characteristics of participants and distribution of variables The general characteristics of the study participants and the distribution of variables are given in Table 2. Of the 504 participants, 485 (96.2%) were female. Mean care worker age was 50.4 years, with most being aged in their 40s (302; 59.9%). With regard to educational status, the largest proportion of care workers had graduated from high school (302; 59.9%). Most participants had worked at the nursing home for 1–2 years (169; 33.5%), with the mean duration of service engagement being 3.2 years. Most
Employment stability
Continuous commitment
Affective commitment
Normative commitment
Formal training
autonomy
H2
HPWPs
Employee participation
H5
Organisational commitment
Turnover intention
H1 H3
Group-based payment
427
H4
Organisational support
H6
Fig. 1. Hypothetical model. Six hypotheses were evaluated: H1, high-performance work practices (HPWPs) will have a positive effect on the organisational support perceived by care workers; H2, HPWPs will have a positive effect on the organisational commitment of care workers; H3, organisational support will have a positive effect on the organisational commitment of care workers; H4, organisational support will have a negative effect on the turnover intention of care workers; H5, organisational commitment of care workers will have a negative effect on turnover intention; H6, HPWPs will have a negative effect on turnover intention.
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Table 2. Characteristics of the study participants and distribution of study variables n (%)
Turnover intention
Organisational support
Organisational commitment
Formal training
High-performance work practices Employee Employment Autonomy participation stability
Group-based payment
Gender Female Male
485 (96.2) 19 (3.8)
2.84 2.57
3.24 3.30
3.13 3.10
3.68 3.69
3.43 3.36
3.50 3.24
3.26 2.51
3.89 3.63
Marital status Unmarried Married Other
52 (10.3) 445 (88.3) 7 (1.4)
2.74 2.55 2.88
3.23 3.30 3.32
3.07 3.11 3.32
3.67 3.70 3.64
3.67 3.70 3.64
3.38 3.23 3.07
2.89 2.50 2.71
3.85 3.62 3.71
Duration of service engagement 7 years 34 (6.7)
2.54 2.55 2.57 2.62 2.67 2.47
3.38 3.31 3.36 3.25 3.21 3.11
3.01 3.08 3.05 3.12 3.18 3.46
3.81 3.77 3.73 3.67 3.35 3.70
3.34 3.50 3.38 3.24 3.20 3.20
3.18 3.31 3.20 3.31 3.06 3.54
2.42 2.54 2.51 2.57 2.63 2.70
3.74 3.82 3.54 3.76 3.69 3.64
Education Elementary school Middle school High school Junior college College Other
22 (4.4) 90 (17.9) 302 (59.9) 46 (9.1) 43 (8.5) 1 (0.2)
2.57 2.52 2.55 2.68 2.73 3.50
3.42 3.23 3.30 3.24 3.44 3.25
3.20 3.19 3.08 3.11 3.08 2.88
3.58 3.81 3.68 3.74 3.49 4.25
3.20 3.46 3.33 3.43 3.36 3.00
3.23 3.30 3.21 3.42 3.27 1.50
2.52 2.46 2.49 2.71 2.94 1.75
3.57 3.46 3.66 3.93 3.63 3.00
Employment status Permanent Temporary
185 (36.7) 319 (63.3)
2.70 2.51
3.18 3.37
3.21 3.04
3.86 3.60
3.50 3.28
3.55 3.07
2.71 2.44
3.68 3.62
504
2.58 ± 0.53
3.30 ± 0.90
3.10 ± 0.48
3.69 ± 0.72
3.36 ± 0.71
3.25 ± 0.90
2.54 ± 0.83
3.64 ± 0.89
Total
participants (445; 88.3%) were married. Of the 504 participants, 319 (63.3%) and 185 (36.7%) were temporary and permanent employees, respectively.
commitment on the influence of work practices on turnover intention was also significant at –0.369 (P < 0.01). The established structural equation model explained 45.6% of the total variance of turnover intention (Table 5).
Test of study models The CFA of variables established the suitability of the data. The structural model was tested based on these variables and its fitness was found to be satisfactory (Table 3). Because the test of the hypothetical model also revealed satisfactory fitness (c2 = 70.57, Q = 2.19, Root Mean Square of Residuals (RMSR) = 0.05, Normed Fit Index (NFI) = 0.93, Comparative Fit Index (CFI) = 0.96, Adjusted Goodness of Fit Index (AGFI) = 0.90), the model was used without revision. Results of hypothesis testing The results of hypothesis testing are given in Table 4. There were significant positive correlations between HPWPs and organisational support (H1), between HPWPs and organisational commitment (H2) and between organisational support and organisational commitment (H3). In contrast, there were significant negative correlations between organisational support and turnover intention (H4), between organisational commitment and turnover intention (H5) and between HPWPs and turnover intention (H6). Indirect effects were also evaluated to verify the effect of organisational support on the influence of work practices on turnover intention; the effect was found to be significant at –0.260 (P < 0.01). Moreover, the effect of organisational
Discussion There have been no accurate statistics published relating to the turnover rate of care workers in Korea because the long-term care system for older people was instituted only 5 years ago. However, the situation is expected to be similar to that in other countries in the mature stage of the system. In the US, most nursing services for frail elderly patients at nursing homes are performed by care workers.22 A high turnover rate of care workers has been found to have a direct negative effect on the continuity of nursing services, as well as on the quality of services for the aged.23 In addition, employee turnover leads to additional costs associated with the recruitment and training of new employees, contributing to inefficiencies in management.24 In a meta-analysis of 92 studies investigating the effects of HPWPs on organisational performance, Combs et al. found that the use of HPWPs is positively related to organisational performance and that this relationship is larger for HPWPs systems than for individual practices.10 The Society for Human Resource Management (SHRM) assesses employment stability as one of the most critical factors, following income and benefits packages.25 Employment stability improves job satisfaction by reducing the stress that accompanies unemployment.
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Table 3. Results of confirmatory factor analysis HPWPs, high-performance work practices; Q, model parameter; RMSR, Root Mean Square of Residuals; NFI, Normed Fit Index; CFI, Comparative Fit Index; GFI, Goodness of Fit Index; AGFI, Adjusted Goodness of Fit Index; TLI, Trucker-Lewis Index
HPWPs Organisational support Organisational commitment Turnover intention
c2
Q
RMSR
NFI
CFI
GFI
AGFI
TLI
Delta2
1855.84 455.23 145.35 55.44
2.06 2.01 2.02 2.03
0.040 0.042 0.022 0.032
0.903 0.902 0.901 0.902
0.911 0.913 0.913 0.934
0.926 0.931 0.934 0.941
0.895 0.915 0.913 0.929
0.921 0.924 0.923 0.921
0.903 0.903 0.902 0.902
Table 4. Results of path analysis for hypotheses tested HPWPs, high-performance work practices. *P < 0.05, **P < 0.01 Hypothesis
Estimate
Critical ratio
H1: HPWPs !organisational support 0.429** H1: HPWPs !organisational commitment 0.638** H3: Organisational support !organisational 0.165* commitment H4: Organisational support !turnover intention –0.134* H5: Organisational commitment !turnover –0.369** intention H6: HPWPs !turnover intention –0.148*
0.667 1.382 11.231 8.467 –4.564 0.627
Table 5. Effects of factors on turnover intention HPWPs, high-performance work practices; SMC, squared multiple comparisons. *P < 0.05, **P < 0.01 Turnover intention
HPWPs
Organisational support
Organisational commitment
Direct effect Indirect effect
–0.148* –0.260**
–0.134* –0.024*
–0.369**
Total effect
–0.408*
–0.158*
–0.369**
SMC
0.456
Participation in decision making is related to bosses’ leadership and abilities, given that democratic bosses will allow their subordinates to participate in decision making. However, although participation in decision making is correlated with job satisfaction, some studies have found no correlation26; thus, it is difficult to reach a conclusion about the relationship. Moreover, bosses’ leadership style can affect employees’ autonomy. If bosses exhibit an authoritative or bureaucratic leadership style, employees would have little autonomy over their work. Previous studies conducted with employees in other industries27,28 have found similar findings for the relative importance of the use of HPWPs. The basis of these work practices should involve competency development, motivation and increased opportunities for contributing to organisational performance. By improving these practices, nursing homes can reap potential benefits in the form of both improved health of frail elderly residents and enhanced management efficiency. Work practices perceived by care workers were also found to have an indirect effect on turnover intention by mediating organisational commitment and organisational support, as well as having a direct effect.29,30 A study by Lee5 showed that organisational commitment decreased turnover intention and found that organisational commitment had the largest direct influence on turnover intention. These findings suggest that nursing homes should make an
effort to improve the organisational commitment for care workers because increased organisational commitment is expected to enhance the quality of service at nursing homes. According to several other previous studies that looked at the relationship between turnover intention of care workers and organisational factors, the potential of professional growth, involvement in work-related decisions and supervision are considered important factors influencing turnover intention or the actual turnover of care workers.31–34 A study by Kim and Kim35 also reported that job satisfaction and organisational commitment of care workers affected the quality of service for the elderly at nursing homes. Moreover, Lee5 proposed that the expertise of care workers should be strengthened and organisational support should be offered to prevent turnover. A study by Lee and Lee36 revealed a close correlation between recognition and rewards from nursing homes with the job satisfaction of care workers. In agreement with the results of these previous studies, care workers participating in the present study perceived the work practices of nursing homes, especially HPWPs, as organisational support for them and subsequently evaluated this category positively. As a result of supportive practices, the employees were more committed to the nursing homes emotionally and morally (and not just of economic necessity); consequently, their turnover intention declined. However, the present study has some limitations. First, our data came from a limited number of facilities in Seoul and Gyeonggi Province, Korea, and this may limit the generalisability of the results. Second, we used turnover intention as an antecedent variable of actual turnover. The relative difference between them in a single model cannot be determined if both are not examined simultaneously. Therefore, it is somewhat difficult to accept that higher turnover intention is expected to be associated with higher actual turnover. However, because statistics for the actual turnover of care workers were not available at the time in Korea, turnover intention was unavoidably used as a dependent variable. Turnover intention is a variable that explains actual turnover as well, and studying it is more accurate and more effective in terms of cost than evaluating turnover itself. In addition, studying turnover intention has the advantage of preventing actual turnover by improving the factors affecting turnover intention. As such, turnover intention has been recognised as an optimal variable to predict actual turnover.37–39 Third, the cross-sectional design of the study was another limitation. Because the study investigated both exogenous and endogenous variables at the same time with a single questionnaire, there could be a bias in that the actual responses affected the endogenous variables. However, the structural equation model used in this study verified the reliability and validity of the measures through CFA, so the bias typically
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observed in studies using cross-sectional data is considered to be offset to some degree. Conclusions This study revealed that the turnover intention of care workers is closely related to how they perceive work practices at their respective nursing homes. In addition, organisational support and organisational commitment were found to be critical parameters in the correlation between work practices, especially HPWPs, and turnover intention. These results imply that nursing homes should actively apply HPWPs for care workers to enhance their emotional and moral commitment to the workplace. As a result, these practices will contribute to the health of the elderly in these facilities, as well as to efficient workplace management, by improving the continuity of nursing care and the quality of service as a result of a reduction in the turnover intention of care workers. Competing interests The authors declare they have no competing interests. References 1
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