The cost crisis in the American healthcare system and the financial reforms initiated by prospective reimbursement have dramatically changed patient care services in acute care hospitals.1,2 Traditional organizational practices are less effective in environments that require speed, innovation, and flexibility.3 Effective leaders need to proactively manage these demands as well as uncertainty in a way that is consistent with the values and the goals of the organization. A key challenge for organizational leaders is to maximize the productivity and longevity of employees by cultivating their involvement and commitment.4
Transformational Leadership and Commitment
The essence of transformational leadership (TFL) is inspiring commitment to achieve the vision of a preferred future. Transformational leadership is a suitable approach in organizations requiring change, development, initiative, and creativity in turbulent and uncertain environments.5,6 In healthcare organizations, there is a need for vision, and nurse executive (NE) leaders are positioned to enliven a collective sense of nursing that sustains a professional connection to the patient. This can inform practice and guides the contribution and involvement of nurses (RNs) in their values and beliefs amidst pervasive organizational change. Nurse executive leaders are responsible for the professional environment within which nurses manage the care provided to patients and their families. More information is needed regarding these essential and influential aspects of the nurse executive leadership role and the effect NE leaders have on involvement among their followers.7
One measure of involvement is organizational commitment. Nurse executive leaders are in a position to influence commitment among nurses. Nurses are frontline providers of care and an essential component in the healthcare delivery system. Patient care in hospitals has become more complex. The velocity of change, fueled by electronic information capability, is creating substantial and diverse demands on organizations. Nurses work in demanding and cost-constrained organizational environments. A better understanding of the nature of their commitment can enlighten strategies to aid retention and job satisfaction. Mowday and his colleagues conclude that organizational commitment is a better and more stable predictor of turnover and group-level performance than job satisfaction and is therefore an important area for continued study.8,9 Examining the relationship between leadership and organizational commitment among nurses is particularly significant in light of rapid and high turnover of new nurses and a worldwide shortage of nurses.
The structure and process of care delivery continues to change profoundly as the focus moves from curative and hospital-based to preventive and community-centered. Nurse executive leadership is a key element in creating such change. Leadership affects how people embrace change, and one measure of that is commitment.
This study was designed to examine the relationship between NE leadership and organizational commitment among hospital-based RNs. Evidence supporting the influence of nursing leadership on commitment among nurses is vital as we confront practice environment conditions that can disrupt work force stability.
Transformational leadership and organizational involvement are the theoretical constructs that frame this study. Transformational leadership theory is based on research by Burns on political leaders and identifying a type of leadership in which the leader inspires and motivates followers to a higher moral level.10 Burns also identifies transactional leadership (TAL) as a relationship with the follower that is based on exchanging one thing for another. Transformational leadership theory incorporates both transactional and transformational leadership as separate but interrelated dimensions of an individual's leadership style.5 It encompasses skills and behavior, as well as characteristics that are critical for transformational leaders to have a positive impact on followers.11 Specifically, transformational leaders convey the connection between the organization's philosophy and shared values, and embed those values in organizational rules and actions. They communicate meaning and inspire followers.12
Organizational involvement as described by Etzioni13 is the other theoretical construct used in this study. Etzioni proposes that a leader can influence an employee's involvement in an organization. Influence is viewed as coercive, remunerative, and normative. Coercive influence by the leader involves using a threat of consequences to overcome resistance. Resistance is active opposition that Etzioni labels alienative commitment or highly negative involvement. Remunerative influence involves allocating rewards and resources to gain compliance. Compliance is a minimal effort to respond with neither driving conviction nor strong objection, labeled calculative commitment or moderately positive or moderately negative involvement. Normative influence involves symbolic rewards or deprivations using esteem, prestige, and ritualistic symbols or by manipulating acceptance and a positive response. This encompasses the concept of personal power, which draws on expertise, friendship/loyalty, and charisma14,15 to inspire an internalized desire to engage successfully, labeled moral commitment or highly positive involvement.
The theoretical framework suggests that a TFL style employed by the chief nursing executive (CNE) would be related to the type of moral commitment among participants in a hospital setting. This study proposes that leadership based on symbolic communication and inspiring vision, that motivates followers to pursue organizational goals and inspires others beyond their self-interests is associated with the type of commitment displayed by nurses in a hospital setting. Furthermore, NE transformational leadership style is expected to have an influence on nurse manager (NM) transformational leadership.
In this study, it is expected that when NEs demonstrate transformational leadership, there will be an associated occurrence of moral (highly positive) commitment among nurses. It is proposed that leadership at the executive level is a predictor of organizational commitment; specifically that TFL is a predictor of moral commitment. Nurse executive TFL is expected to be positively associated with moral commitment and negatively associated with alienative commitment among RNs and NMs. It is further expected that when NEs demonstrate transactional leadership, there will be an associated occurrence of calculative (moderately positive or negative) commitment among nurses. Moreover, personal characteristics such as age, educational preparation, and work characteristics such as job tenure and experience are expected to be positively associated with moral commitment.
Review of the Literature
Three outcomes are hypothesized as being related to the dimensions of transformational and transactional leadership: moral commitment, calculative commitment, and alienative commitment. The following review of the literature discusses conceptualizations and research germane to these variables.
The central premise of TFL theory is the inspiration of followers, through communication of a vision that reflects a collective purpose, toward commitment and contribution beyond self-interests.5,16,17 Research examining the relationship between subordinate satisfaction and leader effectiveness has repeatedly found that subordinates rate themselves more satisfied when led by a transformational rather than a nontransformational leader.5,18,19 Perceptions of leader effectiveness by the follower and extra, individual effort have been associated with TFL as well.18 There is also evidence of a cascading or domino effect of TFL among followers of transformational leaders who exhibit similar leadership qualities.20
Dunham and Klafehn,21 in an exploratory study of 80 NEs, found that these leaders posses a predominant TFL style. Transformational leadership style among NEs has been positively correlated to empowerment among staff nurses, which was positively related to job satisfaction. Leadership style accounted for a significant amount of variance in job satisfaction even beyond that accounted for by empowerment.22 McDaniel and Wolf23 found a cascading effect among NEs and midlevel nurse administrators showing that midlevel administrators who work for transformational leaders, score high in TFL, but not as high as their superior. Research on NMs suggests that NM leadership and commitment will have an effect on RN organizational commitment.24,25 When organizations undergo rapid and dramatic changes, traditional leadership theories do not provide sufficient explanatory power for predicting effectiveness. Other models, such as TFL theory, are more germane under these conditions. More specifically, in their 10-year review of research on nursing leadership, Altierri and Elgin recommend using TFL theory in future research.26
The concept of commitment to an organization involves 3 factors: (1) a strong belief in the organization's goals and values; (2) a willingness to exert considerable effort on behalf of the organization; and (3) a strong desire to maintain membership in the organization.27 Etzioni and others conceptualize commitment as a multidimensional construct that emerges from differing behavioral requirements placed on the individual by the organization.13,28–30 Organizational participants are viewed as being on an involvement continuum that ranges from highly intense and negative involvement labeled alienative commitment, through mildly negative to mildly positive involvement labeled calculative commitment, to a highly positive degree of involvement labeled moral commitment.13 Each of these dimensions of commitment is a possible explanation of an employee's involvement in an organization.
Glisson and Durick reported that leadership is positively associated with organizational commitment and is a significant predictor of organizational commitment.31 Bateman and Strasser32 identify that leadership behaviors are important internal organizational variables that need further study in relation to commitment. Intent to remain, attendance, turnover, job effort/performance, and satisfaction have been identified as outcomes of commitment.22,33–36 Mowday and colleagues conclude that organizational commitment is a better and more stable predictor of turnover8 and group-level performance than job satisfaction and is therefore an important area for continued research. Angle and Perry24 concluded that commitment forms more within the individual during the exchanges between the individual and the organization, and managers then might be in a position to influence the degree of commitment among employees.
Research Questions and Hypotheses
The key points drawn from the theoretical constructs and the research evidence regarding TFL, organizational theory, and commitment can be summarized as follows:
Transformational leadership is associated with inspiring and empowering others toward commitment to a collective vision and to contribute beyond self-interest.
Nurse executive transformational leaders are positively associated with job satisfaction and low turnover among staff nurses, and leadership behaviors of NMs are positively associated with organizational commitment among nurses.
Commitment to an organization is multidimensional and includes a normative, internalized identification called moral commitment, a remunerative or compliance involvement called calculative commitment, and a negative resistance called alienative commitment.
Little is known about how commitment is influenced by the changes that have occurred in the hospital work environment that include cost constraints and shortage conditions. The primary research question is to what extent is NE transformational leadership associated with the type of organizational commitment perceived by RNs and NMs? It was expected that a positive relationship between TFL and moral commitment would exist; that a negative relationship between TFL and alienative commitment would exist; and that a positive relationship between TAL and calculative commitment would exist.
In addition to a direct effect of NE leadership on commitment, an intervening effect was proposed to examine the association between NM leadership and NM organizational commitment on the outcome of RN organizational commitment. This was done to examine whether the inclusion of the NM effect strengthens the explanation of RN organizational commitment beyond that provided by a relationship between NE leadership and RN organizational commitment alone. The model in Figure 1 depicts the expected direct relationship and the expected indirect relationship between leadership and commitment.
This model assumes that in addition to having a direct effect on RNs, the type of NE leadership has an indirect effect on the type of organizational commitment among nurses by having a direct effect on the type of NM leadership and the type of NM organizational commitment. It is expected that NE transformational leadership will directly influence and be positively associated with NM transformational leadership and that NM transformational leadership will be positively associated with RN moral commitment. Similarly, that NE transactional leadership will directly influence and be positively associated with NM transactional leadership, which will be positively associated with RN calculative commitment. NE and NM transformational leadership is expected to have both a direct and indirect negative effect on alienative commitment among RNs.
A descriptive correlational design was used to investigate the relationships between the selected variables. A cross-sectional, quantitative field survey of NE leaders, NMs, and RNs was conducted. A random sample of NEs was selected from the more than 4000 who are members of the American Organization of Nurse Executives (AONE).
The NM sample consists of 148 NMs who each report to an NE participant. The RN sample consists of 651 staff nurses who report to an NM participant. In this way, hierarchical data sets for each NE were formed that included up to 2 NMs and up to 10 RNs. Both the NM and RN participants are convenience samples.
Two survey scales were used in this study. The Transformational Leadership Profile (TLP) is a research and development tool designed to measure transformational and transactional leadership that was developed by Sashkin et al.37 The Organizational Commitment Scale is based on Etzioni's framework, and was developed by Penley and Gould.38
The Organizational Commitment Scale is a 15-item instrument, with a 6-point Likert-type scale and responses that range from 1 (strongly disagree) to 6 (strongly agree). Each subscale, moral, calculative, and alienative, is comprised of 5 items based on factor analysis. Mean scores for the 3 subscales were computed from the sum and average score for each of the items. A higher score means a greater intensity for that commitment type. The internal consistency reliability revealed Cronbach alphas of .79 for moral commitment, .78 for calculative commitment, and .82 for alienative commitment, and are consistent with those reported by Penley and Gould.38 These are shown in Table 1.
The TLP is a 50-item, 5-point Likert-type scale, with responses from 1 (strongly disagree) to 5 (strongly agree). Transformational leadership is measured using 5 scales with questions that are designed to address communication leadership, credible leadership, caring, creative, and confident leadership. Transactional leadership is measured with 2 scales addressing capable management and reward equity. The Cronbach alphas for the 7 scales of the TLP range from .63 to .88 and are reported in Table 2.
Characteristics of the Sample
Survey instruments were mailed to 477 subjects chosen at random from the NE members of AONE. A total response rate of 35% was achieved, which included 64 NEs who declined to participate in the study. Those who declined did so for various reasons that included not currently being in an NE position, not employed in a hospital setting, just started in the NE position, and chose not to participate without offering a reason. One hundred thirteen NEs returned surveys, from acute care hospitals throughout the nation encompassing 35 states, resulting in a response rate of 24%, with 102 (22%) being usable.
The NE sample included 101 (99%) women and 1 (1%) man. National data regarding gender distribution among senior nursing officers reveal a slightly higher percentage of men (6%) in CNE positions.39 The average age of the participants is between 45 and 54 years and ranges from 35 years to 64 years.
The experience in nursing, for these NEs, is almost exclusively greater than 15 years. This finding is consistent with their reported age range. Close to 80% of the NEs hold a master's degree in nursing, business, a combined nursing and business degree, or in a related field, such as healthcare administration, reflective of the recommended educational preparation for advanced practice in nursing administration. In addition, 9% have earned a doctorate. The majority of these NEs are responsible for 1 organization; however, close to 25% do have responsibility for more than 1 organization. Seventy percent of the NEs have more than 15 years' experience in management. There is variation in the length of employment in their current position. Length of employment results are almost equally distributed between the categories of less than 2 years, 2 to 5 years, and 6 to 10 years of employment, with 14% having been in their NE position for 11 to 15 years.
The NM sample consists of 148 NMs. The sample included 141 (95%) women and 7 (5%) men, consistent with national trends for gender distribution in nursing. The mean age ranges from 35 to 44 years, with 43% of the NMs between 45 and 54 years old. Seventy-five percent have been in nursing for more than 15 years. Forty percent of the NMs hold a master's or higher degree, which is consistent with the recommended educational preparation for advanced practice in nursing administration. Thirty-eight percent of the NMs have a baccalaureate degree. One third of them have management responsibility for critical care and/or telemetry-monitored patient care areas. Twenty percent manage medical-surgical areas, while 11% are responsible for areas in women's and children's health, which includes labor and delivery, nursery, and pediatrics, and 13% manage operating room surgery areas.
The majority of NMs have more than 15 years' experience in management. Tenure in the organization, in their current position, ranges from less than 2 years to more than 16 years, with 18% having less than 2 years, 24% with 2 to 5 years, 25% with 6 to 10 years, and 18% with 11 to 15 years as an NM, and 15% for 16 years or more. Close to half report to the vice president/chief nurse executive (CNE). Another 44% report to a director-level nurse administrator, rather than directly to the CNE. One third of the NMs have worked with the current CNE for less than 2 years. Thirteen percent have worked together for 2 to 3 years, 22% for 4 to 6 years, 23% for 7 to 10 years, and 20% for 11 years or more.
The RN sample consists of 651 staff nurses. There are 608 (94%) women and 37 men (6%), consistent with national trends for gender distribution among nurses. The years of experience for 47% of the RNs is greater than 15 years. Approximately 40% of the RNs in this sample are aged 35–44 years. More than 62% of these nurses have 11 or more years of experience in nursing. Close to 40% hold a bachelor of science in nursing degree, which is consistent with the recommended educational preparation for professional nursing practice. Almost as many have an associate degree in nursing, with 6% who have a master's degree or higher. Approximately half of the RNs work in critical care and/or telemetry-monitored patient care areas, 21% work in medical-surgical areas, 8% work in women's and children's health, which includes labor and delivery, nursery, and pediatrics. Less than 10% work in the emergency department or operating room/surgery areas. The tenure of the RNs in their organizations ranges from less than 2 years to more than 20 years. One third of the RNs have worked for their current NM for less than 2 years, while the others have worked for their NM for 2 to 3 years and 6 to 10 years, respectively. The frequency of interaction with the CNE varies from infrequent interaction of zero to 2 times a year (42%); occasional interaction of 3 to 4 times a year (24%); frequent interaction of once a month (14%); and regular interaction with the CNE of 2 to 3 times a month (20%).
The mean of the NE self-report scores for TFL and TAL are 85.3 and 40.5, respectively. The NM self-report mean scores are 83.2 for TFL and 39.5 for TAL. The scales are 100 and 50, respectively. These results are shown in Table 3.
Spearman's rank order correlation coefficients were computed to determine the strength and direction of the relationship between the variables. The matrix in Table 4 shows the correlations between leadership and organizational commitment. A statistically significant negative relationship was found between NE transformational leadership (r = −0.24; P < .05) and alienative organizational commitment among RNs. In addition, a statistically significant negative relationship between NE transactional leadership (r = −0.31; P < .01) and RN alienative organizational commitment was also demonstrated.
Statistically significant positive relationships were found between NE transformational and transactional leadership and NM transformational (r = 0.26; P < .05) and transactional leadership (r = 0.23; P < .05), respectively. A statistically significant negative relationship between NM transformational leadership (r = −0.22; P < .05) and RN calculative commitment was shown. A negative relationship between NE TAL and NM calculative commitment (r = −.44; P <.05) was found. No relationship was found between NM organizational commitment and RN organizational commitment. Registered nurse moral commitment was also shown to be positively correlated with RN job tenure (r = 0.25; P < .001), experience in nursing (r = 0.21; P < .01), and age (r = 0.19; P < .05). A negative relationship was demonstrated between RN age (r = −.16; P < .05) and calculative commitment. These results are shown in Table 4.
Use of a cross-sectional design can be considered a limitation of this study. It is believed that commitment develops slowly, and a longitudinal study would more fully capture a description over time. This study involves the self-report method of data collection that presents the potential for bias among subjects who have described themselves. Nurse executives and NMs provided self-report data on their leadership profile, and NMs and RNs reported on the type of organizational commitment they experienced. Self-report perceptions may not be consistent with actual behaviors or individual experiences.
Implications and Recommendations
The results of this study show support for the conclusion that NE leadership has an effect on the type and degree of commitment experienced by staff nurses in the healthcare organizations in which they are employed. Nurse executives with TFL styles have a direct influence on staff nurses that inversely affects highly negative involvement or alienative commitment. Alienative organizational commitment is characterized by an individual who wants to leave the organization but feels trapped. Leadership serves to engage members of an organization, reduce feelings of alienation, and keep employee involvement productive. Nurse executive leadership, then, is important to organizations in a highly competitive industry with the consequences of a nurse shortage and scarcity of experienced nurses already evident.
Investigating the effects of transformational and transactional leadership style on organizational commitment among nurses in acute care general hospitals is important for expanding the knowledge of organizational commitment among professionals and for expanding knowledge of organizational commitment in times of rapid and dramatic organizational change. Finding a direct effect relationship between nurse executive leadership and organizational commitment among staff nurses amidst a low frequency of interaction between the two is important and it makes explicit the critical significance of this leader role to organizational members.
The finding that TAL style has a negative affect on alienative commitment among staff nurses is significant as well. It emphasizes that effective leadership includes both transformational and transactional leadership styles and that effective leadership has a positive influence on followers by reducing feelings of alienation and preventing negative involvement. Both transactional and transformational leadership behaviors are inversely related to alienative commitment.
Substitutes for leadership may be present in the work environments of professional nurses that neutralize a leader's effect by substituting for it.40 In previous research, formalization of an organization was found to be a strong substitute for leadership in predicting a subordinate's commitment to an organization.41 Substitutes for leadership may be particularly present in professional settings, where the work itself provides intrinsic task satisfaction and directs the professional worker and may mediate the effect of leadership on an individual's commitment to an organization. This may explain why the expected relationship between leadership and positive, moral commitment was not demonstrated in this study.
Factors other than the leadership of the NE must then be considered in determining the degree and type of organizational commitment experienced by nurses. Additional factors that are positively associated with organizational commitment include longer organizational tenure, opportunities for professional development, participation in decision making and empowerment, and supervisor-nurse relationship. In this study, RN job tenure (r = 0.26) and experience in nursing (r = 0.21) were significantly but weakly related to moral commitment. These findings are consistent with previous research on work experiences as the strongest predictors of moral commitment. Age is also significantly but weakly (r = 0.19) related to moral commitment. Higher age has been shown to be positively associated with commitment;42 however, when analyzed longitudinally, according to Bateman and Strasser,32 age is not a predictor.
No significant statistical relationships were found between the leadership of the NM and organizational commitment among nurses. Nurse manager leadership was expected to show a relationship to organizational commitment and to mediate the relationship of NE leadership to commitment among nurses. The NM role has greater interaction potential among nurses than the NE role. The role distance in terms of proximity, frequency of interaction, and familiarity is less than with the NE role, meaning that first-line managers have a physically and psychosocially closer relationship with nurses who work directly for them. Therefore, role distance would not explain an absence of a relationship between leadership and commitment. It is possible that changes in the role of the NM, which include expanded responsibilities and often supervision over more than one patient care area, are affecting the nature of their relationship with subordinates and have increased role distance such that it has mediated the effect of leadership on commitment. It is likely that substitutes for leadership are present in the organizational environment of nurses and this contributes to the absence of a leadership effect. However, the findings from this study are in contrast to those where a significant relationship was found among managers and organizational commitment in their employees.25,43,44 The expected relationship between NM leadership and staff nurse commitment should be measured through a larger sample of staff nurses (>5) per NM.
Several researchers support a multiple-constit-uency approach to analyze commitment. Reichers45 identified that although individuals can experience commitments to 1 or more groups, when organizational commitment to the whole organization is measured, we are capturing an employee's commitment to “top management.” It is likely, then, that the findings in this study regarding the absence of a leadership influence by the NM on the organizational commitment of the RN, are the result of a global measure of organizational commitment that captures an individual's commitment to top management rather than the absence of a relationship with the immediate supervisor.
The predicted association between NE leadership and the leadership of the NM was supported. A positive relationship was expected between the TFL style of the NE and the leadership of the NM. Bass et al20 describe the falling domino effect of TFL that can occur among leaders and followers. Subordinates are influenced by the performance of transformational leaders, which serves as a reference point, as well as by their superior's expectations.46
Nurse leaders are in a position to influence organizational commitment among nurses. Based on the findings and implications of this study, the following recommendations are offered for consideration by NE leaders:
1. Develop and demonstrate TFL and TAL behaviors.
2. Increase the frequency of staff nurse exposure to NE leaders.
3. Nurture the involvement of staff nurses and their relationship to the organization with transformational and transactional leadership behaviors.
4. Involve nurses in determining which factors contribute most to their perceptions of alienative commitment.
5. Assess organizational commitment over time at designated intervals and among nurses who actually quit.
6. Address contributing factors through strategic planning and committed actions to improve obstacles to optimal nursing practice and to retention.
7. Create innovative ways to engage nurses in the decisions that affect their practice and the environment in which they work.
This descriptive study explores more fully the type of commitment perceived among professionals in organizations as reported by this large sample of nurses from hospitals throughout the United States. The relationship between TFL among NEs and NMs and organizational commitment was analyzed, which indicates support for the influence of leadership on staff nurses that diminishes alienative commitment. Knowledge of the effect of leadership, on the type and degree of commitment experienced by nurses in contemporary hospital settings, extends our understanding of how professionals perceive their organizational bonds during a time of dramatic change in healthcare delivery and makes explicit the importance of the nurse leader role to involvement among nurses.
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