Deborah K. Zastocki, RN, DNP President, Chilton Medical Center VP, Atlantic Health System

1. 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

2. Objectives • 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.

3. 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

4. Background & Significance (continued) • 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)

5. Study 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.

6. Research Hypotheses • Nurse manager organizational commitment will be positively related to perceived organizational citizenship altruism behaviors of the nurse executive. • Nurse manager organizational commitment will be positively related to perceived nurse executive leadership behaviors. • Nurse manager affective organizational commitment will be related to intent to stay. • Nurse manager self-reported high role stress levels will be negatively related to intent to stay.

7. Conceptual Framework of Factors Impacting Nurse Managers’ Intent to Turnover NM Unmet Needs Executive Leadership Behaviors NM Organizational Commitment NM Intent to Stay NM Stressors

8. Design & Methodology • Survey of Acute Care Nurse Managers • Target Audience • Survey Instrument: Pre-validated Measures • Organizational 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)

9. Measurement/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

10. Measurement/Instrumentation(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

11. 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 process • Initial email November 6, 2007, follow up emails December 16, 2007 and January 11, 2008 • Personal phone calls to all CNE’s of acute care hospitals • Timeframe • Initial design: November 6, 2007 – January 12, 2008 • Extended survey timeline to March 4, 2008 due to website issues - vendor changed January, 11, 2008

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

13. Organizational Commitment Definition • 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).

14. Organizational Commitment as 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

15. 3-Component Model of 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.

16. 3-Component Model of Organizational Commitment(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.

17. Leadership • Leadership 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)

18. Leadership(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.

19. Leadership(continued) • 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)

20. Organizational Citizenship Behavior-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)

21. Intent 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?

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

23. Data 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

24. Data Analysis(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

25. Profile 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

26. Chart 1: Respondents by Age(n=190)

27. Chart 2: Respondents by Level of Education(n=190)

28. Chart 3: Respondents by Years in Organization, Years in Current Position and As a Nurse(n=190)

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

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

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

32. Descriptive Analysis – Perceived 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%

33. Chart 7: Nurse Managers’ Perceived Challenges / Role Stressors (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.

34. Descriptive Analysis – Perceived 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%

35. Nurse Managers’ Perceived Intent to Turnover(Based on a scale mean: 7=Strongly Agree; 6=Agree; 5=Slightly Agree; 4=Uncertain; 3=Slightly Disagree; 2=Disagree; 1=Strongly Disagree) * 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.

36. Descriptive Analysis – Perceived Leadership • Top nurse executive behaviors for always and almost always (5 point scale) were: • Encourage staff to give best effort-74% • Encourage teamwork-66%

37. Chart 8: Leadership Behavior of Nurse Executives (n=190) (Based on a scale mean: 5 =Always…. 3=Some…. 1 Very Little) Overall Scale Mean(3.70) * * 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.

38. Organizational Citizenship Behavior of 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%

39. Chart 9: Organizational Citizenship Behavior of Nurse Executives (n=190) (Based on a scale mean: 5=Very Characteristic….3=Somewhat… 1=Not at all Characteristic) 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.

40. 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)

41. Findings Research 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)

42. Findings Research 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).

43. 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

44. 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.

45. Participant Comments about Hospital Actions • Work life • More time off • Offer variable and more flexible scheduling • Limit being on call • Support • Provide clerical & budgetary support • Need charge RN

46. Participant Comments about Hospital Actions (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

47. Participant Comments about Hospital Actions (cont.) • Leadership/Professionalism • Encouragement of creative solutions • Empowerment to make change • Autonomy • No micromanaging

48. 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…

49. 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, …”

50. 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