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JAGXXX10.1177/0733464817721111Journal of Applied GerontologyGaudenz et al.

Article
Journal of Applied Gerontology
2019, Vol. 38(11) 1537­–1563
Factors Associated With © The Author(s) 2017
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DOI: 10.1177/0733464817721111
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in Nursing Homes:
A Secondary Data
Analysis of the Swiss
Nursing Homes Human
Resources Project

Clergia Gaudenz1, Sabina De Geest2,

René Schwendimann3, and Franziska Zúñiga2

Abstract
The emerging care personnel shortage in Swiss nursing homes is aggravated
by high turnover rates. As intention to leave is a predictor of turnover,
awareness of its associated factors is essential. This study applied a
secondary data analysis to evaluate the prevalence and variability of 3,984
nursing home care workers’ intention to leave. Work environment factors
and care worker outcomes were tested via multiple regression analysis.
Although 56% of care workers reported intention to leave, prevalences
varied widely between facilities. Overall, intention to leave showed strong
inverse relationships with supportive leadership and affective organizational

Manuscript received: December 13, 2016; final revision received: April 28, 2017;
accepted: June 17, 2017.
1Bildungszentrum für Gesundheit und Soziales, Chur, Switzerland
2Universität Basel, Institut für Pflegewissenschaft, Switzerland
3Universitätsspital Basel, Switzerland

Corresponding Author:
Franziska Zúñiga, Institut für Pflegewissenschaft, Departement Public Health, Universität Basel,
Bernoullistrasse 28, 4056 Basel, Switzerland.
Email: franziska.zuniga@unibas.ch
1538 Journal of Applied Gerontology 38(11)

commitment and weaker positive relationships with stress due to workload,

emotional exhaustion, and care worker health problems. The strong direct
relationship of nursing home care workers’ intention to leave with affective
organizational commitment and perceptions of leadership quality suggest
that multilevel interventions to improve these factors might reduce intention
to leave.

Keywords
affective organizational commitment, intention to leave, leadership, nursing
homes, physical health

Introduction
In European countries, demographic aging increases the demand for care
workers in nursing homes (Colombo, Llena-Nozal, Mercier, & Tjadens,
2011; Jaccard Ruedin & Weaver, 2009). Across the Organisation for
Economic Co-Operation and Development (OECD) countries, the propor-
tion of the overall population aged 80 years and older is expected to increase
from 4% in 2010 to nearly 10% by 2050 (Colombo et al., 2011). In the last
years of life, care dependency increases: Older persons become more frag-
ile, often experiencing reduced functional status, multiple co-morbidities,
polypharmacy, and cognitive impairment (OECD & World Health
Organization [WHO], 2011). Considering the increased burdens their needs
place on family members and other caregivers, growing numbers of older
persons will eventually need stationary long-term care (Colombo et al.,
2011). In 2013, Switzerland’s 1,560 nursing homes housed approximately
92,000 residents, 75% of whom were older than 80 years. The mean length
of stay was 942 days (Bundesamt für Statistik, 2015). With a high preva-
lence of chronic disease, the oldest are often in poor health, leading to a high
degree of dependence in everyday activities (Bundesamt für Statistik, 2012).
Although the number of nursing home care workers in Switzerland increased
by 13.2% between 2010 and 2014, the need for care workers here has already
surpassed the output of Swiss nursing educational programs (Schweizerische
Konferenz der kantonalen Gesundheitsdirektorinnen und-direktoren [GDK]
& OdASanté, 2016).
Faced with widespread staffing shortages, one partial solution is to retain
current staff longer in nursing homes (GDK & OdASanté, 2016).
Unfortunately, considering the high turnover rates in most countries, this
presents a major challenge (Choi & Johantgen, 2012; McGilton, Tourangeau,
Kavcic, & Wodchis, 2013). For U.S. nursing homes, Banaszak-Holl, Castle,
Gaudenz et al. 1539

Lin, Shrivastwa, and Spreitzer (2013) reported a 35.8% annual turnover

among nursing aides (NAs), alongside 19.5% among licensed practical
nurses (LPNs), and 19.3% among registered nurses (RNs). In contrast, in
Denmark, Clausen, Tufte, and Borg (2014) observed only a 6.6% nursing
home care staff turnover rate within 1 year; in Sweden, Colombo et al. (2011)
found an average annual turnover rate of 5%. The relatively low turnover rate
in Sweden might be attributable to excellent working conditions, including
fair wages and family-friendly policies such as day care services for children
(Colombo et al., 2011). As for Switzerland, the most recent data—from
2002—suggested a 22% annual nursing home staff turnover rate (Künzi &
Schär Moser, 2002).
Care worker turnover weakens nursing home care quality (Castle, Engberg,
& Men, 2007). On one hand, many residents are cognitively impaired and
have reduced social resources. Staff changes can increase their disorientation
(Cohen-Mansfield, 1997). On the other hand, higher NA and RN turnover
rates are related to increased restraint and urinary catheter use, more pressure
ulcers, along with insufficient pain management—all potential indicators of
declining quality of care (Castle & Anderson, 2011). Moreover, in addition to
increasing the cost of recruiting and training new staff, staff transitions cause
workload surges for the remaining care workers (Colombo et al., 2011; Hanh,
2013). In turn, these surges and the stress that accompanies them can increase
the intention to leave, leading to a spiraling interaction between turnover and
workload (Cohen-Mansfield, 1997).

Intention to Leave
Mobley, Horner, and Hollingsworth (1978) described three steps in the job-
leaving process: thinking about leaving, intending to leave, and deciding to
seek new employment. This process is further supported by Fishbein and
Ajzen’s (1975) Theory of Reasoned Action, which explains the relationship
between attitudes and behaviors and can be applied to this study in the sense
that stronger intention to leave will increase the likelihood for actual turnover
behavior. Various studies have confirmed the reliability of intention to leave
as a predictor of turnover in nursing homes, hospitals, and commercial enter-
prises (Cowden, Cummings, & Profetto-McGrath, 2011; Firth, Mellor,
Moore, & Loquet, 2004; Hayes et al., 2012; Zhang, Punnett, & Gore, 2014).
For example, in a longitudinal study of certified nursing assistants (CNAs) in
U.S. nursing homes, Rosen, Stiehl, Mittal, and Leana (2011) showed that
reported intention to leave was a significant predictor of actual 1-year turn-
over (odds ratio [OR] = 2.06; 95% confidence interval [CI] = [1.59, 2.67]).
For CNAs reporting low intention to leave, actual turnover was 65% after 1
1540 Journal of Applied Gerontology 38(11)

Figure 1. Factors associated with care workers’ intention to leave employment in

nursing homes.
Source. Adapted from Cohen-Mansfield’s (1997, p. 60) circular model of decision to leave.

year; for those who reported a very high intention to leave it was 92%.
Behavioral intentions such as intention to leave have shown stronger predic-
tive power regarding turnover than affective variables such as job satisfaction
(Steel & Ovalle, 1984). Accordingly, for this study, we interpreted intention
to leave as the first conscious step toward the outcome of not remaining in the
organization (Cowden et al., 2011), that is, focusing on leaving the organiza-
tion as a workplace, and not on leaving the work sector or profession in gen-
eral. The term intention to leave refers here to voluntary turnover.

Factors Related to Intention to Leave

Factors related to intention to leave are most commonly categorized as orga-
nizational, work-related, employee-related, or external factors (Takase,
2010). Our analyses were guided by the turnover model of Cohen-Mansfield
(1997), who suggested that organizational/work-related factors and employee-
related/personal factors affect the decision to leave via a person’s job fit and
individual responses to that fit, which in turn affect employees’ intentions to
remain or leave the workplace (cf. Figure 1). For example, a care worker’s
decision to leave may be influenced by physiological responses (e.g., health
Gaudenz et al. 1541

problems), cognitive reactions (e.g., negative thoughts toward the adminis-

tration), and emotional reactions, which derive from both work-related and
personal factors (Cohen-Mansfield, 1997). In addition, the model suggested
that external factors such as an organization’s environment (e.g., job market)
are also influencing one’s intention to leave. As this study was a secondary
data analysis, we followed Cohen-Mansfield’s model, focusing on a combi-
nation of work-related factors and individual responses, selecting the vari-
ables in accordance with the literature to date, and excluding factors not
measured in the main study, for example, external factors.

Literature Review
Several studies examined the relationship between work-related factors, such
as leadership, staffing and resources adequacy, collaboration/teamwork or
work stressors, and intention to leave. As for the first of these, leadership,
studies identified decreased turnover or intention to leave when leaders’ con-
sidered work groups’ input into their decision making and development of
shared visions, and enabled or encouraged others to act (Chu, Wodchis, &
McGilton, 2014; Donoghue & Castle, 2009). Yet published findings are
inconsistent, and some studies have failed to confirm these findings. For
example, one recent study found no significant relationship between leader-
ship qualities and intention to leave (Tourangeau, Cranley, Spence Laschinger,
& Pachis, 2010). As for staffing and resources adequacy, magnet hospitals
and dialysis facilities show increased care worker retention when care work-
ers perceive sufficient time and staff to deal with all necessary daily work
(Galletta, Portoghese, Penna, Battistelli, & Saiani, 2011; Gardner, Thomas-
Hawkins, Fogg, & Latham, 2007). However, while it might be expected that
nursing home care workers’ perceptions of staff and resources adequacy are
related to their intention to leave, we found no studies that tested that rela-
tionship. Concerning collaboration and teamwork, favorable findings have
been associated with lower turnover percentages (Chu et al., 2014; Dill,
Keefe, & McGrath, 2012; Tummers, Groeneveld, & Lankhaar, 2013), while
higher work stress has been linked to higher intention to leave (Kuo, Lin, &
Li, 2014; Stewart et al., 2011); yet few studies followed Cohen-Mansfield’s
(1995) suggestion to measure how work stress relates to structural-level char-
acteristics, such as on the institutional or unit level (e.g., work climate, inter-
personal conflicts) and resident levels (e.g., demanding care situations due to
behavioral symptoms of residents).
As for care workers’ health, intention to leave has consistently been related
to emotional (e.g., emotional exhaustion) and physical health problems
(Clausen et al., 2014; Rosen et al., 2011). Other studies revealed that affective
1542 Journal of Applied Gerontology 38(11)

organizational commitment, that is, an emotionally positive connection to the

organization (Taylor & Pillemer, 2009) was inversely related to turnover
(Choi & Johantgen, 2012; Decker, Harris-Kojetin, & Bercovitz, 2009; Karsh,
Booske, & Sainfort, 2005; Taylor & Pillemer, 2009; Tourangeau et al., 2010).
Numerous studies found job satisfaction inversely linked with intention to
leave (Apkera, Proppa, & Zabava, 2009; Francis-Felsen et al., 1996; Kuo
et al., 2014; Parsons, Simmons, Penn, & Furlough, 2003). Finally external
factors, for example, unemployment, labor mobility, and travel time to work,
are described to be linked to turnover (Banaszak-Holl & Hines, 1996; Francis-
Felsen et al., 1996; Rondeau, Williams, & Wagar, 2008).
Although intention to leave is a consistent indicator of staff turnover,
recent reviews indicate limited evidence linking intention to leave with pos-
sible contributing factors present in the nursing home context but not in acute
hospitals; and as most studies so far were conducted in the United States,
international evidence is needed. In addition, few studies have simultane-
ously explored the links between work environment factors, individual
responses, and intention to leave in nursing homes (Cowden et al., 2011;
Hayes et al., 2012).
Therefore, the aims of this secondary data analysis were (a) to describe the
prevalence of care workers’ intention to leave and its variability between
facilities in Swiss nursing homes (where care workers included RNs, LPNs,
and NAs in direct contact with residents), and (b) to examine care workers’
intention to leave as it relates to work environment factors (leadership, staff-
ing and resources adequacy, collaboration/teamwork, and three subfactors of
work stressors, namely, “conflict and lack of recognition,” “workload,” and
“lack of preparation”) and individual responses, which are treated here as
care worker outcomes (emotional exhaustion, physical health problems, and
affective organizational commitment). We expected that intention to leave
would be higher with increased work stressors, emotional exhaustion, and
physical health problems and lower with better leadership, staffing and
resources adequacy, collaboration/teamwork, and higher affective organiza-
tional commitment.

Method
Design, Setting, and Sample
This study is a secondary analysis of data from Switzerland’s multicenter
cross-sectional Swiss Nursing Homes Human Resources Project (SHURP)
study (Schwendimann et al., 2014). Using a random initial selection of 162
Swiss nursing homes, SHURP aimed to explore the relations between various
Gaudenz et al. 1543

nursing homes’ characteristics and care worker and resident outcomes in

Swiss nursing homes. Eligible care workers included RNs (≥3-year educa-
tion), LPNs (3-year education), CNAs (1- to 2-year education), and NAs
(short courses or training on the job). Care worker data (N = 5,323) were
obtained via self-reported questionnaire. Unit and facility questionnaires
were completed by unit supervisors or directors of nursing. Administrative
data on residents were supplied by directors of nursing and/or nursing home
administrators.
For study purposes, data from respondents in leadership positions (e.g.,
nurse mangers, unit supervisors), and those from units that did not report
unit-level data were excluded. Full details of the SHURP study design, sam-
pling, methodology, and questionnaire development have been published
elsewhere (Schwendimann et al., 2014).

Variables and Measurements

The variables under study are described in detail in Table 1. The dependent
variable intention to leave was measured with three items, each using a
5-point Likert-type agreement scale ranging from 1 to 5, with higher numbers
indicating stronger agreement. Due to a strongly left-skewed distribution, the
variable was dichotomized into two groups: intention to leave versus no
intention to leave. Two different cutoffs were used to perform sensitivity
analyses and test the robustness of our findings as described below. To esti-
mate the independent variables for leadership, we used data from the Practice
Environment Scale–Nursing Work Index (PES-NWI; Lake, 2002), which
consisted of five items measured on 4-point Likert-type scale. Collaboration/
teamwork was measured with a single item on a 5-point Likert-type scale
derived from the Safety Attitudes Questionnaire (SAQ; Sexton et al., 2006).
Work stressors were assessed with a 12-item shortened version of the Health
Professions Stress Inventory (HPSI; Lapane & Hughes, 2007). The items
were grouped into three subscales: “conflict and lack of recognition” (six
items), “workload” (three items), and “lack of preparation” (three items). As
recommended by Cohen-Mansfield (1995), these address stress sources at
both the unit and the resident level. Emotional exhaustion was assessed with
a single item from the Maslach Burnout Inventory (Maslach & Jackson,
1981). Physical health problems were numbered on an ordinal scale, using a
self-constructed health index based on items chosen from the Swiss Health
Survey (Bundesamt für Statistik, 2007); and finally, to assess affective orga-
nizational commitment, the five-item continuous scale of the Questionnaire
for the Assessment of Affective, Calculatory and Normative Commitment to
the Organization, the Profession/Activity and Business (Felfe, Six, Schmook,
 Table 1. Description of Variables Used in the Study.
1544
Instrument used; number of items/
Variables number of response categories
Dependent variable Two items from the Michigan
Intention to leave Organizational Assessment
Questionnaire developed by
Cammann, Fichman, Jenkins, &
Klesh (1979), one item from
Mobley, Horner, and Hollingsworth
(1978); 3/5 (1 = strongly disagree to
5 = strongly agree)
Independent variables
Work environment
factors
  Leadership Practice Environment Scale–Nursing
Work Index (PES-NWI; Lake,
2002); 5/4 (1 = strongly disagree to 4
= strongly agree)
   Staffing and resources PES-NWI (Lake, 2002); 3/4 (1 =
adequacy strongly disagree to 4 = strongly
agree)
Items/questions
•• I often think about quitting
•• I will probably look for a new job
the next year
•• I am currently looking for another
job (in another organization)
•• A supervisory staff that is
supportive of the care workers
•• Supervisors use mistakes as
learning opportunities, not criticism
•• A nurse/unit manager who is a
competent leader
•• Praise and recognition for job well
done
•• A nurse/unit manager who backs
up the care worker staff in decision
making, even if the conflict is with
other professions
•• Enough time for discussion of
resident problems
•• Enough qualified personnel to
provide quality of care
•• Enough staff to get work done
Scale calculation
Cronbach’s α = .91.
Scale was calculated as sum over all items minus 3
(index starts with 0 for no intention to leave) ranging
from 0 to 12. Due to the left-skewed distribution,
two groups were built intention to leave (0) vs. no
intention to leave (1-12) and a sensitivity analysis was
performed with cutoff of 0-2 vs. 3-12
Cronbach’s α = .84.
The scale was calculated as the mean over all items of
the subscales. Higher values indicate more favorable
ratings.
Cronbach’s α = .74.
The scale was calculated as the mean over all items of
the subscales. Higher values indicate more favorable
ratings.
(continued)
 Table 1. (continued)
Instrument used; number of items/
Variables number of response categories
  Collaboration with Safety Attitudes Questionnaire (SAQ;
colleagues Sexton et al., 2006); Single-item
question 1/4 (1 = very low to 4 =
very high and the option “don’t
know”)
Work stressors: Health Professions Stress Inventory
(HPSI; Lapane & Hughes, 2007);
12/5, (0 = never to 4 = very often)
out of the 12 items, three new
subscales (see below) were built
based on an exploratory factor
analysis
Conflict and lack of HPSI (Lapane & Hughes, 2007); 6/5 (0
recognition = never to 4 = very often)
1545
Items/questions Scale calculation
With respect to your experiences The item was dichotomized into low (very/rather low)
on this unit describe the quality vs. high (rather/very high) collaboration due to a high
of collaboration that you have negative skew.
experienced with: team colleagues on
your unit
How often do you feel stressed . . . Cronbach’s α = .76.
•• because you disagree with other The subscale was measured as mean over all items
health professionals concerning the where higher values indicate a higher frequency of
treatment of a resident? work stress.
•• because you experience conflicts
with supervisors and/or managers?
•• because you do not have adequate
information regarding a resident’s
condition? (e.g., information is not
available or there is no time to
obtain the information)
•• because no one asks for your
opinion when making decisions
about your job?
•• because you are not paid enough?
•• because you are not able to use all
of your skills on the job?
(continued)
1546
Table 1. (continued)
Instrument used; number of items/
Variables number of response categories
Workload HPSI (Lapane & Hughes, 2007); 3/5 (0
= never to 4 = very often)
Lack of preparation HPSI (Lapane & Hughes, 2007); 3/5 (0
= never to 4 = very often)
Care worker outcomes
Emotional exhaustion (Maslach & Jackson, 1981); Single-item
question 1/7 (0 = never to 6 = daily)
Items/questions Scale calculation
How often do you feel stressed . . . Cronbach’s α = .74. The subscale was measured as
•• dealing with “difficult” residents mean over all items where higher values indicate a
(for example, behavior problems)? higher frequency of work stress.
•• because you have so much work
to do that everything cannot be
done well?
•• because there aren’t enough people
working to get the work done well?
How often do you feel stressed . . . Cronbach’s α = .64.
•• because you are not prepared to The subscale was measured as mean over all items
meet the needs of residents based where higher values indicate a higher frequency of
on your training or experience? work stress,
•• because you are afraid you will
make a mistake in the treatment of
a resident?
•• How often does caring for
terminally ill residents make you
overwhelmed?
•• About care workers’ feelings The validity of measuring emotional exhaustion with
regarding emotional exhaustion due a single item has been described by West, Dyrbye,
to their work Sloan, and Shanafelt (2009).
(continued)
 Table 1. (continued)
Instrument used; number of items/
Variables number of response categories
Physical health problems Health Index defined in Swiss Nursing
Homes Human Resources Project
(SHURP) based on items from the
Swiss Health Survey (Bundesamt für
Statistik, 2007); 5/3 (0 = not at all to
2 = strongly)
Affective organizational Assessment of Affective, Calculatory
commitment and Normative Commitment to
the Organization, the Profession/
Activity and Employment
Commitment (COBB; Felfe, Six,
Schmook, & Knorz et al., 2010); 5/5
(1 = strongly disagree to 5 = strongly
agree)
1547
Items/questions Scale calculation
Did you suffer from any of the following Cronbach’s α = .69.
conditions in the last 4 weeks: The index was calculated as the sum over all items.
•• Back pain, low-back pain Higher values indicate more health problems.
•• General weakness, tiredness, lack
of energy
•• Problems with sleeping
•• Headache, pressure in your head
or pain in your face
•• Pain in your joints or limbs
•• I would be very happy to spend the Cronbach’s α = .87.
next years with this organization The subscale was measured as mean over all items
•• I feel a strong sense of “belonging” where higher values indicate a higher affective
to my organization organizational commitment.
•• I do not feel “emotionally attached”
to this organization
•• I am proud of working in this
organization
•• I think, my ideals about good
care fit with the ideals of this
organization
1548 Journal of Applied Gerontology 38(11)

& Knorz, 2010) was used. Although job satisfaction is indicated as a strong
predictor of affective commitment in the SHURP data set (Graf, Cignacco,
Zimmermann, & Zúñiga, 2016), it is less stable than affective commitment as
it is more prone to immediate reactions to specific and tangible aspects of the
work environment (Mowday, Steers, & Porter, 1979); therefore, we selected
affective organizational commitment as a factor related to intention to leave.

Control Variables
Organizational factors were assessed in the unit and facility questionnaires.
They were included as control variables based on prior empirical evidence
(Clausen et al., 2014; Decker et al., 2009; Donoghue & Castle, 2009), except
for language region (1 = German-, 2 = French-, 3 = Italian-speaking), which
was added to control for cultural differences between Switzerland’s three lin-
guistic regions. The control variables included nursing home bed size (20-49
beds = small, 50-99 beds = medium and ≥100 beds = large), profit status (1 =
public, 2 = private subsidized, 3 = private), and service area type (rural vs.
urban; close to a national border vs. not close). For service area type, proxim-
ity to the Swiss border was relevant because Swiss nursing homes close to
neighboring countries report fewer recruitment problems. The staffing level
was compared using the number of full-time equivalent (FTE) positions per
100 beds. Units’ mean care load data (derived from reports supplied to the
Swiss national health care provider reimbursement system) were used as a
proxy for their residents’ care dependency levels. Based on these figures,
residents were grouped into 12 care levels. Each higher level corresponds to
a 20-min increment in daily care needs (e.g., a resident in care group 8 would
receive 160 min of direct-care time per 24-hr period; Curaviva.ch., 2010).
The nursing homes supplied these data from their administrative systems. As
for care worker characteristics, two items from the care worker questionnaire
were assessed: age (years) and education (RNs ≥ 3-year education), LPNs
(3-year education), CNAs (1- to 2-year education), and NAs (short courses or
training on the job).

Data Collection
All SHURP data were collected between May 2012 and April 2013 by the
Institute of Nursing Science, University of Basel. Prior to each facility’s
inclusion in the study, the responsible administrator supplied written informed
consent. For individual respondents, the voluntary return of the anonymous
care worker questionnaire was considered informed consent. The study was
approved by all Swiss cantonal ethics committees (leading ethics committee:
Gaudenz et al. 1549

Ethikkommission Nordwest- und Zentralschweiz [EKNZ]; Ref. Nr. EK: 02 /

12). Detailed information concerning the data collection process is provided
by Schwendimann et al. (2014).

Data Analysis
To assess the prevalence of care workers’ intention to leave and its variability
between facilities, that is, to address Aim 1 of this study, each facility’s ratio
of workers reporting intention to leave (as specified below) to its total num-
ber of included respondents was calculated. To test the relationship between
intention to leave (as a dependent variable) with work environment factors
and care worker outcomes (independent variables)—that is, to address Aim
2—a multiple regression model with generalized estimating equations
(GEEs) was used. First, bivariate models were applied; next, a multivariate
logistic regression was conducted on a model including all variables.
Multicollinearity was tested with the variance inflation factor (VIF), expect-
ing values below 5 (Field, Miles, & Field, 2012). The results indicated that all
variables could be included in the model. To examine whether the care work-
ers’ responses depended upon unit or facility membership, intraclass correla-
tion coefficients (ICC1) were calculated. The resulting facility and unit-level
ICC1s—.08 and .09, respectively—were indicating a need to control for nest-
edness of care workers on both levels. To compare the models’ fits, Quasi-
Likelihoods under the Independence Model Criterion (QICs) were calculated.
As the threshold to differentiate no intention to leave from intention to leave
was initially set very low, with the cutoff set to 1 (i.e., 0 = no intention to
leave; 1-12 = intention to leave), a sensitivity analysis was performed with
the cutoff set to 3 (i.e., 0-2 = no intention to leave; 3-12 = intention to leave).
The significance level was set at a p value of <.05. Cases with missing data
were removed listwise from the analysis. The control variables were used in
the adjusted model. Data analysis was performed with IBM SPSS Statistics
for Windows, Version 22.0 (Armonk, New York: IBM Corp.).

Results
Sample Description
The final sample consisted of 3,984 care workers from 481 units in 156 nurs-
ing homes. The mean response rate across all units was 79.3%. Almost half
of all respondents (48%) were employed in medium-sized nursing homes
(50-99 beds) and had a mean age of 43 years (SD: 12) with 26% of care work-
ers being RNs. Across all units, the average number of FTEs per 100 beds
1550 Journal of Applied Gerontology 38(11)

was 51 (SD: 15). Based on 3,960 valid responses and a scale of 0 to 12, using
0 (cutoff: 1) as no intention to leave, 56% respondents had an intention to
leave. When using ratings between 0 and 2 (cutoff: 3) as an indicator of no
intention to leave, 38% respondents showed intention to leave. As for vari-
ability between nursing homes, in two facilities, no care workers expressed
any intention to leave, while in two other, all care workers indicated intention
to leave. In 11 of the remaining 152 nursing homes, 80% or more care work-
ers reported intention to leave their facility; and in three, 20% or fewer indi-
cated so. The percentage of respondents who were rather or very satisfied
with their collaboration with colleagues was 96%. Overall, leadership was
rated as encouraging and positive (mean: 3.1 on a scale of 1-4). More detailed
information on the independent variables is shown in Table 2.

Relationship Between Work Environment Factors and Care

Worker Outcomes
On average, respondents with higher overall intention to leave reported lower
leadership ratings (OR = 0.62, 95% CI = [0.50, 0.76]) and higher stress due
to conflict and lack of recognition (OR = 1.61, 95% CI = [1.32, 1.98]). Higher
intention to leave was also related to lower affective organizational commit-
ment (OR = 0.14, 95% CI [0.11, 0.16]). Intention to leave increased with
higher emotional exhaustion (OR = 1.18, 95% CI = [1.10, 1.26]) and more
physical health problems (OR = 1.09, 95% CI = [1.04, 1.14]). The results of
unadjusted and adjusted models were very similar. The sensitivity analysis
with a higher cutoff for intention to leave showed no differences. Further
details are provided in Table 3.

Discussion
This study described both the overall prevalence of intention to leave of
respondents and the interfacility variability of intention to leave in addition to
a number of factors related to care worker intention to leave in Swiss nursing
homes. Although prevalences varied widely between facilities (range:
0%-100%), more than half of the surveyed care workers reported intention to
leave. When looking at the work environment factors, our results confirm the
excepted relationship between nursing home care workers’ intention to leave
and their perception of having a supportive and competent leadership as well
as their experiences of workplace stress due to “conflict and lack of recogni-
tion.” Moreover, for all care worker outcomes (i.e., emotional exhaustion,
physical health problems, and affective organizational commitment), our
assumptions were confirmed. However, perceptions of staffing and resources
Gaudenz et al. 1551

Table 2. Sample Characteristics.

Characteristics/factors % M SD Missing (%)

Facility characteristics (n = 156)

Facility size
   Small (20-49 beds) 37.8 0 (0)
   Medium (50-99 beds) 48.1 0 (0)
  Large (≥100) 14.1 0 (0)
Ownership status
  Public 37.2 0 (0)
  Private subsidized 26.3 0 (0)
  Private 36.5 0 (0)
Language regions
  German 75.6 0 (0)
  French 18.6 0 (0)
  Italian 5.8 0 (0)
Service area
  Urban 37.8 0 (0)
  Rural 62.2 0 (0)
   Close to the country border (yes) 23.7 0 (0)
Unit characteristics (n = 481 units)
Number of FTE/100 beds 51 15.4 0 (0)
Mean care load (scale from 1 to 12) 5.8 1.6 0 (0)
Care worker characteristics (n = 3,984)
Age (years) (n = 3,875) 43.1 12.3 109 (2.8)
Education (n = 3,949) 35 (0.9)
   Registered nurse (3-4 years of education) 25.7
   Licensed practical nurse (3 years of education) 21.8
   Certified assistant nurse (1-2 years of education) 19.5
   Nurse aide (training on the job) 29.8
  Other 3.2
Work environment factors (scale range)
PES-NWI: Leadership (1-4) (n = 3,984) 3.1 0.6 0 (0)
PES-NWI: Staffing and resources adequacy (1-4) (n = 3,977) 2.8 0.7 7 (0.2)
Collaboration with colleagues very/rather satisfied (n = 3,932) 96.1 52 (1.3)
HPSI Work stressors: Lack of preparation (0-4) (n = 3,971) 0.7 0.6 13 (0.3)
HPSI Work stressors: Conflict and lack of recognition (0-4) 0.9 0.7 7 (0.2)
(n = 3,977)
HPSI Work stressors: Workload (0-4) (n = 3,977) 1.5 0.8 7 (0.2)
Care worker outcomes
Emotional exhaustion (0-6) (n = 3,938) 2.1 1.6 46 (1.2)
Physical health problems (Health Index (0-10)) (n = 3,878) 3.5 2.3 106 (2.7)
COBB: Affective organizational commitment (1-5) (n = 3,978) 3.8 0.8 6 (0.1)

Note. Preferable scores are underlined. FTE = full-time equivalent; PES-NWI = Practice Environment
Scale–Nursing Work Index; HPSI = Health Professions Stress Inventory; COBB = Assessment of Affective,
Calculatory and Normative Commitment to the Organization, the Profession/Activity and Employment
Commitment.

adequacy, collaboration/teamwork, and work stress due to “workload” and

“lack of preparation” did not show any relationship with intention to leave.
1552 Journal of Applied Gerontology 38(11)

Table 3. Relationship of Work Environment Factors and Care Worker Outcomes

With Intention to Leave.
Unadjusted (n = 3,663) Adjusteda (n = 3,663)

Factors OR 95% CI p value OR 95% CI p value

Work environment factors

PES-NWI: 0.62 [0.51, 0.76] .00 0.62 [0.50, 0.76] .00
Leadership
PES-NWI: Staffing 1.13 [0.94, 1.36] .18 1.18 [0.98, 1.42] .09
and resources
adequacy
Collaboration with 0.92 [0.52, 1.64] .79 0.79 [0.43, 1.46] .46
colleagues
HPSI Work 1.55 [1.27, 1.89] .00 1.61 [1.32, 1.98] .00
stressors: Conflict
and lack of
recognition
HPSI Work 1.12 [0.96, 1.30] .16 1.15 [0.98, 1.35] .08
stressors:
Workload
HPSI Work 0.82 [0.68, 0.98] .03 0.84 [0.70, 1.02] .07
stressors: Lack of
preparation
Care worker outcomes
Emotional 1.21 [1.13, 1.29] .00 1.18 [1.10, 1.26] .00
exhaustion
Physical health 1.09 [1.04, 1.14] .00 1.09 [1.04, 1.14] .00
problems (Health
Index)
COBBAOC: 0.14 [0.12, 0.16] .00 0.14 [0.11, 0.16] .00
Affective
organizational
commitment
QIC 3,256.99 3,209.44

Note. Bold = significant. OR = odds ratio; CI = confidence interval; PES-NWI = Practice Environment
Scale–Nursing Work Index; HPSI = Health Professions Stress Inventory; COBB = Assessment of Affective,
Calculatory and Normative Commitment to the Organization, the Profession/Activity and Employment
Commitment; QIC = Quasi-Likelihoods under the Independence Model Criterion; FTE = full-time
equivalent.
aThe adjusted model was controlled for nursing home level: Size, profit status, language region, service

areas; unit level: FTE/100 beds, mean care load; care worker level: Age, education.

Since definitions for intention to leave differ concerning inclusion criteria

and settings between studies of this topic (Takase, 2010), we are unable to
compare either our prevalences or the interfacility variability with those of
other studies. Our sample’s high prevalence of intention to leave is certainly
Gaudenz et al. 1553

due to the high sensitivity of the scale used: Arguably, a cutoff of 1 (with 0 as
no intention to leave and 1-12 as intention to leave) on a scale from 0 to 12 is
a rather rigorous cutoff. Still, our sensitivity analysis showed that even with
a cutoff of 3 (with 0-2 as no intention to leave and 3-12 as intention to leave),
38% of the care workers still indicated intention to leave. The high interfacil-
ity variability of intention to leave might reflect the importance of the organi-
zational context.
Congruent with previous studies (Chenoweth, Jeon, Merlyn, & Brodaty,
2010), our findings support the claim that individual nursing homes’ leader-
ship practices (e.g., supporting care workers in decision making, using mis-
takes as learning opportunities) affect their staff turnover. As previous studies
(Blomberg, James, & Kihlgren, 2013; McGilton, Boscart, Brown, & Bowers,
2014; Tourangeau et al., 2010) have linked lower intention to leave with more
acknowledgment from superiors, this issue might be reduced in facilities
where care workers receive praise and other forms of recognition from their
supervisors and leaders. Another explanation for this relationship might be
the challenging nature of the care work with multimorbid and cognitively
impaired nursing home residents (Cohen & Golan, 2007; Moseley, Jeffers, &
Paterson, 2008). The most successful leaders empower and support care
workers not only to face these challenges but to develop meaningful relation-
ships with residents (McGilton et al., 2014), thereby decreasing the intention
to leave of their employees. They also incorporate care workers’ input in
decision making and inspire a shared vision (Donoghue & Castle, 2009;
Moseley et al., 2008). Furthermore, other studies have found that care work-
ers whose leaders offer learning opportunities, skills training and other pro-
fessional development report lower intention to leave (Chenoweth et al.,
2010; McGilton et al., 2014). In fact, one defining characteristic of support-
iveness in leadership is the encouragement of employees to develop new
skills and pursue further education (Erenstein & McCaffrey, 2007).
Although one might reasonably expect a relationship between intention to
leave and staffing and resources adequacy based on studies in the hospital
setting (Galletta et al., 2011; Gardner et al., 2007), our analyses did not con-
firm such a relationship. To our knowledge, no research has yet specifically
examined this relationship in nursing homes. Based on our results, nursing
homes care workers might define staffing and resources adequacy differently
from their hospital counterparts. Blomberg et al. (2013) explained that, com-
pared with similar employees in hospitals, nursing home care workers con-
sider their work basically less stressful (even when personnel is low), and
accept that, while they usually have enough personnel, there will be days
when they have to work shorthanded.
1554 Journal of Applied Gerontology 38(11)

Contrary to our expectations—and previous research findings (McGilton

et al., 2014; Prentice & Black, 2007; Tummers et al., 2013)—no significant
relationship was found between collaboration/teamwork and intention to
leave. This difference from previous findings might result partly from differ-
ing definitions of collaboration/teamwork. For example, Tummers et al.
(2013) referred to it as a “good working atmosphere characterized by a pleas-
ant interaction with colleagues working in the same unit, a good team spirit
and collegial behavior” (p. 2829). In contrast, our study addressed the issue
using a single-item and a dichotomized 4-point Likert-type scale to assess
overall quality of collaboration with team colleagues, which showed little
variability.
As for the relationship between work stressors and intention to leave, only
work stress due to “conflict and lack of recognition” was related to intention
to leave. The other two factors—“workload,” that is, measuring perceived
workload and staffing resources, and “lack of preparation,” that is, the man-
agement of complex resident situations and care workers’ skills/training—
showed no significant relationship. In general, research shows a direct
relationship between work stressors and intention to leave (Karantzas et al.,
2012; Stewart et al., 2011). It should be noted that work stressor measure-
ment methods differed between studies: Stewart et al. (2011) measured per-
ceived stress with a global four-item measurement. Therefore, our result for
this variable is only partially comparable with those of the other studies cited.
It is also possible that we found a significant association only in the “conflict
and lack of recognition” subfactor because, considering care workers’ strong
positive feelings about the care they provide, stress related to residents is
simply less severe. That is, they may have assessed the stress they felt in rela-
tion to interpersonal problems with coworkers and leaders much more seri-
ously—and associated it much more with intention to leave—than
worker-resident issues, which may be comparatively transitory (Cohen-
Mansfield, 1989; Schaefer & Moos, 1996).
In line with other studies, both emotional exhaustion and health problems
had modestly significant relationships to intention to leave. In a longitudinal
study, Rosen et al. (2011) found that care workers’ intention to leave was
predicted both by reduced emotional well-being and by increased physical
health problems. Care workers exposed to a continuously high level of physi-
cal and/or emotional strain suffering from health problems might prefer to
leave to protect themselves from further deterioration of their situation
(Clausen et al., 2014).
Similar to previous studies in the nursing home setting (Karsh et al., 2005;
Takase, 2010), our findings indicate that high affective organizational com-
mitment is significantly linked with decreased intention to leave (Westphal &
Gaudenz et al. 1555

Gmür, 2009). One possible explanation could be that high affective organiza-
tional commitment accompanies trust in the organization, satisfaction with
management and superior behavior, leading to increasingly close affiliation
with the organization and increasing self-esteem and in turn to less intention
to leave (Westphal & Gmür, 2009).
Finally, it should be acknowledged that the work environment factors and/
or care worker outcomes researched in this study account only for one set of
intention to leave factors that depend on presumably modifiable characteris-
tics within nursing homes. Other linked factors, for example, relocation,
career advancement, family/personal issues, and mobility (LeVasseur, Wang,
Mathews, & Boland, 2009; Rondeau et al., 2008) were beyond the scope of
this study.

Strengths and Limitations

The SHURP study’s high response rate, large sample size, and stratified ran-
dom selection of participating facilities permit generalization of our findings
to all nursing homes with at least 20 beds across Switzerland. However, con-
sidering the particular characteristics of Swiss nursing homes (e.g., 31%
RNs, 46% medium size nursing homes with 50-99 beds), international com-
parisons should be addressed with caution. The selection of previously vali-
dated instruments is another important strength. Nevertheless, the following
potential limitations should be noted.
First, the obtained survey measurements stem from a single study, leaving
the possibility of method bias; second, the cross-sectional study design pre-
cludes the inference of causal relationships between independent and depen-
dent study variables. Moreover, the secondary data analysis limited the ability
to fully evaluate the relationship between intention to leave and other factors
found in the literature such as the market situation. Third, we may have lost
statistical power by dichotomizing intention to leave, which we did because
of its high skewness. However, a sensitivity analysis showed the robustness
of our results. Our study showed a high variability of intention to leave
between nursing homes. Although the exploration of positive deviant cases
with very low rates of intention to leave might contribute to interventions to
reduce turnover, such an in-depth examination was beyond the scope of this
secondary analysis.

Implications for Education and Research

For future research, to permit national and international comparison, work
stressor data should be collected and assessed with standardized measurement
1556 Journal of Applied Gerontology 38(11)

tools. Likewise, future studies should consider variables not included in this
study, for example, external factors such as the organization’s surrounding
environment (e.g., job market, family conditions, and mobility). Longitudinal
research is needed to explore and illustrate causal relationships between inten-
tion to leave and related factors. In this study, we assumed that intention to
leave would be strongly related to turnover, but it is possible that care workers
remain in institutions despite their intention to leave (e.g., because they cannot
find suitable alternatives). From this perspective, it would be interesting to
examine the consequences of such noncommitted behavior (e.g., absenteeism,
decrease of care performance quality).

Implication for Practice and Policy

According to our findings, a positive and attractive work environment with
supportive leadership is crucial for workforce retention. Our findings indicate
that more investment is warranted in leadership training for nursing home
managers (Cummings et al., 2014; Jeon et al., 2015; Vogelsmeier, Farrah,
Roam, & Ott, 2010). In addition to focusing on the evidence regarding risk
factors and correlates of intention to leave, this training should emphasize
options for multilevel interventions that can be used by nurse managers to
reduce turnover. One concrete goal would be the provision of a positive orga-
nizational climate with the possibility to offer high-quality care, ongoing
education, and family-friendly services (Blomberg et al., 2013; Chenoweth
et al., 2010; Curaviva.ch, 2013). Although emotional exhaustion and physical
health problems were only modestly associated with intention to leave, it
should be noted that the impact of these factors could be reduced by leader-
ship commitment to empowering and supporting care workers regarding the
physical and emotional strains of their daily work (Schaefer & Moos, 1996).
Moreover, work incapacitation and absenteeism due to emotional exhaustion
and physical symptoms impact not only the individual but also the organiza-
tion, generating high costs and reducing quality of care and patient safety
(Letvak, Ruhm, & Gupta, 2012). Therefore, it is crucial that protective mea-
sures for care worker health begin at the organizational level, for example,
with a systematic approach to recording and examining reasons for work
incapacity, and include action plans to promote care worker health (Keller,
2006). Accordingly, evidence-based nursing home management demands
that nurse managers be prepared to take policy initiative, advocating for opti-
mal working conditions for their workforce both in- and outside the nursing
home.
At the policy level, it is necessary to formulate strategies and action plans
that will allow nursing homes to offer equal pay as other health sectors . Also,
Gaudenz et al. 1557

the dissemination of best practice examples should support nursing homes in

developing and tailoring strategies to improve retention, facilitate open dis-
cussions between stakeholders about emerging trends and challenges, and
promote the creation of networks to encourage more efficient use of resources
(GDK & OdASanté, 2016).

Conclusion
Nursing homes are struggling to maintain high care quality in the face of
increased demand, difficulties in staff recruitment and staff retention, while
experiencing high turnover rates. As intention to leave is a powerful and
potentially useful predictor of turnover, awareness of related factors (work
environment factors and care worker outcomes) will allow nursing home
administrators to implement multilevel countermeasures, for example, inter-
ventions to modify their leadership styles and bolster care workers’ affective
organizational commitment.
The study findings indicated that, of the factors explored, leadership and
affective organizational commitment were most strongly related to intention
to leave. Although the cross-sectional design allows no causal inferences, it
can be suggested that supportive leadership fosters a sense of organizational
commitment in staff members, thereby reducing their intention to leave. In
Swiss nursing homes, leadership development interventions incorporating
the findings described above may decrease care workers’ intention to leave.

Acknowledgments
We acknowledge the contributions of all members of the Swiss Nursing Homes
Human Resources Project (SHURP) research team and express our thanks to the par-
ticipating nursing homes and the care workers for their time and collaboration.

Declaration of Conflicting Interests

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

Funding
The authors disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This study was funded by the Swiss
Health Observatory, Neuchâtel, Switzerland, the Nursing Science Foundation
Switzerland, Basel, Switzerland, the University of Basel’s Research Fund 2012,
Basel, Switzerland, the Swiss Alzheimer Association, Yverdon, Switzerland, and pri-
vate sponsors.
1558 Journal of Applied Gerontology 38(11)

References
Apkera, J., Proppa, K. M., & Zabava, W. S. (2009). Investigating the effect of nurse-
team communication on nurse turnover: Relationships among communication
processes, identification, and intent to leave. Health Communication, 24, 106-
114. doi:10.1080/10410230802676508
Banaszak-Holl, J., Castle, N. G., Lin, M. K., Shrivastwa, N., & Spreitzer, G.
(2013). The role of organizational culture in retaining nursing workforce. The
Gerontologist, 462-471. doi:10.1093/geront/gnt129
Banaszak-Holl, J., & Hines, M. A. (1996). Factors associated with nursing home staff
turnover. The Gerontologist, 36, 512-517. doi:10.1093/geront/36.4.512
Blomberg, K., James, I., & Kihlgren, A. (2013). Meanings over time of working as a nurse in
elderly care. Open Nursing Journal, 7, 107-113. doi:10.2174/1874434620130726005
Bundesamt für Statistik. (2007). Schweizerische Gesundheitsbefragung 2007—
Telefonischer und schriftlicher Fragebogen [Swiss health survey 2007—sur-
vey by phone and mail]. Retrieved from http://www.bfs.admin.ch/bfs/portal/de/
index/infothek/erhebungen__quellen/blank/blank/ess/03.Document.118255.pdf
Bundesamt für Statistik. (2012). Gesundheit von Betagten in Alters-und Pflegeheimen
[The health of older persons in nursing homes]. Retrieved from https://www.bfs.
admin.ch/bfs/de/home/statistiken/gesundheit/gesundheitszustand/alter.assetde-
tail.348093.html
Bundesamt für Statistik. (2015). Indikatoren der Pflegeheime 2013 [Indicators of
nursing homes 2013]. Retrieved from http://www.bfs.admin.ch/bfs/portal/de/
index/news/publikationen.Document.197245.pdf
Cammann, C., Fichman, M., Jenkins, D., & Klesh, J. (1979). The Michigan
Organizational Assessment Questionnaire. Ann Arbor: University of Michigan.
Castle, N. G., & Anderson, R. A. (2011). Caregiver staffing in nursing homes and
their influence on quality of care: Using dynamic panel estimation methods.
Medical Care, 49, 545-552. doi:10.1097/MLR.0b013e31820fbca9
Castle, N. G., Engberg, J., & Men, A. (2007). Nursing home staff turnover: Impact
on nursing home compare quality measures. The Gerontologist, 47, 650-661.
doi:10.1093/geront/47.5.650
Chenoweth, L., Jeon, Y. H., Merlyn, T., & Brodaty, H. (2010). A systematic review
of what factors attract and retain nurses in aged and dementia care. Journal of
Clinical Nursing, 19, 156-167. doi:10.1111/j.1365-2702.2009.02955.x
Choi, J., & Johantgen, M. (2012). The importance of supervision in retention of
CNAs. Research in Nursing & Health, 35, 187-199. doi:10.1002/nur.21461
Chu, C., Wodchis, W. P., & McGilton, K. S. (2014). Turnover of regulated nurses
in long-term care facilities. Journal of Nursing Management, 22, 553-562.
doi:10.1111/jonm.12031
Clausen, T., Tufte, P., & Borg, V. (2014). Why are they leaving? Causes of actual
turnover in the Danish eldercare services. Journal of Nursing Management, 22,
583-592. doi:10.1111/j.1365-2834.2012.01484.x
Cohen, A., & Golan, R. (2007). Predicting absenteeism and turnover intentions
by past absenteeism and work attitudes: An empirical examination of female
Gaudenz et al. 1559

employees in long term nursing care facilities. Career Development

International, 12, 416-432.
Cohen-Mansfield, J. (1989). Sources of satisfaction and stress in nursing home
caregivers: Preliminary results. Journal of Advanced Nursing, 14, 383-388.
doi:10.1111/j.1365-2648.1989.tb01545.x
Cohen-Mansfield, J. (1995). Stress in nursing home staff: A review and a theo-
retical model. Journal of Applied Gerontology, 14, 444-466. doi:10.1177/
073346489501400406
Cohen-Mansfield, J. (1997). Turnover among nursing home staff: A review. Nursing
Management, 28(5), 59-64.
Colombo, F., Llena-Nozal, A., Mercier, J., & Tjadens, F. (2011). Help wanted?
Providing and paying for long-term care. OECD Health Policy Studies, OECD
Publishing. doi:10.1787/9789264097759-en
Cowden, T., Cummings, G., & Profetto-McGrath, J. (2011). Leadership practices and
staff nurses’ intent to stay: A systematic review. Journal of Nursing Management,
19, 461-477. doi:10.1111/j.1365-2834.2011.01209.x
Cummings, G., Mallidou, A. A., Masaoud, E., Kumbamu, A., Schalm, C., Spence
Laschinger, H. K., & Estabrooks, C. A. (2014). On becoming a coach: A pilot
intervention study with managers in long-term care. Health Care Management
Review, 39, 198-209. doi:10.1097/HMR.0b013e318294e586
Curaviva.ch. (2010). Q&A-Katalog Pflegefinanzierung [Question & answer catalogue
health care financing]. Retrieved from http://www.curaviva.ch/files/OXTM11F/
Katalog-mit-Fragen-und-Antworten-zur-neuen-Pflegefinanzierung.pdf
Curaviva.ch. (2013). Massnahmen und Empfehlungen zur Steigerung der
Arbeitgeberattraktivität [Measures and recommendations to increase employer
attractiveness]. Bern, Switzerland: Author.
Decker, F. H., Harris-Kojetin, L. D., & Bercovitz, A. (2009). Intrinsic job satisfac-
tion, overall satisfaction, and intention to leave the job among nursing assistants
in nursing homes. The Gerontologist, 49, 596-610. doi:10.1093/geront/gnp051
Dill, D. M., Keefe, J. M., & McGrath, D. S. (2012). The influence of intrinsic and
extrinsic job values on turnover intention among continuing care assistants in
Nova Scotia. Home Health Care Services Quarterly, 31, 111-129. doi:10.1080/0
1621424.2012.681526
Donoghue, C., & Castle, N. G. (2009). Leadership styles of nursing home administra-
tors and their association with staff turnover. The Gerontologist, 49, 166-174.
doi:10.1093/geront/gnp021
Erenstein, C. F., & McCaffrey, R. (2007). How healthcare work environments influ-
ence nurse retention. Holistic Nursing Practice, 21, 303-307. doi:10.1097/01.
HNP.0000298615.25222.de
Felfe, J., Six, B., Schmook, R., & Knorz, C. (2010). Fragebogen zur Erfassung von
affektivem, kalkulatorischem und normativem Commitment gegenüber der
Organisation, dem Beruf/der Tätigkeit und der Beschäftigungsform (COBB)
[Questionnaire for the assessment of affective, calculatory and normative com-
mitment to the organization, the profession/activity and employment (COBB)].
1560 Journal of Applied Gerontology 38(11)

In A. Glöckner-Rist (Ed.), Zusammenstellung sozialwissenschaftlicher Items und

Skalen. ZIS Version 14.00. Bonn, Germany: GESIS.
Field, A., Miles, J., & Field, Z. (2012). Discovering statistics using R. London,
England: SAGE.
Firth, L., Mellor, D. J., Moore, K. A., & Loquet, C. (2004). How can managers reduce
employee intention to quit? Journal of Managerial Psychology, 19, 170-187.
doi:10.1108/02683940410526127
Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An intro-
duction to theory and research. Reading, MA: Addison-Wesley.
Francis-Felsen, L. C., Coward, R. T., Hogan, T. L., Duncan, R. P., Hilker, M. A., &
Horne, C. (1996). Factors influencing intentions of nursing personnel to leave
employment in long-term care settings. Journal of Applied Gerontology, 15, 450-
470. doi:10.1177/073346489601500404
Galletta, M., Portoghese, I., Penna, M. P., Battistelli, A., & Saiani, L. (2011). Turnover
intention among Italian nurses: The moderating roles of supervisor support and
organizational support. Nursing & Health Sciences, 13, 184-191. doi:10.1111/
j.1442-2018.2011.00596.x
Gardner, J. K., Thomas-Hawkins, C., Fogg, L., & Latham, C. E. (2007). The rela-
tionships between nurses’ perceptions of the hemodialysis unit work environment
and nurse turnover, patient satisfaction, and hospitalizations. Nephrology Nursing
Journal: Journal of the American Nephrology Nurses’ Association, 34, 271-281.
Graf, E., Cignacco, E., Zimmermann, K., & Zúñiga, F. (2016). Affective organi-
zational commitment in Swiss nursing homes: A cross-sectional study. The
Gerontologist, 56, 1124-1137. doi:10.1093/geront/gnv053
Hanh, N. (2013). A literature review on nursing turnover and its financial implica-
tions (Master’s thesis). University of Pittsburgh, PA.
Hayes, L. J., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F., . .
.North, N. (2012). Nurse turnover: A literature review—An update. International
Journal of Nursing Studies, 49, 887-905. doi:10.1016/j.ijnurstu.2011.10.001
Jaccard Ruedin, H., & Weaver, F. (2009). Ageing workforce in an ageing society:
Wieviele health professionals braucht das Schweizer Gesundheitssystem bis 2030?
[Ageing workforce in an ageing society: how many health professionals does the
Swiss health system need until 2030?]. Neuchâtel: Swiss Health Observatory
(Obsan). Retrieved from http://www.obsan.admin.ch/de/publikationen/ageing-
workforce-ageing-society
Jeon, Y. H., Simpson, J. M., Li, Z., Cunich, M. M., Thomas, T. H., Chenoweth, L., &
Kendig, H. L. (2015). Cluster randomized controlled trial of an aged care specific
leadership and management program to improve work environment, staff turn-
over, and care quality. Journal of the American Medical Directors Association,
16, 629e619-629e628. doi:10.1016/j.jamda.2015.04.005
Karantzas, G. C., Mellor, D., McCabe, M. P., Davison, T. E., Beaton, P., & Mrkic, D.
(2012). Intentions to quit work among care staff working in the aged care sector.
The Gerontologist, 52, 506-516. doi:10.1093/geront/gnr161
Karsh, B., Booske, B. C., & Sainfort, F. (2005). Job and organizational determinants
of nursing home employee commitment, job satisfaction and intent to turnover.
Ergonomics, 48, 1260-1281. doi:10.1080/00140130500197195
Gaudenz et al. 1561

Keller, M. (2006, March). So lassen sich Fehlzeiten wirksam reduzieren [This is how
absences at work can be reduced effectively]. Kmu-magazin. Available from
http://gesundheitsfoerderung.ch
Künzi, K., & Schär Moser, M. (2002). Die Arbeitssituation im Pflegebereich im
Kanton Bern [The working situation of the nursing personnel in the canton of
Bern]. Bern, Switzerland: Gesundheits- und Fürsorgedirektion des Kantons Bern.
Kuo, H. T., Lin, K. C., & Li, I. C. (2014). The mediating effects of job satisfaction
on turnover intention for long-term care nurses in Taiwan. Journal of Nursing
Management, 22, 225-233. doi:10.1111/jonm.12044
Lake, E. T. (2002). Development of the Practice Environment Scale of the nursing
work index. Research in Nursing & Health, 25, 176-188. doi:10.1002/nur.10032
Lapane, K. L., & Hughes, C. M. (2007). Considering the employee point of view:
Perceptions of job satisfaction and stress among nursing staff in nursing homes.
Journal of the American Medical Directors Association, 8(1), 8-13. doi:10.1016/j.
jamda.2006.05.010
Letvak, S., Ruhm, C. J., & Gupta, S. N. (2012). Nurses’ presenteeism and its effects
on self-reported quality of care and costs. American Journal of Nursing, 112(2),
30-38. doi:10.1097/01.NAJ.0000411176.15696.f9
LeVasseur, S. A., Wang, C. Y., Mathews, B., & Boland, M. (2009). Generational
differences in registered nurse turnover. Policy, Politics, & Nursing Practice, 10,
212-223. doi:10.1177/1527154409356477
Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout.
Journal of Occupational Behaviour, 2, 99-113. doi:10.1002/job.4030020205
McGilton, K. S., Boscart, V. M., Brown, M., & Bowers, B. (2014). Making tradeoffs
between the reasons to leave and reasons to stay employed in long-term care
homes: Perspectives of licensed nursing staff. International Journal of Nursing
Studies, 51, 917-926. doi:10.1016/j.ijnurstu.2013.10.015
McGilton, K. S., Tourangeau, A., Kavcic, C., & Wodchis, W. P. (2013). Determinants
of regulated nurses’ intention to stay in long-term care homes. Journal of Nursing
Management, 21, 771-781. doi:10.1111/jonm.12130
Mobley, W., Horner, S. O., & Hollingsworth, A. T. (1978). An evaluation of precur-
sors of hospital employee turnover. Journal of Applied Psychology, 62, 237-240.
doi:10.1037/0021-9010.63.4.408
Moseley, A., Jeffers, L., & Paterson, J. (2008). The retention of the older nursing
workforce: A literature review exploring factors which influence the retention
and turnover of older nurses. Contemporary Nurse, 30, 46-56.
Mowday, R. T., Steers, R. M., & Porter, L. W. (1979). The measurement of organizational
commitment. Journal of Vocational Behavior, 14, 224-247. doi:10.1016/0001-
8791(79)90072-1
Organisation for Economic Co-Operation and Development & World Health Organization.
(2011). OECD Reviews of Health Systems: Switzerland 2011. Swiss Federal Office
of Public Health. Retrieved from http://dx.doi.org/10.1787/9789264120914-en
Parsons, S. K., Simmons, W. P., Penn, K., & Furlough, M. (2003). Determinants of
satisfaction and turnover among nursing assistants: The results of a statewide
survey. Journal of Gerontological Nursing, 29, 51-58. doi:10.3928/0098-9134-
20030301-11
1562 Journal of Applied Gerontology 38(11)

Prentice, D., & Black, M. (2007). Coming and staying: A qualitative exploration of
registered nurses’experiences working in nursing homes. International Journal
of Older People Nursing, 2, 198-203. doi:10.1111/j.1748-3743.2007.00072.x
Rondeau, K. V., Williams, E. S., & Wagar, T. H. (2008). Turnover and vacancy
rates for registered nurses: Do local labor market factors matter? Health Care
Management Review, 33, 69-78. doi:10.1097/01.HMR.0000304494.87898.bc
Rosen, J., Stiehl, E. M., Mittal, V., & Leana, C. R. (2011). Stayers, leavers, and
switchers among certified nursing assistants in nursing homes: A longitudinal
investigation of turnover intent, staff retention, and turnover. The Gerontologist,
51, 597-609. doi:10.1093/geront/gnr025
Schaefer, J., & Moos, R. (1996). Effects of work stressors and work climate on long-
term care staff’s job morale and functioning. Research in Nursing & Health, 19,
63-73. doi:10.1002/(SICI)1098-240X(199602)19:1<63::AID-NUR7>3.0.CO;2-J
Schweizerische Konferenz der kantonalen Gesundheitsdirektorinnen und-direktoren,
OdASanté. (2016). Nationaler Versorgungsbericht für die Gesundheitsberufe
2016 [National health service report for health professions 2016]. Retrieved from
http://www.gdk-cds.ch/fileadmin/docs/public/gdk/themen/gesundheitsberufe/
nichtun._gesundheitsberufe/versorgungsbericht/versorgungsbericht_2016-de-
v2.2-web.pdf
Schwendimann, R., Zúñiga, F., Ausserhofer, D., Schubert, M., Engberg, S., & de
Geest, S. (2014). Swiss Nursing Homes Human Resources Project (SHURP):
Protocol of an observational study. Journal of Advanced Nursing, 70, 915-926.
doi:10.1111/jan.12253
Sexton, J. B., Helmreich, R. L., Neilands, T. B., Rowan, K., Vella, K., Boyden, J., . .
.Thomas, E. J. (2006). The Safety Attitudes Questionnaire: Psychometric proper-
ties, benchmarking data, and emerging research. BMC Health Service Research,
6, Article 44. doi:10.1186/1472-6963-6-44
Steel, R. P., & Ovalle, N. K. (1984). A review and meta-analysis of research on the
relationship between behavioral intentions and employee turnover. Journal of
Applied Psychology, 69, 673-686. doi:10.1037//0021-9010.69.4.673
Stewart, N. J., D’Arcy, C., Kosteniuk, J., Andrews, M. E., Morgan, D., Forbes, D., . .
.Pitblado, J. R. (2011). Moving on? Predictors of intent to leave among rural and
remote RNs in Canada. The Journal of Rural Health, 27, 103-113. doi:10.1111/
j.1748-0361.2010.00308.x
Takase, M. (2010). A concept analysis of turnover intention: Implications for nursing
management. Collegian, 17, 3-12. doi:10.1016/j.colegn.2009.05.001
Taylor, C., & Pillemer, K. (2009). Using affect to understand employee turnover:
A context-specific application of a theory of social exchange. Sociological
Perspectives, 52, 481-504. doi:10.1525/sop.2009.52.4.481
Tourangeau, A. E., Cranley, L., Spence Laschinger, H. K., & Pachis, J. (2010).
Relationships among leadership practices, work environments, staff communica-
tion and outcomes in long-term care. Journal of Nursing Management, 18, 1060-
1072. doi:10.1111/j.1365-2834.2010.01125.x
Gaudenz et al. 1563

Tummers, L. G., Groeneveld, S. M., & Lankhaar, M. (2013). Why do nurses intend
to leave their organization? A large-scale analysis in long-term care. Journal of
Advanced Nursing, 69, 2826-2838. doi:10.1111/jan.12249
Vogelsmeier, A. A., Farrah, S. J., Roam, A., & Ott, L. (2010). Evaluation of a leader-
ship development academy for RNs in long-term care. Nursing Administration
Quarterly, 34, 122-129. doi:10.1097/NAQ.0b013e3181d91778
West, C. P., Dyrbye, L. N., Sloan, J. A., & Shanafelt, T. D. (2009). Single item
measures of emotional exhaustion and depersonalization are useful for assess-
ing burnout in medical professionals. Journal of General Internal Medicine, 24,
1318-1321. doi:10.1007/s11606-009-1129-z
Westphal, A., & Gmür, M. (2009). Organisationales commitment und seine
Einflussfaktoren: Eine qualitative Metaanalyse. Journal Für Betriebswirtschaft,
59, 201-229. doi:10.1007/s11301-009-0054-x
Zhang, Y., Punnett, L., & Gore, R. (2014). Relationships aamong employees’ work-
ing conditions, mental health, and intention to leave in nursing homes. Journal of
Applied Gerontology, 33, 6-23. doi:10.1177/0733464812443085