자녀를 둔 기혼간호사의 이직의도에 미치는 영향요인: 계획된 행위이론의 적용
Factors Affecting Turnover Intention of Married Nurses with Children in Korea Based on the Theory of Planned Behavior
Article information
Trans Abstract
Objectives
The purpose of this study was to identify the factors influencing the turnover intention of married nurses with children based on Theory of Planned Behavior.
Methods
The study subjects were 178 married female nurses with children working at two general hospitals in Gangneung city. Data collection was conducted from 7th to 30th September in 2020. Data analysis were analyzed using percentage, mean and standard deviation, ANOVA, Scheffé test, Pearson's correlation coefficient, and hierarchical multiple regression with the WIN SPSS 22.0.
Results
Significant correlations were found among parenting stress, participation in the parenting of spouses, work-family conflict, attitude to turnover, subjective norm, perceived behavioral control and turnover intention. As a result of a hierarchical multiple regression analysis, attitude to turnover (β = 0.55), work-family conflict (β = 0.20), economic reasons (β = 0.18), support for parenting (β = −0.15) were found to significantly influence turnover intention of married nurses with children. The explanatory power of the model was 54.2% (F=18.46, p <0.001).
Conclusions
In order to lower the work-family conflict and reduce the turnover intention of married nurses with children, it is necessary to reduce the work-family conflict in the hospital and home and to improve various family-friendly systems and family-friendly atmosphere.
Abstract
목적
본 연구의 목적은 계획된 행위이론에 근거하여 자녀를 둔 기혼간호사의 이직의도에 영향하는 요인을 확인하기 위한 것이다.
방법
본 연구의 대상자는 강릉시의 2개의 종합병원에서 근무하는 178명의 자녀를 둔 기혼간호사로 2020년 9월 7일부터 30일까지 자료수집 하였다. 자료는 SPSS 22.0를 이용하여 백분율, 평균과 표준편차, 분산분석, Scheffé 검정, Pearson 상관관계, 위계적 회귀분석으로 분석하였다.
결과
자녀를 둔 기혼간호사의 이직의도는 태도(r=0.66, p<0.001), 주관적 규범(r=0.45, p<0.001), 일-가정 갈등(r=0.42, p<0.001), 양육스트레스(r=0.27, p <0.001), 인지된 행위통제(r=-0.15, p = 0.044) 간 유의한 상관관계가 있었다. 자녀를 둔 기혼간호사의 이직의도에 영향을 주는 요인은 태도(β = 0.55, p <0.001), 일-가정 갈등(β = 0.20, p = 0.001), 경제적 이유(β = 0.18, p = 0.013), 양육지지도(β =-0.15, p = 0.010)였으며 54.2%의 유의한 설명력을 보였다(F=18.46, p<0.001).
결론
자녀를 둔 기혼간호사의 이직에 영향하는 요인은 이직에 대한 태도, 일-가정 갈등, 경제적 이유, 양육지지도였다. 그러므로 기혼간호사의 이직을 감소시키기 위해서는 일-가정 갈등을 감소시키고 자녀양육을 도와줄 대책이 필요하다.
INTRODUCTION
Novel coronavirus (COVID-19) pandemic unprecedentedly affects people worldwide [1]. Health care providers have been brave enough to fight the epidemic while COVID-19 shut down the world [2]. During the COVID-19 pandemic, Korean nurses have stood at the forefront of medical care and fought the epidemic more bravely than anyone else.
Various changes in hospitals in Korea consistently call for resolving the shortage of nurses and the imbalance in supply and demand of nurses [3]. The number of nurses is steadily increasing every year in Korea. However, according to Organisation for Economic Co-operation and Development (OECD) Health data, the number of nurses operating in Korea in 2018 was 7.2 per 1,000 people, below the OECD average of 8.7 [4].
According to a survey on hospital nurses’ placement in Korea, the turnover rate of nurses as of 2016 was an average of 12.4 percent. 13.7 percent, which is the third highest, of the turnovers were due to marriage, childbirth, and childcare [5]. According to another survey, female married nurses account for 46.6 percent of nurses in Korea's medical institutions [6]. The average working life of nurses in Korea was about 7.8 years. Long-term service difficulty includes overwork due to lack of nurses, irregular working hours, low welfare conditions, marriage, childbirth and childcare, and work-family conflicts [3,7]. This conflict over nurses’ work-family compatibility leads to stress, career interruption, turnover, job circulation, exhaustion, and job dissatisfaction, and aggravating nurses’ shortage, resulting in undesirable results such as inhibitors to nursing development expertise [8,9]. Nurses are under high parenting stress because they feel tired from extended housework, such as returning home from work, taking care of their children, and neglecting their duty to raise their children [10]. In particular, in the COVID-19 era, the parents’ parenting stress with children, including nurses, is gradually increasing. Indeed, recent studies have shown that parents’ perceived impact on COVID-19 is associated with increased parenting stress [11]. A recent nationwide poll found that US parents are experiencing higher levels of stress during COVID-19 than adults without children, given the added challenges of managing children's at-home schooling, halts to extracurricular activities, and navigating children's emotions around uncertainty and change [12].
There have been reports of nurse turnover's adverse effects on medical institutions, site staff, and patient care worldwide [13,14]. The high turnover rate of nurses causes an absolute shortage of nursing staff and has many adverse effects. There is an increasing proportion of patients to nurses in nursing services, urinary tract infection rate, surgical area infection rate [15], etc., and medical error rate [13,16]. Hospitals will pay time, effort, and enormous costs to train new nurses for employment and work training. Also, there is an increase in the cost of goods wasted due to the handling of new unskilled nurses, damage to equipment, and other inefficiencies [17]. Therefore, it is meaningful for nursing personnel management to establish a working environment so competent and experienced married nurses can work without changing jobs and identify related factors. It is necessary to determine whether nurses can change careers and analyze behavioral science on the determinants of nurses’ turnover intention.
Theory of Planned Behavior (TPB) was developed by Ajzen in 1991 based on the rational theory of conduct and has been researched, applied, and supported to explain various acts [18]. The intent to act in the TPB is best predicted when individuals positively evaluate intention, when colleagues believe they will support it (subjective norms), and when they perceive that they can perform it (cognitive behavior control) [19]. In Korea, research using TPB was widely used in various studies on health-related behaviors of nurses, such as intentions to be vaccinated [20], to exercise [21], and to abstain from drinking [22]. However, studies applied to the turnover intention rarely found except those of men serving in the Navy [23]. Few studies have used the TPB, especially those of nurses.
Therefore, this study aims to analyze the relationship among TPB, parenting stress, spouse's parenting participation, work-to-family conflict, and turnover intention and to identify the determinants of the turnover intention of married nurses with children based on the TPB.
METHODS
Study design
This study is a descriptive correlation study to determine the factors influencing a married nurses’ intention to a turnover based on the TPB.
Participants
This study targeted married female nurses with children working at two hospitals with 500 beds or more in Gangneung city, Gangwon-do, Korea. The study sample size calculated using the G-power 3.1.9 program [24]. Considering the size of the two-sided test effect for regression was 0.15 (medium size), 0.05 significant level, and 0.90, the minimum sample size was 175. Compensating for the 11% of dropout rate, 195 people participated in the study. A total of 195 questionnaires were distributed, and a total of 185 (94.9%) were retrieved. A total of 178 (91.3%) were used for the final analysis of this study, except for seven parts with insufficient responses.
Measurement
The structured questionnaire used in the study contained a total of 101 questions: 6 on general characteristics, 36 on parenting stress, 30 on the Participation in the parenting of spouses, 10 on Work-to-family conflict (WFC), 15 on Theory of planned behavior (TPB), and 4 on turnover intention.
General characteristics
The subjects’ general characteristics included age, number of children, income, place of work, work experience, type of work, reasons for changing jobs, ease of using family-friendly systems (5 points Likert scale), and support for raising children (5 points Likert scale).
Parenting stress
To assess parenting stress, Parenting Stress Index-Short Form-IPS was developed by Abidin [25]. Our study used the Korean Parenting Stress Index-Short Form (K-PSI-SF) translated by Lee et al. [26], with verified reliability and validity. The K-PSI-SF consists of three subdomains with 36 questions: 12 on parent pain, 12 on parent-child dysfunctional inter-action, and 12 on demanding children. Each item with a 5-point scale, and a score range of 36 points and 180 points. The higher the parent's stress. Cronbach's alpha was 0.95 when developed [25]; in this study, it was 0.93.
Participation in the parenting of spouses
To assess the spouse's parenting level, Choi [27] developed and validated the father-rearing tool. The father-rearing tool comprises three subdomains with 30 items: 13 on leisure activities, 9 on life guidance, 4 on household activities, 4 on learning guidance. Each item with a 5-point Likert scale and a score range of 30 points to 150 points. The higher the spouse's child-rearing participation. Cronbach's alpha was 0.69-0.89 when developed [27]; in this study, it was 0.96.
Work-to-family conflict
To assess Work-to-family conflict (WFC), Work-to-family conflict was developed by Netemeyer et al. [28]. Our study used the WFC translated by Choi [29], with verified reliability and validity. The WFC comprises two subdomains with 10 items: 5 on family-to-work conflict, 5 on Work-to-family conflict. Each item with a 5-point Likert scale and a score range of 10 points to 50 points. Cronbach's alpha was 0.90 when developed [28]; in this study, it was 0.89.
Theory of planned behavior
To assess the TPB, TPB scale was constructed by Son [30] based on a book of Lee et al. [31]. TPB scale comprises three subdomains with 15 items: 5 on attitude to turnover, 5 on subject norms, 5 on perceived behavior control. Each item with a 5-point Likert scale. Each subdomain's score range from 1 point to 5 points. Cronbach's alpha was the attitude to turnover 0.92, subject norms 0.93, perceived behavior control 0.90 when developed [30]; in this study, attitude to turnover was 0.92, subject norms were 0.93, perceived behavior control was 0.90.
Turnover intention
To assess turnover intention, the turnover intention scale was developed by Lawler [32]. Our study used the turnover intention translated and modified a nurses’ turnover intention by Park [33], with verified reliability and validity. The turnover intention comprises four items. Each item with a 5-point Likert scale and the range of 4 points to 20 points. The higher the turnover intention. Cronbach's alpha was 0.88 when developed [32]; in this study, it was 0.86.
Data collection
This study was approved by the Institute of Research Board (IRB No: GNAH 2020-07-001-005) of Gangneung Asan Hospital in Gangwon-do, Korea, for the rights and ethical protection of subjects, and data was collected from September 7 to September 30, 2020. The nursing department approved the study's recruitment of each hospital by visiting two general hospitals with more than 500 beds located in Gangneung city, Gangwon-do, Korea. Subsequently, each department explained the purpose, contents, and ethical aspects of the study to the subjects, distributed the questionnaire to the nurses who expressed their intention to participate in the study, prepared a written consent form and responded to the questionnaire. It took 15-20 minutes to prepare the questionnaire, and it was required to provide the questionnaire recovery envelope, seal it, and submit it to ensure the confidentiality of the individual subject.
Data analysis
The collected data was analyzed using the SPSS 22.0 (IBM Corp., Amonk, NY, USA) Program. Descriptive statistics analyzed the general characteristics of the subjects. The degree of parenting stress, spouse involvement, work-family conflict, attitude to turnover, subjective norms, perceived behavior control, and turnover intention were analyzed as mean and standard deviation. Parenting stress, spouse involvement, work-family conflict, attitude to turnover, subjective norms, perceived behavior control, and turnover according to general characteristics were analyzed by t-test and ANOVA. Post-verification was conducted using the Scheffé test. The correlations between the subject's parenting stress, the spouse's parenting participation, work-family conflicts, attitudes, subjective norms, perceived behavior control, and the turnover intention were analyzed as Pearson's correlation coefficient. Factors affecting the turnover intention of the target were analyzed with a hierarchical regression analysis.
RESULTS
Characteristics of married registered nurse
Adults in their 30s accounted for the largest proportion of respondents (47.2%). Two children accounted for 97 (54.5%) with the most age, while preschoolers (0-year-old to 7 years old) accounted for 96 (54.0%). Income was the largest with 132 (74.2%) with less than 5 million won to 10 million won, and working places were the largest with 72 outpatient departments (40.4%). Fifty-four workers (30.3%) worked for more than 20 years, and 94 (52.8%) worked during the day. The most common reason for working was 131 (73.6%) for “ economic reasons”, and the reason for turnover was 71 (53.8%) for “ child-rearing”. The ease of using the family-friendly system was 80 for “ no” (45.0%), and parenting support was 109 for “ neutral” (61.2%) (Table 1).
The degree of parenting stress, spouses’ participation in parenting, work-family conflict, attitude, subjective norms, perceived behavioral control and intention to turnover
Subjects’ parenting stress was 2.12/5 points. The spouses’ parenting participation was 3.59/5 points, work-family conflict was 3.25/5 points, attitude toward turnover was 2.93/5 points, subjective norms were 2.25/5 points, perceived behavior control was 3.53/5 points, and turnover intention was 3.18/5 points (Table 2).
Turnover intention by general characteristics
There was a statistically significant difference in age of turnover, the reason for working, easy to use of the family-friendly system, parenting support (Table 1).
Correlation between the married registered nurse's attitude, subjective norms, perceived behavior control, parenting stress, father's parenting participation, work-family conflict, and turnover intention
The turnover intention correlated to parenting stress, work-family conflict, the attitude to turnover, subjective norms, and recognized behavior control. However, the spouse's parenting participation did not correlate (Table 3).
Factors influencing the married registered nurse's intention to turnover
To determine the factors affecting a married nurse's intention with children to turnover, it was verified that the regression analysis conditions before the hierarchical analysis were met. First, looking at the independence test of residuals, we found that the Durbin-Watson statistic was 1.843, which represents almost zero autocorrelation as it is close to 2, and the multicollinearity analysis showed that the Variance Inflation Factor (VIF) was not more than 10 in the range of 1.033 to 1.976. The tolerance was found to be in the range of 0.506 to 0.968 and well within the range of 0.1 to 1.0, which indicates that there is no multicollinearity problem.
In Model I, general characteristic variables were put as control variables that affect a married nurse's intention to change jobs. Factors that affect the turnover intention were age, economic reasons, and support for raising children. They showed a significant 21.0% explanation of turnover intention.
Model II adds parenting stress, spouse involvement, and work-family conflict variables to Model I. Factors affecting the turnover intention have been due to age, economic reasons of working, support for raising children, and work-family conflicts. The value of Adjusted. R2 was 0.296, showing a significant explanatory power of 29.6%, up 8.6% from the model I.
In Model III, the behavioral theory variables planned for Model II, such as attitude, subjective norms, and perceived behavior control were added. Factors affecting the intention of changing jobs have been due to economic reasons, such as working life, support for raising children, work-family conflicts, and attitudes toward changing jobs. The Adjusted R2-value was 0.542, a significant explanatory power of 54.2%, up 24.6% from Model II's explanatory power (Table 4).
DISCUSSION
This study was conducted on married nurses with children to understand the planned behavioral theory and parenting stress, the spouse's parenting participation, and the factors of work-family conflict.
According to the study, the factors that affect married nurses’ intention with children to turnover were attitudes toward turnover, work-family conflicts, parenting support, and working life due to economic reasons, and 54.2% showed significant explanation. Prior research on the factors influencing married female nurses’ turnover showed job satisfaction, role conflict, and position with 37% explanation [34]. Also, job stress, social support, work-family conflict, and exhaustion showed 32% explanation [35]. Furthermore, parenting stress and role conflict showed 44% explanation [36], job satisfaction, work-family conflict, and life-cycle non-parenting showed 37% explanation [37]. Adding these transfer-related factors to the prior study to conduct a repeat study would also increase the explanation of 45.8% of the factors influencing the turnover of married nurses not described in this study.
According to this study, only the attitude toward turnover among the variables in the theory of planned conduct was an influential factor in turnover intention. In the preceding study, Son [30] found that attitudes, subjective norms, and perceived behavior control, which are other factors in the theory of planned behavior, all have a static effect on turnover intention. In similar studies [38], attitudes were found to be the only influential factor to hurt career stagnation among the factors in planned theory of conduct. Attitude increases when a nurse thinks positively of what she or she is trying to do. In this study, we found that nurses show difficulty using the family-friendly system when they have less work experience and work more shifts due to economic reasons. Also, the study shows that only attitude among the planned behavior theory variables is more important than the belief that people around them can think and change jobs. Personal factors seem to have the most significant influence on the intention and change of jobs, motivation for working by controlling for personal effects, job satisfaction, organizational immersion, and environmental support such as bosses, colleagues, and spouses.
Although working life due to economic reasons was shown to be an influential factor in turnover intention, there was a significant difference in “ economic reasons” among the reasons for working in the study by Oh and Kim [39]. Moon and Jung [34] found that the group that responded “ because they are fit and able to serve” during the clinical selection motivation was less likely to move than other groups.
In this study, parenting support was a significant factor in turnover intention. In modern society, the responsibility of parents in raising and educating children has been increasing. Besides, women's participation in economic activities increases due to improved living standards, and increased family maintenance costs, but more married women quit their jobs due to difficulties in both work and childcare. Spouse parenting includes the role of a father of financial ability, providing a physical environment, delivering a social tradition or value philosophy, working with his mother as a family leader to harmonize the family, and developing children's intellectual and social skills [40]. In child-rearing, the father, a spouse, is no longer a supportive role for the mother, but a co-parenting role with the mother is emphasized. As such, modern spouses are required to participate in child care actively. The spouse's participation in child care seems to be indirectly related to changing jobs as it affects the mother's parenting stress. Therefore, a policy is needed to smoothly use the family-friendly system to increase spouses’ participation in parenting children. According to a recent national poll, American parents experience a higher stress level than adults without children, given additional issues such as managing children's home education, stopping extracur-ricular activities, and exploring children's emotions for uncertainty and change during COVID-19 [12]. However, it is unknown what strategies parents use to effectively manage stress and childcare difficulties and how many changes they make in the COVID-19 process.
As a result of this study, the work-family conflict showed significant differences and correlations between turnover intentions, and turnover seems an essential variable of influential factors. Work-family conflict occurs when a person cannot play a role in the workplace, and work and psychological immersion continue to be work-related concerns at home, and mental and physical fatigue from the job reduces the energy to use at home [41]. Poor work-life balance can lead to poor psychological and physical health, reduced individual and family quality of lives, reduced organizational immersion, diminished job satisfaction and increased turnover [42,43]. Female employees in demanding occupations are more likely to experience work-family conflict. They strive to maintain house-wives’ and mothers’ roles [44]. Therefore, it is necessary to actively utilize and expand family-friendly policies to reduce work-family conflicts among married nurses with children.; Expansion of childcare facilities in the workplace, operation of childcare leave system, flexible work system, reduction of working hours during childcare, etc. In Korea, women avoid marriage and childbirth due to the burden of employment and raising their children. To increase nurses’ birth rate, represent female professionals, and reduce stress on child care, various methods should be considered such as changing working conditions, recommending paid parental leave, and creating a workplace atmosphere for nurses with children (24-hour work daycare facilities, education facilities, etc.). It would be desirable for hospitals, society, and the state to seek improvement measures and introduce laws and systems actively.
Turnover intention is to start thinking about finding a new job, leaving the current job [45]. It means an organization member's intention to transfer from an organization or profession, and we believe that it is possible to predict their turnover to some extent [46]. According to this study, economic reasons due to working, parenting support, work-family conflict, and attitudes also influenced married nurses’ turnover. Adjusting the impact factors of such turnover is the core of hospital nursing workforce management.
This study is significant because it applied the TPB, which is known to have high explanatory power, predicts behavior, and confirmed the factors that influence married nurses’ turnover intention. Also, applying the planned behavior theory contributes to managing hospital nursing personnel by predicting and preventing married nurses’ turnover. The latest research on married nurses’ turnover intentions compared to nurses’ and new nurses’ turnover intentions. Since it is relatively small, it is significant that we have conducted repeated studies to support the turnover intention of married nurses.
However, as a limitation of this study, it is difficult to explain the results of this study logically due to the lack of prior studies on the intention to turnover applying the planned behavior theory, and the subjects of this study were only for married nurses working in general hospitals in a region. Therefore, there are limitations in generalizing the research results.
CONCLUSION
Hiring and retaining an adequate level of nursing staffs is an important factor in maintaining the quality of medical services. It is necessary to provide an environment in which competent and experienced nurses can work without changing jobs. As a result of this study, factors influencing turnover intention of married nurses with children were found to be attitudes to turnover, work-family conflict, economic reasons, and support for parenting. Therefore, in order to reduce the turnover of married nurses, there is a need for measures to reduce work-family conflict and support parenting.