839189

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WJNXXX10.1177/0193945919839189Western Journal of Nursing ResearchLee and Jang

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Western Journal of Nursing Research
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Nurses’ Fatigue, Job © The Author(s) 2019
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DOI: 10.1177/0193945919839189
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Culture, and Turnover journals.sagepub.com/home/wjn

Intention: A Culture–
Work–Health Model

Eunsook Lee1 and Insil Jang2

Abstract
We examined the factors affecting clinical nurses’ turnover intention and
constructed a structural equation model based on the Culture–Work–Health
Model. This cross-sectional study utilized self-administered questionnaires.
Registered nurses (N = 252) from four tertiary hospitals participated. Factors
affecting nurses’ turnover intention included the organizational culture, job
stress, and fatigue (explanatory power = 56.7%), and the model showed
acceptable goodness of fit. In the final turnover intention model, fatigue and
job stress had direct effects and the organizational culture had indirect effects.
The organizational culture also had indirect effects on turnover intention
through job stress and fatigue. This model, therefore, effectively explained
how nursing organizational culture, job stress, and fatigue affect their turnover
intention. The results provide support for theory-driven interventions to
address developing intention to stay at work among experienced nurses.

Keywords
nursing, organizational culture, occupational stress, fatigue, personnel
turnover

1Asan Medical Center, South Korea

2University of Ulsan, South Korea

Corresponding Author:
Insil Jang, Department of Nursing, University of Ulsan, 93 Daehak-ro, Nam-gu, Ulsan, 680-
749, South Korea.
Email: isjang@ulsan.ac.kr
2 Western Journal of Nursing Research 00(0)

There is a global shortage of nurses, which has become an urgent priority and
brought many challenges recently. Despite considerable efforts, nurses’ turn-
over intention and actual turnover threaten health organizations (E. Kim &
Kim, 2014; Takase, Teraoka, & Yabase, 2016). Nurse turnover has a negative
impact on organizational management and makes it difficult to secure and
maintain high-quality nursing. Therefore, nurses’ intention to stay in the
workplace and retention are critical concepts for nurse administrators glob-
ally (AbuAlRub & Nasrallah, 2017; Wan, Li, Zhou, & Shang, 2018).

Factors Affecting Nurses’ Turnover Intention in

South Korea
In South Korea, the demand for nursing care is rapidly increasing because
patients with chronic diseases are living longer owing to improved living
standards and advanced medical technology; consequently, South Korea is
becoming an aged society. According to a survey of working conditions by
the Korean Hospital Nurses Association (KHNA), the average nursing turn-
over rate was 12.4% in 2015 (KHNA, 2017a). Furthermore, the Ministry of
Health and Welfare of Korea reported a nurse-to-patient ratio of 5.2 nurses
per 1,000 people in 2015, whereas the average among Organisation for
Economic Co-operation and Development countries was 9.8 per 1,000 peo-
ple (KHNA, 2017a). As a solution, the Korean Hospital Association requested
an increase in nurses (KHNA, 2017b). Since 2008, the government has grad-
ually increased the number of nursing students; however, the nursing short-
age problem has not been solved (E. Kim & Kim, 2014), and simply increasing
the number of nursing students can degrade the quality of both the education
and health care system. It is necessary to develop a strategy to decrease nurs-
ing turnover in clinical settings. Nurse administrators must focus on main-
taining nursing staff to reduce the cost of recruiting, selecting, and educating
new nursing staff (Wan et al., 2018).
Factors shown to influence nurses’ turnover intention include individual
factors such as age, clinical career, education level, marital status, financial
status, and bullying and organizational factors such as burnout, emotional
labor, job involvement, the organizational culture, the environment, job
stress, job satisfaction, and internal marketing (Arslan Yurumezoglu &
Kocaman, 2016; M. Yu & Lee, 2018). Prior studies have systematically
examined the nursing environment and organizational culture as related to
nurses’ turnover (AbuAlRub & Nasrallah, 2017). Advanced clinical settings
have devoted much effort to address systematically managed rather than
individual factors. Improvement of nursing practice environment and
Lee and Jang 3

Figure 1. Culture–Work–Health Model (Peterson & Wilson, 2002).

organizational culture, efficient management of stress and bullying, and

increasing quality of work life were implemented (Brunetto et al., 2013;
Dogbey, 2008; Labrague et al., 2017; Zhang et al., 2018). However, the
activities of Korean clinical trials are at an early stage; thus, it is necessary
to present the interrelationship of important factors that may affect the turn-
over intention (M. Kim & Ryu, 2015).
Organizational culture refers to concepts that bind members of the organi-
zation such as beliefs, symbols, consciousness, and faith (Glaser, Zamanou,
& Hacker, 1987). Organizational culture is a force that transforms members
and has a strong influence on their behavior, attitude, and performance (Yom,
Noh, Kim, Ji, & Kim, 2013). It also influences health-related quality of life,
emotional fatigue, emotional labor, job satisfaction, organizational commit-
ment, job stress, empowerment, and turnover intention among nurses (Choi,
Jang, Park, & Lee, 2014; Dogbey, 2008). In addition, the organizational cul-
ture changes over time; therefore, it is essential to grasp the current organiza-
tional culture accurately to determine effective ways to promote a positive
nursing organization culture based on the Korean culture.
The Culture–Work–Health Model (CWHM) of Peterson and Wilson
(2002) can be used to explain the relationship between nurses’ organizational
culture, health, and work-related productivity (see Figure 1). The CWHM
aims to improve job stress and foster a healthy organization that includes an
interrelationship between the organizational culture, management system,
employee health, organizational health, and quality of work life (Peterson &
Wilson, 2002). Organizational culture is generated and characterized as a
dynamic relationship with management system. The organization’s manage-
ment system not only affects the health of the organizations and individuals,
but also the interaction between organizational health and personal health
affects organizational management and management systems (Peterson &
Wilson, 2002). The CWHM in this study was based on the experiences faced
4 Western Journal of Nursing Research 00(0)

by clinical nurses in South Korea, including organizational productivity and

their quality of work life.
Employees’ health problems affect the productivity of the organization in
the CWHM (M. Kim & Ryu, 2015). Fatigue is a common daily occurrence
among nurses, and it can negatively affect their health as the increased physi-
cal and mental burden is associated with their turnover intention, job stress,
job dissatisfaction, and reduced health promotion behaviors (Labrague et al.,
2017; M. Yu & Lee, 2018). Fatigue affects not only nurses but also patients’
well-being and the functioning of health care organization.
Many researchers have examined nurses’ organizational culture, job stress,
health problems, and turnover intention; however, there is insufficient evidence
on the pathway between how organizational culture, job stress, and fatigue affect
nurses’ turnover intention. CWHM is useful in studying the relationship with risk
factors of turnover intentions because it can provide an overall understanding of
organizational culture, job stress, personal health, and organizational health.

Purpose
This study was conducted to (a) identify factors affecting nurses’ turnover
intention in South Korea (e.g., organizational culture, job stress, and fatigue),
(b) examine their relationships, (c) construct an appropriate structural equa-
tion model of clinical nurses’ turnover intention based on a literature review
and CWHM, and (d) investigate the adequacy of the developed model.

Method
Study Design
A multicenter, cross-sectional survey design was used to examining the ade-
quacy of the model. Our study used the STROBE checklist of items.

Setting and Sample

Participants included registered nurses who were working in various wards in
four tertiary general hospitals in Seoul, Korea. Participants voluntarily agreed
to participate. Questionnaires (N = 260) were distributed; of these, 255 ques-
tionnaires (response rate = 98%) were completed and collected. After exclud-
ing three incomplete questionnaires, 252 questionnaires were analyzed.
The sample size was based on the rule of thumb for sample size estimation
for a structural equation modeling analysis (10-20 times of measurable vari-
ables) using AMOS (Bae, 2011; Martynova, West, & Liu, 2017). In addition,
Lee and Jang 5

the minimum number of the participants required for multivariate analysis

was 116 nurses, which was calculated using a priori sample size calculator
with a significance level of .05, test power of 80%, and effect size of 0.30.

Data Collection and Ethical Considerations

Data were collected from August to September 2015. A researcher visited the
Directors of Nursing at each hospital to obtain permission for data collection.
Sufficient explanation was given to the participants, including that the infor-
mation gathered from this study would not be used for any purpose other than
the current research, and that all information provided by participants would
be treated with complete confidentiality during the study and stored
appropriately.
Furthermore, participants were informed that the study did not include any
dangerous treatments or medication, and that they would not face disadvantages
from responding to the questionnaires, which were only used to analyze their
opinions. To preserve participants’ rights and interests, participants completed
the questionnaire only after providing written consent. This study was approved
(2014-6095) by an appropriate Institutional Review Board and the investigation
conformed to the principles outlined in the Declaration of Helsinki.

Measurements
Nursing organizational culture. A Korean version of the Organizational Cul-
ture Survey (OCS) was used to measure nursing organizational culture with
permission from the original authors (Glaser et al., 1987). The original OCS
includes 31 items across seven subdimensions; however, an exploratory fac-
tor analysis using principal component analysis and varimax rotation revealed
that all the subdimensions were derived from five factors (total explanatory
power = 63.77%). One item from “information flow” was removed because
it had an eigenvalue <1.0 and a factor loading <.50. Consequently, the
Korean OCS comprised 30 items across five subdimensions: team communi-
cation and morale (10 items), information flow (2 items), employee involve-
ment (5 items), supervision (4 items), and meetings and customer service (9
items). Items were rated with a 5-point Likert-type scale (1 = “strongly dis-
agree” to 5 = “strongly agree”), and higher scores indicated a more positive
organizational culture. Cronbach’s αs reported by Glaser et al. (1987) were
.80 (total) and .81 to .91 (seven subdimensions). In this study, Cronbach’s αs
were .96 (total scale), .91 (team communication and morale), .66 (informa-
tion flow), .83 (employee involvement), .85 (supervision), and .91 (meetings
and customer service).
6 Western Journal of Nursing Research 00(0)

Job stress. Job stress is a harmful physical and emotional response that occurs
when job requirements do not match workers’ abilities, resources, or needs
(Sauter et al., 1999). In this study, job stress referred to the management sys-
tem component of the CWHM and participants’ scores on the Korean Job
Stress Factor measurement, which was developed by the Korea Occupational
Safety and Health Agency (Chang et al., 2005). This tool consists of 24 items
measured with a 4-point Likert-type scale (1 = not at all to 4 = very much)
across several dimensions: job demands (four items), job autonomy (four
items), conflicts (three items), job instability (two items), organization system
(four items), improper compensation (three items), and organization culture
(four items). Each item was evaluated by converting the actual score to 100
points. Cronbach’s αs reported by Cho (2006) ranged from .60 to .73 for all
subdimensions. In this study, Cronbach’s αs were .51 (job autonomy; this sec-
tion was thus removed), .83 (total scale), .83 (job demands), .71 (conflicts),
.70, (job instability), .71 (organization system), .65 (improper compensation),
and .73 (organization culture).

Fatigue. The balance of energy is broken owing to increased physical and

mental burden due to fatigue (Jang, 2013). We measured fatigue using the
nurse fatigue tool developed by Jang (2013) and referring to the CWHM
personal health component. This tool consists of 24 items across three dimen-
sions: exhaustion fatigue (16 items), tension fatigue (three items), and cumu-
lative fatigue (five items). Each item is rated on a 5-point Likert-type scale
from 1 (strongly disagree) to 5 (strongly agree). Total scores ranged from 24
to 120, and higher scores indicated greater fatigue. In the work by Jang
(2013), Cronbach’s αs were .93 (total scale), .92 (exhaustion fatigue), .70
(tension fatigue), and .75 (cumulative fatigue). In this study, Cronbach’s αs
were .95, .74, .93, and .79, respectively.

Turnover intention. Turnover intention was measured using a tool developed by

Lawler (1983) as revised by Paek (2012) and referred to the CWHM organiza-
tional health component. This tool consists of four items measured with a 5-point
Likert-type scale from “not at all” (1) to “very much” (5). Total scores ranged
from 4 to 20, and higher scores indicated higher turnover intention. Cronbach’s
αs were .89 and .91 in this study and in the work by Paek (2012), respectively.

Data Analyses
Data were analyzed using SPSS 21.0 and AMOS 21.0 for Windows (SPSS Inc.,
Chicago, IL, USA). Before analysis, data were examined for outliers and miss-
ing responses. Demographic characteristics were analyzed using descriptive
Lee and Jang 7

statistics including frequencies, percentage, means, and standard deviations.

Internal consistency coefficients (Cronbach’s α) were calculated. Listwise
deletion was used to handle missing data because there was only a very small
amount missing (3%). A confirmatory factor analysis (CFA) was performed to
verify the validity of each variable. The CFA was performed based on fit indi-
ces of goodness-of-fit index (GFI), adjusted GFI (AGFI), comparative fit index
(CFI), Tucker–Lewis index (TLI), and root mean square error of approxima-
tion (RMSEA). To verify the validity, convergent validity, discriminant valid-
ity, and nomological validity were evaluated. Parameter estimation of the
hypothesized model was analyzed using the maximum likelihood method,
which considers missing values of the analyzed data and assumes multivariate
normality. To evaluate the goodness of fit of the model, the following fit indices
and criteria were used: χ2 statistics, GFI, AGFI, CFI, TLI, RMSEA, and normed
χ2 (χ2/df). The significance of the effects of independent variables on depen-
dent variables was verified by applying the bootstrapping method.

Results
Participants’ Characteristics
Participants’ demographics and work-related characteristics are shown in
Table 1. Participants’ mean age was 29.9 (SD = 6.62) years. Most were
women (98.8%), single (67.6%), and had a baccalaureate degree in nursing
(58.7%). Participants had an average of 7.2 years of clinical experience. Staff
nurses accounted for 82.1% of the sample. Most (92.9%) worked shift work,
and more than one third (38.5%) visited the clinic for medical treatment more
than once during the past month.

Descriptive Statistics and Correlations

The scores of the individual variables are presented in Table 2. Descriptive
statistics of the main variables are as follows: nursing organizational culture
3.50 (±0.43), job stress 47.48 (±9.89), fatigue 3.25 (±0.62), and turnover
intention 3.52 (±0.93). Turnover intention was negatively correlated with
nursing organizational culture (r = –.31, p < .001), and positively correlated
with job stress (r = .52, p < .001) and fatigue (r = .60, p < .001).

Verification of the Hypothesis Model

CFA. After creating the parcels, the structural and convergent validities of the
scales were tested using CFA. As shown in Table 3, the full measurement
model with four latent factors fits the data well (χ2 = 261, χ2/df = 3.002,
8 Western Journal of Nursing Research 00(0)

Table 1. General Characteristics of Participants (N = 252).

Characteristics Categories Frequency (%) M ± SD

Gender Male 3 (1.2)
Female 249 (98.8)
Age (years) <30 152 (60.3) 29.93 ± 6.62
≥30 100 (39.7)
Marital status Single 170 (67.5)
Married 82 (32.5)
Religion Yes 120 (47.6)
No 132 (52.4)
Education Associate degree 60 (23.8)
Baccalaureate 148 (58.7)
Master or above 44 (17.5)
Total clinical career <1 23 (9.1) 7.18 ± 6.58
(years) 1-5 97 (38.5)
5-10 61 (24.2)
≥10 71 (28.2)
Current clinical career <1 49 (19.4) 3.98 ± 3.94
(years) 1-5 124 (49.2)
5-10 59 (23.4)
≥10 20 (7.9)
Position Staff nurse 207 (82.1)
Charge nurse or 43 (17.1)
above 2 (0.8)
Others (CNS,
coordinator, etc.)
Work unit Medical unit 112 (44.4)
Surgical unit 136 (54.0)
Others 4 (1.6)
Shift work Yes 234 (92.9)
No 18 (7.1)
Income (monthly, 1,000 <2,500 17 (6.7)
won) 2,500-3,500 172 (68.3)
3,500-4,500 45 (17.9)
≥4,500 18 (7.1)
Clinic visit for medical No 155 (61.5)
treatment for 1 month One time 57 (22.6)
More than two 40 (15.9)
times

p < .001, GFI = .872, AGFI = .824, CFI = .905, TLI = .885, RMSEA =
.089). More than 0.9 for GFI, AGFI, CFI, and normed fit index (NFI) is suit-
able. Concerning RMSEA, scores ≤0.05 are appropriate and scores from 0.05
Lee and Jang 9

Table 2. Descriptive Statistics and Correlations (N = 252).

Correlation

Variables Range M ± SD Minimum Maximum 1 2 3 4

Nursing 1-5 3.50 ± 0.43 2.20 4.93 1
organizational
culture
Team 3.49 ± 0.49 2.00 5.00
communication
and morale
Information flow 3.56 ± 0.54 1.50 5.00
Employee 3.48 ± 0.50 1.80 5.00
involvement
Supervision 3.51 ± 0.59 1.75 5.00
Meetings and 3.48 ± 0.49 2.11 4.78
customer
service
Job stress 0-100 47.48 ± 9.89 18.06 74.54 −.57 1
Job demands 73.25 ± 15.06 33.33 100.00
Conflicts 33.46 ± 11.67 0.00 8.89
Job instability 41.75 ± 20.76 0.00 100.00
Organization 46.63 ± 14.53 8.33 100.00
system
Improper 47.69 ± 14.64 11.11 100.00
compensation
Organization 42.13 ± 14.78 0.00 75.00
culture
Fatigue 1-5 3.25 ± 0.62 1.69 5.00 −.32 .49 1
Exhaustion 3.17 ± 0.68 1.38 5.00
Tension 3.61 ± 0.69 1.33 5.00
Cumulative 3.07 ± 0.73 1.40 5.00
Turnover 1-5 3.52 ± 0.93 1.00 5.00 −.31 .52 .60 1
intention

Note. Scale reliability (Cronbach’s α) is indicated in the parentheses. All the correlations are
statistically significant at p < .001. 1 = Nursing organizational culture, 2 = job stress; 3 =
fatigue, 4 = turnover intention.

to 0.08 are acceptable (J. P. Yu, 2012). Consequently, the model was revised by
selecting the items with the same relevance from the order of modification
index and reanalyzed after setting the final modification model (J. P. Yu, 2012).
Table 3 shows the overall fitness of the final modified model, which was
improved compared with the hypothetical model (χ2/df = 2.46, GFI = .90,
AGFI = .86, CFI = .93, TLI = .93, RMSEA = .07).
10 Western Journal of Nursing Research 00(0)

Table 3. Model Fitness Index for the Hypothesized Model and Modified Model
(N = 252).

RMSEA

Model Fit Measure χ2 df χ2/df p Value GFI AGFI CFI TLI Low High
Hypothesized model 261 87 3.00 <.001 .87 .82 .91 .89 .09
.08 .10
Modified model 209 85 2.46 <.001 .90 .86 .93 .93 .07
.06 .08

Note. GFI = goodness-of-fit index; AGFI = adjusted goodness-to fit-index; CFI = comparative
fit index; TLI = Tucker–Lewis index; RMSEA = root mean square error of approximation.

Goodness of fit of the hypothesized and final structural models. The modified model,
with the variables shown, is provided in Figure 2. The standardized direct, indi-
rect, and total effects of clinical nurses’ turnover intention structural equation
model based on CWHM are shown in Table 4. The significance of the effects of
independent variables on dependent variables was verified by applying the boot-
strapping method (J. P. Yu, 2012). Specifically, nursing organizational culture
had a direct effect on job stress (β = –.70, p = .003). The nursing organizational
culture explained 48.9% of job stress. After analyzing the effects of factors
affecting fatigue, nursing organizational culture had a significant indirect effect
(β = –.39, p = .002) and job stress had a significant direct effect (β = .56, p =
.003). Nursing organizational culture and job stress explained 31.4% of fatigue.
Finally, nursing organizational culture had an indirect effect on turnover inten-
tion (β = –.43, p = .001), and job stress had a direct effect (β = .32, p = .002),
an indirect effect (β = .30, p = .001), and a significant total effect (β = .61, p
= .002) on turnover intention. Fatigue also had a significant direct effect (β =
.53, p = .002) on turnover intention. Overall, nursing organizational culture, job
stress, and fatigue explained 56.7% of turnover intention.
In summary, in AMOS, when the squared multiple correlations exceed
.40, it can be inferred that the independent variable is well explained (J. P. Yu,
2012). Therefore, the modified model effectively explained job stress,
fatigue, and turnover intention.

Discussion
We constructed a structural equation model to explain the effect of nursing
organizational culture, job stress, and fatigue on clinical nurses’ turnover inten-
tion based on CWHM. Fatigue had the greatest direct effect on turnover inten-
tion, which means that as nurses’ fatigue increases, so too does their turnover
Lee and Jang 11

Figure 2. Path diagram for modified model.

Note. C1 = team communication and morale; C2 = information flow; C3 = employee
involvement; C4 = supervision; C5 = meetings and customer service; JS1 = job demands; JS2
= conflicts; JS3 = job instability; JS4 = organization system; JS5 = improper compensation;
JS6 = organization culture; F1 = exhaustion fatigue; F2 = tension fatigue; F3 = cumulative
fatigue; T = turnover intention.

Table 4. Effects of Predictor Variables in the Modified Model (N = 252).

Standardized Standardized Standardized
Direct Effect Indirect Effect Total Effect
Endogenous
Variable Exogenous Variable β (p) β (p) β (p) SMC

Job stress Nursing organizational −.70 (.003) −.70 (.003) 0.489

culture
Fatigue Nursing organizational .56 (.003) −.39 (.002) −.39 (.002) 0.314
culture .56 (.003)
Job stress
Turnover Nursing organizational .32 (.002) −.43 (.001) −.43 (.001) 0.567
intention culture .53 (.002) .30 (.001) .61 (.002)
Job stress .53 (.002)
Fatigue

Note. SMC = squared multiple correlation.

12 Western Journal of Nursing Research 00(0)

intention. Previous literature has revealed that fatigue affects nurses’ physical
and mental health, which interferes with their daily and social functioning
(Jang, 2013; M. Yu & Lee, 2018). Consequently, attention should be paid to
both nurses’ physical symptoms and mental exhaustion. Some studies showed
that interventions such as aroma therapy can lower nurses’ fatigue levels; how-
ever, these interventions only provided temporary relief of fatigue symptoms
(Lee, Park, Kim, & Jung, 2014; Park et al., 2012). Therefore, it is necessary to
promote effective measures such as counseling, massage, and exercise, which
may reduce nurses’ fatigue and thus decrease their turnover intention.
Job stress was directly related to turnover intention, indicating that
increased job stress leads to higher turnover intention. In addition, job stress
had a direct effect on fatigue, which was consistent with past research
(Labrague et al., 2017; Lo, Chien, Hwang, Huang, & Chiou, 2018). In addi-
tion to patient care, nurses are responsible for many tasks such as administra-
tive duties, participation in research activities, education, and participation in
various committees. Nurses need to be provided professional counseling for
managing job stress (Wan et al., 2018). To prevent burnout, an adequate com-
pensation system and healthy working environment should be a priority
(Wong & Laschinger, 2015).
Nursing organizational culture was directly related to job stress and indi-
rectly related to turnover intention. Peterson and Wilson (2002) argue that
organizational culture influences the way members perceive the causes of
stress by influencing members’ interactions, behaviors, and communication
styles. The values and beliefs shared by nurses affect the thinking and behav-
iors of nursing organization members; thus, organizational culture affects
perceived job stress. In a relationship-oriented organizational culture with
high nurse–physician collaboration or an innovation-oriented organizational
culture with good communication, turnover intention decreases (Galletta,
Portoghese, Carta, D’Aloja, & Campagna, 2016). In addition, nursing orga-
nizational culture indirectly affected fatigue, which supports the results that
it is associated with nurses’ mental health (Dogbey, 2008). As previous stud-
ies have suggested the need for a positive nursing organization culture, inter-
ventions aimed at lowering nurses’ job stress, fatigue, and turnover intention
by fostering a positive nursing organization culture are needed (Galletta
et al., 2016; Yom et al., 2013). In a healthy organizational culture, the health
of workers is promoted, improving the productivity of the organization and
further improving the quality of work life (AbuAlRub & Nasrallah, 2017;
Peterson & Wilson, 2002). Thus, accurate assessment and understanding of
nursing organizational culture by CWHM is crucial for improving the quality
of nursing services, improving patient safety, increasing organizational pro-
ductivity, and selecting strategies to improve the quality of life at work.
Lee and Jang 13

Few studies have measured nurses’ organizational culture using the OCS.
We employed the Korean version of the OCS to analyze the positive effects
of the nursing organization culture as perceived by nurses and analyze the
direct and indirect effects of this culture on nurses’ turnover intention and
related variables. The OCS does not comprise a total view of the nursing
organizational culture, but a subcategory of related items in the subelements.
Supported relationships have a positive effect on nurses’ intention to stay in
the organization (Shacklock & Brunetto, 2012).
Teamwork did not directly affect turnover intention; however, the paths
affecting turnover intention through well-being were significant (Brunetto
et al., 2013). In addition, nursing organizational culture influenced job stress
and indirectly affected fatigue (Dogbey, 2008; M. Kim & Ryu, 2015). Therefore,
to develop a positive nursing organization culture, it is necessary to create a
positive communication channel to improve nurses’ teamwork and to execute
efficient meetings. Nursing organizational policies and nurses’ participation in
their management can stimulate morale and motivate nurses. It is also neces-
sary to provide sufficient opportunities for nurses to participate in organiza-
tional decision-making. To increase nursing quality, we must cultivate a culture
that includes respect, communication, praise, and effective feedback.
In this study, the organizational culture affected the formation and man-
agement of the organizational system, which supports the theory posited by
the CWHM—that the organizational culture affects the health status of an
organization and the health of individuals who perceive it as a stressful situ-
ation. Therefore, to reduce nurses’ turnover intention, it is important to accu-
rately assess and evaluate how positively the nursing organization culture is
being accepted by the organization in a clinical setting (Wan et al., 2018; M.
Kim & Ryu, 2015; Yom et al., 2013). Continued efforts to establish systemic
strategies that strengthen positive parts and complement weak parts of the
nursing organizational culture will improve quality of work life and intention
to stay at work by decreasing fatigue and job stress.
Participants from a sample of clinical nurses working in four tertiary hos-
pitals were included, limiting the generalization and representation of our
conclusions. Replication of the present findings with larger sample sizes
from more centers is needed. In addition, our findings were based on self-
reported measures. Objective indicators such as behavioral measures should
be included in future studies. There is also a need for research that considers
other factors that affect nurses’ turnover intention based on CWHM.
The purpose of this research was to investigate the factors affecting nurses’
turnover intention based on CWHM. We proposed and tested a hypothesized
model regarding nursing organization culture, job stress, and fatigue related
to clinical nurses’ turnover intention in South Korea. In the modified model,
14 Western Journal of Nursing Research 00(0)

nursing organization culture directly affected job stress and fatigue, explain-
ing 48.9% and 31.4%, respectively. Overall, the organizational culture, job
stress, and fatigue had an explanatory power of 56.7%, and the model showed
acceptable goodness of fit. In sum, the results of this study confirm that the
influence factors of nurses’ turnover intention are based on the theory of
CWHM and suggest that improvement of nursing organization culture and
job stress and fatigue management are necessary to increase intention to stay.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

ORCID iD
Insil Jang https://orcid.org/0000-0003-3344-0347

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