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Alexandria Journal of Medicine (2011) 47, 243–249

Alexandria University Faculty of Medicine

Alexandria Journal of Medicine

www.sciencedirect.com

ORIGINAL ARTICLE

Relationship between management styles

and nurses’ retention at private hospitals

Magda E. Nassar, Hala Ahmed Abdou *, Naglaa A. Mohmoud

Faculty of Nursing, Nursing Adminstration, Alexandria, Egypt

Received 30 May 2011; accepted 18 June 2011

Available online 21 September 2011

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KEYWORDS

Likert’s model;

Consultative management

style;

Exploitative/authoritative

management style;

Qualified nurse;

Nongovernmental for profit

sector

Corresponding author.

-mail address: h_abdou_eg@

90-5068 ª 2011 Alexandr oduction and hosting by Els

er review under responsibilit

edicine.

i:10.1016/j.ajme.2011.06.003

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Abstract Introduction: Management styles are an essential issue from both theoretical and man-

agerial perspectives. However, success in nursing management is found in being flexible and adapt-

able 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 Char-

acteristics (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 sys-

tems, 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.

om (H.A. Abdou).

ersity Faculty of Medicine.

. All rights reserved.

xandria University Faculty of

lsevier

244 M.E. Nassar et al.

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 pro-

fessional practice.

ª 2011 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. All rights reserved.

1. Introduction

Dramatic changes have occurred in the healthcare environ-

ment 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 re- design their traditional management models in an effort to control costs, improving efficiency and outcomes.

2 Essentially,

management involves organizing and directing a group of peo- ple to accomplish specific tasks. Also, it has a unique purpose and outcome that is needed to maintain a healthy organiza- tion. 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 manage- ment 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 manage- ment 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 organiza- tional 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 associates 7 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 orga- nizational theory of a continuum of four management systems. These are exploitative/authoritative management style, benev- olent/authoritative management style, consultative manage-

ment 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 deci- sions are delegated down the hierarchy. In addition, consulta-

tive management style describes that the managers have substantial confidence, but not complete confidence in subor- dinates, and they are allowed to make less important decisions

on the lower hierarchy levels. Lastly, participative manage- ment 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 pre- dicting and creating professional workplaces, i.e. hospitals that attract and retain nurses.

9 According to Upenieks

10 , who

pointed out that hospitals would attract and retain more qual- ified 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 re- tain capable nurses.

11,12 Retention is a process that should

be started before a nurse is hired and needs to be continued un- til the nurse resigns. Retention of well qualified nurses directly

benefits the nurses as individuals, their organizations, and pa- tients 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 discon-

tinuity 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 com- pletes 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 be- tween management styles and nurses’ retention at private

hospitals. Hopefully, this study will help hospital administra- tor and nurse executives to comprehend an effective retention program as a systematic effort to create and foster an envi-

ronment that encourages nurses to remain employed by hav- ing 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 ful- filling the aim of this study.

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

Relationship between management styles and nurses’ retention at private hospitals 245

The study was conducted in three private hospitals affili-

ated to nongovernmental for profit sector at Alexandria gover- norate. 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 Cen- ter (four units), and El Shefaa hospital (four units). The num- ber 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 hospi- tal, 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’ percep-

tion 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 man- agement patterns which are exploitative/authoritative manage-

ment 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 organiza- tional 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/author- itative 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 estab-

lished 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 eth- ical committee of the Faculty of Nursing, as well as directors of the studied hospitals to collect necessary data. The question-

naire 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 modifi-

cation 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 question-

naires 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 state- ments. Therefore, the rewording or rephrasing of the state-

ments 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 explana- tion 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.

246 M.E. Nassar et al.

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 oblig- atory and non-obligatory reasons.

– A record form was designed by the researcher including the number and the names of nurses who had quit from hospi- tals, 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.

Retention percent

¼ Total number of nurses � the number of quitted nurse

Total number of nurses

�100

2.3. Statistical analysis

After completing the data collection, data were coded, fed and verified prior to computerized data entry. Data were analyzed

Table 2 Nurses perception of management styles as distributed by

Management styles Study hospitals

El Shefaa (n = 36) El Salama N

hospital (n

No % No

Exploitative/authoritative 0 0.00 1

Benevolent/authoritative 12 33.30 37

Consultative 20 55.60 73

Participative 4 11.10 2

X 2

26.68 *

* p 6 0.05 at 5% level denotes a significant difference.

Table 3 Distribution for reasons for quitting as perceived by studi

Study hospitals Retained Reasons for quitting

Obligatory reasons

Family

obligations

Non fami

obligation

El Shefaa No 24 3 6

% 66.70 8.30 16.70

El Salama New hospital No 65 5 15

% 57.50 4.40 13.30

Alex New Medical center No 61 3 2

% 77.20 3.80 2.50

Total No 150 11 23

% 65.80 4.80 10.10

X 2

9.46 *

* p 6 0.05 at 5% level denotes a significant difference.

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 v2, Kruskal–Wallis v2. Level of significance se- lected 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 carry- ing 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 de- gree and were working in inpatients units for 1 year up to three. More than three quarter of them work in rotating shift.

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 consul- tative 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 (v2 = 26.68, p < 0.05).

Distribution of reasons for quitting as perceived by studied

nurses at study hospitals were shown in Table 3, it was found

their study hospitals.

Total

ew

= 113)

Alexandria New Medical

Center (n = 79)

% No % No %

0.90 9 11.40 10 4.40

32.70 29 36.70 78 34.20

64.60 38 48.10 131 57.50

1.80 3 3.80 9 3.90

ed nurses at study hospitals.

Total quitting

percent Non obligatory reasons

ly

s

Transfer to

other hospital

Resignation Termination

of services

1 2 0 12

2.80 5.60 0.00 33.4

6 22 0 48

5.30 19.50 0.00 42.5

0 10 3 18

0.00 12.70 3.80 22.8

7 34 3 78

3.10 14.90 1.30 34.2

Table 4 Relationship between mean percentage of manage-

ment 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 6 0.05 at 5% level denotes a significant difference.

Table 5 Non obligatory reasons for quitting by work dura-

tion 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

Relationship between management styles and nurses’ retention at private hospitals 247

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 per-

centage was presented for Alexandria New Medical Center (22.8%).

Table 4 illustrates the relationship between mean percent- age of management styles and non-obligatory quitting among

studied nurses. This table highlighted that a significant relation was documented between management styles and non obliga- tory quitting (v2 = 9.138, p 6 0.05). The highest mean percent- age of quitting was observed for exploitative/authoritative management style (37.50%).

Table 5 illustrates non-obligatory reasons for quitting by

work duration in months among studied nurses at study hos- pitals. From this table, it is apparent that the difference be- tween mean score of duration in months till quitting due to non-obligatory reasons and study hospitals was not statisti-

cally significant (KW v2 = 1.624, p = <0.05). Also, it is obvi- ous 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.

4. Discussion

Nurses’ retention is an important priority of nursing adminis- tration. Research in business and industry has shown that

management styles were related to retention, but documenta- tion of this relationship is lacking for nurses in hospitals.

10,12

This research describes how management styles is directly re-

lated 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 hav-

ing a consultative management style. A significant difference was found between nurses working in inpatients units at pri- vate 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 Dolan

23 who indicated that the majority of respondents per-

ceived 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 substan-

tial, but not complete trust in their nurses. In this issue, Lasch- inger

24 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 reg- ular 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 ri- gid disciplinary polices, increased workload, and stress from double effort in using both electronic and paper charting

which resulted in late endorsement leading to nurses’ dissatis- faction. This finding goes parallel to Gamel

25 who reported

that about two-thirds of staff nurses at El Salama New hospi-

tal 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 sug-

gested that the reasons for quitting among nurses can be clas- sified 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 be- cause of their shifts in governmental hospitals in internship

or mandatory period as nurse in charge. This result is congru- ent with Chappell and Prince

26 who found that non-family

obligation is an important obligatory reasons. In addition, Force

27 showed that work-related factors are instrumental in

nurses’ employment decisions, and must be addressed if reten- tion 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’ resigna-

tion, which were shortage of nurses, increase workload, auto- cratic management styles, lack of opportunities for promotion

248 M.E. Nassar et al.

or continuing one’s professional education, dissatisfaction

with working conditions. This is substantiated by Barrett and Yates

28 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, Mrayyan

29 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 Roche 31

they asserted that the management style used by the nurse managers have an impact on reasons for quitting

among staff nurses. Harper and Hirokawa 32

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 punish- ment and occasional rewards. Communication is primarily

downward with little interaction or teamwork. Also, decision making and control reside primarily at the top of the organiza- tion as one of the risks for work related stress that results in nurses’ job dissatisfaction. This finding goes relatively with

the results of Thompson 33

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 sug- gested that, job satisfaction is the most influential predictor of staying in practice. Creamer et al.

35 found higher job satisfac-

tion 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 contin- ued 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 per-

centage was apparent for exploitive/authoritative management style.

6. Recommendations

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

� Hospital leaders should plan and implement effective strat- egies 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 effec- tive 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 pri- vate nurses may differ, by further comparative studies between governmental and private hospitals.

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