Relationship between management styles and nurses’ retention at private hospitals

Available online 21 September 2011

Peer review under responsibility of Alexandria University Faculty of Medicine

Abstract

Introduction

Management styles are an essential issue from both theoretical and managerial perspectives. However, success in nursing management is found in being flexible and adaptable to a variety of situations which increase quality of care. One of the best ways to ensure quality of care is to recruit and retain sufficient nursing staff. The study aimed to determine the relationship between management styles and nurses’ retention at private hospitals.

Methods

A descriptive correlational study was conducted in all inpatients units (n = 16) at three private hospitals with bed capacity more than 50 beds namely: El Salama New hospital, Alexandria New Medical Center, and El Shefaa hospital. All nurses with at least 3 months experience in the previously mentioned settings were included in the study (n = 228). Profile of Organizational Characteristics (POC) developed by Likert et al. was used to measure nurses’ perception for management styles in their work unit. The questionnaire consists of 16 items classified into four parts called systems, which are exploitative/authoritative management style, benevolent/authoritative management style, consultative management style, and participative management style.

Results

The findings of this study show that more than half of the respondents perceived their manager to have a consultative management style. Alexandria New Medical Center has a greater retention time as compared to other two hospitals.

Conclusion

Management style and nurses’ retention were significantly interrelated in terms of exploitative/authoritative management style. Recommendation, the researcher recommended that hospital leaders should plan and implement effective strategies to promote nurse retention. This can be done through creating a work environment that is caring and conducive for the nurse's professional practice.

Keywords:

• Likert's model
• Consultative management style
• Exploitative/authoritative management style
• Qualified nurse
• Nongovernmental for profit sector

1 Introduction

Dramatic changes have occurred in the healthcare environment over the last decade.¹ These changes include increases in nursing shortages, staff retention, and turnover which have become the prime concern of the health care organization. Healthcare organizations have been faced with the need to redesign their traditional management models in an effort to control costs, improving efficiency and outcomes.² Essentially, management involves organizing and directing a group of people to accomplish specific tasks. Also, it has a unique purpose and outcome that is needed to maintain a healthy organization. The history of management science provides managers with a background into what came before so they are well grounded in the past. They continue to use some past theories in coping with management problems today. Additionally society has changed remarkably, providing current management theorists with new insights and challenges.^1,3

Management styles of the health organization play a vital role in promoting workplace empowerment, organizational commitment and job satisfaction amongst nurses in management positions at hospital settings.⁴ It includes the personal traits and behavioral characteristics of the person in a position to influence group interaction and achievement of organizational goals. Moreover, management style is an overall method of leadership used by nurse managers. Therefore they have to perform many roles in an organization and how they handle various situations will depend on their style of management in their work.^5,6

Likert and his associates⁷ studied the patterns and styles of managers at the University of Michigan, USA, and identified a model of management system. Likert's model was estimated as more appropriate for the current study. They describe an organizational theory of a continuum of four management systems. These are exploitative/authoritative management style, benevolent/authoritative management style, consultative management style, and participative management style. Exploitative/authoritative management style means that manager has no trust in subordinates. All the decisions are being made at the top. Benevolent/authoritative management style indicates that manager has some trust in subordinates. Some routine decisions are delegated down the hierarchy. In addition, consultative management style describes that the managers have substantial confidence, but not complete confidence in subordinates, and they are allowed to make less important decisions on the lower hierarchy levels. Lastly, participative management style identifies that the manager has complete confidence in the subordinates. All hierarchical levels are included into the decision making process.^7,8

Management style was found to be the key variable in predicting and creating professional workplaces, i.e. hospitals that attract and retain nurses.⁹ According to Upenieks¹⁰, who pointed out that hospitals would attract and retain more qualified nurses; the more participative the nurses perceived their managers’ leadership style to be, the more satisfied they were.

Nursing as a profession is a service whose core mission is caring and nurturing of human beings in their experiences of heath and illness. As many organizations have realized the key to their effectiveness lies in their ability to recruit and retain capable nurses.^11,12 Retention is a process that should be started before a nurse is hired and needs to be continued until the nurse resigns. Retention of well qualified nurses directly benefits the nurses as individuals, their organizations, and patients entrusted to their care.¹³ In accordance with Baumann et al.¹⁴, they defined retention as ’'the maintenance of an appropriate supply of nursing personnel to meet the health needs of any given population”.

Nurses have a basic role not only as care providers but also coordinate and need to manage the environment in which improving quality of care is given.¹⁵ Retention of nurses is a recognized issue for the health organization, as evidenced by the many studies undertaken with regard to the reasons why nurses leave nursing.^16–18 Among these reasons are the costs related to high turnover in terms of recruitment and training, as well as the loss of productivity that can result from discontinuity in the level of performance while new recruits are being trained.^10,11,15 Nurses’ retention is measured by the number of nurses that stay with a manager for a given period.¹⁹ Managers who retain staff start by communicating clear expectations to the nurse. They share their picture of what constitutes success for the nurse with regard to both the expected deliverables and the performance of their job. These managers provide frequent feedback and make the nurse feel valued. When a nurse completes an exchange with a manager who retains staff, he or she feels empowered, enabled, and confident in his or her ability to get the job done.^5,12

No attempt was done to determine the relationship between management styles and nurses’ retention at private hospitals. Hopefully, this study will help hospital administrator and nurse executives to comprehend an effective retention program as a systematic effort to create and foster an environment that encourages nurses to remain employed by having policies and practices in place that address their diverse needs.^20,21

This study aimed to determine the relationship between management styles and nurses’ retention at private hospitals.

2 Methods

2.1 Materials

A correlation descriptive research design was selected for fulfilling the aim of this study.

The study was conducted in three private hospitals affiliated to nongovernmental for profit sector at Alexandria governorate. All in-patient care units (n = 16) in the selected hospitals were approved to be the setting for study conduction. Each hospital has a bed capacity more than 50 beds namely: El Salama New hospital (8 units), Alexandria New Medical Center (four units), and El Shefaa hospital (four units). The number of private hospitals at Alexandria governorate that were equipped with more than 50 beds amounted to six hospitals which have number of beds that ranged from 65 to 160 and number of nurses that ranged from 45 to 186. Therefore, half of the private hospitals were selected yielding El Shefaa hospital, El Salama New hospital and Alexandria New Medical Center.

The target population was all nurses (n = 228) affiliated to work in the selected hospitals and available at the time of data collection who were invited to participate in the study. The meeting criteria included a minimum of at least 3 months and people who did not assume any managerial positions. They classified as follow: Alexandria New Medical Center n = 79 nurses, El Salama New hospital n = 113 nurses and El Shefaa hospital n = 36 nurses.

2.2 Tool one: Likert's Profile of Organizational Characteristics

Profile of Organizational Characteristics (POC) was a modified version developed by Likert et al.,⁷ to measure nurses’ perception of management styles in their work unit. Also, it allowed nurses to briefly describe the management system as they perceived being practiced in the organization, and gave them an opportunity to indicate which management system they desired in the future. It consists of 16 items classified into four parts called systems; each system represented different management patterns which are exploitative/authoritative management style, benevolent/authoritative management style, consultative management style, and participative management style. In this profile, the four management systems have been compared with one another on the basis of certain organizational variables namely: leadership processes (three items), motivation forces (three items), communication process (four items), decision making process (two items), goals setting (two items), and control process (two items). To characterize management system, it was assumed that exploitative/authoritative management style covers the range from 0% to 24.9%; benevolent/authoritative management style covers 25–49.9%; consultative management style covers 50–74.9%; and participative management style covers 75–100%. Responses to each sub-items were measured on eight point scale as following 8 = strongly very often and 1 = rarely. The reliability coefficient of POC has been previously established with alpha coefficient 0.92 < 0.05.²² For the current questionnaire POC, alpha coefficient was 0.89 < 0.05. Also, demographic characteristics of the studied subjects were added.

Permission to conduct the study was obtained from the ethical committee of the Faculty of Nursing, as well as directors of the studied hospitals to collect necessary data. The questionnaire was translated into Arabic and submitted to a panel of eight experts in the field of study to be tested for its statement relevance, (its content validity). Accordingly, necessary modification was made. Cronbach's alpha was used to test internal consistency of the items to test reliability of questionnaire. After obtaining the nurses’ consent, a pilot study for questionnaires was carried on 10% of nurses from inpatients units at the International Cardiac Center (ICC) not included in the study were selected to check and insure the clarity of the statements. Therefore, the rewording or rephrasing of the statements was done.

Data collection: included three phases as follow:-

 Phase I

–	The researcher obtained a list about numbers and names of all nurses who were employed at least 3 months at the time of study induction either having diploma or baccalaureate degree from the head nurses in studied hospitals (units).

–	Individualized structured interview was conducted by the researcher for nurses to collect data concerning: Likert's Profile of Organizational Characteristics.

–

The interviews started by informing the nurses an explanation of the aim of the study. They were interviewed on an individual basis using the questionnaire, interview lasted approximately 30–45 min to complete. Data were collected for this phase over a period of four months from 3/1/2010 to 30/4/2010.

 Phase II

–	The researcher returned to the previous studied hospitals after 9 months to collect data from director of nursing and head nurses about the numbers and names of nurses who had quit and reasons for leaving their units.

–	The reasons for quitting hospitals were classified into obligatory and non-obligatory reasons.

–	A record form was designed by the researcher including the number and the names of nurses who had quit from hospitals, hospital name, reasons for quitting, and work duration until quitting.

–	Nurses’ retention was calculated through subtracting the number of nurses who had quit the hospitals from the total number of nurses available during data collection, divided by the total number of nurses and then multiplied by 100.

$\text{Retention percent}=\frac{\text{Total number of nurses}-\text{the number of quitted nurse}}{\text{Total number of nurses}}\times 100$

2.3 Statistical analysis

After completing the data collection, data were coded, fed and verified prior to computerized data entry. Data were analyzed using SPSS (statistical package for social science) with version (v = 11.5 for windows) to perform tabulation and statistical analysis including, frequencies and percentage, arithmetic mean, standard deviation, and different multiple statistical measures as χ², Kruskal–Wallis χ². Level of significance selected for this study was 5% (p < 0.05).

3 Results

Table 1 presents distribution of studied nurses according to their socio demographic characteristics. This table shows that the studied subjects consisted of 228 nurses enrolled for carrying out direct and indirect activities in the inpatient units. The majority of the nurses were female, currently single, ageing 20 to less than 30 years old. Also, they were holding BSc. N degree and were working in inpatients units for 1 year up to three. More than three quarter of them work in rotating shift.

Table 1 Distribution of the studied nurses according to their socio demographic characteristics.

Socio-demographic characteristics	Studied nurses (n = 228)
	No	%
Age
<20	10	4.4
20−	182	79.8
30−	31	13.6
40+	5	2.2
Sex
Male	39	17.1
Female	189	82.9
Marital status
Single	176	77.2
Married	48	21.1
Divorced/widow	4	1.7
Educational level
Secondary diploma	78	34.2
Technical health institute diploma	47	20.6
BSc	103	45.2
Type of unit
Inpatient	109	47.8
Coronary care unit	12	5.3
Intensive care unit	89	39.0
Neonates Intensive care unit	18	7.9
Years of experience in unit
<1	68	29.8
1–<3	72	31.6
3–<5	50	21.9
5+	38	16.7
Shift
Morning shift	28	12.3
Evening shift	7	3.1
Night shift	31	13.6
Rotating	162	71.0

Table 2 shows nurses’ perception of management styles as distributed by their study hospitals. This table points out that the highest percentage of total studied subjects were perceived for consultative styles (57.50%). Also, it was observed that the highest mean percentage of management style was for consultative style at El Salama New hospital (64.60%) as compared to 0.90% for exploitative/authoritative management style. A statistically significant difference was found in this respect (χ² = 26.68, p < 0.05).

Table 2 Nurses perception of management styles as distributed by their study hospitals.

Management styles	Study hospitals						Total
	El Shefaa (n = 36)		El Salama New hospital (n = 113)		Alexandria New Medical Center (n = 79)
	No	%	No	%	No	%	No	%
Exploitative/authoritative	0	0.00	1	0.90	9	11.40	10	4.40
Benevolent/authoritative	12	33.30	37	32.70	29	36.70	78	34.20
Consultative	20	55.60	73	64.60	38	48.10	131	57.50
Participative	4	11.10	2	1.80	3	3.80	9	3.90
X^2	26.68^*

* p ⩽ 0.05 at 5% level denotes a significant difference.

Distribution of reasons for quitting as perceived by studied nurses at study hospitals were shown in Table 3, it was found that the significant difference indicated that the highest mean percentage of quitting reasons was recorded for El Salama New hospital (42.5%), while, the lowest mean percentage was presented for Alexandria New Medical Center (22.8%).

Table 3 Distribution for reasons for quitting as perceived by studied nurses at study hospitals.

Study hospitals		Retained	Reasons for quitting					Total quitting percent
			Obligatory reasons		Non obligatory reasons
			Family obligations	Non family obligations	Transfer to other hospital	Resignation	Termination of services
El Shefaa	No	24	3	6	1	2	0	12
	%	66.70	8.30	16.70	2.80	5.60	0.00	33.4
El Salama New hospital	No	65	5	15	6	22	0	48
	%	57.50	4.40	13.30	5.30	19.50	0.00	42.5
Alex New Medical center	No	61	3	2	0	10	3	18
	%	77.20	3.80	2.50	0.00	12.70	3.80	22.8
Total	No	150	11	23	7	34	3	78
	%	65.80	4.80	10.10	3.10	14.90	1.30	34.2
X^2	9.46^*

* p ⩽ 0.05 at 5% level denotes a significant difference.

Table 4 illustrates the relationship between mean percentage of management styles and non-obligatory quitting among studied nurses. This table highlighted that a significant relation was documented between management styles and non obligatory quitting (χ² = 9.138, p ⩽ 0.05). The highest mean percentage of quitting was observed for exploitative/authoritative management style (37.50%).

Table 4 Relationship between mean percentage of management styles and non obligatory quitting among studied nurses.

Management style	Non obligatory quitting				X^2
	Retained		Quit
	No	%	No	%
Exploitative/authoritative	5	62.50	3	37.50	9.138^*
Benevolent/authoritative	44	67.70	21	32.30
Consultative	96	85.70	16	14.30
Participative	5	83.30	1	16.70
Total	150	78.50	41	21.50

* p ⩽ 0.05 at 5% level denotes a significant difference.

Table 5 illustrates non-obligatory reasons for quitting by work duration in months among studied nurses at study hospitals. From this table, it is apparent that the difference between mean score of duration in months till quitting due to non-obligatory reasons and study hospitals was not statistically significant (KW χ² = 1.624, p = <0.05). Also, it is obvious that Alexandria New Medical Center had the highest mean score (27.4 ± 31.444 months) which indicate greater retention time as compared to the other two hospitals.

Table 5 Non obligatory reasons for quitting by work duration in months among studied nurses at study hospitals.

Study hospitals	Non obligatory reasons of quitting	Kruskal Wallis X^2
	X ± SD
El Shefaa hospital (n = 3)	6.67 ± 4.619	1.624
El Salama New hospital (n = 28)	19.32 ± 19.083
Alexandria New Medical Center (n = 10)	27.4 ± 31.444
Total	20.37 ± 22.283

4 Discussion

Nurses’ retention is an important priority of nursing administration. Research in business and industry has shown that management styles were related to retention, but documentation of this relationship is lacking for nurses in hospitals.^10,12 This research describes how management styles is directly related to expected retention of nurses working in inpatients units.

Generally, in this study the data obtained through Profile of Organizational Characteristics analysis, indicated that more than half of the respondents perceived their managers as having a consultative management style. A significant difference was found between nurses working in inpatients units at private hospitals regarding means percentage of management styles. These findings were supported with a survey study of full-time registered nurses working in the inpatients units by Dolan²³ who indicated that the majority of respondents perceived that their manager who worked with them all the time as displaying a consultative management style. This was apparent by the manager's use of nurses’ ideas, opinions and their frequent involvement in decision making with substantial, but not complete trust in their nurses. In this issue, Laschinger²⁴ supported this finding and identified that participants had perceived a positive relationship between power to engage in consultation with the leader and substantial confidence and trust.

It is interesting to notice that there was a highly statistically significant difference between nurses’ reasons for quitting and their study hospitals. It reflects that nurses who were working in El Salama New hospital had the highest mean percent of quitting in comparison with Alexandria New Medical Center, which had the lowest mean percent. Specifically, the current finding can be justified due to extra pay given to nurses for regular attendance and those caring for bed ridden patients at Alexandria New Medical Center. On the other hand, nurses who worked at El Salama New hospital were suffering from rigid disciplinary polices, increased workload, and stress from double effort in using both electronic and paper charting which resulted in late endorsement leading to nurses’ dissatisfaction. This finding goes parallel to Gamel²⁵ who reported that about two-thirds of staff nurses at El Salama New hospital had problems in using the computer system as a result of increased workload and limited time for documentation. Staff nurses mentioned that they have to stay after finishing their work shift to complete the documentation on the computer while they are not paid for these extra hours.

Based on the findings of the current study, it has been suggested that the reasons for quitting among nurses can be classified into obligatory reasons and non-obligatory reasons. Obligatory reasons include family obligations (reasons related to family) and non-family obligations (e.g. enrollment in army for males, governmental employment in hospitals). Non-obligatory reasons include resignation, transfer to other hospitals and termination of services. Apparently, with some specification this study indicated that non-family obligations had almost high mean percent as one reason for obligatory reasons reported by nurses. One explanation of this finding could be related to most nurses working part time being absent from duty not only because of personal illness, but also because of their shifts in governmental hospitals in internship or mandatory period as nurse in charge. This result is congruent with Chappell and Prince²⁶ who found that non-family obligation is an important obligatory reasons. In addition, Force²⁷ showed that work-related factors are instrumental in nurses’ employment decisions, and must be addressed if retention is to be improved.

From the findings of the present study, it was found that, the main reason for non-obligatory reasons which received the highest mean percentages among nurses was resignation. This finding might be due to the reasons for nurses’ resignation, which were shortage of nurses, increase workload, autocratic management styles, lack of opportunities for promotion or continuing one's professional education, dissatisfaction with working conditions. This is substantiated by Barrett and Yates²⁸ who identified that workload can also affect the nurse's intent to stay or leave. A heavy workload causes job tension, emotional exhaustion, and decreased job satisfaction, increasing the probability of leaving one's position. Moreover, Mrayyan²⁹ showed that resignation rate in private hospitals is higher than public hospitals.

Additionally, the present findings proved that management styles significantly differ among nonobligatory reasons for quitting. This was apparent that management styles of nurse managers can influence nonobligatory reasons for quitting among their nurses. Specifically, more than one-third of the respondents who had quit from study hospitals report that their managers used exploitive/authoritative management style. These findings were supported by Anthony,³⁰ Duffield and Roche³¹ they asserted that the management style used by the nurse managers have an impact on reasons for quitting among staff nurses. Harper and Hirokawa³² found that nurse managers rely more often on punishment-based strategies, when attempting to influence a subordinate to comply with non obligatory reasons for quitting. This could be explained in the light of nurses’ motivation which is based on punishment and occasional rewards. Communication is primarily downward with little interaction or teamwork. Also, decision making and control reside primarily at the top of the organization as one of the risks for work related stress that results in nurses’ job dissatisfaction. This finding goes relatively with the results of Thompson³³ who concluded that use of the authoritative management style by nurse managers negatively impacts nursing staffs’ satisfaction, intention to stay, and retention. This finding is similar to those Pan et al.³⁴ who suggested that, job satisfaction is the most influential predictor of staying in practice. Creamer et al.³⁵ found higher job satisfaction if nurses have a variety of tasks in their job, peer feedback, and collaborative teamwork.

The present study discloses a considerable variation of the nurses’ perception of management styles and retention among private hospitals. It could be attributed to the need for continued transformation support of the traditional management styles by nurse managers. Transformed nurse managers get their nurses involved through sharing of information, vision, challenging them to think creatively, and coaching them in decision making. Also, it emphasizes on retention policy that creates an atmosphere regarding security in the workplace.³⁶

5 Conclusion

The present study is considered as a cornerstone that gives strong support towards understanding of nurses’ perception of management styles and their retention at Private Hospitals. It highlighted that a significant difference was found between management styles and nurse’ retention. Highest mean percentage was apparent for exploitive/authoritative management style.

6 Recommendations

Based on the study results, the following strategies are recommended in order to develop Nurses ‘retention through:

•	Hospital leaders should plan and implement effective strategies to promote nurses’ retention.

•	Creating a more supportive professional nursing practice that allows nurses to practice to their full opportunities for professional interactions. This can be done through the development of a clinical ladder for advancement within the organization.

•	Motivating nurses through providing job enrichment and developing reward systems for nurses based on their workloads.

•	Improving the image of nursing profession through effective marketing, good media, as well as emphasizing the actual role of mercy angels.

•	Creating opportunities to attract and retain nurses by strengthening the interpersonal leadership and management skills within the hospital.

•	Enhancing a positive work environment through promotion of teamwork, encouraging continuous education, trust, respect and flexible scheduling.

7 Future research studies are needed to

•	Assess how retention strategies for governmental and private nurses may differ, by further comparative studies between governmental and private hospitals.

Notes

Available online 21 September 2011

Peer review under responsibility of Alexandria University Faculty of Medicine