Predictors of Hospital Nurse Managers’ Retention: Impact of Executive Leadership Behaviors,

Organizational Commitment and Role Stressors

Deborah K. Zastocki, RN, DNP

President, Chilton Medical Center

VP, Atlantic Health System

12th Annual ONE NJ Research Conference Day

June 13, 2014

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ObjectivesObjectives

Identify factors related to nurse manager retention by measuring selected demographic factors and perceived nurse executive leadership behaviors.

Compare nurse manager prioritized stressors and organizational factors with the results of a systematic review of the literature to identify best practices to support nurse managers in being successful and satisfied in their role.

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Background & Significance Background & Significance Importance of nurse managers in the

acute care environment

Nurse managers have been described as the Chief Retention Officers

Nurse managers are expected to sustain a viable, productive workforce & to provide quality, cost-effective patient care (Parsons & Stonestreet, 2003)

For chief nursing executives to provide organizational leadership and direction for patient care, nursing managers are essential

Management interventions to evaluate hospital activities and address the issues

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Vacancy rates for nurse managers were over 8% in an AONE (2002) study

Stressors in the workplace are increasingly identified as a factor in turnover

Nurse manager age demographics are similar to the average age of the staff nurse

Retention and encouraging recruitment into the role of manager is a key initiative in the next few years ( Parsons & Stonestreet, 2003)

Background & SignificanceBackground & Significance (continued)(continued)

Study Goals & ObjectivesStudy Goals & Objectives

Purpose: Identify predictors of nurse manager intent to turnover through understanding the thoughts and opinions of nurse managers as a means of changing the environment.

Objectives / Aims:– Examine the perceptions of nurse managers regarding the

leadership behaviors of the nurse executive in the acute-care setting;

– Examine the association between nurse managers’ organizational commitment and intention to stay; and,

– Examine the associations between selected organizational variables and nurse managers reported intent to stay.

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Research HypothesesResearch Hypotheses

1. Nurse manager organizational commitment will be positively related to perceived organizational citizenship altruism behaviors of the nurse executive.

2. Nurse manager organizational commitment will be positively related to perceived nurse executive leadership behaviors.

3. Nurse manager affective organizational commitment will be related to intent to stay.

4. Nurse manager self-reported high role stress levels will be negatively related to intent to stay.

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Conceptual Framework of Factors Impacting Conceptual Framework of Factors Impacting Nurse Managers’ Intent to TurnoverNurse Managers’ Intent to Turnover

NMStressors

Executive Leadership Behaviors

NMOrganizational Commitment

NMIntent to Stay

NM Unmet Needs

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Design & MethodologyDesign & Methodology

Survey of Acute Care Nurse Managers– Target Audience

Survey Instrument: Pre-validated MeasuresOrganizational commitment using Meyer and Allen three-component model

Leadership using LEAP Leadership Behaviors and Organizational Climate Survey-leadership scale and Organizational Citizenship Behavior-altruism scale

Intent to stay using Michigan Organizational Assessment Questionnaire (3 questions on intent turnover)

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Measurement/InstrumentMeasurement/Instrument

Organizational commitment measurement by Meyer & Allen

3 – Component Model (Meyer & Allen, 1997)

- Affective commitment – Reliability .82

- Normative commitment – Reliability .73

- Continuance commitment – Reliability .76

Leadership behaviors measured by LEAP Leadership Behaviors and Organizational Climate Survey-leadership subscale (Hollinger-Smith, Lindeman, Leary & Ortigara, 2002)

- Reliability .94

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Measurement/InstrumentationMeasurement/Instrumentation(continued)(continued)

Organizational Citizenship Behavior altruism scale (Smith, Organ, & Near, 1983)

- Reliability .72 to .91

Intent to stay measured by Michigan Organizational Assessment Questionnaire (Cammann, Fichman, Jenkins, Klesh, 1983).

- Internal Reliability .83

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Design & Methodology Design & Methodology

Survey Administration– Conducted using a third party web-based survey– Survey electronically distributed to all Chief

Nursing Officers at NJ acute care hospitals and all members of NJ ONE

– Data collection processInitial email November 6, 2007, follow up emails December 16, 2007 and January 11, 2008Personal phone calls to all CNE’s of acute care hospitals

– TimeframeInitial design: November 6, 2007 – January 12, 2008

Extended survey timeline to March 4, 2008 due to website issues - vendor changed January, 11, 2008 1111

Organizational Commitment Organizational Commitment Conceptual FrameworkConceptual Framework

Meyer, J., & Allen, N. (1997). Commitment in the Workplace: Theory, Research, and Application. Thousand Oaks, Ca.: Sage Publisher.

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Organizational Commitment Organizational Commitment DefinitionDefinition

A belief in and acceptance of organizational goals and values

The willingness to exert effort towards organizational goal accomplishment

A strong desire to maintain organizational membership (Mowday, et al., 1979)

Employee’s relationship with the organization with the potential implications for decisions to stay (Meyer & Allen, 1991).

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Organizational Commitment Organizational Commitment as a Conceptual Frameworkas a Conceptual Framework

Commitment- psychological and behavioral components

Mathieu and Zajac’s (1990) meta-analysis supports that OC is conceptually and empirically different from other forms of work commitment, and that turnover processes have had the most theoretical and methodological rigor in terms of employee OC and behavior

Studied with nursing populations

Multidimensional aspect

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3-Component Model 3-Component Model of Organizational Commitmentof Organizational Commitment

Psychological state with three separate components:

– Affective: emotional attachment to the organization-the person ”wants to” stay: need for achievement, affiliation, autonomy and compatibility with the work environment; decentralization of decision-making; job-related characteristics such as role clarity and feelings of importance; and work experiences like competence and comfort needs.

3-Component Model 3-Component Model of Organizational Commitmentof Organizational Commitment

(continued)(continued)

Normative: repay the debt-the person feels they “ought to” stay (Meyer & Allen, 1991) : pressure from family, culture or society; and rewards received in advance such as tuition payment or specialty training (Meyer & Allen, 1991, 1997,; Meyer & Herscovitch, 2001).

Continuance: high cost of losing organizational membership-the person “has to” stay (Becker’s 1960 side-bet theory): number and magnitude of investments and length of tenure (pension); and availability and number of options and attractiveness of alternatives.

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LeadershipLeadershipLeadership research has examined the correlation between leadership behavior and numerous indicators of leadership effectiveness

The results are conflicted about which behaviors are relevant and meaningful

Leadership models suggest newer labels of earlier themes: power sharing, mutual trust, & participative decision making (Yukl, 1989)

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LeadershipLeadership (continued)(continued)

Commitment to the supervisor and commitment to the profession exert a positive influence on organizational commitment which reduces intention to resign (Boshoff & Mels, 2000)

Bennis (2007) portrayed leadership as the triad of leader, follower, and a common goal.

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LEAP study identified 4 behaviors that differentiate effective nurse leadership:

– Pay attention to subordinates– Encourage idea exchanges– Encourage staff to give their best – Set an example

LEAP instrument derived from the Survey of Organizations II (Taylor, 1972) focused on mentoring, consulting, rewarding, and resolving conflict situations (Hollinger-Smith, Lindeman, Leary & Ortigara, 2002)

LeadershipLeadership (continued)(continued)

Organizational Citizenship Organizational Citizenship Behavior-DefinitionBehavior-Definition

Discretionary individual behavior not recognized by a formal reward system which promotes efficient and effective organizational functioning (Organ, Podsakoff, & MacKenzie, 2006)

Altruism or helping-a type of OCB that can be aimed at a specific individual

Affective commitment is related to altruism (Organ & Ryan, 1995)

2020

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Intent to StayIntent to Stay

Michigan Organizational Assessment Questionnaire-3 questions on intent to stay

Additional questions about retirement from Dr. McIntosh:

– At what age do you plan to retire?

– Do you plan to continue working in nursing after retirement?

Study ModelStudy Model

Nurse Manager Personal Characteristics:

age, gender, education professional tenure, positional tenure, organizational tenure, perceived personal competence, intention to seek promotion, intention to transfer

Organizational Characteristics:

bedside, location, type, magnet status, role challenges/stressors

Nurse Executive Leadership Behaviors:

informing, encouraging others to share ideas, receptivity to ideas, willingness to listen, acknowledging performance, rewarding, mentoring, managing conflict

Organizational Commitment:

Affective commitmentNormative commitmentContinuance commitment

Retention:

Intention to stay

Nurse Executive Organizational Citizenship Behaviors:

assisting with workload, helping others,

Adopted from Meyer, J., & Allen, N. (1997). Commitment in the Workplace: Theory, Research, and Application. Thousand Oaks, Ca.: Sage Publisher. 2222

Data AnalysisData Analysis

Quantitative data analysis involved univariate, multivariate, and inferential statistics

Descriptive statistics such as means and standard deviation used for combined survey questions

Correlational analysis for numerical variables was conducted and multiple regression analysis used to estimate the effect of one variable upon a numerical response variable while controlling for others

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Data AnalysisData Analysis(continued)(continued)

Frequency tables and cross-tabulated contingency tables were used for survey questions

Regression analysis was used to model the variable of intent to stay

Correlational matrix for select survey items displayed in a row and a column with coefficients displayed at intersections

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Profile of Survey RespondentsProfile of Survey Respondents

Demographic Characteristics

(Age, Gender, Level of Education)

Professional Characteristics(Years in Current Organization, Years in Current Position, Years as a

Nurse, Title / Current Position, Area of Specialty)

Characteristics of Affiliated Organizations(Bed Size, Location, Type, Union Status, Magnet Status)

# of Completed Surveys: 190

Response rate was difficult to determine due to no data base availability of total # of eligible participants

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Chart 1: Respondents by AgeChart 1: Respondents by Age(n=190)(n=190)

0.5%

16.3%

41.1%

30.0%

7.4%

1.1%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Under 25 years

25 – 35 years

36 – 45 years

46 – 55 years

56 – 65 years

Greater than 65

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Chart 2: Respondents by Level of Chart 2: Respondents by Level of EducationEducation (n=190)(n=190)

1.1%

35.3%

46.8%

15.8%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Associate

Bachelors

Master

Doctorate

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Chart 3: Respondents by Years in Chart 3: Respondents by Years in Organization, Years in Current Position and Organization, Years in Current Position and

As a NurseAs a Nurse (n=190)(n=190)

12% 13%

18%

8%

17%

33%32%

25%

8% 10%

2% 2%

12%

65%

10%

16%

10% 10%

0%

10%

20%

30%

40%

50%

60%

70%

1 – 2 years 3 – 5 years 5 – 10 years 11 – 15 years 16 – 20 years Greater than 20years

Current Org Current Position As a Nurse

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Chart 4: Respondents by Current PositionChart 4: Respondents by Current Position (n=190)(n=190)

63.7%

26.8%

7.4%

0%

20%

40%

60%

80%

100%

Nurse Manager Unit Director Other

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Chart 5: Respondents by Bed Size of Chart 5: Respondents by Bed Size of Affiliated Organizations Affiliated Organizations (n=190)(n=190)

37.9%

28.4%

27.9%

4.2%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Under 100

101 - 250

251 - 350

Over 350

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Chart 6: Respondents by Magnet Status Chart 6: Respondents by Magnet Status of Affiliate Organization of Affiliate Organization (n=190)(n=190)

34.2%37.4%

27.4%

0%

10%

20%

30%

40%

50%

Yes No In Process

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Descriptive Analysis – Descriptive Analysis – Perceived Role StressorsPerceived Role Stressors

The highest stressors ranked by strongly agree, agree, & slightly agree were:– Staffing concerns -89%– Role overload-86%– Excessive work hours/load-85%

The lowest stressors were:– Lack of support from your peers-62%– Lack of support from your supervisor-63%

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3.1 3.15

3.89 4.03

4.85

5.59 5.7 5.816.01 6.02

0

1

2

3

4

5

6

7

Lack ofsupervisor

support

Lack ofpeer

support

Lack of org.support

Qualityconcerns

Lack ofresources

Emotionalexhaustion

Work/Lifebalance

Excessivework

hours/load

Staffingconcerns

Roleoverload

Chart 7: Nurse Managers’ Perceived Chart 7: Nurse Managers’ Perceived Challenges / Role Stressors Challenges / Role Stressors (n=190)(n=190)

(Based on a mean scale: 7=Strongly Agree; 6=Agree; 5= Slightly Agree; 4=Uncertain; 3=Slightly Disagree; 2=Disagree; 1=Strongly Disagree)

Overall Scale Mean (4.81) *

* The overall scale mean is calculated by summing the scores of all respondents on all items and dividing by the total number of items and of respondents.

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Descriptive Analysis – Descriptive Analysis – Perceived Organization CommitmentPerceived Organization Commitment

Top 4 combined strongly agree, agree, & slightly agree were:

– Organization has a great deal of personal meaning to me-83%

– Believe in the value of remaining loyal to one’s organization-85%

– Very happy to spend the rest of my career here-76%– Enjoy discussing my organization with people

outside-81%

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Nurse Managers’ Perceived Intent Nurse Managers’ Perceived Intent to Turnoverto Turnover

(Based on a scale mean: 7=Strongly Agree; 6=Agree; 5=Slightly Agree; (Based on a scale mean: 7=Strongly Agree; 6=Agree; 5=Slightly Agree; 4=Uncertain; 3=Slightly Disagree; 2=Disagree; 1=Strongly Disagree)4=Uncertain; 3=Slightly Disagree; 2=Disagree; 1=Strongly Disagree)

Intent to Turnover Indicators/StatementsMeanScore

I could find a job with another employer with the same pay and benefits

5.15

I often think about quitting 3.49

I will probably look for a new job in the next year 2.78

Intent to Turnover Overall Mean * 3.80

Intent to Transfer within Organization

I intend to transfer to another leadership position within my organization

3.79

* The overall mean is calculated by summing the scores of all respondents on all items and dividing by the total number of items and of respondents.

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Descriptive Analysis – Descriptive Analysis – Perceived LeadershipPerceived Leadership

Top nurse executive behaviors for always and almost always (5 point scale) were:

– Encourage staff to give best effort-74%

– Encourage teamwork-66%

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Chart 8: Leadership Behavior of Nurse Chart 8: Leadership Behavior of Nurse Executives Executives (n=190)(n=190)

(Based on a scale mean: 5 =Always…. 3=Some…. 1 Very Little)(Based on a scale mean: 5 =Always…. 3=Some…. 1 Very Little)

3.23.58 3.6 3.64 3.69 3.7 3.77 3.81 3.93

4.12

0

1

2

3

4

5

Show staff -improveperform.

Offer newideas - jobproblems

Praise staffjob

perform.

Willing tolisten - staffproblems

Payattention to

staffconcerns

Receptiveto ideas of

others

Encrge staffto

exchangeopinions

Keep staffinformed of

org.changes

Encourageteamwork

Encrge stafffor besteffort

* The overall scale mean is calculated by summing the scores of all respondents on all items and dividing by the total number of items and of respondents.

Overall Scale Mean (3.70) *

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Organizational Citizenship Behavior Organizational Citizenship Behavior of Nurse Executivesof Nurse Executives

Top citizenship behaviors rated as very characteristic and fairly characteristic (5 point scale) were:

– Make innovative suggestions to improve the hospital-77%

– Attend functions not required but help with the hospital’s image-77%

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Chart 9: Organizational Citizenship Chart 9: Organizational Citizenship Behavior of Nurse Executives Behavior of Nurse Executives (n=190)(n=190)

(Based on a scale mean: 5=Very Characteristic….3=Somewhat… 1=Not at all (Based on a scale mean: 5=Very Characteristic….3=Somewhat… 1=Not at all Characteristic)Characteristic)

2.94 3.09 3.113.4 3.54

4.12 4.14

0

1

2

3

4

5

Help othersw/ heavy

workloads

Orient newpeople

Assistsupervisors

Help othersabsent

Volunteer forthings notrequired

Attendfunctionshelping

hospital'simage

Makeinnovative

suggestions

Overall Scale Mean

(3.55) *

* The overall scale mean is calculated by summing the scores of all respondents on all items and dividing by the total number of items and of respondents. 3939

FindingsResearch Hypothesis 1

Research Hypothesis 1: Nurse manager organizational commitment will be positively related to perceived organizational citizenship altruism behaviors of the nurse executive.

– Positive significant correlation (r = .396, p < .01) between nurse manager affective organizational commitment and perceived organizational citizenship altruism

– Positive correlation (r = .199, p < .01) for normative commitment

– Not significant correlation for continuance commitment (r = .048, p > .05)

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Findings Findings Research Hypothesis 2Research Hypothesis 2

Research Hypothesis 2: Nurse manager organizational commitment will be positively related to perceived nurse executive leadership behaviors.

– There was a significant positive correlation between nurse manager affective organizational commitment (r = .432, p < .01) and perceived nurse executive leadership behaviors

– Correlations were positive and significant for normative commitment (r= .171, p < .05) and continuance commitment (r = -.184, p < . 05)

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Findings Findings Research Hypothesis 3Research Hypothesis 3

Research Hypothesis 3: Nurse manager affective organizational commitment will be related to intent to stay.

– The highest positive correlation for intent to stay was found with nurse manager affective organizational commitment (r = .542, p < .01).

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Findings (cont.)

Correlations were positive and significant between intent to stay and other variables

organizational citizenship behavior (r = .385, p < .01)

leadership behavior (r = .461, p < .01)

normative commitment (r = .298, p < .01)

continuance commitment was not found to be significant (r = .059, p = .434)

Negative correlation was found with stress (r = -.489, p = <.01) and intent to stay

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Findings Research Hypothesis 4

Research Hypothesis 4: Nurse manager self-reported high role stress levels will be negatively related to intent to stay.

– There was a significant negative correlation (r = .489, p < .01) that nurse manager self-reported high role stress levels and intent to stay.

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Participant Comments about Participant Comments about Hospital ActionsHospital Actions

Work life– More time off– Offer variable and more flexible scheduling– Limit being on call

Support– Provide clerical & budgetary support– Need charge RN

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Participant Comments about Comments about Hospital Actions Hospital Actions (cont.)(cont.)

Acknowledgement– Recognition of the difficulty of the role– Hold other departments accountable– Nursing Directors need to be more respectful

Compensation– More money– Offer greater tuition reimbursement

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Leadership/Professionalism

– Encouragement of creative solutions

– Empowerment to make change

– Autonomy

– No micromanaging

Participant Comments about Participant Comments about Hospital Actions Hospital Actions (cont.)(cont.)

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Participant Open Comments

The narrative comments are consistent with themes in the literature regarding work/life balance, role overload, and the need for autonomy and support.

“Finally, someone who is addressing what I believe is the next crisis in nursing, a shortage of qualified nurse managers! The role of the nurse manager must be re-evaluated given the turnover rate and dissatisfaction…

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Participant Open Comments

While much emphasis has been placed on staff satisfaction, the nurse manager frustration is ignored. As a result of this, the position has become increasingly difficult to fill adding more stress and responsibility to those who are then asked to cover additional units. It is a vicious cycle that must be broken, younger nurse’s are not interested in advancing into this role, …”

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Study Limitation

Biases of observation and recall of leadership behaviors in perceptually based surveys

Study model was limited to the reliability of instruments and scope of study

Sample size and survey conducted in one state limit generalizability

Stress questions were not a validated instrument

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Discussion

Themes from Nurse Manager Engagement study are consistent with findings– Socialization and education for entry into role – Designated mentorship-short and long term – Work/life balance

Flexible scheduling Incentives to avoid burnout

– Compensation to reflect contribution & diminish stress– Reduction and division of workload

(Mackoff & Triolo, 2007)

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Discussion (continued)

Nurse managers differ

– Differing age cohorts require differing approaches based on professional and work values.

– Arioan’s, et al. (1997) study, nurse managers with less than 5 years in the position experienced role confusion and stress regarding staffing due to lack of clarity about their role and uncertainty about the correctness of their actions

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Discussion (continued)

Commitment to the supervisor and commitment to the profession has exerted a positive influence on OC and significantly reduced turnover intention (Boshoff & Mels, 2000)

Affective commitment by nurse managers is influenced by being able to see the “big picture”; therefore, nurse executive communication and leadership behavior are essential in the dynamic state of acute care hospitals (Bolon, 1997)

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Discussion (continued)

Affective commitment, and to a smaller extent normative commitment, increased with age and career stage suggesting that maturity and age cohort may be important variables to consider in strategy development

(Allen & Meyer, 1993)

Age was related to affective and normative occupational commitment in a sample of nurses (Meyer, et al. 1993)

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Discussion (continued)

Need to design strategies for managerial engagement job enhancement and exploration of value differences that may arise wit a multigenerational workforce

Understanding what employees’ value is important in reward system design and organizational strategy

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Discussion – Hospital Actions

Hardiness for dealing with the dynamic nature of the turbulent complex and changing healthcare environment

Developing supportive organizational practices consistent wit Magnet guidelines are shared governance, participatory management and access to information resources, and support

Structural empowerment theory proposes that organizational support and nursing leadership are positively related to role satisfaction and organizational commitment (McDermott, et al., 1996; Parsons & Stonestreet, 2003, Laschinger, et al., 2001)

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Discussion

Evaluate and build upon work of nurse manager

Qualitative methods such as appreciative inquiry and participative action research for organizational understanding and strategy and development

Longitudinal studies

Nursing leaders, particularly in NJ, need to begin succession planning

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QUESTIONS

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