International Journal of Nursing Studies 52 (2015) 17351745

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

A structural equation model of turnover for a longitudinal

survey among early career registered nurses
Carol S. Brewer a,*, Ying-Yu Chao a,1, Craig R. Colder b, Christine T. Kovner c,
Thomas P. Chacko d
a

University at Buffalo School of Nursing, 210 Wende Hall, 3435 Main Street, Buffalo, NY 14214, United States
Department of Psychology, Park Hall, 227, University at Buffalo, NY 14260-4110, United States
College of Nursing, New York University, 726 Broadway, 10th Floor, New York, NY 10003, United States
d
University at Buffalo School of Social Work, 205 Parker Hall, 3435 Main Street, United States
b
c

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 17 February 2015
Received in revised form 22 June 2015
Accepted 27 June 2015

Background: Key predictors of early career nurses turnover are job satisfaction,
organizational commitment, job search, intent to stay, and shock (back injuries) based
on the literature review and our previous research. Existing research has often omitted one
of these key predictors.
Objectives: The purpose of this study in a sample of early career nurses was to compare
predictors of turnover to nurses actual turnover at two time points in their careers.
Design: A multi-state longitudinal panel survey of early career nurses was used to compare
a turnover model across two time periods. The sample has been surveyed ve times.
Participants: The sample was selected using a two-stage sample of registered nurses
nested in 51 metropolitan areas and nine non-metropolitan, rural areas in 34 states and
the District of Columbia.
Methods: The associations between key predictors of turnover were tested using
structural equation modeling and data from the earliest and latest panels in our study.
We used predictors from the respondents who replied to the Wave-1 survey in 2006 and
their turnover status from Wave 2 in 2007 (N = 2386). We compared these results to
the remaining respondents predictors from Wave 4 in 2011 and their turnover status
in Wave 5 in 2013 (N = 1073). We tested and found no effect for missingness from Wave
15 and little evidence of attrition bias.
Results: Strong support was found for the relationships hypothesized among job
satisfaction, organizational commitment, intent to stay, and turnover, with some support
for shock and search in the Wave 12 sample. However, for Wave 45 sample (n = 1073),
none of the paths through search were signicant, nor was the path from shock to turnover.
Conclusions: Nurses in the second analysis who had matured longer in their career did
not have a signicant response to search or shock (back injuries), which may indicate
how easily experienced registered nurses nd new jobs and/or accommodation to
jobs requiring signicant physicality. Nurse turnover is a major concern for healthcare
organizations because of its costs and related outcomes. The relevant strength and
relationships of these key turnover predictors will be informative to employers for

Keywords:
Early career nurses
Intent to stay
Job satisfaction
Job search
Longitudinal studies
Organizational commitment
Personnel turnover
Shock
Work environment

* Corresponding author. Tel.: +1 716 713 7625; fax: +1 716 829 2067.
E-mail address: csbrewer@buffalo.edu (C.S. Brewer).
1
Current address: Rutgers, the State University of New Jersey School of Nursing, Ackerson Hall, Room 360, 180 University Avenue, Newark, NJ 071021803, United States.
http://dx.doi.org/10.1016/j.ijnurstu.2015.06.017
0020-7489/ 2015 Elsevier Ltd. All rights reserved.

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C.S. Brewer et al. / International Journal of Nursing Studies 52 (2015) 17351745

prioritizing strategies to retain their registered nurse workforce. We need more research
on programs that implement changes in the work environment that impact these two
outcomes, as well as research that focuses on the relevant strength or impact to help
administrators prioritize translation of results.
2015 Elsevier Ltd. All rights reserved.

What is already known about the topic?

 Turnover is a continual concern for organizations
because of its costs and impact that it has on patient
outcomes; however, nothing is known about what
impacts turnover in the same sample over time.
 Four key concepts that are consistently identied in the
literature predicting turnover are intent to stay or leave,
search, job satisfaction, and organizational commitment,
but much of the research omits at least one or more of
these.
 Additional research has identied shocks as initiating
one of four possible pathways to turnover.
What this paper adds
 This study identies the signicant pathways among
four key variables (intent, search, job satisfaction, and
organizational commitment, and incorporates a measure
of shock in the comparison of the model at two time
periods in the early careers of RNs.
 Using longitudinal data this study shows a causal
relationship between predictor variables and turnover
at both time periods. In the earlier time period search and
shock are both signicant, but they are not signicant in
the later time period.
 Our research suggest that when controlling for confounding factors, attrition, and missing data, we can
conclude that change among the sample over time may
explain the lack of importance of search in the model
of intent to stay and turnover.
Turnover is a continual concern for organizations
because of its costs and impact that it has on patient
outcomes (Jones and Gates, 2007; Li and Jones, 2013), and
many factors have been proposed to explain it. Two
substantive integrated reviews of turnover literature
(Gilmartin, 2012; Griffeth et al., 2005) resulted in two
remarkably consistent models with a set of four variables
forming the core of both reviews. These variables are job
satisfaction, organizational commitment, job search
(search), and intent to stay (or leave; intent). In addition,
the meta-analysis of Griffeth et al. (2000) supported that
job satisfaction, organizational commitment, search, withdrawal cognitions, and quit intentions were the best
predictors of turnover. Withdrawal cognitions are a group
of constructs that mediate intent and turnover. Lee and
Mitchell (1994) include these constructs in a voluntary
turnover model but also posit that shocks play a signicant
role (Lee et al., 1999; Morrell et al., 2004).
Generally researchers examine a cross section of an
organizations workforce at one point in time; at best,
turnover may be examined one time period later. We found
no literature that uses a panel survey at different points in

time to determine whether the turnover predictor relationships vary over time. One problem in evaluating literature
about turnover is that much of the research is based on
underspecied models in which only a subset of these
variables theoretically related to turnover are included. For
example, Coomber and Barriball (2007) reviewed literature
examining the relationship of job satisfaction to intent to
stay (or leave) and turnover. Some of the research studies
included organizational commitment (e.g., Gurney et al.,
1997; Simon et al., 2010 and some did not (e.g., Galletta et al.,
2011; Meeusen et al., 2011). Studies that include all ve key
variables posited as signicant in reviews are less common
than those that include a subset (Blau, 2007; Brewer et al.,
2012). Thus, a direct relationship of satisfaction to intent is
proposed when in fact that relationship may be indirect
(mediated) through organizational commitment. The same
issue exists for turnover.
Another issue is that many researchers (Beecroft et al.,
2008; Simon et al., 2010) examine intent rather than
turnover. While there is a moderate relationship between
intent and turnover (Brewer et al., 2012; Griffeth et al.
2000) using a longitudinal data set is a stronger method
to show a causal relationship than cross-sectional studies
(Estryn-Behar et al., 2010), but more difcult methodologically to accomplish. The purposes of this study are
to determine the pathways among all ve key variables
using longitudinal data, and to compare the model at
two time periods for differences in a group of new
nurses compared to the nurses at a later point in their
careers.
1. Background
The search procedure captured articles addressing
turnover in primarily populations of registered nurses,
practical nurses, or other health professionals (i.e.,
physicians). To identify potentially relevant studies that
were published in English from 1981 to January 2014, we
conducted searches using CINAHL, MEDLINE, EconLit, Web
of Knowledge, and IngentaConnect databases along with
manual searches of the reference lists of the articles
retrieved. The search was limited to quantitative or metaanalytic empirical studies, systematic reviews, and at least
two of the three major constructs that have been used in
turnover research to predict either intent or turnover, job
satisfaction, organizational commitment, and search.
Studies were included in this review if they provided
evidence of level 1 through level 3 based on Evaluation
standards of management research (Reay et al., 2009): Level
1 includes randomized controlled trials or meta-analyses;
Level 2 includes a high quality review or a systematic
literature review; and Level 3 includes large sample,
multisite quantitative studies.

C.S. Brewer et al. / International Journal of Nursing Studies 52 (2015) 17351745

Twenty-two empirical studies were identied in our

review (see Supplementary Data Table A1). We compared
and synthesized studies that investigated the relationships
between turnover and its four proximal antecedents, and
among the antecedents themselves, especially those that
had turnover and/or intent as the dependent variable.
Among these studies, eight studies (Allen et al., 2003; Blau,
2007; Brewer et al., 2012; Camerino et al., 2008; Felps
et al., 2009; Griffeth et al., 2000; Mueller and Price, 1990;
Smith et al., 2011) had turnover as a dependent variable
and also included the major proximal variables (job
satisfaction, organizational commitment, and intent) to
turnover. Of these, only two also included search (Blau,
2007; Brewer et al., 2012). Search was not signicant in the
study of Brewer and colleagues. The study of Blau (2007)
showed that intent mediated searchs effect on turnover.
Contrariwise, Hom and Griffeth (1991) included search but
not organizational commitment, and posited that withdrawal cognitions and the utility of withdrawal (the most
comparable concepts to intent) occur before search. The
role of search and its measurement is thus uncertain in
turnover models.
The following studies have intent to stay or leave a job
as a dependent variable and also both the major variables
job satisfaction and organizational commitment (Beecroft
et al., 2008; Brewer et al., 2012; Cox et al., 2010; De Gieter
et al., 2011; Garbee and Killacky, 2008; Griffeth et al., 2005;
Gurney et al., 1997; Halbesleben and Wheeler, 2008;
Ingersoll et al., 2002; Kim and Hwang, 2011; Kim et al.,
1996; Kovner et al., 2009; Mueller and Price, 1990; Simon
et al., 2010; Wang et al., 2012). Of these 15 studies, only
Kim et al. (1996) and Hom and Griffeth (1991) also
included search, which was signicant and antecedent
to intent. However, Swider et al. (2011) excludes intent
and uses search to predict turnover, whereas Somers
(1996) uses search to predict turnover, but omits
organizational commitment and intent: job satisfaction
is not signicant. Conversely, Castle (2006) uses intent and
organizational commitment to predict turnover, but omits
job satisfaction.
Another model of turnover (Brewer et al., 2012; Kovner
et al., 2009) was developed based on initial work
completed by Price (2001) on the four key concepts
(intent, search, job satisfaction, and organizational commitment) that are consistently identied in the literature
reviews on turnover (Gilmartin, 2012; Griffeth et al., 2005).
In this review, these constructs had a direct relationship
or both a direct and indirect relationships with turnover
that was supported by at least two studies rated as level
3 or higher on Reays evidence-based scale for management literature (Reay et al., 2009). In summary, there is
evidence to support both a direct and indirect relationships
of search (through intent) to turnover, and evidence of
a direct relationship of intent to turnover.
1.1. Job satisfaction
Job satisfaction is dened as the affective orientation
that an employee has toward his or her work (Price and
Mueller, 1981; Price, 2001). There are two approaches to
job satisfaction. One approach is to use a global measure of

1737

general satisfaction, such as Minnesota Satisfaction

Questionnaire (Weiss et al., 1967) and global job satisfaction (Hackman and Oldham, 1975). The second approach is
to use a faceted measurement, such as the Work Quality
Index (Whitley and Putzier, 1994) and the Nurse Work
Index-Revised (Aiken and Patrician, 2000). For our
purposes, we use global measures such as used by Brewer
et al. (2012) and Quinn and Staines (1979). There is
substantial evidence that job satisfaction directly predicts
intent to stay and job turnover, but studies often exclude
organizational commitment or intent when examining
satisfactions relationship to turnover (Lee et al., 2008;
Murrells et al., 2008; Price and Mueller, 1981; Somers,
1996). We propose that the job satisfactions relationship
to turnover is indirect through organizational commitment, search and or intent.
1.1.1. Job satisfaction and organizational commitment
Studies are inconsistent regarding the causal relationship between job satisfaction and organizational commitment. Most researchers conclude job satisfaction predicts
organizational commitment (Gaertner, 1999; Gurney et al.,
1997; Kim et al., 1996; Mueller and Price, 1990) which
impacts turnover through intent and/or search. On the
contrary, some researchers report that organizational
commitment is a direct predictor of job satisfaction (Lu
et al., 2007; Vandenberg and Lance, 1992).
1.1.2. Impact of job satisfaction on search
Griffeth et al. (2005) described that job satisfaction had
a signicant direct negative effect on intent to search
among faculty and staff in a major state university in the
southwestern United States. However, Kim et al. (1996)
and Kovner et al. (2009) found indirect effects of job
satisfaction on intent through search.
1.1.3. Impact of job satisfaction on intent
Mobley (1982) proposed that the relationship between
job satisfaction and turnover is moderated by intent. This
proposition is supported by several studies (e.g., Allen
et al., 2003; Hom and Griffeth, 1991; Murrells et al., 2008;
Price and Mueller, 1981). Some researchers established
that when both organizational commitment and job
satisfaction are included in the model, only organizational
commitment was a signicant predictor of intent to stay
(Garbee and Killacky, 2008; Ingersoll et al., 2002; Mueller
and Price, 1990), and others found that both are signicant
(De Gieter et al., 2011; Griffeth et al., 2005; Kovner et al.,
2009; Wang et al., 2012). Cox et al. (2010) reported
contradictory results, as only job satisfaction was a
signicant predictor on nurses intent to stay in the U.S.
Navy reserve when job satisfaction and commitment were
both included. All of these studies omitted search and
turnover.
1.1.4. Impact of job satisfaction on turnover
A vast body of literature links nurses job satisfaction
with their turnover (Coomber and Barriball, 2007; Hayes
et al., 2006). Some researchers report that job satisfaction
has signicant direct effects on turnover. For example,
Brewer et al. (2012) found that overall job satisfaction was

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C.S. Brewer et al. / International Journal of Nursing Studies 52 (2015) 17351745

a direct negative signicant predictor of turnover; while

Blau (2007) reported that a faceted job satisfaction
measure (including satisfaction with co-workers, personal
growth options, and supervision) was a direct negative
signicant predictor of turnover. On the other hand, some
researchers reported that job satisfaction had signicant
indirect effects on turnover through intent to stay (Brewer
et al., 2012; Allen et al., 2003; Price and Mueller, 1981).
To our knowledge, there have been no longitudinal
studies to sort out the direction of effects for job satisfaction
and organizational commitment in predicting turnover,
although most researchers conclude that job satisfaction
predicts organizational commitment. For the purposes of
this study, therefore, we make the following hypotheses:

comprehensively described in Prices later papers (Price,

2001, 2004) found in a random sample of U.S military
physicians that organizational commitment was a signicant positive predictor of intent to stay, but job satisfaction
was not. Search behavior was also signicant. Kim and
Hwang (2011) showed that affective commitment was a
direct signicant positive predictor of intent to stay among
quality improvement nurses; however, search was omitted
and job satisfaction was not signicant.

Hypothesis 1c. Job satisfaction directly and positively predicts intent to stay.

1.2.3. Impact of organizational commitment on turnover

There is some empirical evidence that organizational
commitment directly predicts turnover. Griffeth and
colleagues (2000) explicated that organizational commitment predicts turnover more strongly than does overall
job satisfaction in a meta-analysis of antecedents and
correlates of employee turnover. Castle (2006) also found
that organizational commitment had a signicant negative
direct effect on voluntary turnover as well as search and
intent, but a mediating effect was not tested, and job
satisfaction was omitted. Thus, there is evidence to support
each of the following hypotheses:

Hypothesis 1d. Job satisfaction directly and negatively

predicts turnover.

Hypothesis 2a. Organizational commitment directly and

negatively predicts search.

1.2. Organizational commitment

Hypothesis 2b. Organizational commitment directly and

positively predicts intent to stay.

Hypothesis 1a. Job satisfaction directly and positively predicts organizational commitment.
Hypothesis 1b. Job satisfaction directly and negatively
predicts job search.

Organizational commitment is a central feature of

models of intent to stay or turnover in nursing and other
professions (Meyer et al., 2002; Mowday et al., 1979;
Wagner, 2007). We use the denition of organizational
commitment as loyalty of employees to their employers
(Kim et al., 1996; Price, 2001).
1.2.1. Impact of organizational commitment on search
Researchers have reported that organizational commitment was a signicantly negative predictor of search
among physicians (Kim et al., 1996). However, organizational commitment was not a signicant predictor on
search in hospital nurses (Kovner et al., 2009), or among
university faculty and staff (Griffeth et al., 2005).
1.2.2. Impact of organizational commitment on intent
There is some evidence that organizational commitment is a signicant predictor of nurses intent to stay in
hospital jobs (De Gieter et al., 2011; Kovner et al., 2009;
Mueller and Price, 1990; Wang et al., 2012) and faculty to
stay in nursing education jobs (Garbee and Killacky, 2008;
Gurney et al., 1997). Allen et al. (2003) established that the
relationship between organizational commitment and
turnover was mediated by turnover intent. Particularly,
organizational commitment had greater impact on intent
than satisfaction. Castle (2006) used logistic regression
to show a (direct) relationship between organizational
commitment and intent; however, no indirect relationship
was tested. Halbesleben and Wheeler (2008), in contrast,
showed that affective commitment and job satisfaction did
not have a signicant impact on turnover intent. Kim et al.
(1996) using Prices early model (Mueller and Price, 1990)

Hypothesis 2c. Organizational commitment directly and

negatively predicts turnover.
1.3. Search
Job search is dened as the degree to which an employee
is looking for another job(s) (Kim et al., 1996; Price, 2001).
Job search, job search attitude, job search intention, job
search behavior and search behavior are terms used in
the literature to describe activities, attitude toward and
behaviors by which job seekers explore alternative job
opportunities (Griffeth et al., 2000; Kim et al., 1996). Search
itself can be considered either an attitude (Kim et al., 1996;
Price, 2001) or set of activities (Griffeth et al., 2000).
1.3.1. Impact of search on intent
The relationship between job search behavior and the
various dimensions of job, career or professional intentions
is not well established (Brewer et al., 2009). Kim et al.
(1996) and Kovner et al. (2009) found that search was
signicant, when job satisfaction, organizational commitment, and job search were regressed on intent to stay. In
summary, there is strong evidence that intent directly
predicts turnover, but whether search is mediated by intent
or is related directly to turnover is not clear, and in addition
maybe be affected by how or when search is measured.
1.3.2. Impact of search on turnover
There are mixed ndings about the impact of search on
turnover. The meta-analysis by Griffeth et al. (2000)
established that search intention was the only signicant
turnover predictor among various measures of job search

C.S. Brewer et al. / International Journal of Nursing Studies 52 (2015) 17351745

behaviors (search intentions, general job search scales,

job search behaviors, and job search methods). The
relationships between turnover, intent, and the various
constructs of job search have not been widely studied. Kim
et al. (1996) places search distal to intent as a predictor, but
others (Blau, 2007; Hom and Griffeth, 1991; Somers, 1996;
Swider et al., 2011) have search directly predicting
turnover (mediating intent). Among ve studies that used
all ve variables, Blau (2007) found that job search was an
independent positive predictor of turnover. However,
Brewer et al. (2012) reported that the effect of intent on
turnover was mediated by job satisfaction and organizational commitment, but not search. Griffeth et al. (2000)
found both job search and intent signicantly independently predicted turnover. These studies have not focused
on a thorough examination of mediators and moderators.
However, Felps et al. (2009), illustrated that job search was
the only signicant predictor of individual turnover when
job satisfaction, organizational commitment, and search
were included. Several authors have found that search was a
signicant direct predictor of turnover (Blau, 2007; Somers,
1996; Swider et al., 2011). Another reason study ndings
may be mixed is that a successful job search may be heavily
dependent on the job market at a given time. In a nurse labor
shortage, nding a job may require little if any search in
advance; a tighter job market may require more search. The
intent to leave may occur concurrently with job search,
without clear causality. Because of the mixed support for
this construct, we do not propose a direct relationship.
Hypothesis 3a. Job search is not related to intent to stay.
Hypothesis 3b. Job search is not related to turnover.
1.4. Intent
Measures of intent are varied and the variation in
measures and slight differences in concepts make it
difcult to assess their role (s) in turnover theory. Intent
to stay (Kim et al., 1996) and desire to stay (Kirschling et al.,
2011) indicate employees willingness to stay in their
jobs, professions or organizations. Intention to leave
(MorBarak et al., 2001) and turnover intention (Lum
et al., 1998) are comparable but are the reverse of intent to
stay. Hom and Griffeth (1991) proposed an expansion of
the concept of intent into several related concepts called
withdrawal cognitions and expected utility of withdrawal.
However, the common thread for all of these concepts is
that they are generally proposed as the most immediate
direct precursor to turnover. Most researchers now accept
the premise that intent to stay or leave and similar
concepts compose the nal cognitive steps in the decision
making process of voluntary turnover (Blau, 2007; Brewer
et al., 2012; Camerino et al., 2008; Griffeth et al., 2000;
Mobley, 1982; Mueller and Price, 1990).
All these studies support that intent has consistent and
direct effect on turnover. Thus we posit the following
hypothesis:
Hypothesis 4a. Intent to stay is directly and inversely
related to turnover.

1739

1.5. Shocks
One less tested development in turnover theory has
been the concept of shocks. Lee and Mitchell (1994) have
developed the unfolding model of voluntary turnover, in
which the pathways described unfold along one of four
pathways depending on whether shocks are present or not.
Shock is dened as a particular, jarring event that initiates
thoughts of quitting a job (Lee et al., 1999). Shock triggers
four pathways of turnover including: (1) leaving without
considering current attachment to the organizations and
alternatives; (2) reconsidering organizational attachment;
(3) leaving after evaluating current jobs and searching
alternatives; and (4) leaving due to lower levels of job
satisfaction instead of shock (Lee et al., 1999). Our dataset
allows us to test this rst pathway, if we assume that the
shock proxy (injuries including back sprains and strains) is
in fact a shock as suggested by (Brewer et al., 2012). Hence
we postulate the following:
Hypothesis 5a. Work related injury (shock) directly predicts turnover.
2. Methods
2.1. Study design
We used a longitudinal panel design to test a model
linking major turnover variables (job satisfaction, organizational commitment, search, intent, shock, and turnover)
among a national sample of early career registered nurses
(Kovner et al., 2007). We compare the results from the
earliest surveys in our panel to those of the latest surveys
to accentuate any potential differences in the career
trajectories. The surveys were conducted one year apart for
the rst two waves, and every two years after that; at this
point we have completed ve surveys over seven years in
2006, 2007, 2009, 2011, and 2013.
2.2. Participants
Data were obtained from surveys mailed and emailed to
early career registered nurses (RNs). The rst survey was
mailed to those RNs who passed the National Council
Licensure Examination (NCLEX) between September
2004 and August 2005. The sample was selected using a
two-stage sample of RNs nested in 51 metropolitan areas
(MSA) and nine non-MSA rural areas in 34 states and the
District of Columbia. The sampling method and the
eligibility criteria were described in detail elsewhere
(Kovner et al., 2007). For each wave of the survey, we used
the Dillman survey method with a $5 incentive (Dillman,
2007). The sample sizes were: Wave 1 (2006; N = 3370),
Wave 2 (2007; N = 2386), Wave 3 (2009; N = 2007), Wave 4
(2011; N = 1544), and Wave-5 (2013; N = 1073). For testing
the SEM model, we used the respondents who replied to
both Wave-1 and Wave-2 and Wave-4 and Wave-5. Wave
1 and Wave 2 were one year apart, but Wave 4 and Wave
5 were two years apart. We compared the nurses who
responded in Wave 1 to Wave 5 and found only one
signicant difference on non-local job opportunities

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C.S. Brewer et al. / International Journal of Nursing Studies 52 (2015) 17351745

(p < .01), thus little evidence of attrition bias. Wave

5 respondents had found a more difcult non-local job
opportunities environment.
2.3. Variables and measures
2.3.1. Major variables
Job satisfaction (Quinn and Staines, 1979), organizational commitment, search, and intent to stay (Price, 2001)
were measured by scales described in Table 1. Job
satisfaction was dened as a workers general affective
reaction to the job without reference to any specic
job facet (Quinn and Staines, 1979; p. 205); e.g., all in all,
how satised would you say you are with your job? The
second variable, organizational commitment was dened
as loyalty of employees to their employers, (Price, 2001;
p. 608); e.g., my present employer inspires the very best in
me in the way of job performance. Price (2001) dened
intent to stay as the extent to which employees plan to
continue membership with their employers, (p. 608); e.g.,
I plan to stay with my employer as long as possible.
Finally, search behavior was dened as the degree to
which employees are looking for other jobs, (Price, 2001;
p. 608); e.g., I almost always follow up on job leads.
We dened shock for this study as the rate of strains,
sprains, including back injury per year for each respondent.
Prices original theory and our original study was not
designed to measure shock, so we used this measure as a
proxy. These variables were chosen from Wave 1. Turnover
was calculated using RN-reported employer changes
between Wave 1 and Wave 2, and then Wave 4 and Wave
5 datasets.
2.3.2. Control variables
We identied variables that were signicantly correlated with turnover in our previous study (Kovner et al.,
2009) and supported by the literature that might be
considered potential confounders of our hypothesized

associations, and added Wave 1 variables that were

signicantly correlated with Wave 2 turnover as statistical
control variables in our path models. The following
demographic and work attributes were included as
statistical control variables: gender (Estryn-Behar et al.,
2010; Nooney et al., 2010), affectivity (Chen et al., 2008;
Price, 2001), overtime (Paquet et al., 2013), direct care
(Harrington and Swan, 2003; Kash et al., 2007), unit
(Staggs and Dunton, 2012), types of health institution
(Camerino et al., 2008; Josephson et al., 2008), and
perceived availability of alternative job opportunities
(Josephson et al., 2008; Kovner et al., 2009), and had left
at least one job prior to our rst data collection (Suzuki
et al., 2008, 2010).
3. Data analysis
SPSS (version 21) was used to compute descriptive
statistics. Pearson correlation and Chi-square were used
to test the associations between variables and turnover.
Mplus (version 7.11) was used to estimate path models.
Our dependent variable (turnover) was dichotomous, and
therefore, we used weighted least squares estimation for
the path models. While there is some skewness in the
shock variable, Weighted Least Squares (WLS) estimation
yields asymptotically normal estimates regardless of the
distribution in the population (Bollen, 1989; Muthen
et al., 1997). Indirect effects were tested using bootstrapped condence intervals computed using 5000 bootstrapped samples (MacKinnon, 2008). We report
standardized coefcients to allow comparison of different scale metrics. Several criteria were used to evaluate
model t, including the model chi-square (x2), Comparative Fit Index (CFI), and Root Mean Square Error of
Approximation (RMSEA). A CFI  0.90 and RMSEA < .06
suggest a good t (Hu and Bentler, 1999; Kline, 2005). We
also used several methods to control for missing data
and sample attrition.

Table 1
Major variables and time of data collection.
Variable

Possible range

Wave

Mean  SD

Reliability
(Cronbachs a)

Turnover

Yes/no
0 = no change
1 = change employer

W2

2386

NA

W5

1073

1 = totally unexpected
7 = totally expected
Item range: 15
1 = very dissatised
7 = very satised
Item range: 17
1 = strongly disagree
5 = strongly agree
Item range: 15
1 = strongly disagree
5 = strongly agree
Item range: 15
1 = strongly disagree
5 = strongly agree
Item range: 15

W1
W4

2197
984

0 = 1910
1 = 476
0 = 872
1 = 201
1.03  2.70
0.98  1.63

W1
W4

2326
1009

5.21  1.54
5.31  1.46

0.829
0.843

W1
W4

2323
1003

3.79  0.78
3.74  0.77

0.862
0.859

W1
W4

2378
1039

2.83  0.44
2.81  0.46

0.765
0.813

W1
W4

2321
993

3.41  0.95
3.56  0.99

0.893
0.886

Shock

Job satisfaction (Quinn and Staines, 1979)

Organizational commitment (Price, 2001)

Search behavior (Price, 2001)

Intent to stay (Price, 2001)

NA
NA
NA

C.S. Brewer et al. / International Journal of Nursing Studies 52 (2015) 17351745

4. Results

1741

signicantly correlated with turnover for the Wave 12

samples (p < .01), but not for the Wave 45 samples.

4.1. Sample characteristics

4.3. Test of the hypothesized model
A sample of 2386 (Wave 12) was used for the rst data
analysis, and a sample of 1073 (Wave 45) was used for the
second analysis. Findings from descriptive analyses are
summarized in Tables A2 and A3 in the Supplementary
Data. In the sample of 2386, participants had an average
age of 32.45 years (S.D. = 8.84). In Wave 1 mandatory
overtime, negative affectivity, job change, direct care
position and gender were positively correlated with
turnover. In both Wave 1 and 4 job opportunities, working
in a hospital (negatively), and type of unit (positively) were
correlated with turnover.
The majority of the sample was White (82.3%), female
(91.1%), and held an associate (56.5%) or baccalaureate
degree (39.3%) as their basic nursing degree. Most worked
full-time (84.5%) in hospital settings (87.1%) and provided
direct care (92.3%). About 10.8% of participants changed
their job after working a year as a RN. Full Information
Maximum Likelihood (FIML) estimation was used in our
path models to allow inclusion of cases with data missing
due to attrition in our analysis (Wave 12 sample).
Moreover, we also used inverse probability weighting
(IPW; Seaman and White, 2014) based on Wave 15
sample attrition to control for any potential attrition bias
in the Wave 45 sample due to attrition.
4.2. Correlations between major variables
As seen in Table A4 in the supplementary data, job
satisfaction, organizational commitment, intent, search,
shock, and turnover were signicantly correlated with
each other for the Wave 1 and Wave 2 samples, as well as
for Wave 4 and Wave 5 samples, except for search. In
particular, job satisfaction, organizational commitment,
and intent to stay were signicantly negatively correlated
with turnover for both Wave 12 samples (p < .01) and
Wave 45 samples (p < .01). Search and shock were

For Waves 12 sample (N = 2386) the initial analysis

(Model 1, not shown) of the hypothesized model without
control variables revealed a good t to the data
(x2 = 24.348, df = 3, p = 0.00, CFI = 0.988, RMSEA = 0.055,
R2: organizational commitment = 0.437, intent = 0.626,
search = 0.037, turnover = 0.170). When control variables
were added (Model 2, not shown), the model continued to
provide a good t to the data (x2 = 224.894, df = 36,
p = 0.00, CFI = 0.968, RMSEA = 0.047, R2: organizational
commitment = 0.672, intent = 0.704, search = 0.040, turnover = 0.210). We examined modication indices for
potential specication errors, and modication indices
suggested that paths from work units and local job
opportunities be changed from turnover to organizational
commitment (modication indices > 132.266). The nal
model (Model 3, see Fig. 1) including these two additional
paths provided a good t to the data (x2 = 132.786, df = 36,
p = 0.00, CFI = 0.983, RMSEA = 0.034; R2: organizational
commitment = 0.566, intent = 0.693, search = 0.040, turnover = 0.213).
We tested the same model (Model 4) with the Wave 4
5 sample (N = 1073). Model 4 (see Fig. 2) also provided a
good t to the data x2 = 82.336, df = 36, p = 0.00, CFI = 0.983,
RMSEA = 0.035, R2: organizational commitment = 0.409,
intent = 0.657, search = 0.012, turnover = 0.165.
In none of the models was there direct signicant
relationships between job satisfaction or organizational
commitment and turnover, but there were signicant
direct positive relationships between job satisfaction or
organizational commitment and intent to stay, and then
between intent to stay and turnover (see Table 2 for tests of
indirect effects). In the nal model for Wave 12 sample
(Model 3), all of the indirect pathways through search to
turnover were statistically signicant (see Table 2 for tests
of indirect effects). However, when Model 4 was rerun with

Fig. 1. Model 3: Wave 12; Sample (N = 2386). Note: *p < .05, **p < .01; unstandardized coefcient (standard coefcients); paths from control variables are
not presented working units** and local job opportunities** signicantly predict OC; settings** and changed job** signicantly predict turnover.

1742

C.S. Brewer et al. / International Journal of Nursing Studies 52 (2015) 17351745

Fig. 2. Model 4: Wave 45; Sample (N = 1073). Note: *p < .05, **p < ; unstandardized coefcient (standard coefcients); paths from control variables are not
presented; working units** and local job opportunities** signicantly predict OC; settings** signicantly predict turnover.

the respondents from Wave 45 sample (N = 1073), none of

the paths through search were statistically signicant, nor
was the path from shock to turnover.
Models 5 to7 (see these were not included to proof???Supplementary Data Figures A1, A2, and A3) were
developed to identify whether the lack of signicance
for these two pathways was a sample attrition effect or
history effect: we proceeded in three ways. All three tests
produced fairly comparable results in terms of the
magnitude and signicance of the pathways. First, we
re-ran the Wave 12 model using the subsample that was
present at Wave 4 and 5 (N = 1073). If the model (Model 5)
was the same as the Wave 1 and 2 model estimated with
the entire sample (N = 2386), then differences between

the Waves 1 and 2 and Waves 4 and 5 models could be

attributable to a history or experience effect. The Model
5 yielded a good t to the data (x2 = 107.891, df = 36,
p = 0.00, CFI = 0.969, RMSEA = 0.043, R2: organizational
commitment = 0.558, intent = 0.629, search = 0.037, turnover = 0.196). Model 5 results suggested that the path from
search to intent was still signicant, but shock was not
signicantly related to turnover. The ndings suggested
that our results are robust to a small attrition bias and
missing data.
Thus taken together these tests suggest that differences
in our Wave 1 to Wave 2 and Wave 4 to Wave 5 models are
attributable to history effects such as changes in behavior
of nurses over time rather than sample bias or differences

Table 2
Indirect effects for structural paths.
All structural paths from:

Model 3 (Fig. 1)

Model 4 (Fig. 2)

JS ! OC ! search

.025** (.084**)

.009 (.027)

JS to intent to stay
 JS ! OC ! intent
 JS ! OC ! search ! intent
 JS ! search ! intent
JS to turnover
 JS ! OC ! turnover
 JS ! OC ! intent ! turnover
 JS ! OC ! search ! turnover
 JS ! OC ! search ! intent ! turnover
 JS ! intent ! turnover
 JS ! search ! intent ! turnover
OC ! search !intent
OC to turnover
 OC ! intent ! turnover
 OC ! search ! turnover
 OC ! search ! intent ! turnover
Search ! intent ! turnover

.219** (.337**)
.213** (.327**)
.003** (.005**)
.003* (.005*)

.181** (.260**)
.178** (.256**)
.001 (.001)
.002 (.003)

.159** (.233**)
.041 (.061)
.089** (.131**)
.003 (.005)
.001* (.002*)
.105** (.154**)
.001 (.002)

.201** (.286**)
.025 (.036)
.080** (.114**)
.001 (.001)
.000 (.000)
.145** (.207**)
.001 (.001)

.009** (.007**)
.277**(.213**)
.263**(.202**)
.010 (.008)
.004* (.003*)
.052** (.023**)

.002 (.002)
.252** (.192**)
.253** (.193**)
.002 (.002)
.001 (.001)
.037 (.017)

Note. *p < .05; **p < .01; Unstandardized coefcient (standardized coefcients); JS = job satisfaction; OC = organizational commitment.

C.S. Brewer et al. / International Journal of Nursing Studies 52 (2015) 17351745

1743

Table 3
Results of Hypotheses Testing.
#

Hypotheses

Wave 12

Wave 45

1a
1b
1c
1d
2a
2b
2c
3a
3b
4
5

JS signicantly directly and positively predicts OC

JS has a signicant negative direct effect on job search
JS has a signicant positive direct effect on intent to stay
JS does not have a signicant effect on turnover
OC has a signicant negative direct effect on search
OC has a signicant positive direct effect on intent to stay
OC does not have a signicant effect on turnover
Job search has a signicant negative direct effect on intent to stay
Job search has a signicant positive direct effect on turnover
Intent to stay has a signicant negative direct effect on turnover
A work related injury/shock signicant direct predicts turnover

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
No
Yes
Yes
No
Yes
Yes
No
No
Yes
No

Note. JS = job satisfaction; OC = organizational commitment.

in the markets. It also points to the value to employers that

experienced nurses may have in the market over new
nurses. In summary, Table 3 summarizes the results for the
hypotheses as follows from Models 3 and 4).
5. Discussion
Relationships among job satisfaction, organizational
commitment, intent to stay, shock, and turnover were
stable as the early career RN sample matured. We also
wanted to sort out the multiple pathways that impact
turnover. We believe this is the only study to test a turnover
model in one sample at two different time periods.
The central roles of job satisfaction, organizational
commitment, and intent are supported. There was no
indication that job satisfaction or organizational commitment had direct effects on turnover; instead they clearly
acted indirectly through intent. The role of search was not
consistent. All of the paths through search were signicant
in the larger and earlier Wave 12 sample (Models 13);
but, in the smaller Wave 12 sample (Model 5) only the
path from search to intent was signicant; in the Wave 45
sample (Model 4) this path was not signicant.
There are several possible explanations for these differences. First, our measure of search was global, indicating the
degree to which employees are looking for other jobs (Price,
2001). The meta-analysis by Griffeth et al. (2000) identied
that search intention was the only signicant turnover
predictor; but Hom and Griffeth (1991) have shown that in
fact search could be a complex construct that needs to
indicate more specic behaviors. If our measure is closer to
intent to search rather than degree of actual search, then
it may overlap considerably with the formation of the intent
to leave, although Griffeth and colleagues (2000) found
that search intent was a signicant predictor.
A second explanation is that while newer nurses may
feel the need to search more carefully for a job before they
quit, as nurses mature they may not spend signicant time,
if any, searching for a job. They know the job market
and are likely have friends or colleagues in many settings.
They are likely to be relatively condent that they can or
cannot get a job when they want it. Thus, search as a
stage may be less important for later career nurses than for
those in other occupations. The historical shortages in the
nursing labor market, particularly for experienced nurses,
make this especially likely.

Lastly, another explanation could be that the two year

time difference between Wave 4 and 5 compared to the
one year time difference in Wave 12 may have attenuated
the relationships, so that search became unimportant.
The other hypothesis that was not supported was the
lack of signicance in the model for Wave 45 for shock.
The theory (Morrell et al., 2004; Morrell, 2005) suggests
that any number of unexpected events could be shock, and
a back strain for nurses working in hospitals, as the majority
of the nurses in this study did at Wave 12 (87.1%) could
signicantly impair the RNs ability to care for patients. By
Wave 45, however, only 72.6% of the sample were working
in hospitals. Fewer nurses thus were exposed to this
occupational hazard, and if they were working for their
preferred employer by that time, they may have moved to a
setting with that employer that reduced the risk of injury or
the intent to stay was stronger than the risk of injury. We
also explicitly dened turnover as leaving the employer, so
it is possible that nurses who experienced back strains could
stay with the employer but move to a less physically
demanding position. One of the major historical effects was
the economic recession beginning in 2008 and resulting
high unemployment rates may also have inuenced these
nurses. While we controlled for perception of job opportunities, it could be that nurses were less likely to leave due
to shocks of any kind because of economic uncertainties. As
discussed above, it could also be due to the time difference
between the surveys attenuating the relationships.
A research implication is that studies that exclude
either organizational commitment or job satisfaction have
an omitted variable bias, as both job satisfaction and
organizational commitment are clearly important factors
in inuencing intent to stay. Employer-modiable predictors of job satisfaction and organizational commitment
need to be identied and tested as solutions to turnover
because of the clear and strong relationship to intent. A great
deal of research has been conducted on job satisfaction, and
somewhat less on organizational commitment, but few
systematically tested interventions exist. Reducing turnover
is a major goal of most employers, especially in a growth
economy. Helping employers understand what factors have
the biggest bang for the buck, or in research language,
effect size, would be a useful direction for the eld.
Implementation of interventions to improve job satisfaction
and organizational commitment must be developed and
tested in order to control and manage personnel turnover.

1744

C.S. Brewer et al. / International Journal of Nursing Studies 52 (2015) 17351745

5.1. Limitations

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While the large sample size is a strength of this study,

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sample sizes, we can condently state that the differences
in the pathways is not a result of differences in the sample.
Our data indicated that there have been only a few changes
in the sample characteristics. We found only one signicant difference on non-local job opportunities between
nurses who did respond in Wave 1 to Wave 5 compared to
those who did not (*p < .05; **p < .01).
Unfortunately, when we started this study we did not
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would result in a lack of honesty in the answers anyway. To
mitigate this problem we used the phrase laid off rather
than red. We think the potential inuence is very small,
given the very small percentages in Wave 2 and 4.

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6. Conclusions
There is strong support over time for the relationships
hypothesized among job satisfaction, organizational
commitment, intent and turnover, with some support
for shock and search for nurses who have just entered the
workforce. We controlled for both missing data and
attrition bias, strengthening the conclusion that nurses
who have been in the workforce for longer time periods
are less likely to turnover if they have a back injury, and
were less likely to search for a job before nding their
next one. In both cases the important role of job
satisfaction as well as organizational commitment, and
the impact of job satisfaction on organizational commitment, in reducing turnover and enhancing retention are
clear and have been addressed in many studies. We need
more research on programs that implement changes in
the work environment that impact these two outcomes,
as well as research that focuses on the relevant strength or
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Conict of interest: None.
Funding: The Robert Wood Johnson Foundation.
Ethical approval: Approved by the Institutional Review Boards
of both the University at Buffalo and New York University.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/j.
ijnurstu.2015.06.017.

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