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journal-of-nursing-sciences/2352-0132

Original Article

The impact of work support and organizational

career growth on nurse turnover intention in China

Yang Yang, Yan-Hui Liu*, Jing-Ying Liu, Hong-Fu Zhang

School of Nursing, Tianjin University of Traditional Chinese Medicine, Tianjin, China

article info abstract

Article history: Objective: The paper aimed to explore the impact of work support and potential for career
Received 21 October 2014 advancement on the nurse turnover intention in order to find an effective approach to curb
Received in revised form high turnover.
28 April 2015 Methods: A cross-sectional survey of 526 nurses from eight teaching hospitals in Tianjin,
Accepted 29 April 2015 China, was conducted to test the hypothesized multilevel model. The organizational career
Available online 8 May 2015 growth scale, work support scale, and the nurse turnover intention scale were used to
measure the effect of organizational career growth and work support on nurse turnover
Keywords: intention. Finally, SPSS 17.0 and AMOS 17.0 software were used to analyse the relationship
Nurse of these variables.
Organizational career growth Results: The score of the three scales nurse turnover, organizational career growth, and
Turnover intention work support were 1.98 ± 0.60, 2.40 ± 0.50, and 4.06 ± 0.98, respectively. The total and direct
Work support effects of work support on turnover intention were
0.361 (p < 0.01) and
0.147 (p < 0.01),
respectively. The indirect effect was
0.169 with a 95% bootstrap confidence interval of

0.257 to
0.102.
Conclusion: The study showed a lack of work support negatively and directly associated
with nurse turnover intention. Additional opportunities for career growth within the or-
ganization may strengthen the effect of work support and consequently increase the
retention of qualified nursing staff.
Copyright © 2015, Chinese Nursing Association. Production and hosting by Elsevier
(Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

of challenges to hospitals across the world [2]. Recent studies

1. Introduction
Nurse staff and their experience level are an important part of
the medical health system that can directly affect the quality
of care [1]. Shortage of nurses has become an increasingly
urgent priority in the recent decades and has brought a series
suggested that the high rate of nurse turnover may be due to
the work overload, long work shifts, complex work relation-
ships, and lack of opportunities for career advancement [3,4].
A report in 2014 showed that in New Zealand, the United
States of America, Canada, and Australia, nurse turnover rate
reached 44.3%, 26.8%, 19.9% and 15.1%, respectively [5]. The

*
Corresponding author.
E-mail address: yh_liu888@163.com (Y.-H. Liu).
Peer review under responsibility of Chinese Nursing Association.
http://dx.doi.org/10.1016/j.ijnss.2015.04.006
2352-0132/Copyright © 2015, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 1 3 4 e1 3 9 135

high nurse turnover rate not only affected the care quality, but latent variable, and organizational career growth an endoge-
it also brought severe economic losses to these countries. nous latent variable and a mediator.
Waldman et al. [6] found that the total cost for low retention of
nursing staff, including productivity loss and costs of hiring 2.2. Research sites and sample
and training new staff, could reach up to more than 5% of the
annual operating budget in a major medical centre in Mexico. A total of 650 registered nurses were recruited from eight
The initial intention of the nursing staff to leave the posi- teaching hospitals in Tianjin, China, from Oct 2013 to Nov
tion (turnover intention) is recognized as a pre-variable before 2014. All of these hospitals have >500 beds. A cluster sampling
the actual demission, which has a good predictive power of design was used to choose the sample. All of the participants
the actual turnover behaviour [7]. In 2012, 40.4% nurses were registered nurses with a direct contact with patients.
intended to leave their current nursing position in China [8]. Questionnaires were distributed and collected during morn-
Therefore, it is important to determine the factors influencing ing or evening meetings in the nursing departments. A total of
the nurse's desire to remain, hence eliminate the nurse 565 feedbacks were received, a response rate of 86.9%. After
intention to leave. Organizational and personal factors eliminating incomplete questionnaires, a final number of 526
together can be used to predict the rate of nurses considering questionnaires were included in the study.
leaving their current position [9]. On the organization level,
work support, such as the flexible schedule, career advance- 2.3. Characteristics of the participants
ment opportunities has shown to sway directly the nurses
from leaving their position [10]. Furthermore, other studies The characteristics of the participants are in the Table 1. Only
also found a correlation between the employee-driven career two nurses were male (0.004%). The age distribution was as
growth within the organization and the retention rate most follows: 53.0% (279/526) between 20 and 29 years, 31.7% (167/
likely due to increase in overall job satisfaction [11]. 526) between 30 and 39 years, and 14.8% (78/526) partici-
Organizational career growth is the core of the career pants > 40 years. Concerning the educational level 50.6% of
development theory. The theory emphasizes the importance the participants had a junior college degree, and 46.2% had a
of the speed of employee career growth within their current bachelor degree. Most participants (69.0%) were married or
organization [12]. According to Weng et al. (2010), the four lived with a partner. Of work experience ranged from 1 to 5
dimensions of organizational career growth include the speed
of professional skill acquisition, the speed of career goal
realization, the speed of promotion, and the speed of salary
increase [13]. Organizational career growth needs the coop- Table 1 e The participants' characteristics.
eration of both the employer and the employee. Organizations
Characteristics Number Percent (%)
that provide nurses with opportunities to advance their career
Gender
who then pursue the opportunities can, as a result, see
Male 2 99.6
employee-led organizational improvements [14]. Therefore,
Female 524 0.4
organizations may see an increase in loyalty from the nurses Age (year)
by providing them with the opportunities for career growth <20 2 0.4
[12]. 20e29 279 53.0
The value of organizational career growth has been indi- 30e39 167 31.7
cated [15], however, there is few study considered organiza- >40 78 14.8
Educational level
tional career growth as a personal factor and work support as
Secondary nursing education 13 2.5
an organizational factor to explore their relationship and their
Junior college education 266 50.6
function on reducing nurse intention of leaving their current Undergraduate education 243 46.2
position. It is important to understand the extent at which Graduate education 4 0.8
work support influences nurse turnover intention and how Marital status
accelerating organizational career growth may add to that. Single 163 31.0
Nurse managers may play an important role in establishing Married 363 69.0
Personnel
the guidelines for professional growth within an organization
Government staff 312 56.3
potentially increasing the nurse retention rate. Contract nurse 214 40.7
Working time (years)
<1 27 5.1
2. Materials and methods 1e5 191 36.3
6e10 134 25.5
11e20 96 18.3
2.1. Study objectives and design
>20 78 14.8
Income (RMB/month)
We conducted a cross-sectional survey. This study aimed to <1000 6 1.1
explore the impact of work support and organizational career 1000e1999 17 3.2
growth on nurse intention to leave their current workplace to 2000e2999 95 18.1
find an effective approach to retain the nursing staff. A hy- 3000e3999 181 34.4
pothesis model was built which regarded work support as an 4000e4999 114 21.7
>5000 113 21.5
exogenous latent variable, turnover intention an endogenous
136 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 1 3 4 e1 3 9

years (36.3% of nurses), 6e10 years (25.5%), 11e20 years months?; ” and “How often do you attempt to look for a new
(18.3%), and >20 years (14.8%). job at present?” The results were rated on a five-point scale
ranging from 1 (very much) to 5 (not at all). The overall
2.4. Instrument Cronbach's a in our study was 0.85.

Three scales were used to do this research: the organizational

career growth scale, the work support scale and the nurse
turnover intention scale.
2.4.1. Organizational career growth scale (CGS)
The nurse organizational career growth was measured by a
15-item index called organizational career growth scale (CGS)
developed by Weng et al. [12] The questionnaire was divided
into four dimensions: the speed of professional ability
improving, the speed in realize one's career objective, the
speed of promotion, and the speed in salary increase. All
participants were asked to match their answer to a five-point
Likert scale from strongly disagree (1) to strongly agree (5).
Cronbach's alpha coefficients in the current study were
0.878. Cronbach's a for each subscale ranged from 0.725 to
0.859, which indicated acceptable internal consistency.
2.4.2. Work support scale
The work support scale was originally developed by Zhao and
Li [16]. The scale includes two subscales: organizational sup-
port and leader support. Each subscale has ten items. The
items were rated on a seven-point rating scale, with 1 indi-
cating ‘none’ and 7 indicating ‘very much.’ The higher the
score, the higher level of work support.
The overall Cronbach's a in our study was 0.939 and the
Cronbach's a for each subscale ranged from 0.896 to 0.900.
2.4.3. Nurse turnover intention scale
Nurse turnover was measured using the nurse turnover
intention scale developed by Brough and Frame [17]. This scale
included three questions: “How often did you generate the
idea to leave the hospital in the past six months?; ” “How likely
are you going to look for a new job in the following six
2.5. Statistical analyses
The SPSS 17.0 software (SPSS Inc, Chicago, IL, USA) and AMOS
17.0 software (Analysis of Moment Structures, version 17
Chicago, IL, USA) were used to do statistical analysis. The
participant characteristics were analysed by the descriptive
statistics. The correlation between work support and organi-
zational career growth and turnover intention was used
initially to explore the relationships between these variables.
The structural equation modelling was used to estimate the
predictive effect of work support and organizational career
growth on nurse turnover intention.
3. Results
3.1. Status of nurse turnover intention
The score of the three scales were presented in Table 2. On a
scale 1e5 of turnover intention scale, the nurse turnover
mean score was 1.98 ± 0.60 (mean ± standard deviation).
Nurses had a moderate level of organizational career growth,
with a mean score of 2.40 ± 0.50 points (scale 1e5). The scores
for the four dimensions of career growth scale were as follows:
3.01 ± 0.61 points for the speed of professional ability
improving, 2.64 ± 0.69 points for the speed of realizing one's
career objective, 1.86 ± 0.71 points for the speed of promotion,
and 2.00 ± 0.71 points for the salary increase. The value of
work support was 4.06 ± 0.98 points (scale 1e7), and the
leader support and organizational support were 4.11 ± 1.12
points and 4.06 ± 0.98 points (scale 1e7), respectively.

Table 2 e The correlations between nurse turnover intention, organizational career growth and work support.
Mean SD 1 2 3 4 5 6 7 8 9
TOa 1.98 0.60 1
CGb 2.40 0.50
0.46** 1
CGc 2.64 0.69
0.51** 0.78** 1
PAd 3.01 0.61
0.44** 0.63** 0.57** 1
Promotion 1.86 0.71
0.20** 0.75** 0.35** 0.13** 1
Salary 2.00 0.71
0.20** 0.74** 0.34** 0.18** 0.69** 1
WSe 4.06 0.98
0.52** 0.57** 0.48** 0.44** 0.35** 0.39** 1
OSf 4.11 1.12
0.50** 0.58** 0.48** 0.41** 0.40** 0.41** 0.95** 1
LSg 4.46 1.08
0.49** 0.49** 0.44** 0.42** 0.25** 0.31** 0.93** 0.78** 1

**p < 0.01.

a
TO: Turnover.
b
CG: Career growth.
c
C-goals:Career goals.
d
Pro-ability: Professional ability.
e
WS: Work Support.
f
OS: organizational support.
g
LS: Leader support.
 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 1 3 4 e1 3 9 137

Fig. 1 e Revised model-estimates of path coefficients and their standard errors.

3.2. The correlation between nurse turnover intention the mediators was
0.169 with a 95% percentile bootstrap
and career growth and work support confidence interval of
0.257 to
0.102 (See in Table 3).

The correlation between the nurse turnover intention and

career growth and work support is presented in Table 2. All
four dimensions of organizational career growth and the two
dimensions of work support were found to be negatively
related to nurse turnover intention.
3.3. Testing the hypothesized model
The relationships of these variables are shown in the final
model (Fig. 1). After a modification had been made according
to the goodness-of-fit indices, the final model fitted the data
very well. All the parameter estimates of the final model
appeared to be in the expected range of values. The fit indicts
were: 1 < c2/degree of freedom ¼ 2.65 < 3,
RMSEA ¼ 0.074 < 0.05, GFI ¼ 0.986 > 0.09, AGFI ¼ 0.933 > 0.09,
IFI ¼ 0.990 > 0.09, TLI ¼ 0.963 > 0.09 and CFI ¼ 0.989 > 0.09.
Furthermore, all of the path coefficients were statistically
significant. Bootstrapping is a method that resamples from an
original sample, which was recommended to test the effect of
a mediator to derive a more accurate estimate [18]. The point
estimate of the total and direct effects of work support on
turnover intention were
0.361 (p < 0.01) and
0.147(p < 0.01),
respectively. The point estimate of the indirect effect through
4. Discussion
First, our findings showed that nurse turnover intention could
be decreased through strong work support. This result was
consistent with a previous study in which work support was
one of the most important factors in reducing the intention of
nurses to leave [19]. Second, work support was positively
associated with career growth. Work support had a significant
impact on employees' career exploration, career goal and
career strategy, benefiting the overall nurses career growth
and self-fulfilment [20]. Third, the retention rate was higher
when nurses had a higher level of organizational career
growth. This result corresponds to Bonenberger et al. who
indicated that effective human resource management prac-
tices at district level positively influenced health worker
motivation and job satisfaction, thereby reducing the likeli-
hood of turnover [21]. In a qualitative study on nurses who left
their jobs, the most important reason for them leaving was
dissatisfaction with prospects for personal career develop-
ment and feeling worthless [22].
Correlation analysis demonstrated that out of four career
growth domains, professional ability and career goal had a

Table 3 e Mediation effect of work support on nurse turnover through organizational career growth.
WSa/TOb Point estimate Product of coefficients Percentile 95% CIe
c d
SE Z Lower Upper
Total effect
0.361 0.034 10.61
0.387
0.252
Indirect effect
0.169 0.044 2.84
0.257
0.102
Direct effect
0.147 0.039 3.76
0.233
0.057
a
WS: Work support.
b
TO: Turnover.
c
SE: Standard Error.
d
Z: Z value.
e
CI: Confidence interval.
138 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 1 3 4 e1 3 9
significantly more negative correlation with turnover inten-
tion (r ¼
0.44 and r ¼
0.51, respectively). This suggests that
nurses today consider their career goals and professional
ability more important than salary and promotion. This result
supports Asegid's research on nurses in South Ethiopia [23].
In Maslow's hierarchy theory of needs, the need for career
development belongs to the self-actualization, and it is the
highest level of human need [24]. Nowadays, most employees
pay more attention to career development and self-
actualization than salary and remuneration. Organizations
and nursing leaders provide nurses with support in different
ways. Managers should know what employees' most urgent
needs are and how to meet these needs.
On the individual level, nurses with a higher level of career
growth usually have a more positive working attitude and a
higher level of professional skill [25]. Therefore, at the unit
level, providing the nurse with the opportunity for organiza-
tional career growth may help build a better working envi-
ronment, as well as increase the overall patient care. The
combination of both work support and organizational career
growth at both individual and unit level may further increase
the sense of fulfilment in nurses and lead to high quality
nursing service, more job satisfaction and decrease in turn-
over intention [23].
There were several limitations to our study. First, the par-
ticipants were only chosen from teaching hospitals in Tianjin.
Second, this survey did not use random sampling to choose
the sample, potentially leading to a selection bias. Third,
organizational career growth is a long process; it may take a
long time for work support to come into play. A longitudinal
study or an intervention study may increase the reliability of
this result. Finally, there may be additional factors influencing
nurse career growth and turnover intention that were not
considered in our survey.
5. Conclusion
This study provided a more comprehensive theoretical un-
derstanding of the relationship between turnover intention
in nursing staff and work support and organizational career
growth. Our findings demonstrated the importance of work
support in improving nurse organizational career growth
and reducing nurse turnover, as well as the mediating effect
of organizational career growth on work support and turn-
over intention. It is believed that nurse managers should
provide nurse with more support for their daily life and work,
and the result of this study also remindered that specific
policies be established by the nurse managers in effort
to increase opportunities for the organizational career
growth, so that nurses are willing to stay in the current
employment.
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