Healthcare Questions

How commitment and involvement influence the development of strategic consensus in health care organizations: the multidisciplinary approach

MARIE CARNEY M B A , P h D , R G N , R M , R N T , F F N M , R C S I

Lecturer, UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland

Literature review

The role of the clinician or non-clinician head of

department is a key role in health service delivery

(Carney 2004a). Currie (1999) identifies the positive

influence of middle managers in the business planning

process. Harrison and Miller (1999) argue that clini-

cians, including nurse managers, are embracing new

Correspondence

Marie Carney

Head, UCD School of Nursing

Midwifery and Health Systems

University College Dublin

Belfield

Dublin 2

Ireland

E-mail: [email protected]

C A R N E Y M . (2007) Journal of Nursing Management 15, 649–658

How commitment and involvement influence the development of strategic consensus in health care organizations: the multidisciplinary approach

Aim The aim of this study was to describe how clinician and non-clinician managers achieved consensus of strategy in hospitals. This was the first empirical study

undertaken that investigated the impact of organizational commitment on the

strategic involvement–strategic consensus relationship. Background Clinicians and non-clinician managers hold a pivotal role in health care

management from the strategic perspective. The importance of multidisciplinary

collaboration is recognized, yet how strategic consensus is achieved amongst health

service managers, has not been previously researched.

Key issues The focus of the professional is often on local concerns rather on the

broader organizational strategy. This orientation has led to the charge by health

service management that clinicians are not interested in, or do not seek to be

involved in strategy development. As half of the clinician group in this study were

registered nurses and midwives it is important, for multidisciplinary and inter-

disciplinary collaboration and for strategic development that this group has an

awareness of the importance of strategic involvement and organizational commit-

ment in the attainment of strategic consensus.

Conclusion A descriptive study was undertaken and quantitative data were gener-

ated through the survey method. The aims of the study were articulated through

hypotheses. Almost 400 middle manager heads of department, working in acute

care not-for-profit health service organizations, in the Republic of Ireland,

responded. Findings indicated that a stronger relationship existed between con-

sensus and commitment than between involvement and commitment. In addition,

when present in the organization, involvement and commitment together were

better predictors of consensus than each of those factors on its own, but significantly

commitment had a greater impact in predicting consensus than involvement had.

Keywords: clinicians, commitment, consensus, involvement, non-clinicians, nurses

Accepted for publication: 13 October 2006

Journal of Nursing Management, 2007, 15, 649–658

ª 2007 The Author. Journal compilation ª 2007 Blackwell Publishing Ltd 649

roles that are strategic, but that there is no agreement

yet in relation to the requirement for clinicians at head

of department or clinical directorate level to be involved

in strategic development. Still, there appears to be an

assumption that these roles are of strategic importance

(Cowling & Newman 1994, Dawson et al. 1995). Cli-

nicians are now being faced with complex and com-

peting pressures (Dopson 1996, Schein 1997, Drenkard

& Cohen 2004). Management of these pressures

requires a greater level of strategic involvement than

was required in the past (Drucker 1988, Wells 1999,

Carney 2004b,c).

The importance of strategy making is noted in the

literature. Floyd and Wooldridge (1992b) found that

few middle managers articulate the same goals of

superiors, and that those who disagree with strategic

initiatives block the implementation of strategy.

Dopson et al. (1992), in their study of the changing role

of the middle manager in Britain found resistance to

change by middle managers in public sector organiza-

tions, such as the National Health Service (NHS), and

related this to their distinctive sense of professional

identity. Professional clinicians seek to control their

own work to their own standards (Freidson 1976),

while at the same time resisting taking instruction from

their administrative superiors who are asserting the

aims of the employing organization (Ong 1998). It is

recognized in the current health care structure that there

is a potential for redistribution of power within

organizations and a resultant shift in power and control

from the clinician towards the managerial components

(Shortell et al. 1988, Carney 2006c). Professional cli-

nicians can influence the management of the organiza-

tion by having an impact on the policy formulation

process if permitted (Carney 2004a, 2005), and should

be involved in exercising an upward influence through

strategic planning and formulation of strategy (Floyd &

Wooldridge 1996, 1997, Dutton et al. 1997, Currie &

Proctor 2005, Rouleau 2005). Strategic planning is an

on-going decision-making process, the purpose of

which is to specify the ideals, goals and objectives

required by the organization in the future.

Dess (1987) demonstrates that strategic consensus is

achieved through the sharing of strategic information

and through direct exposure to strategic priorities.

Health service organizations are staffed by a combina-

tion of clinicians and non-clinicians, therefore of

importance to professionals is the manner in which

strategic consensus is achieved. Nurses, who form the

largest group of health service clinicians, have attracted

considerable management attention during the past

decade and have developed their own ways of

reinterpreting management’s intentions (Carney 2002,

Bolton 2004). Of importance is the service to society

that the members of a profession provide, and the

public acceptance that follows this service (Miller et al.

1993), a perception based upon a sense of �professional excellence� (Bowen & Ford 2002, Douglas and Ryman 2003). Consequently, the focus of the professional is

often on local concerns rather on the broader organi-

zational strategy (Mintzberg & Quinn 1992, Harrison

& Miller 1999). This orientation has led to the charge

by health service management that clinicians are not

interested in, or do not seek to be involved in strategy

development (Wells 1995a, Carney 2004a,b). Further-

more, the non-clinician manager provides some services

that have a long-term focus such as financial or capital

management that are often perceived to be at variance

with those services provided by clinicians that have a

short-term focus, thus resulting in conflicting inter-

pretations regarding each other’s roles (Fitzgerald 1996,

Exworthy & Halford 1999, Carney 2004b). Even

though clinician managers are also concerned with

those areas, their focus is on the immediate nature of

health care delivery. Bolton (2004) in a longitudinal

study carried out in a large NHS Trust hospital in

Britain, which charted the changes that occurred in the

nursing work process over the 6-year period to 2000

argues that the control of health care professional work

is now firmly in the hands of hospital management.

Therefore, reaching an understanding of each other’s

role in achieving consensus on organizational strategy is

an important goal for clinicians and non-clinicians

(Carney 2004c).

Authors have highlighted the importance of consen-

sus in strategic decision-making, and of strategy devel-

opment as a consensus-building process (Nielsen 1981,

Hrebiniak & Joyce 1984). There is a lack of empirical

research relating to the extent of senior management

strategic consensus (Dess & Origer 1987), and little

evidence to suggest that this differs with middle man-

agement. In an individual capacity strategic consensus is

defined �as agreement amongst top, middle and oper- ating level managers on the fundamental priorities of

the organization� (Floyd & Wooldridge 1992b: 28). Wooldridge and Floyd (1990) define consensus �as the product of middle management commitment to, and

understanding of, strategy� (p. 235), resulting in the combination of collective heart and mind in managers

who are acting in consort with a common set of stra-

tegic priorities. Dess (1987), in his study on consensus

in strategy formulation undertaken in American hospi-

tals, found that strategic consensus is achieved through

the sharing of strategic information and through direct

M. Carney

650 ª 2007 The Author. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 649–658

exposure to strategic priorities, and also that the rele-

vance of involvement in strategy formulation to the

achievement of consensus is not well understood (Dess

& Origer 1987, Floyd & Wooldridge 1992b). Carney

(2002) found that strategic consensus occurs when

managers are involved in, and are committed to strategy

development and when the organizations culture and

structure are favourable. However, it is also recognized

that strategic consensus may not always occur due to

the fast moving pace of organizational change (Collins

1998), presence of multiple cultures (Thorne 2000,

Carney 2006c) and the fact that organizations are often

the sites of multiple and converging forms of conflict in

relation to how the organization should be managed

(Willmott 1987) and how patient services should be

delivered (Carney 2006c). In a research study related to

50 000 responses made to the authors� website (http:// www.orgdna.com). Neilson et al. (2005) write of the

passive-aggressive organizations that suffer from a

�cluster of pathologies� (p. 83) whereby employees work at �cross-purposes� to one another in a seemingly con- genial atmosphere where consensus of strategy appears

to have been achieved, yet these agreed-upon plans and

strategies are not implemented as employees are paying

lip-service and putting in just enough effort to appear

compliant.

The role of commitment in the achievement of stra-

tegic consensus is not known. The concept of organ-

izational commitment is complex and encompasses

many dimensions. Corser (1998) asserts that commit-

ment is employees� encompassing a complex sense of loyalty that involves a strong belief in the goals of the

organization and congruence with the value system of

the organization. Carney (2006b) identified commit-

ment as a willingness to serve the organization through

continued membership. Commitment to the organiza-

tion influences individual levels of commitment in var-

ious ways (Randall and Cote 1991, Cote 1991, Cohen

1993, 2000), and it could therefore be argued that

employee commitment and, by extension, middle

manager commitment to the organization implies

commitment to key organizational strategies.

The psychological approach to organizational com-

mitment is defined as employees having a psychological

identification with the goals and beliefs of the organ-

ization, and a willingness to concentrate efforts towards

helping the organization to achieve its goals (Porter

et al. 1974, Mowday 1978, Mowday et al. 1979). This

process results in identification with the organization’s

objectives to the extent that individual and organiza-

tional goals are closely aligned (Guth & Macmillan

1986). Research conducted by Porter et al. (1974) was

based on a series of studies involving 2563 employees

working in nine divergent organizations. Commitment

is portrayed as the internalization of the values of the

organization, i.e. a willingness to concentrate efforts

towards helping the organization to achieve its goals and

a desire to remain as a member of the organization.

Carney (2002) identified that even when professional

and organizational commitment is at variance and

resulting in conflict, commitment predicted strategic

involvement. Mowday et al. (1979) noted that this

represents more than passive loyalty to the organization

and that this loyalty develops over a period of time and

remains stable over time. An extension of this thinking is

the commitment model that incorporates high commit-

ment, high involvement and high performance (Lawler

et al. 1995, Porter O’Grady & Malloch 2002).

Organizational factors play a major role in affecting

the behaviour and attitudes of employees (Cohen 1993,

Taylor et al. 1996). Organizational systems and struc-

tures that align organizational goals with those of the

middle manager will build commitment into strategy

(Floyd & Wooldridge 1992a), and for this to occur,

middle managers must commit to and understand

strategy (Wooldridge & Floyd 1990). A number of

authors classify commitment as an attitudinal or beha-

vioural concept (Bateman & Strasser 1984, Putti et al.

1990) that results in positive behavioural benefits to the

organization in terms of commitment. Ogilvie (1986)

says this is an all-encompassing attitude that results from

a sense of support, and acknowledgement of one’s

efforts on behalf of the organization. Strategic commit-

ment by middle managers is not evident in the literature,

apart from reference to this form of commitment by

Floyd and Wooldridge (1992a). In their case study

research, undertaken in manufacturing and financial

sector industries, Floyd and Wooldridge (1992a) found

that poor implementation of strategy resulted from poor

middle management understanding and commitment to

organizational strategy. Guth and Macmillan’s (1986)

study, which involved examining 330 written reports,

found that middle managers were motivated more by

perceived self-interest than by organizational interest,

and stated that organizational and middle manager

objectives should be aligned in order to achieve com-

mitment to strategy implementation. It may be assumed

that strategic policy will positively influence organiza-

tional commitment (Putti et al. 1990).

Summary of study design

The aim of the study was to explore the extent to which

a relationship exists between strategic involvement and

Commitment and involvement influence the development of strategic consensus

ª 2007 The Author. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 649–658 651

strategic consensus and to determine the influence of

organizational commitment on this relationship. A

descriptive study was used to achieve the study aims.

Quantitative data were generated through a question-

naire.

Sample

A total frame of 860 clinicians and non-clinicians,

working in positions as head of department, in 60 of the

65 acute care not-for-profit hospitals in the Republic of

Ireland, was used.

Data collection

The total population was surveyed via a questionnaire.

Ethical principles relating to confidentiality and ano-

nymity were followed. The overall response rate was

50%; however, due to non-completion for various

reasons, the valid response rate was 42% (n ¼ 352), comprising 66% (n ¼ 234) professional clinicians and 34% (n ¼ 118) non-clinicians. Of the 66% profes- sional clinician respondents, just over 50% (n ¼ 120) were nurse or midwife managers. Data analysis com-

menced in September 2001 and was completed in May

2002.

Research instrument: survey scales

A four-part self-reported data questionnaire was

designed to measure the two hypotheses posed. Two new

measurement scales (Organisational Consensus and

Biographical) and two existing scales (Organisational

Commitment and Strategic Involvement) were used.

Apart from the Biographical scale, each item in each of

the other three scales was scored on a 5-point scale,

ranging from 0 (strongly disagree) to 5 (strongly agree).

Cronbach’s alpha, supporting the scales� internal con- sistency and content validity are, for Strategic Consen-

sus ¼ 0.96, Organisational Commitment ¼ 0.93 and Strategic Involvement ¼ 0.90 (Table 1).

New Instruments: Strategic Consensus Scale development

The 20-item �Strategic Consensus� Scale was used to measure strategic consensus. The scale used was

adapted, in format only, from Floyd and Wooldridge’s

(1996) �The Strategic Consensus Questionnaire� (Resource A) that was based on Porter’s 1980 theory

of competitive strategy (Porter 1996). �The Strategic Consensus Questionnaire� was designed by Floyd and Wooldridge (1996) to assess the relative importance

of reducing costs and increasing differentiation in the

organization’s competitive strategy. These areas were

not the focus of the present study; therefore a scale

that related to 5-key strategic areas: strategic plan-

ning, operational, financial, new initiatives and human

resource management, identified from strategic man-

agement literature, was designed to measure strategic

consensus. Scale items related to focusing staff on

meeting organizational goals and reaching agreement

on strategy in these five strategic areas. Items also

related to the reaching of consensus in decision-

making on service delivery and to the 5-key strategic

areas. The mean value for strategic consensus was

3.98.

The Biographical scale was developed by the author

to measure respondent data. This scale included bio-

graphical and demographic data.

Research instrument: existing survey scales – Strategic Involvement and Organisational Commitment Scales

The 20-item Likert-type instrument scale devised by

Floyd and Wooldridge (1996), and distributed to 259

middle managers in 25 mainly for-profit organizations,

was used to explore if middle managers perceived that

they were involved in the development of strategy in

their organizations. Items on this scale addressed a

number of factors, including the frequency with which

middle managers perceived that they were involved in

operational and human resource planning, evaluated

the merits of new operational proposals generated in the

department, translated the organizational goals into

objectives for other staff and evaluated the merits of

new proposals concerning budgetary management.

Additionally, items addressed communication of infor-

mation to higher-level managers, searching for new

opportunities and bringing them to the attention of

higher-level managers, communicating and selling top-

management initiatives to subordinates and encour-

aging multidisciplinary problem-solving teams. On the

Table 1 Summary of Cronbach's alpha (reliability factor) for Strategic Involvement, Strategic Consensus and Organisational Commitment Scales

Measurement scale Number of items

Cronbach's alpha N

Strategic Involvement 23 0.90 326 Strategic Consensus 20 0.96 312 Organisational Commitment 15 0.88 306

M. Carney

652 ª 2007 The Author. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 649–658

0–5 response scale, the mean value for Strategic

Involvement was 3.35 (Table 2).

The 15-item �Organisational Commitment� Scale was used to measure organizational commitment. The scale

items assessed respondents� willingness to help the organization be successful, loyalty to and pride in the

organization, desire to remain with the organization

and similarity of personal and organizational values.

Following a review of the relevant literature, the

researcher decided to use an unabridged version of the

�Organisational Commitment� Questionnaire (OCQ; Mowday et al. 1979). The OCQ was based on a series

of studies, carried out by Mowday et al. (1979),

involving 2563 employees in nine divergent organiza-

tions. This 15-item scale was considered to be the most

suitable instrument to measure organizational commit-

ment in the context of this study. Analysis undertaken

to measure reliability was thus performed on the indi-

vidual items of the scale supported alpha 0.8798

(N ¼ 306, number of items ¼ 15), supporting the measurement scales� internal consistency (Cronbach 1951). Convergent validity for this measure of organ-

izational commitment was assumed due to the fact that

a wide range of studies (approximately 352) utilized the

OCQ measurement instrument in the past 20 years

(Mowday et al. 1982).

Data analysis

All quantitative data from the study instruments were

coded, entered, verified and analysed using S P S S , Version

11. Inferential analyses were undertaken. Univariate

and multivariate assumptions were tested for violations,

and parametric and non-parametric statistical analyses

were utilized. Normality was determined through the

utilization of histograms, measures of Kurtosis and the

Kolmogorov–Smirnov test for normality. Hypotheses

were tested using Pearson correlation coefficients to

determine relationships between variables, and corre-

lation analyses were performed on the principal meas-

urement scales. Recoding of data was undertaken prior

to regression analysis. Significance was established at

the 0.05 level of probability. Statistical regression

analyses models were developed in order to answer the

hypotheses posed.

Research findings

Sample characteristics

Just over half were in the 31–45 age group (n ¼ 191) and only 3% were in the <30 age group. Slightly more

than one-third consisted of males (n ¼ 123) and the remainder (n ¼ 223) females. Just over 60% were clinicians (n ¼ 234) and 34% (n ¼ 118) were non- clinicians. Of the professional clinician group 50%

(n ¼ 110) were nurse and midwife managers. Eight of every 10 respondents (n ¼ 257) were educated to degree level and beyond.

The first hypothesis tested was �that there is a positive relationship between strategic involvement and strategic

consensus�. The hypothesis was supported as findings reported that involvement accounted for 18% of the

variance in consensus, indicating that involvement was

making a moderate contribution to the prediction of

consensus (R2 ¼ 0.179, F(7, 281) ¼ 8.74, P ¼ 0.000), and that the regression model was statistically signi-

ficant.

The second hypothesis tested was �that the strength of the association between strategic involvement and

strategic consensus is influenced by organizational

commitment�. Statistical analyses were undertaken in three steps through multiple regression analysis. In Step

1, involvement and consensus were entered into the

regression model. Findings indicated that for every unit

rise in involvement, consensus increased by 0.37 of a

unit (range: 0–5, b ¼ 0.371, P ¼ 0.01), suggesting that involvement predicted consensus.

In Step 2, involvement and commitment were entered

in combination into the regression equation with con-

sensus. The correlation of involvement with consensus

(r ¼ 0.379, P < 0.01), and commitment with consensus was significant (r ¼ 0.407, P < 0.01), suggesting that involvement and commitment significantly related to

consensus. The regression equation of involvement and

commitment with consensus was R2 ¼ 0.231, F(2, 348) ¼ 52.20, P ¼ 0.0005, indicating that involvement and commitment explained 23% of the variance in

strategic consensus.

The correlation of commitment with consensus was

also significant (r ¼ 0.407, P < 0.01), suggesting that commitment was significantly related to consensus. For

every unit rise in commitment, consensus increased

by 0.46 of a unit (scale: 0–5, b ¼ 0.461, P ¼ 0.0001).

Table 2 Mean, standard deviation and sample size: Strategic Involvement, Organisational Commitment and Strategic Consensus

Variable

Mean scores ranged from

0 to 5 Standard deviation

Sample size

Strategic Involvement 3.35 0.60 352 Organisational Commitment 3.55 0.72 351 Strategic Consensus 3.98 0.82 352

Commitment and involvement influence the development of strategic consensus

ª 2007 The Author. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 649–658 653

The regression equation, R2 ¼ 0.165, F(1, 349) ¼ 69.165, P ¼ 0.000, indicated that commitment accoun- ted for 17% of the variance in consensus.

In summary, the total regression equation demon-

strated that involvement and commitment, when both

were present, were better predictors of consensus than if

involvement or commitment were present as single

entities. The regression model further indicated that

commitment (b ¼ 0.461, P ¼ 0.0001) was the variable having the greatest impact in predicting the variance in

consensus followed by involvement (b ¼ 0.371, P ¼ 0.0001). When allowing for commitment, the effect of involvement on consensus was less. Commit-

ment did affect the relationship between involvement

and consensus, and when one adjusted for commitment

or kept it constant, the pure effect of involvement on

consensus was reduced. Commitment had a significant

direct effect on consensus (b ¼ 0.461) and therefore commitment on its own had a higher effect on con-

sensus than commitment going through involvement.

Regression analyses indicated that commitment made a

unique contribution to the prediction of consensus, and

commitment and involvement in combination, were

making a moderate contribution to the prediction of

consensus. The hypothesis was supported as findings

indicated that the regression model was statistically

significant (Tables 3 and 4). The response rate was a

satisfactory 42% and justification for the non-response

rate from certain respondents was previously provided

to the researcher. Nevertheless, the non-response rate

would be important to investigate in future studies

undertaken in the health service context. Additionally,

measurement contamination is often a cause for con-

cern and this factor always requires scrutiny.

Discussion

Findings demonstrated that clinicians and non-clini-

cians managers achieved consensus in relation to the

strategies developed in their organizations. Nine of 10

respondents (n ¼ 281) agreed on the importance of focusing staff on meeting organizational goals, eight of

10 (n ¼ 272) indicated that ensuring budgetary controls was important, and the same number (n ¼ 272) agreed that encouraging the development of new programmes

was moderately to very important. Findings support

Floyd and Wooldridge (1996), in indicating that a high

level of strategic awareness and consensus, allied to

strategic operational knowledge, exists amongst clini-

cian and non-clinician heads of department. Findings

also support the Quality and Fairness Health Strategy

(Department of Health 2001) that health care must be

delivered through inter-professional partnerships and

consensus, and that turf wars and old hierarchical

thinking in relation to the professions must disappear,

for the benefit of the patient.

Still, factors influencing strategic consensus vary.

Notably, Ashmos et al. (1998) suggest that two differ-

ent perspectives may be obtained through the partici-

pation of clinicians and non-clinicians in strategic

matters, and that difficulties will arise in strategy

development if consensus is not reached amongst senior

and middle managers. Dooley and Fryxell (1999), in

their study of 86 decision-making teams, undertaken in

American hospitals, found that consensus building was

an important factor in the strategic decision process,

and that this was influenced by loyalty to the team and

to the organization. Dess and Origer (1987) say that

there is a requirement for the integration of strategic

consensus when formulating strategy. Authors have

highlighted difficulties in the achievement of strategic

consensus and have suggested that as health care is

delivered in a turbulent and constantly changing envi-

ronment (Edwards & Hale 1999) this has resulted in

less consensus on the organizations� strategic direction

Table 3 Multiple regression analysis: Strategic Involvement, Strategic Consensus and Organisational Commitment

Model 2 Unstandardized

coefficients Standard

error Standardized coefficient b

Strategic Involvement* 0.517 0.230 0.379 Strategic Involvement� 0.371 0.068 0.272 Organisational Commitment

0.355 0.057 0.314

Organisational Commitment�

0.461 0.055 0.407

*Predictors: strategic involvement; dependent variable: strategic consensus. �Predictors: strategic involvement, organizational commitment; dependent variable: strategic consensus. �Predictors: organizational commitment; dependent variable: stra- tegic consensus.

Table 4 Regression model summary: Strategic involvement, organisational commitment and strategic consensus

R R2 Adjusted

R2

Standard error of the

estimate F-value Sig.

change

1 0.379 0.144 0.148 0.758 58.710 0.000 2 0.480 0.231 0.226 0.719 52.19 0.000 3 0.407 0.165 0.163 0.748 69.17 0.000

Predictors: (1) strategic involvement, (2) strategic involvement and organizational commitment, (3) organizational commitment; dependent variable: strategic consensus.

M. Carney

654 ª 2007 The Author. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 649–658

(Wells 1999). This view supports Floyd and Wooldridge

(1992b) who report difficulties in managing strategic

consensus in a turbulent environment, where priorities

are constantly shifting.

The present study was the first empirical study to

investigate the impact of organizational commitment on

the strategic involvement–strategic consensus relation-

ship. Findings indicated that a stronger relationship

existed between consensus and commitment than

between involvement and commitment. In addition,

when present in the organization, involvement and

commitment together were better predictors of con-

sensus than each of those factors on its own, but signi-

ficantly, commitment had a greater impact in predicting

consensus than involvement had. These are important

findings as research up to now has focused on these three

areas as discrete concepts and researchers have not

identified if relationships existed. The importance of

the effect of organizational commitment on strategic

consensus is an important area for further research and it

is important to develop new ways of thinking about and

measuring strategic consensus and to identify other

factors that may impact on strategic consensus.

Authors have suggested that employees display feel-

ings of loyalty, affection and belongingness (Jaros et al.

1993, Carney 2006b), and emotional attachment to the

organization (Allen & Meyer 1990, Gruen et al. 2000),

or that they bond with the organization (Iverson &

Buttigieg 1999, Gruen et al. 2000). This personal

commitment appears to lead to work commitment

(Mottaz 1988, Putti et al. 1990, Carney 2006b), and to

increased levels of cooperative behaviour amongst

employees (Gruen et al. 2000), that would indicate that

for strategic involvement to occur there should also be

commitment to the organization. It is possible that the

measures of organizational commitment, strategic

involvement and strategic consensus used in this present

study could have produced spurious interrelations

because these constructs tap the affective domain.

However, Cronbach’s alpha for the measurement scales

was satisfactory. Also, the relationships existing

amongst the three major variables used in the study may

be more complicated than regression analysis or path

analyses are capable of determining. Nevertheless, the

measurement scales and statistical analyses undertaken

appeared to be robust, resulting in statistically signifi-

cant findings.

Research has indicated that strategy is formulated by

consensus building amongst senior management (Dess

1987), but also that up to 1990 research had not

focused on the middle manager. Previous research has

suggested that organizational commitment appeared to

influence strategic involvement (Porter et al. 1974,

Wood & de Menezes 1998). Guth and Macmillan

(1986) aligned commitment with a sense of identifica-

tion with the organizational objectives that in response

led to strategic involvement in the development of

strategic goals and objectives (Wooldridge & Floyd

1990). Floyd and Wooldridge (1992b) related organi-

zational commitment to middle managers� level of consensus in the achievement of specific organizational

objectives, and argue that the strategic context in which

the organization operates will influence strategic con-

sensus. Corser (1998) links this commitment to

employees� having a high level of involvement in work- based activities that results in a sense of support and

acknowledgement by top managers of their efforts on

behalf of the organization (Ogilvie 1986). Willingness

and goodwill result from employees perceiving that

support for their ideas and well-being exists in the

organization (Carney 2002, 2004b, 2005a, 2006a,

2006b). This form of support produces a reciprocal

sense of obligation to support the organizational goals

and united vision for the organizations� future direction and purpose and as a result leads to organizational

commitment (Eisenberger et al. 1990, Shore & Tetrick

1991), and confers benefits in terms of employees hav-

ing a psychological identification with the organiza-

tional goals and beliefs (Mowday et al. 1979). Carney

(2004b) also found that further justification for the

influence of commitment on involvement and consensus

is indicated by comments made by middle managers

who expressed a willingness to put in a great deal of

effort beyond that normally expected in order to help

the organization be successful, to tell friends that the

organization was a great place to work and that they

really cared about the fate of the organization.

Findings from this study indicated that involvement

and commitment together were better predictors of

consensus than each of those concepts on its own, and

also that commitment had a greater impact in predicting

consensus than involvement had. Findings indicated that

six in 10 (n ¼ 214) demonstrated commitment by moderately strongly agreeing that they told their friends

that the organization was a great place to work in and a

similar number (n ¼ 213) agreed that they were extremely glad that they had chosen to work for the

organization over others they had considered at the time

they joined. Seven in 10 (n ¼ 249) were proud to tell others that they were part of the organization and

slightly less (n ¼ 213) agreed that the decision to work for their organization was a good one. As other authors

have pointed out that employees bring a set of expecta-

tions to their role, and how they perceive these

Commitment and involvement influence the development of strategic consensus

ª 2007 The Author. Journal compilation ª 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 649–658 655

expectations to have been met or exceeded will deter-

mine their commitment level to the organization (Putti

et al. 1990, Morrison and Robinson 1997, Chang 1999,

Carney 2004b, 2006a), these findings that respondents

were positive in their attitude to the organization, are

important for organizational human resources manage-

ment. It is recognized that professional commitment and

organizational commitment may often be at variance

particularly amongst professional clinicians where

commitment to the profession and commitment to the

organization may conflict (Scoble 1991, Corser 1998).

However, this research does not support this perspective.

Rather, findings supported the importance of organiza-

tional commitment and the critical impact of commit-

ment on the relationship between involvement and

consensus. This finding has important implications for

the management of not-for-profit organizations, and

highlights the necessity for middle manager commitment

to their organizations. It was further demonstrated that

middle managers had strategic involvement and strategic

consensus, and that in order to nurture, promote and

grow this relationship commitment to the organization is

a critical success factor. However, the dynamic nature of

the health service environment may be a unique one,

consequently it would be important to undertake this

research in a for-profit setting, and establish if findings

are similar, and also to determine if the relationships

explored in this study change as a result of changing

environments.

Brodwin and Bourgeois (1984) in their study of

management practices, undertaken in 19 organizations,

found that �collaborative� and �cultural� patterns served to utilize consensus building amongst the organizations� hierarchical levels. Hewison and Stanton (2002) argue

that such change is taking place and that �policy emphasis has shifted towards collaborative and

co-operative approaches to the provision of health care� (p. 349). However, Long (2004), in respect of nurses

working in the United States, notes that more nurses

must be educationally prepared as problem solvers in

order to meet the management challenges of complex

health care environments. In a recent research under-

taken in the United States, Lopopolo et al. (2004)

highlight how the administration, management and

professional skills of one group of clinicians – physical

therapists are not known and have put forward the

�extensive knowledge� components required for multi- disciplinary collaboration (p. 145). Additionally,

Kupperschmidt (2004) discusses new models of health

care delivery that incorporate partnership, equity and

ownership. Meehan (2003) recommends trustworthy

collaboration between clinicians in the delivery of

patient care. It was demonstrated in this study that

commitment to the organization combines positive ele-

ments that assist in the promotion of strategic consensus.

Conclusion

This study highlights the importance of heads of

department achieving strategic consensus and of the

strong influence of organizational commitment on

the attainment of strategic consensus. Additionally, the

importance of strategic involvement on this relationship

was identified. Factors such as organizational goals and

strategies, the environment and the strategic context in

which the organization operates influence strategic

consensus. Therefore, agreement amongst all categories

of managers on the fundamental priorities of the

organization will enhance strategic goal achievement

and result in consensus on the organizational goals.

Findings bode well for future health professional clini-

cian and non-clinician manager collaboration. Nurse

managers are ideally positioned to influence employee

commitment to the organization and thereby to

encourage strategic consensus amongst clinician and

non-clinician colleagues.

Acknowledgements

I gratefully acknowledge with thanks the heads of department (clinicians and non-clinicians) working in acute care organi- zations in the Republic of Ireland who participated in this study. I thank my colleague Mr Jonathan Drennan for his statistical support.

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