1

ICNE YALE #96

Title: Turnover intention of Korean nurses

Authors: Haejung Lee, PhD, RN, Associate Professor, College of Nursing, Pusan National University,

Pusan, South Korea

Myungsoo Kim, PhD, RN, Full time lecturer, Department of Nursing, Ulsan College, Ulsan,

South Korea

Jung-A Yoon, MA, RN, Master graduates, College of Nursing, Pusan National University;

staff nurse, Pusan National University Hospital

Corresponding Author: Haejung Lee, RN, PhD

Associate Professor, Pusan National University, College of Nursing

1-10 Ami-Dong, Suh-Gu, Pusan, South Korea

Tel: +82-51-240-7756, +82-11-9501-7756

Fax: +82-51-248-2669

e-mail: haejung@pusan.ac.kr
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Abstract

Purpose: Internal marketing has been highlighted for its importance in hospital management and its

influence of human resources. However, little is known about the role of internal marketing to the intention

of turnover along with job stress and organizational commitment among Korean nurses. The purpose of this

study was to examine discriminating factors of turnover intention among job stress, organizational

commitment, and internal marketing.

Method: Nurses (N=185) who worked for one to ten years were recruited from 6 general hospitals in South

Korea. The data were collected using questionnaires and analyzed with descriptive statistics, t-test,

discriminant analyses using SPSS WIN 14.0 program.

Results: The participants were grouped into two groups depending on the levels of the turnover intention:

higher turnover intention group (n=80), lower turnover intention group (n=105). Members of higher turnover

intention group had thought about quitting the job one and more times in a month. One function produced

was significantly discriminated between high turnover intention group and low turnover intention group and

classified 65.4% of original grouped cases correctly into the two groups. Job stress, organizational

commitment, promotion and reward components of internal marketing were significant discriminating

factors.

Conclusion: Based on the findings of this study, we could conclude that internal marketing plays an

important role in nurses’ turnover intention in addition to organizational commitment and job stress.

Considering the fact that internal marketing is not actively adopted in Korean nursing society, facilitating

internal marketing strategies in healthcare system could minimize the turnover of competent nurses. Further

managerial intervention which facilitates internal marketing would warrant better insight about the

relationship between internal marketing and turnover intention.

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Turnover intention of Korean nurses

Introduction

Turnover intention (TI) is a direct predictor of real turnover (Alexander et al., 1998), and makes a

negative effect on job performance and productivity (AbuAlRub & Al-Zaru, 2008; Gardner, Thomas-

Hawkins, Fogg, & Latham, 2007). High turnover rate among nursing staff is regarded as a big problem in

healthcare facilities because of not only its cost of recruitment and training new staffs but also quality of

patient care (Gaddy & Bechtel, 1995; Jones, Havens, & Thompson, 2008). Turnover also influence retained

nurses by decreasing organizational commitment and increasing burnout, which could result in additional

turnover (Castle, 2006). Annual turnover rate of Korean nurses was pretty high compared with other Korean

professionals. The reported turnover rate of Korean nurses was 9.8 %, which was much higher than workers

(2.4%) in electronic industry and workers (3.2%) in constructing industry (Korea Ministry of Labor, 2006).

Since the quality and capabilities of nurses are critical for quality of patient care (Chang & Chang, 2007),

turnover of competent nurses could cause much detrimental influence on nursing climate and the

organization (Orsolini-Hain & Malone, 2007).

Marketing-oriented approach was suggested to solve the problems associated with high turnover rates

among health care providers (Peltier, Boyt, Westfall, 1997). Internal marketing is the management

philosophy of concerning employees as customers and of offering jobs that meet employee’s demands to

gain employee loyalty and commitment (Longbottome et al., 2006). In other word, internal marketing is

perceived satisfaction of internal consumers for their work environment in the areas of education, promotion,

communication, segmentation, working environment, reward, and employee's management philosophy (Lee,
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2001; Doo, 2004). Internal marketing has positively influenced on job satisfaction and organizational

commitment among nurses (Chang & Chang, 2007), motivated employees’ job performance and improved

organizational productivity (Kim, 2006), and reduced absenteeism and turnover of nursing staff (Choi & Ha,

2007). Promotional opportunities and organizational characteristics have been found to decrease the

likelihood of turnover and a management style that encourage staff involvement in decision-making

enhances organizational and professional job satisfaction, resulting in lower turnover rates (Leveck & Jones,

1996). Overtime, weekends, nights, holiday shifts, and perception to the shift schedule have been found to be

predictors of turnover (Pisarski et al., 2006; Sasaki, Iwasaki, More, Hisanaga, & Shibata, 2007;Shader et al.,

2001; Strachota et al., 2003). Direct relationship between internal marketing and turnover intention was

observed among Korean nurses (Choi & Ha, 2007; Doo et al., 2005; Yoon & Lee, 2007). However, the levels

of internal marketing perceive by Korean nurses were extremely low and there was a significant difference

between Korean nurses’ expectation (mean=3.83) and perception (mean=2.54) of internal marketing

including education, vacation, welfare, communication and reward (Lim, 2006).

Organizational commitment (Bentein, Vandenberghe, Vandenberg, & Stinglhamber, 2005) and job-

stress (AbuAlRub & Al-Zaru, 2008) of nurses have been known to be significant predictors of TI. Nurses

who had lower levels of organizational commitment (OC) and higher levels of job stress reported higher

intention of leaving the profession (Beecroft, 2008; Chang & Chang, 2007; Kim & Lee, 2001; Lu et al.,

2002; Lopopolo, 2002). Ha and Choi (2000) also indicated OC as a key determinant of TI explaining 44.4%

of the variance in Korean nurses' TI. Developing OC was considered as important strategies to reduce TI

among nurses (Conklin, & Desselle, 2007). Nurses with higher levels of job stress tend to experience higher
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levels of burnout, and TI (Dickinson & Wright, 2008). However, little is known about the relative importance

of internal marketing, OC, and job stress on TI. It may be worthwhile to explore which aspect should be

considered more importantly to succeed in retention of nurses. The purpose of this study was to define the

discriminating factors for TI and to convince the important role of organizational aspect including internal

marketing on TI. Specific research questions are (1) what are the levels of OC, job stress, and TI of Korean

nurses, (2) what are the discriminating factors of TI of Korean nurses.

Method

Respondents

A sample of 210 staff nurses from 6 general hospitals was surveyed from August 26 to September 26,

2006. Sixteen general hospitals were contacted to distribute the questionnaire but 6 hospitals permitted the

data collection. The most common reason to refuse the data collection was that the board of administration

was concerned about the busy schedule of nurses. After approval from the committee board of each institute,

the questionnaires were conveniently distributed to nurses with a written consent form explaining the

purpose of the research, the voluntary trait of participation, and the confidentiality of the data. After nurses

completed the questionnaire and sealed it, and unit managers send it to one of the author. Inclusion criteria of

the participants were 1) working experience between 1 and 10 year; 2) working at internal medicine unit.

Among 6 hospitals, the bed size of 3 hospitals were below 900, 2 hospitals 900-1200, and 1 hospital

1200 and more. Anonymous self-administered questionnaires were distributed to 210 nurses and 207 were

returned. After excluding the questionnaire with 22 questionnaires whose working experience were under 1

year (11), above 10 years (2), or missing (9), 185 questionnaires were finally included in the analysis.

Instruments
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The organizational commitment (OC) was measured by the Korean version of Organizational

Commitment Questionnaire (OCQ) (Mowday, Steers, & Porter, 1979), which was translated into Korean by

Kim (1986) and widely used in Korea. The OCQ consists of 15 items with response range from 1 (definitely

disagree) to 5 (definitely agree). Higher scores indicate greater organizational commitment. Previously

reported Cronbach’s alpha was 0.89 (Kim, 1986) and Cronbach’s alpha for this study was 0.91.

Job stress was measured by the Job Stress Scale (JSS) developed Hingley (1986), translated into

Korean by Kim (2004). The measure was consisted of 30 items on a 5-point scale ranging from 1 (definitely

disagree) to 5 (definitely agree). Possible scores ranged from 30 to 150, with higher score indicating higher

job stress. Previously reported Cronbach’s alpha was 0.91 and Cronbach’s alpha in this study was 0.90.

Internal marketing was measured by the instrument developed by Lee (2001), and revised by Doo

(2004). The scale consists of 20 items with possible responses ranging from 'definitely disagree' (1) to

'definitely agree' (5). Higher score means higher perception of internal marketing, which meant higher

perceived satisfaction of internal consumers for their work environment. The scale has 7 components:

education-training factor (5 items), affair-promotion factor (2 items), communication factor (3 items),

segmentation factor (2 items), working environment factor (3 items), reward factor (2 items), employee's

management philosophy factor (3 items). Previously reported Cronbach’s alphas were 0.91 (Lee, 2001) and

0.87 (Doo, 2004) and Cronbach’s alpha in this study was 0.90.

Turnover intention was measured by 3 questions developed by Micheals and Spector (1982), and

translated into Korean by Kim (2003). Items were as follows: ' I seriously consider changing my present job',

' I have an actual plan to quit my present jobt', 'I want to quit my present job'. The respondents asked to
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respond from 'never (1)' to ‘everyday (7)’. Internal consistency of this instrument was Cronbach's α = .87.

Respondents were classified into two groups, 'higher TI group (1)' and 'lower TI group (0)', according to their

levels of turnover intention. Respondents who reported greater than 6 point (every week) in at least one out

of three questions were classified into ‘high TI group (2)’ and respondents who reported 1 point in at least

one out of three questions were classified into ‘no TI group (0)’. The rest were classified into ‘moderate TI

group (1). Nurse characteristics, such as age, educational level, average monthly income, total years

experienced as a nurse, past turnover experience, type of shift, average night shift per month, and bed size of

the hospital were also collected using the questionnaire.

Ethical considerations

After obtaining approval from the committee board of each institution, Questionnaires were

distributed to potential participants with a cover page, explaining the purpose of study and providing

assurance of the anonymous, voluntary and confidential nature of the responses. Written consent was

obtained from the participants. After completion of the questionnaires, respondents put the questionnaires in

a box located at the nurses’ station on each floor and the research assistant collected the box. To maintain

confidentiality, data were collected without identifier.

Statistical analysis

To answer the research questions, SPSS WIN 11.5 program was used. Descriptive statistics were

carried out to explore the individual characteristics (age, educational level, income, total experience in

nursing, turnover experience, night shift, bed size) and the levels of organizational commitment, job stress

and internal marketing of the nurses in the study. Discriminant function analysis was conducted to identify

discriminating factors of turnover intention. Included discriminating factors were nurse characteristics
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(educational level, total income, number of night shift per month, total working experience as a nurse)

organizational commitment, job stress, and seven sub-dimensions of internal marketing.

Results

1. Demographic and job-related characteristics of respondents

All participants were women and staff nurses, 84% were unmarried, and about 89% were in their

twenties (mean age=26 years). Forty nine percent of the participants had Bachelor degree and 44% had

associate degree. About 79% of the respondents reported their annual salary lower than $ 24,000. Mean

duration of total experience in nursing was 48.25 months (about 4 years), 73.5% of respondents reported no

turnover experience in the past. About 95% of the participants had more than 5 night shifts per month. Forty

two percents of the respondents worked in the hospitals between 400 and 900 beds, 42% between 900 and

1200 beds, and 16% with 1200 beds and more.

2. Discriminant factors of turnover intention

A discriminant function analysis was performed to examine significant discriminating factors of

turnover intention. Included discriminating factors were selected nurse characteristics organizational

commitment, job stress and sub-dimensions of internal marketing.

1) Evaluation of assumptions

Before conducting discriminant function analysis, the assumptions satisfying discriminant analysis

were checked. The sample size of the smallest group should exceed the number of predictor variables to

prevent the overfitting. The least cases in the cell were 31 and predictor variables were nine, power of the

analysis was estimated adequate. Box’s M of this study was 231.74 (p<0.001) indicating the covariance of

the groups are not homogeneous. We examined the variance of the groups using scatter plot and similarity of
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the variance within groups was observed indicating least risk of Type I error. Multicollinearity among

predictor variables was examined using correlation matrices. The correlation among predictor variables

ranged from 0.12 to 0.69. The correlation among sub-dimensions of internal marketing was pretty high.

Evaluation of assumptions of linearity, normality, or singularity, and revealed no threat to multivariate

analysis.

2) Mean differences in predictor variables among high TI, moderate TI, and no TI groups

Before examining discriminating factors of TI groups, we compared the mean of predictor variables

among groups (Table 1). There were significant mean differences in organizational commitment, job stress,

and 6 sub-dimensions of internal marketing in education, promotion, segmentation, working environment,

reward, and employee’s management philosophy. None of nurse characteristics were significantly different

among groups.

3) Analysis of discriminant function

Two discriminate functions were produced with 13 predictor variables and only one discriminant

function was significant (eigen value=0.449, Wilk’s lambda=0.633, χ²=80.59, p<0.0001), which significantly

discriminating high TI and no TI groups. Therefore, additional discriminant analysis with two groups was

conducted. One discriminant function produced with two groups explained 48% of the variance in turnover

intention (Table 2). The relative importance of the predictor variables was examined by standardized

canonical discriminant function coefficients and loadings. Since discriminant loadings were suggested as

more valid information (Hair et al., 1995, p220), the interpretation of the findings was based on the

discriminant loadings and the cut-point used to identify significant discriminant loading was +.30 as

suggested by Hair et al. (1995, p221). Seven predictors were identified. Organizational commitment, job
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stress, and five-dimensions of internal marketing showed higher discriminate loading than +0.30.

Organizational commitment was most important discriminating factor (0.662). Nurses belonging to high TI

group tend to have lower organizational commitment, high job stress and lower perception of internal

marketing in affair-promotion, reward, employee’s management philosophy, working environment, and

segmentation (Table 3).

4) Cross-validation of the discriminate function

Classification of 89 nurses using produced function was shown in Table 4. Using 13 discriminating

factors, 75 nurses out of 89 nurses (84.3%) were correctly classified into high TI and no TI groups. The

cross-validation of the produced discriminant function with hold-out sample showed hit ratio of 77.5%.

Discussion

The main objectives of this study were to identify discriminating factors of turnover intention and to

suggest possible effective managerial intervention to decrease nurses’ turnover intention. Respondents of this

study were grouped into three groups depending on the level of turnover intention. High, moderate, and no

TI groups were 16.8%, 51.9%, and 31.4%, respectively. Sixteen percent of the Korean nurses think quitting

the job more than once a week, which would seriously influence nurses productivity and the climate of the

hospital. It seems that proper intervention to reduce turnover intention is needed for Korean nurses.

The findings of discriminant function analysis showed that organizational commitment, job-stress, and

five sub-dimensions of internal marketing significantly discriminate high TI group form no TI group. From

the findings of this study, we could assume that nurse characteristics such as annual income, educational

level, years worked as a nurse, and numbers of night shift are no longer influential factor on turnover

intention when organizational commitment, job stress and internal marketing were considered together. Since
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organizational commitment was most important discriminating factor for turnover intention of Korean

nurses, strategies enhancing organizational commitment should be considered. Since perception of working

environment, annual income, and job stress were significant predictor of turnover intention among Korean

nurses (Yoon & Lee, 2007), improving working environment and annual salary and reducing job stress can

be considered to improve organization commitment of nurses.

Korean nurses rated the levels of internal marketing as low to medium. Especially, they reported low

levels of internal marketing in the areas of promotion and rewards. Healthcare system in Korea seldom

employs the concept of internal marketing in the hospital management and hardly values their employee as a

customer. Aggressive strategies may be needed to enhance internal marketing in Korean healthcare system.

Especially, almost all Korean nurses should work full-time if they want to work. Otherwise, they have to

leave the work. Since most nurses were female and in their thirtieth, they would need time for raising kids

and sometimes they may need time off for further education such as pursuing the master’s degree. In Korean

healthcare system, they were no allowed to work part-time, they could not choose less hours than 40 hours if

they want to continue to work. In addition, they could not choose their shift. As long as they are staff nurse,

they should do 5-6 night shifts per month. Flexible shift system can be applied experimentally and can be

examined further for the effects of the flexible scheduling.

Another serious concern for Korean nurse is there are little opportunity for staff nurses to get

promoted. According to Tzeng (2002), satisfaction of promotion was significant predictor of nurses’ TI.

Therefore, more opportunities for promotion and various recognition systems is needed for Korean nurses.

Most staff nurses in Korea try to be a head nurse or nurse manager because that is the only way to avoid
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night shifts. The quality of patient is better equipped when experience excellent nurses provide care to the

patients at bedside. Therefore, variety choices in shift and allowing clinically specialized position for

experienced nurses would facilitate expert nurses stay beside patients providing highly qualified care.

Internal marketing has been known critical factor to improve employees’ commitment to their organization

and to reduce job stress (Chang & Chang, 2007). Conservative tradition of Korea society, called ‘seniority

system’, it exacerbates the lack of opportunity in promotion among nurses. Conservative culture in

promotion would not allow credits for capable nurses and their contribution to organization, which

discourage nurses’ personal development.

Nurses usually gave more than one reason why they left their institution, many nurses mentioned

salary. Nurses having higher TI showed significantly lower satisfaction of reward than lower TI group

(t=4.74, p=.031). Result of this study was consistent with another research (Kim & Lee, 1999; Strachota et

al., 2003). According to study of Stordeur et al (2006), attractive hospitals maintained adequate balance

between their employees’ efforts and rewards. Organizational values play critical role in developmental

efforts of employees. High effort-reward imbalance was associated with increased burnout43 and turnover

intention (Hasselhorn et al., 2004). Korean nurses felt that there was imbalance between working hours and

payment, which increased job-stress (Park & Kang, 2007). Therefore, appropriate payment, praise and

reward system according to their labor intensity and amount of working time must be constructed for nurses.

Relationships among demographic, job-related characteristics and TI have been discovered in many

literatures, there were great diversity consequences about the direction of the relationship. While age was

considered as an important positive factor (Tourangeau, & Cranley, 2006), Wage level was also significant
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negative factor to predict their TI (Lu et al., 2002). And if they had a higher educational level, respondents

were more likely to be shown higher TI (Beecroft, Dorey, & Wenter, 2007), hospital type such as bed size

(Hwang & Chang, 2006), total years experience in nursing (Chan, & Morrison, 2000) were also be related to

TI positively. But the results of this study among age, educational level, wage, total years in nursing

experience, night shift, and bed size were inconsistent with other researches which proved these variables'

significance. Individual aspect is highly correlated with group cohesion and control over practice as

organizational aspect (Hinshaw et al., 1986) and influence perceptions of the work environmental support as

internal marketing (Beecroft, Dorey, & Wenter, 2008). Therefore, we concluded that this finding supported

literature review of turnover intention (Hayes et al, 2007), it could be considered that individual aspect didn't

influence directly on turnover intention, but would play an indirect role in another factor as organizational

and internal marketing aspects

Many nurses seem to perceive lower OC if they feel the gap between actual competencies and career

needs (Chang, Chou, & Cheng, 2007). In study of Drenkard and Swartwout (2005), nurses participated in

career development program showed increased retention and cost saving effect owing to decreased turnover.

Career development can be applied for nurses to harmonize with their career stage to improve OC. Career

development according to clinical, educational experience and nursing competency level would be approving

and rewarding system (Chang, Chou, & Cheng, 2007).

Job stress was next significant factor on TI. The levels of job stress of Korean nurses were moderately

high as about three out of five point (Hong et al., 2007). The contents of stress were related with work

environment especially internal marketing that was consisted of working time, overtime allowance and
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income. Hsu et al (2007) also proved insufficient workforce or too much workload were main aspect of job

stress. Because many nurses must delegate their job to another healthcare assistant (Kleinman & Saccomano,

2006), they suffer from professional role conflict such as distinguishing the range of delegation and

identifying right and wrong on their clinical situation, subsequently feel ‘moral distress’. Job stress contains

various types of stress, one of them is moral distress. Job stress is regarded as another type of moral distress

(Corley, 2002), but nurses usually are unaware of moral distress in themselves (Pendry, 2007).

In summary, our consequences suggest that improving institutional internal marketing such as affair-

promotion and reward system, increasing OC and reducing job stress lead to lower turnover intention. To

reduce the turnover intention, we have provided the following conclusions according to discriminating

factors in this paper; 1) Korean hospital manager should change the conservative organizational climate such

as ‘seniority system’ of new promotion policy and valance of effort-reward should be provided. 2) Improving

OC management strategies as career development should be developed, 3) job related stress due to another

nurses’ turnover should be alleviated by work environment renovation.

Limitation

This study had some limitations. First, it is difficult to generalize of the study because that the survey

1) were conducted on internal medicine department in some tertiary and educational hospital, 2) had

convenience sampling method not random sampling. Another problem is that there was no actual measure of

turnover, it is unknown to us about differences between turnover intention and real turnover rate of

respondents. So, the present findings should be carefully interpreted.

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<Table 1> Mean differences and standard deviations in predictor variables among lower, moderate and

higher TI groups (N=185)

Predictor variables Low TI GP Moderate TI GP High TI GP Wilks' λ F p

(# of items) (n=58) (n=96) (n=31)

Organizational commitment 49.78±6.98 44.97±7.01 39.84±8.62 .823 19.55 .000

(15)
J ob stress (30) 76.74±13.19 81.94±13.24 90.65±13.32 .899 10.28 .000
IM-education-training (5) 16.95±3.61 16.00±3.12 14.87±3.49 .958 4.00 .020
IM-affair/promotion (2) 6.33±1.22 5.94±1.08 5.10±1.04 .882 12.18 .000
IM-communication (3) 9.88±1.86 9.85±1.49 9.13±1.96 .974 2.42 .092
IM-segmentation (2) 6.91±1.14 6.42±1.38 5.94±1.67 .943 5.48 .005
IM-working environment 10.05±1.77 8.93±1.94 8.39±2.47 8.80 .000

(3) .912
IM-reward (2) 6.10±1.17 5.54±1.34 4.90±1.47 .913 8.71 .000
IM-employee's management 9.69±1.86 7.68±2.65 9.54 .000

philosophy (3) 9.07±1.99 .905

Educational level 1.79±.67 1.55±.58 1.58±.56 .968 3.00 .052

Annual income 5.33±2.14 4.97±2.26 5.35±1.92 .993 .67 .515

Number of night shift 3.29±.73 3.41±.83 3.45±.62 .994 .56 .570

Working years as a nurse 2.24±1.14 1.94±1.04 2.19±1.30 .983 1.53 .219

Note. mean±SD, GP=group, TI=turnover intention, IM=internal marketing

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<Table 2> Canonical Discriminant Functions

Discriminant Function Eigen value Canonical Wilks' λ Chi-Square df p-value

analysis Correlation

1st stage 1 .449 .557 .633 80.59 26 .000

2 .091 .288 .917 15.27 12 .227

2nd stage 2 .908 .690 .524 52.02 13 .000

<Table 3> Standardized canonical discriminant function coefficients and loadings

Predictor variable Discriminant loadings Standardized weights

Organizational commitment .662 .679
IM-Affair/promotion .536 .436
Job stress -.509 .-.288
IM-Reward .475 .108
IM-Employee's management philosophy .470 .304
IM-Working environment .412 -.196
IM-Segmentation .367 .389
IM-Education/training .294 .019
IM-Communication .200 -.596
Educational level .169 .059
Frequency of night shift -.116 -.354
Total year in nursing experience .020 -.115
Annual income -.007 .087
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<Table 4> Classification matrices for two-group discriminant analysis (N=89)

Groups Predicted Group Membership Total

lower TI group higher TI group
Original lower TI group 49 (84.5) 9(15.5) 58 (100.0)
higher TI group 5 (16.1) 26 (83.9) 31 (100.0)
Hit ratio 84.3%
Cross- lower TI group 46 (79.3) 12 (20.7) 58 (100.0)
higher TI group 8 (25.8) 23 (74.2) 31 (100.0)
validation
Hit ratio 77.5%
 18

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