Improving nurse retention is a continuous challenge for most nurse managers and administrators. Clarifying the role that locus of control plays in registered nurse (RN) job embeddedness and self-efficacy provides a framework for the nurse manager seeking retention best practices. Personality traits, such as internal locus of control have been linked to people’s ability to successfully participate in social networking (Gazit et al., 2020; Peltokorpi et al. 2017) and high perceived levels of self-efficacy (Açıkgöz Çepni, S., & Kitiş, 2017; Bujnowska-Fedak et al., 2019). Internal locus of control has also been linked to job satisfaction (Shahan, 2018) and organizational job embeddedness (Peltokorpi et al., 2017). The reasons why people remain in a current job, even if they are not completely satisfied with the job, form the main constructs of the job embeddedness theory. The purpose of this topical review is to provoke an awareness of the significant role that locus of control may have toward the job embeddedness and self-efficacy of nurses.

Review of Literature

The search terms (including Booleans “or”/”and”): locus of control, job embeddedness, self-efficacy, and retention guided an EBSCO literature search. Peer-reviewed, scholarly publications published between 2010 – 2020, written in English, and related to nursing administration were included. The initial search yielded 16 relevant articles included in this review. Upon examination of the articles, it was noted researchers referred to several seminal studies. The search was expanded to include the years 1979 through 2020 to capture these publications. The expanded search yielded five articles with relevant theories and definitions applying to the current review. Additionally, one website was included to illustrate workforce retention statistics. Of note, none of the studies addressed the effect of cultural differences on locus of control perceptions. Studies from the USA and abroad were included. Each article was reviewed for reliability, validity, appropriateness for project inclusion.

Nurse Retention
The projected shortage of registered nurses (RN), specifically related to retiring baby boomers, has been the topic of healthcare concern for decades. Nursing Solutions Incorporated (NSI) collected statistical data related to nurse retention from 164 hospitals in 42 states in the 2020 NSI National Health Care Retention & RN Staffing Report (2020). Based on this report, the Bureau of Labor Statistics (BLS) projects an increasing need for an additional 200,000 RNs per year over the next six years (NSI, 2020). Hospitals that risk financial losses due to patient safety concerns opt to engage travel nurses at an average increased cost of $70K annually for each RN rather than closing patient beds (NSI, 2020). Compounding the issue, since 2015, RN vacancy rates hover at 9% with an average turnover rate of 82%. At an average turnover cost of $44,375 for a bedside RN, a hospital potentially loses $4.9 million per year alone due to RN turnover. Although 83.3% of hospitals viewed RN retention as a top priority, only 39.4% of these hospitals have retention strategies in place (NSI, 2020). Data and projections critically demonstrate the necessity for nurse retention. A focus on reasons why RNs remain at the bedside could help manage this crisis. A shift in managerial focus from negative (what are we doing wrong) to positive (what can we do to make it even better) can provide ideas from organizational and community perspectives for retention strategies that will retain RNs.

Job Embeddedness
The Job Embeddedness Theory was developed by Mitchell et al to examine job retention.The Job Embeddedness Theory was developed by Mitchell et al (2001) to examine job retention. The theory is based on two dimensions (organizational and community) with three constructs (fit to role, links, and sacrifices when leaving). The first construct, fit to role, describes the employee’s compatibility with the company and community, such as personal values, morals, and goals. The second construct, links, ties the person to the organization through matters such as resources, shared decision-making and committees, and to the community, such as children’s activities and community involvement. The third construct, sacrifices when leaving, describes the employee’s understanding of sacrifices when the decision is made to leave the job, such as compromising retirement funds, loss of job incentives, selling a house and moving away from the community (Mitchell et al, 2001). These elements tie together to define the depth of commitment the person has to the job and intent to stay.

Organizational leaders in nursing could use this theory to examine employee job embeddedness and how it impacts RN retention. Porter et al. (2019) demonstrated in a study among nurses that high levels of organizational job embeddedness dampened the chances that informal job searches would lead to voluntary turnover. Moreover, Hopson et al. (2018) identified specific factors that contribute to job embeddedness of nurses working in acute care facilities. Five themes emerged from interviews: “(a) the professional nurse, (b) building lasting relationships, (c) the power of family and community, (d) personal resiliency, and the desire for improved conditions” (p. 34). Respondents commented on the value that they place on professional growth and involvement in committees. Teamwork and the special bonds that the nurses form at the hospital, but also within their communities, specifically family bonds, are major contributors to job embeddedness. Personal resilience was a controversial subject with varying responses. For some nurses, making a significant change was easy to do, while others viewed it as life-altering. The desire for improved conditions was mostly aimed at pay discrepancies and schedule flexibility (Hopson et al, 2018). Educational and research efforts examining this topic may be a worthwhile endeavor for nurse leaders to help address the issue of RN retention.

Self-Efficacy
Self-efficacy is the belief in one’s own capability to succeed in specific situations (Bandura, 1977). Bandura identified four key elements of self-efficacy (a) mastery of skills that will improve confidence, (b) role models that are succeeding raises confidence, (c) verbal conformation from influential people, and (d) emotional and psychological influences where positive emotions will boost confidence in own skills (1994). Bandura posited that people with high levels of self-efficacy are applying three different cognitive motivational techniques to influence themselves: (a) casual attributions, (b) outcome expectancies, and (c) cognized goals. People who regard themselves as highly efficacious contribute this ability to personal efforts, goal orientation, and a desire to succeed and overcome challenges (Bandura, 1994).

Nurses are often involved in situations that require crucial decision making and quick action activities.Nurses are often involved in situations that require crucial decision making and quick action activities. Self-efficacy has been related to job performance (Bandura, 1982; Guo et al. 2020; Kurniawan et al., 2019), organizational commitment, organizational justice and job satisfaction (Chegini et al., 2019), academic success (Bartimote-Aufflick et al., 2016; Hilliger et al., 2020; Xie et al., 2019), personality traits such as neuroticism, conscientiousness and openness (Bahçekapili & Karaman, 2020; Baykal & Yildirim, 2020) and internal locus of control (Kim & Lee, 2018; Türk-Kurtça & Kocatürk, 2020; Uzun & Karatas, 2020).

Locus of Control
Locus of control is an individual’s perception of control over causes for success and failure.Locus of control is an individual’s perception of control over causes for success and failure. Locus of control is generally divided into the categories of external and internal. Individuals with an external locus of control believe that their surroundings control the events of their lives rather than anything that they personally do (Liang et al., 2019). Rather than being in control, they see themselves as victims of external forces in their environments (Liang et al., 2019; Ng & Feldman, 2011; Rotter, 1975; Valentine et al., 2019). Conversely, individuals who have an internal locus of control attribute themselves as the causes of events and believe in their control over these events and their environment (Liang et al., 2019; Ng & Feldman, 2011; Rotter, 1975; Valentine et al., 2019). People with internal locus of control have a perceived job security which produces confidence in their actions (Liang et al., 2019). Leaders who are aware of the impact of locus of control on subordinates’ reactions to negative and positive stimuli may be able to influence performance. Individual responses to a negative emotional stimulus from a leader vary significantly between workers with external locus of control compared to those with internal locus of control (Li et al, 2019). Workers with internal locus of control believe that the environment responds to their actions and that they are in control of what happens. They take responsibility for the negative emotion and show efforts to improve from within. A nurse with an internal locus of control might be more apt to see problems as challenges which can be controlled by specific actions. In contrast, a nurse with stronger external locus of control tendencies would see the problem as someone else’s fault and be less likely to accept ownership and responsibility for finding a solution.

Changing Locus of Control Orientation
Locus of control can be changed based on the Social Learning Theory, but the change depends on various determinants (Rotter, 1975). Experiences such as similar situations, expectancies of reinforcement of behavior in that situation, and the current psychological situation that the person perceives influence locus of control (Rotter, 1975). For nurses, repeated opportunities to practice skill development may help to shift their orientation from external to internal.

In a study among Master of Business Administration (MBA) students, researchers demonstrated that a person’s locus of control orientation can change with meaningful education (Thompson et al., 2020). Emotional intelligence, self-efficacy, and internal locus of control were measured before the start of a one-year program and again after completion of the program. Participants demonstrated significant improvement in all three concepts. More research is necessary to identify which components of the MBA program contributed to the psychological improvements of these students (Thompson et al., 2020). This finding has significant relevance to nursing management education. Components from the MBA program could be incorporated into nursing leadership courses to increase internal locus of control perceptions among nurse leaders, and ultimately, bedside nurses.

Linking the Concepts

Locus of Control and Job Embeddedness
Locus of control is related to the person’s degree of job embeddedness as a factor of organizational commitment and identification with the community (Ng & Feldman, 2011) Internal locus of control is an antecedent for organizational job embeddedness (Ng & Feldman, 2011). A positive relationship exists between internal locus of control and social networking behavior and between social networking behavior and organizational job embeddedness (Ng & Feldman, 2011). These findings align with the Job Embeddedness Theory (Mitchell et al, 2001). For example, employees with a high internal locus of control can negotiate deals for unique contracts which improve the organizational fit concept. Secondly, these employees are more effective in developing social network resources which will help them to ensure future benefits in their current companies, improving the organizational link concept. Lastly, this network will strengthen the sacrifice construct, by making the risk of leaving more of a sacrifice than the employee is willing to undertake, securing the organizational sacrifice concept. This study demonstrates that internal locus of control empowers employees to be more likely to acquire and retain valuable resources at work which enhances their sense of control over their environment and decision making, and positively impacts job embeddedness (Mitchell et al, 2001).

Locus of Control and Self-Efficacy
In a study examining the relationships between self-efficacy, work locus of control, coping skills, caring efficacy, and job satisfaction of registered nurses, Reid (2012) demonstrated that general self-efficacy had a significant positive correlation with caring efficacy and a negative correlation between work locus of control and general self-efficacy. Twenty four percent of the variation in caring efficacy could be accounted for by general self-efficacy, work locus of control and practice environment, thus theoretically linking self-efficacy and locus of control. Note that this researcher has tested participants for work locus of control, not internal or external locus of control (Reid, 2012), yet these findings add information regarding how these concepts work together for some people.

People with internal locus of control will be more likely to find ways of dealing with work issues that create higher levels of involvement in the organization. The relational premise is that self-efficacy is expected to occur when a person has an internal locus of control and feels control over, and a commitment to, their decisions. If an internal locus of control provides the basis for linking decisions to something within the individual, then one must consider how confidence in internal self-directed actions can influence one’s decision making. Employees with a firm confidence in their own capabilities and that have strong organizational and community ties will most likely be equipped to face work stressors such as decision-making, succeeding during changes, and leading teams effectively. Employees with a strong sense of internal locus of control create resources and links to improve their social networking and strengthen professional ties. Employees with internal locus of control may demonstrate increased job embeddedness and high levels of self-efficacy.

Self-Efficacy and Job Embeddedness
Self-efficacy refers to a person’s belief in own capability to perform in specific situations while self-leadership is a person’s ability to strategize actions to motivate oneself to succeed in a leadership role. From this perspective, an assumption that self-efficacy is an antecedent for self-leadership makes sense. In a study to evaluate the mediating effect of job embeddedness on self-efficacy and self-leadership, researchers reported significant direct relationships between self-efficacy and job embeddedness with an effect size of 0.359 (p = .018), and self-leadership and job embeddedness with an effect size of 0.580 (p = .013). The effect size between self-efficacy and self-leadership increased significantly by 0.208 when job embeddedness was added as a mediator 0.638 (p = .008) (Kim H.& Kim K., 2019).

In a study where the relationship between job embeddedness on nurses’ self-efficacy during changes at work was explored, the researchers found that nurses with higher organizational embeddedness reported a higher perceived self-efficacy (β = .42, p < .01) (Vardaman et al, 2020). 

Those with high self-efficacy, confidence in their abilities to succeed, a tendency to take control of their environment, and responsibility for their decisions experience organizational commitment and organizational justice. Involvement in organizational activities and a personal fit with organizational values aligns with the fit and link concepts of Job Embeddedness Theory (Mitchell et al., 2011).

Proposed Conceptual Model

Locus of control, job embeddedness, and self-efficacy are critical factors in the future of nursing care delivery and retention of nurses in US healthcare. Relationships between internal locus of control, self-efficacy, and job embeddedness in the literature point to these conclusions: a) Internal locus of control is positively related to organizational job embeddedness, b) Work locus of control is negatively associated with self-efficacy, and c) Job embeddedness and self-efficacy are positively related. The proposed conceptual model offers the following hypothesis: a) Internal locus of control is positively related to organizational job embeddedness, b) Internal locus of control is positively associated with self-efficacy, and c) Job embeddedness and self-efficacy are positively related with internal locus of control as a mediator that will result in increased nurse retention rates.

Figure 1.

Implications for Practice and Research

The proposed model could guide organizational leaders to implement strategies focused on personal development (self-efficacy and internal locus of control) and a practice environment that fosters organizational job embeddedness. Nurses are typically hired based on academic performance, clinical interests, and nursing experience; they are not commonly evaluated on locus of control perceptions. Thus, locus of control orientations of employees will vary in any work environment. Early testing, upon interviewing and hiring, may ensure a well-balanced unit with optimal opportunities for managers to tailor communication, education, and performance evaluations. Nursing leaders have been searching for answers to retain employees. Critical attention to locus of control tendencies might provide the pathway to progress in the matters Lassonde (2014) demonstrated that students with higher levels of internal locus of control succeed personally and professionally. Increased awareness of locus of control perceptions and training during orientation might increase performance and retention of students. The same principal applied to hiring and orientation of nurses can potentially produce similar results.

Research to explore professional training opportunities, with a focus on shifting locus of control perceptions in work environments, may open doors for leaders to improve work relationships, professional conduct, and retention. The different components of an educational program to convert external locus of control to more internal locus of control tendencies, deserve further investigation to determine an action plan. A comparison study between nursing and business administration students might offer valuable insight into the preparation needs of potential leaders. Cultural diversity should be considered when the proposed model is applied. Research to account for the effect of cultural differences on locus of control will broaden practical application strategies of the model.

An employee’s perception of the work environment can significantly impact decision making.An employee’s perception of the work environment can significantly impact decision making. An environment where nurses are inspired to engage in various roles and are involved in work opportunities will improve retention rates. This is consistent with Reid’s (2012) findings that nurses believe that they should be able to make decisions about their practices to function effectively. Outcomes of decisions might be directly related to a person’s perception of causes for life events. Shared governance committees provide nurses with means to voice opinions and make decisions that can impact their work environments significantly. The committees also provide an environment for nurses from both locus of control spectrums to balance their perceptions for the advancement of the company and above all, share decision-making and accountability for those decisions.

Nurses with internal locus of control have a sense of self-efficacy which enables them to value choice in decision making. They benefit from advanced job opportunities and greater responsibilities. Conversely, nurses with external locus of control may tend to procrastinate and may benefit from one-on-one mentorship. Nurses need ongoing, professional development programs to enhance internal locus of control perceptions during initial and on-going employment. Managers may benefit from exploring employee locus of control to customize continuous education and evaluations making feedback more meaningful and improving retention.

Jong Kyung, et al. (2014) found that improvement in hospital support for the work and patient care environments, as well as improvement in manager leadership skills, will reduce burnout and increase job embeddedness. Encouragement and positive feedback, particularly when nurses with external locus of control step out of their comfort zone and take responsibility for choices or offer input into decisions, will reinforce the benefits of adopting a more internal focus for decisions and accountability. Strategies to increase levels of internal locus of control through continuous education and positive reinforcement may result in higher levels of employee job embeddedness, self-efficacy, and retention. Longitudinal studies examining these relationships would offer support for intervention development.

Conclusion

Nursing has never been more challenged than in today’s healthcare environment that is overwhelmed by pressures to adopt increasingly complex technologies, address public skepticism about ethical decision-making processes, and deal with fluctuations in the availability of a committed workforce. Organizational leaders strive to improve employee retention as a quality-improvement and cost-containment strategy. One solution is to create an environment where embedded employees can achieve their highest levels of self-actualization and happiness. When employees find a personal fit within their jobs, they can benefit from linking personal and organizational resources. They demonstrate compatible personal values with those of the organization by making decisions aligning with employer expectations. Managers who focus on employee locus of control and tailor continuous education programs and staff evaluations to meet the specific needs of their employees may create a work environment where each person can grow personally and professionally. This win-win solution allows empowered employees to experience greater levels of self-efficacy, make decisions to the benefit of the organization and patients, and become embedded in their jobs, thus leading to organizational retention.

Author

Zelda Gibbs, Ph.D., RN
Email: zeldagibbs@vetcarehosp.com
ORCID ID: 0000-0001-6918-4360

Dr. Gibbs completed her Bachelor in the Science of Nursing (BSN) degree in 2010, Masters in the Science of Nursing (MSN) Executive Track degree in 2012, and her Ph.D. in nursing at The University of Texas at Tyler in 2015. Her clinical and research activities examine the topics of registered nurse retention and the role of health care assistants in patient care. Currently, she is teaching in several undergraduate and graduate nursing progams.