Abstract
Purpose
In recent decades, human resource management (HRM) in health organizations has faced several problems associated with employees' efficiency and happiness, which has been particularly exacerbated after the pandemic crisis. In this scenario, this study seeks to analyze nurses' turnover intention by comparing Portuguese public and private healthcare organizations. As determining factors, transformational leadership, perceived organizational support and organizational commitment were considered.
Design/methodology/approach
A survey was digitally applied to 277 nurses from Portuguese public and private healthcare organizations.
Findings
Results suggested that there are differences in nurses' turnover intentions: there is a greater likelihood of nurses in the private sector planning to leave the healthcare organizations the nurses work for when compared to public hospital nurses. Furthermore, nurses in public hospitals perceive lower levels of transformational leadership, organizational support and organizational commitment than those in the private sector. The underlying cause as to the intention of leaving the public sector resides in normative commitment. On the other hand, lower affective commitment explains the intention to abandon the private sector.
Practical implications
This study is relevant for human resource managers and administrators in public and private hospitals since it enables a diagnosis of the situation, as well as a definition of the most appropriate policies for each of the sectors as a strategy to attract and retain health professionals.
Originality/value
This study is significant as the study provides a better understanding of the reasons which lead nurses to consider leaving the organization where the nurses work and the difference between nursing professionals in public and private hospitals.
Keywords
Citation
Freire, C. and Azevedo, A. (2023), "“Look before you leap”: comparing the turnover intention of nurses as public servants and private employees", Journal of Organizational Effectiveness: People and Performance, Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/JOEPP-03-2023-0072
Publisher
:Emerald Publishing Limited
Copyright © 2023, Carla Freire and Adriano Azevedo
License
Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode
Introduction
Human resource management (HRM) in health organizations has encountered problems associated with staff efficiency and happiness, namely overwork (Bosak et al., 20021), demotivation and difficulty in retaining professionals. This problem was particularly exacerbated after the pandemic crisis by those in front-line response (Caldas et al., 2020). The issues of budget cuts in public health systems in recent decades, the growing pressure in the demand for health services (Schmidt et al., 2017) and the difficulties revealed in the management of people in hospitals during the pandemic crises (Nicola et al., 2020) have resulted in great challenges for health professionals and nurses in particular. These organizational dynamics have had an impact on the performance and happiness of health professionals (de Waal, 2018; Gray et al., 2019), as well as on the quality of patient care (Top et al., 2015). In certain countries, such as Portugal, these problems tend to be more pronounced in public organizations after the pandemic crisis (Martins et al., 2023), mainly due to the increasing overload in services and budgetary difficulties (OECD, 2021). The consequences for HRM in these organizations are diverse, namely, health professionals in public organizations have shown an increasing interest in moving to private organizations, or even in seeking better conditions in other countries (Simões et al., 2017).
Generally speaking, public health organizations have tended to provide greater stability in employment contracts. As such, public servants usually enjoy a status of greater security in the contractual relationship than professionals from private organizations. As such, job security has somehow compensated for the worse working conditions – more specifically, the lower wages and heavy workload that nurses in the public have seen (OECD, 2021). In this context, there has been a demand for better working conditions, especially in the public sector, which has been accompanied by a recent growing trend of departure or intention to leave these job positions. In this scenario, the performance of health professionals and health systems can be better understood and planned if there are studies on the perception of workers regarding their intention to leave the organization. This is often determined by fundamental management issues associated with organizational behavior such as leadership, the perception of organizational support and organizational commitment.
Bearing all these facts in mind, this study seeks to analyze nurses' turnover intention by comparing Portuguese public and private healthcare organizations, considering transformational leadership, perceived organizational support and organizational commitment as determining factors. Understanding the reasons behind the intention to leave the organization is useful at several levels. For human resource managers, this knowledge makes it possible to devise plans to retain the most talented people, as well as reduce recruitment and training costs. For health organizations and their administrators, it enables a diagnosis of the situation as well as a definition of the most appropriate policies for each of the sectors, as a strategy to attract and retain health professionals.
Conceptual framework and hypotheses
Transformational leadership
According to Burns (1979), transformational leadership occurs when “leaders and followers raise one another to higher levels of motivation and morality” (p. 20). Subsequently, Bass (1985) defined transformational leadership as the inspiring and motivational behavior of leaders in relation to their followers, so that the latter exceed the former's expectations when exercising their professional activities.
A transformational leadership approach focuses on identifying the features of leadership behaviors that influence employees (Burns, 1979; Bass, 1985, 1990; Bass and Avolio, 1994, 2000; Yukl, 2013). These are: idealized influence; inspiring motivation, intellectual stimulation and individualized consideration (Bass and Riggio, 2005; Bono and Judge, 2004).
Idealized influence refers to leaders who develop high standards of moral and ethical conduct, who are held in high personal regard by those they lead and who generate a sense of loyalty. Leaders who possess this characteristic serve as a model for those they lead: they are respected, admired and trusted. Additionally, they are recognized for their abilities, persistence and determination (Bass and Riggio, 2005; Bono and Judge, 2004). Inspiring Motivation refers to leaders with a strong vision of the future based on their values and ideas. They motivate and inspire followers, showing them the meaning and purpose of the work at hand. In this dimension, leaders tend to stimulate enthusiasm, build trust and inspire their followers by using symbolic actions and persuasive language. They promote team spirit, involve employees, lead with an optimistic vision of the future, create clear expectations and demonstrate a shared vision and commitment to goals (Bass and Riggio, 2005; Bono and Judge, 2004). Intellectual stimulation refers to leaders who challenge organizational norms, promote lateral thinking, as well as encourage employees to be more creative and to develop alternative solutions and innovative strategies (Bass and Riggio, 2005; Bono and Judge, 2004). Individualized consideration refers to leader behaviors that acknowledge employees' real need for growth and development. In this process, transformational leaders support, motivate and guide without making subordinates feel that they are controlled. The delegation of tasks is seen as a strategy to develop individual capacities and monitoring is carried out with the aim of guiding and assessing needs (Bass and Riggio, 2005; Bono and Judge, 2004).
Carless et al. (2000) grasped the essence of the abovementioned studies (e.g. Bass and Avolio, 1994; Podsakoff et al., 1990) and developed a scale which is able to measure seven characteristic behaviors of a transformational leader. This is someone who (1) communicates a vision and image of the future of the organization; (2) develops team members, seeking to diagnose the needs and capabilities of each employee and to express an individual interest; (3) provides support, thus assisting employees to achieve goals through coordinated teamwork; (4) empowers and gives authority to employees so that they may implement policies and supports them in the decisions made; (5) follows unconventional strategies to meet established goals; (6) leads by example, adopting behaviors that are congruent with his/her attitudes and values, and (7) and shows charisma in inspiring employees to transcend individual interests, developing a collective conscience and guiding the group towards the achievement of extraordinary goals.
In the health sector, studies on transformational leadership also establish a link between positive outcomes for the individual and the organization (e.g. Loke, 2001; Leach, 2005). For example, the study by Loke (2001), which included 100 nurses and 20 head nurses, was able to conclude that the leader's exemplary behavior influenced job satisfaction, organizational commitment and productivity (Loke, 2001). Another study undertaken with 520 nurses from a Singapore hospital (Avolio et al., 2004) revealed that the direct and indirect forms of leadership exercised by the head nurse were significantly correlated with organizational commitment. The study further established that psychological empowerment had a moderating effect on the relationship between transformational leadership and organizational commitment (Avolio et al., 2004).
The theory states that transformational leadership elevates employees' engagement, leading them to go beyond their personal interests and acquire a sense of group mission. In addition, transformational leaders guide their employees towards the development of positive relationships and a positive perception of the organization and, subsequently, the support they can expect from it.
Perceived organizational support
Eisenberger et al. (1986) defined the concept of perceived organizational support as the general understanding developed by employees regarding how far the organization values their contributions and cares about their well-being. These authors suggest that the ability of organizations to reward employees' efforts, as well as to recognize their need for rewards and approval, develops a sense among staff that their contributions are valued and that the company truly cares about their well-being (Eisenberger et al., 2001). This understanding depends on the frequency, intensity and sincerity of praise, as well as on the material and social reward of companies towards their members. A favorable perception of organizational support is related to an expectation of superior performance and a greater involvement of employees to achieve the company's goals, thus favoring the organization.
The perception of organizational support is influenced by several aspects of the organization's behavior towards the employee which, in turn, influences the employee's interpretation of the reasons for the behavior at hand. This implies that the employee has expectations as to the level of support provided by the organization in different situations, whether in future absences due to illness, in the mistakes made, or in situations of higher-than-expected performance. Perceived organizational support depends on the same attribution process that people commonly use to infer engagement in a social relationship (Eisenberger et al., 1986).
In the organizational support theory, Kurtessis et al. (2017) determine that the perception of organizational support is related to the attributions employees make regarding the favorable or unfavorable treatment received from the organization. In turn, the perception of organizational support initiates a process of social exchange, during which employees feel an obligation to help the organization achieve goals and objectives and hope that this additional effort is translated into rewards (Eisenberger et al., 2001). Additionally, when social and emotional needs are met through the perception of organizational support, this generates identification, commitment and a desire to help the organization, ultimately leading to greater psychological well-being (Kurtessis et al., 2017).
The perception of organizational support is then related to the employees' perceptions of the way they are treated. When the organization has favorable treatment criteria, as opposed to external factors such as labor market restrictions and government regulations, this heightens the perception of organizational support. Likewise, providing benefits that employees actually use and addressing their real needs, also increases the perception of organizational support (Gouldner, 1960).
The organizational support theory focuses on the notion of social exchange, through which the employee perceives that he or she exchanges effort and loyalty for tangible benefits and social resources from the organization. The perception of organizational support is thus associated with the concept of reciprocity: as the employee seeks to help the organization, there is also the expectation of being rewarded for this behavior. As a result, employees with a high perception of organizational support engage in greater work efforts, leading to an improved performance of their roles and even those which are not directly assigned to them, but which contribute to the smooth running of the organization (Eisenberger et al., 2001).
The organizational support theory is often understood to be a process of predominant social exchange. However, when the employees' social and emotional needs (approval, esteem, affiliation and emotional support) are associated with a perception of organizational support, this appreciation heightens their sense of identification with the organization. This connection can ultimately enhance affective commitment through the development of common values, thus promoting a close relationship between employees and the organization.
Paschoal et al. (2010) developed a study in which 403 employees at a company responded to a scale of perceived organizational support containing four aspects: performance management, workload, material support and promotion, as well as salaries. The results revealed that organizational support has a direct impact on employees' well-being, with performance management being the main predictor of positive affect and accomplishment at work. On the other hand, workload was the main predictor of negative affect at work. In 2003, Allen, Shore and Griffeth carried out a study involving two samples of 215 and 197 employees, which aimed to verify the role of Perceived Organisational Support (PSO) in voluntary turnover. The results suggest that the employees' perceptions of the support provided by human resource policies contributed to an increased perception of organizational support. This, in turn, contributed to the development of organizational commitment and job satisfaction. Consequently, the perception of organizational support seems to impact negatively on the intention to leave the organization.
As can be seen, the attributions employees make regarding favorable or unfavorable treatment by the organization is the greatest explanation for various organizational behaviors, namely those of organizational commitment and the intention to remain with the organization.
Organizational commitment
Organizational commitment is defined as the relationship between individuals and the organization (Meyer and Allen, 1991; Meyer and Parfyonova, 2010), which generates an impact on the individual, group and organizational performance (Rego et al., 2004). In literature, one can identify two perspectives of organizational commitment: the behavioral perspective, which considers the way individuals attach themselves to the organization; and the behavior that results from this thinking process (Salancik, 1977). The definitions of behavioral commitment focus on behaviors that exceed formal and normative expectations (Decotiis and Summers, 1987). In contrast, the attitudinal perspective of commitment, which has been developed more often in literature, focuses on the process during which employees think about their relationship with the organization and consider both parties' values and goals (Mowday et al., 1979; Allen and Meyer, 1990; Meyer and Allen, 1991; Meyer and Parfyonova, 2010) This commitment often includes a reciprocal relationship, in which employees expect to receive certain rewards in return for their efforts.
Some authors conceptualize attitudinal commitment as being synonymous with the affective component of the three-dimensional model presented by Meyer and Allen (1991). They have defined it as an effective response that ensues from an assessment of the work situation linking the employee to the organization. It represents the extent of involvement, loyalty and identification with the organization (Mowday et al., 1979), thus making turnover intentions less evident (Moreira et al., 2022). Meyer and Allen (1991) analyzed organizational commitment according to a three-dimensional model, consisting of three domains: affective, instrumental and normative. These authors consider dimensions rather than types of commitment; they believe that each dimension of commitment does not exclude the other and can co-exist (Meyer et al., 2002; Meyer and Parfyonova (2010). Furthermore, this model can be applied to organizational commitment in general (Meyer and Herscovitch, 2001).
The affective component refers to the employee's emotional connection, identification and involvement with the organization (Meyer and Allen, 1991). Employees with an affective dimension remain and want to remain in the organization (Meyer and Allen, 1991; Moreira et al., 2022). This connection develops when employees perceive that the organization respects and supports them, when they trust their superiors, or when they find fulfillment at work and realize that the organizational goals and values match their own (Meyer and Allen, 1991). Based on the study by Becker (1960), the instrumental component focuses on the individual's choice to align with the organization's objectives, taking into account a balance of the costs and benefits of leaving the organization. This balance contributes to a final decision of whether or not to remain in the job (Becker, 1960).
For Meyer and Allen (1991), instrumental commitment develops when the employee recognizes that losses will ensue in the prospective abandonment of the organization, or feels that he/she does not have attractive alternatives in other organizations. The instrumental component refers to the employee's awareness of the costs associated with leaving the organization. Individuals with instrumental-based commitment remain in the organization because they need to (Meyer and Allen, 1991). The model by Meyer and Allen (1991) suggests that instrumentally committed people are unlikely to perform beyond the expected minimum (Rego and Souto, 2004).
The model argues that the employee's instrumental commitment is centered on the exchange relationship that occurs between the employee and the organization. If, during this relationship, the employee feels rewarded, or if leaving the organization means significant economic, social and psychological harm, the individual develops an attitude of passivity and ultimately stays with the organization (Becker, 1960).
Finally, the normative component concerns the employee feeling obliged to remain in the organization. Individuals whose attachment to the organization is based on the normative dimension stay with the organization out of a sense of duty. Normative commitment emerges when the individual internalizes organizational norms through socialization and is based on loyalty and duty to the organization. This dimension of commitment is natural and stems from the socialization process; it can be explained by the individual's commitment to other social phenomena, such as marriage, family and/or religion. Therefore, in his/her relationship with the organization, this moral obligation also prevails (Meyer and Parfyonova, 2010).
Turnover intention
The intention to leave, or turnover, is defined as the conscious and deliberate process of leaving an organization. Studies on the intention to leave are anchored in the theory of Planned Behavior (Ajzen, 2011), as well as in the model proposed by Mowday et al. (1982) which indicates that intention is what precedes actual departure from the organization. It is usually measured in terms of time and is described as a consequence of thoughts of organizational withdrawal, dismissal and the intention to seek an alternative to current employment (Tett and Meyer, 1993). Turnover intention constitutes an important indicator of the behavior which severs a relationship with an organization and has potential consequences for both the person and the organization involved (Porter and Steers, 1973).
Given the negative impact of organizational turnover (for example, the costs associated with the dismissal process, loss of productivity and less satisfaction of the remaining employees), the challenge facing HRM today is the development of human resource policies that invest in employees. Besides these measures, practices which develop a perception of organizational support, such as individual recognition and opportunities for professional development, generate within the employee a sense of duty in assisting those who helped him/her, in order to counterbalance the benefits and opportunities offered by the organization, thus leading to lower turnover intention (Mobley, 1982).
Allen et al. (2003) proposed a theoretical model which claims that employee-centered human resource practices, which enable the development of staff and recognize their contribution, lead to an increase in the perception of organizational support, consequently impacting on turnover intention. With this model, the authors also suggest that the perception of organizational support is positively correlated with commitment and satisfaction which, in turn, is negatively related to turnover intention.
Some studies have analyzed the impact of nurses' leadership in management positions and its effect on employee turnover (e.g. Sellgren et al., 2007; Galletta et al., 2013; Labrague et al., 2020). By using a sample of 770 nurses from 15 hospitals in the Philippines, Labrague et al. (2020) concluded that transformational leadership influenced the intention to leave the organization.
Differences between private and public healthcare organizations
Some studies have examined the differences in levels of transformational leadership, perceived organizational support, organizational commitment and turnover intention, between nurses who work in public hospitals and those who work in private hospitals (Chan et al., 2013; Top et al., 2015; Abdelhafiz et al., 2016; Martins et al., 2023) (see Figure 1). Studies point to the specificities of health systems in different countries and show different conclusions. For example, the study by Abdelhafiz et al. (2016) conducted in Jordan, concluded that nurses in public hospitals perceived higher levels of transformational leadership when compared to those in private hospitals. And the study undertaken by Pillay (2009) found that nurses in public hospitals experienced higher levels of dissatisfaction in general, which determined higher levels of turnover intention when compared to those in private hospitals.
However, the combination of these variables in a single study is innovative in literature. In this sense, the present study seeks to fill this gap by exploring the combination of these variables in the comparison between nurses who work in public hospitals and those employed by private hospitals. In this sense, the following hypothesis was formulated:
There are significant differences in the levels of transformational leadership, perceived organizational support, organizational commitment and the turnover intention of nurses as public servants, when compared with nurses as private employees.
Transformational leadership, perceived organizational support, organizational commitment and turnover intention
Various studies have sought to analyze the impact of several organizational variables on turnover intention, such as: the impact of transformational leadership on voluntary turnover intention (Wells and Peachey, 2011; Sun and Wang, 2017); the impact of transformational leadership on organizational commitment (Iqbal et al., 2020) and on perceived organizational support (Bernarto et al., 2020); or the impact of the perceived level of organizational and supervisory support on voluntary turnover (Allen et al., 2003; Newman et al., 2011). For example, the study by Engelbrecht and Samuel (2019) tested a model, concluding that transformational leadership influences employees' turnover intention through the perception of organizational support (Engelbrecht and Samuel, 2019). Additionally, the study by Martins et al. (2023) concluded that turnover in public hospitals is due to transformational leadership through the effect of affective and normative commitment. However, few studies have explored the effect of these variables by taking into account the differences between health professionals in the private sector and those in the public sector (Top et al., 2015).
This study seeks to fill this gap by exploring the effect of transformational leadership, perceived organizational support and organizational commitment on turnover intention by analyzing the differences between nurses who work in public hospitals and those who work in private hospitals. In this sense, the following hypotheses were formulated:
Transformational leadership, perceived organizational support and organizational commitment influence the turnover intention of nurses as public servants.
Transformational leadership, perceived organizational support and organizational commitment influence the turnover intention of nurses as private employees.
Method
Data collection procedure
Before applying the questionnaire, a pre-test was carried out in order to verify its intelligibility and to detect possible typographical errors in the construction. To this end, the questionnaires were answered by six nurses, who were subsequently consulted in an attempt to understand potential difficulties in interpreting the instrument, as well as their opinion regarding the clarity of the questions. All the pre-test participants revealed that the questionnaire was clearly written, easy to understand and quick to answer. After carrying out a pre-test of the questionnaire and receiving feedback from the participants, the process of implementing the questionnaires in an online version began, which was supported by the Microsoft Forms platform. The questionnaires were applied during the month of October 2021 and a short url was created to access the questionnaire. This was sent by email to all the nurses and professional colleagues of one of the researchers, in which they were invited to participate in the study by answering the questionnaire. They were also asked to share the short url with other nurses/co-workers. Aiming to follow the principles of the Declaration of Helsinki and the Oviedo Convention, the header of the questionnaire contained an explanation of the study objectives, as well as a clarification concerning the guarantee of confidentiality and anonymity of the data throughout the study phases, the possibility of abandoning the study at any time and a consent form with additional reference to the fact that the respondent was free and fully informed.
Sample
From the application of the questionnaires, 277 valid responses were obtained. The sector of activity most represented in the sample was the public sector, with 159 individuals (57.4%), followed by the private sector, with 118 responses (42.6%).
The respondents' detailed characterization regarding gender, age, educational background, contractual relationship and seniority in the organization are provided in Table 1.
Measures
In order to measure transformational leadership, perceived organizational support, organizational commitment and turnover intention, scales were selected from literature and a translation into Portuguese was undertaken. This translation was then compared to others already produced previously for Portuguese studies in the context of health (e.g. Van Beveren et al., 2017), As a result of this procedure, a few changes were made to the initial translation. The following scales were selected:
Transformational leadership – 7 items from the scale by Carless et al. (2000) were used. Some examples are “My leader promotes trust, involvement, and cooperation among team members”; and “My leader is clear about his values, and practices what he/she stands for.” The scale ratings consisted of five points, ranging from 1. Strongly disagree to 5. Strongly agree.
Perceived Organizational Support – 8 items from Eisenberg et al. (1986) were used. Response options ranged from 1. Strongly disagree to 5. Strongly agree. Examples of items are: “The organization values my contribution to institutional well-being” and “The organization really cares about my well-being”.
Organizational commitment – the revised scale by Meyer and Allen (1991) was used to measure the three dimensions of commitment: affective, normative and continuation (6 items for each subscale). Response options ranged from strongly disagree to strongly agree (5 points). “This organization has great personal meaning to me” (affective); “This organization deserves my loyalty” (normative) and “I believe that there are very few alternatives to think about leaving this organization” (continuance).
Turnover intention – Bozeman and Perrewé's (2001) 5-item scale was used to indicate the level of respondents' agreement regarding the intention to leave the organization. Some illustrative examples are: “You are likely to look for another job in the near future” and “I am currently looking for another job in another organization”. A five-point Likert scale was used, ranging from 1. Strongly disagree to 5. Strongly agree.
Data analysis procedure
Data analysis was performed using the 27th version of the IBM SPSS (Statistical Package for the Social Sciences) statistical program (Field, 2013) and IBM SPSS AMOS (Analysis of Moment Structures) Graphics (Byrne, 2016). For the construction of validity and reliability, one first conducted an exploratory factor analysis (EFA) by following two assumptions: (1) items should have loadings higher than 0.50 (Field, 2013); and, (2) Cronbach's alpha factors should have values greater than 0.70 (Nunnally, 1978). Secondly, a Confirmatory factor analysis (CFA) was performed following the Maximum likelihood method. The indices considered to determine the model fit were: Chi-square tests, the mean square error of approximation (RMSEA), goodness-of-fit statistics (GFI), standardized root mean square residual (SRMR), comparative fit index (CFI), incremental fit indices (IFI) and the Tucker–Lewis coefficient (TLI). Reference values are, for example, above 0.90 for the CFI (IFI) and RMSEA values equal to or less than 0.08 (Fornell and Larcker, 1981). For the indicator χ2/df, the values should be less than 3 (Kline, 2016). Convergent validity was then estimated and the following indexes were considered: Average variance extracted (AVE-above 0.50 for variance) and composite reliability (CR-above 0.70 for reliability) (Field, 2013). In order to proceed with a diagnosis of Multicollinearity, the following values were considered: Tolerance Values (greater than 0.20) and the Variance Inflation Factor (less than 4).
Correlations among the study variables and descriptive statistics (mean and standard deviation) were performed to detect some trends relating to the type of association between turnover intention and other variables (estimation for both sectors).
Finally, the t-Test was used to examine the proposed hypotheses, since it enabled one to compare the means of nurses' responses as public servants and as workers in private organizations. For the t-Test, some assumptions were considered: the Kolmogorov–Smirnov test (p > 0.05) for normality and Durbin–Watson tests (approximately 2, not less than 1) (Field, 2013) for the independence assumptions of the residues. Multiple linear regression models were finally performed to determine the reasons for the turnover intention of these professionals in both the public and private sectors.
Common Method Variance
The use of a long, multi-scale questionnaire in a cross-sectional study may pose a risk of the occurrence of common method variance (CMV). In order to minimize this possibility (Podsakoff et al., 2003), Harman's single-factor test (Harman, 1967) was run, considering all the items on the scales that comprise the questionnaire. The variance values obtained (34%) were much lower than the maximum value of 50% considered. As such, it was concluded that the values do not indicate problems associated with CMV.
Results
Construction of validity and reliability
After conducting an EFA, CFA was performed (for all the latent variables, namely: transformational leadership, perceived organizational support, organizational commitment and turnover intention), with the values indicating a good fit with the data: χ2/df = 1.639, CFI = 0.974, IFI = 0.974, GFI = 0.880, TLI = 0.967, SRMR = 0.072, RMSEA = 0.048. In this analysis, all the indicators obtained significant factor loadings in the latent construct (Byrne, 2016). One then estimated convergent validity and composite reliability, the values of which were found to be within the reference values (Field, 2013). Finally, and according to the diagnosis of multicollinearity undertaken, the correlation between the study variables proved to be acceptable. Consequently, one proceeded with the subsequent analysis.
Correlations among the study variables and descriptive statistics (mean and standard deviation) are presented in Table 2. The correlation matrix allowed for the detection of some trends relating to the type of association between turnover intention and other variables (estimation for both sectors). From this analysis, there seem to be strong and negative correlations with organizational commitment (r = −0.501; p < 0.001), more specifically in the cases of the affective (r = −0.527; p < 0.001) and normative dimensions (r = −0.372; p < 0.001), with no association to continuation commitment. The data thus allow one to conclude that nurses who show greater commitment, whether in the affective aspect or in the normative component, reveal less intention to leave the organization.
Hypotheses testing
In order to analyze the different perceptions of nurses in the public sector, in comparison to the private sector, the average scores for the study variables were considered. Table 3 reveals significant mean differences between the public and private sectors for transformational leadership, perceived organizational support, organizational commitment (global, affective and normative) and turnover intentions.
The mean scores of private sector nurses were higher than the mean scores of nurses as public servants. Mean scores for transformational leadership were also higher for private hospital nurses (3.117) when compared to public servant nurses (2.799). The average value of organizational support perceptions was 2.934 in the private sector (SD (standard deviation) = 0.807) and 2.509 in the public sector (SD = 0.835). The average value of commitment was also higher in the private sector (3.119) than in the public (3.055). Continuance commitment was the only dimension that did not show significant differences in the comparison between nurses working in public and private hospitals. While the turnover intention was higher in the private sector, with an average score of 2.956 (SD = 1.027), it was 2.674 (SD = 1.069) in the public sector. In average terms, the greatest difference between the public and private sectors was found to be in the perceptions regarding organizational support and normative commitment, which register higher values in private hospitals. Results confirmed that there are significant differences in transformational leadership, perceived organizational support, organizational commitment and the turnover intentions of nurses as public servants when compared with nurses as private employees. Thus, H1 was accepted.
Table 4 records the values obtained in the multiple regression analysis to determine the predictors of the turnover intention of nurses in public hospitals versus private hospitals. Thus, according to the analysis, the values indicate that 22.5% of the variance (Adjusted R2 = 0.20; F = 8.898; p < 0.001) of nurses' turnover intention as civil servants was explained by the independent variables (transformational leadership, perceived organizational support, overall commitment, affective commitment, normative commitment and continuance commitment).
The regression analysis values revealed that normative commitment (β = −0.353; t = −3.356; p < 0.001) has a significant effect on the dependent variable turnover intention of nurses in public hospitals. The strongest predictor of the turnover intention of nurses in public hospitals is organizational commitment (normative). However, normative commitment negatively influences turnover intention. Consequently, H2 was partially confirmed insofar as it is only the organizational commitment variable that influences the turnover intention of nurses as public servants.
In the private sector, the results of regression analysis (Table 3) showed that 53.8% of the variance (Adjusted R2 = 0.517; F = 26.075; p < 0.001) of nurses' turnover intention as private employees was explained by the independent variables.
The values indicated that affective commitment (β = −0.891; t = −7.010; p < 0.001) had a negative and significant effect on the turnover intention of nurses in private hospitals. The strongest predictor of the turnover intention of nurses in private hospitals was affective commitment, which negatively influenced turnover intention. Consequently, H3 is partially confirmed insofar as it is only the affective dimension of organizational commitment that negatively influences the turnover intention of nurses as private employees.
Discussion and conclusions
One of the most relevant contributions of this research is the comparison of nurses’ turnover intentions in both public and private healthcare organizations, exploring the effect of several organizational variables such as transformational leadership, perceived organizational support and organizational commitment. The choice of this set of predictor variables for turnover intention is innovative in literature. However, some studies had already analyzed the impact of some of these variables on turnover intention in healthcare organizations (Martins et al., 2023). For instance, the impact of transformational leadership on nurses' turnover intention (Sellgren et al., 2007; Galletta et al., 2013; Labrague et al., 2020; Wells and Peachey, 2011; Moreira et al., 2022) and the higher levels of organizational commitment shown by their subordinates (Park, 2017; Sun and Wang, 2017; Anwar et al., 2021). Another example is the study by Avolio et al. (2004), which used a sample of staff nurses employed by a large public hospital in Singapore. It found a positive association between transformational leadership and organizational commitment. In addition, the study by Wells and Peachey (2011) also concluded that transformational leadership had an impact on voluntary turnover intention. Other studies have analyzed turnover intention through transformational leadership and the perception of organizational support (Engelbrecht and Samuel, 2019; Allen et al., 2003), or the relationship between transformational leadership and organizational commitment through the perception of organizational support (Anwar et al., 2021).
As expected, the results of this study indicated that commitment has a significant direct effect on turnover intention (e.g. Meyer and Allen, 1991; Moreira et al., 2022). Data revealed that normative commitment has a significant direct and negative effect on the turnover intention of nurses in public hospitals and affective commitment has a significant direct and negative effect on the turnover intention of nurses in private hospitals.
For Meyer and Parfyonova (2010) the intensity with which normative commitment manifests itself depends on the strength of the other components, the affective and instrumental. In the case of public hospitals, the intensity was greater due to feelings of moral duty or a sense of indebtedness to the organization. In contrast, in the context of the private sector, the affective bond emerged more strongly and produced a greater impact on the intention to leave than the other components.
These results show that nurses as civil servants, who have traditionally enjoyed more stable employment contracts than nurses in the private sector, intend to leave and may not do so due to a normative bond and feelings of obligation towards the organization. This sense of duty and loyalty to the organization now seems to be the condition to keep health professionals in public organizations. Normative commitment emerges when the individual internalizes organizational norms through socialization, or when he/she receives benefits and experiences (Meyer and Allen, 1991). This dimension, which points to a feeling of indebtedness regarding what the professional received from the organization, or a sense of duty to the public cause and common good, now seems to constitute a determining factor in wishing to remain.
These results are also in line with the study by Meyer and Allen (1991), who indicated that the main predictor (or antecedent) of turnover intentions is organizational commitment. In line with this research, Meyer and Parfyonova (2010) suggested that the impact of commitment on the intention to leave is related to the exchange relationship established between the individual and the organization and the way the individual feels that he/she is treated by the organization. In the current study, transformational leadership and perceived organizational support, despite registering significantly lower levels in the perception of nurses from public hospitals, do not determine nurses' intention to leave. This evidence appears to indicate that these professionals “look before they leap”; that is, they are farsighted and cautious in their intention to leave because they consider that their stronger contractual bond compensates for the difficulties encountered in the profession. In the private sector, the intention to leave does not seem to be influenced by an employment status perspective. Nurses reveal that turnover intention can occur even when there is an affective bond between the health professional and the organization.
Managerial implications
The way people are managed in the health sector has an extremely significant impact on organizational efficiency and, more specifically, on the provision of health services which ensure that the population is treated according to criteria of safety and quality (Anwar et al., 2021). In this sense, hospital administrators, particularly those in the public health sector, must bear in mind that organizational commitment has an important effect on an employee's desire to remain in the organizations (normative in the public sector and affective in the private sector) and, subsequently, on the employee's performance and organizational success.
In this context, human resource policies should focus on measures that provide the support required for nurses to carry out their duties by creating the conditions that lead to sustainable organizational success in the medium and long term. In other words, the necessary conditions must be ensured so that these professionals feel they are supported by the organization and by leadership (Dahleez et al., 2022) and that their careers are valued in order to increase sustainable employability. Communicating high expectations, fostering training and development, providing single attention and treating each employee individually, inspiring by example and providing a sense of mission: all of these aspects tend to enhance organizational commitment, reduce the intention to leave the organization and contribute to organizational success, whether it be public or private. For Labrague et al. (2020), these behaviors and practices should be included in human resource strategies for the retention of nurses. Increasing the organizational and leader support perceived by employees can be an easy-to-implement measure for organizations, which is less expensive and less complex than increasing remuneration or redesigning tasks. Indeed, it can produce better results in terms of organizational commitment and turnover intention. A greater recognition on the part of the organization regarding the contributions made by employees may also prove to be an effective tool in retaining professionals, particularly in the case of nurses. Other measures to enhance organizational commitment could be, for example, the creation of career development plans and integrated performance and training programs (Nasurdin et al., 2008), as well as a concern with measures that promote a well-adjusted work-life balance. In short, the development of these HRM policies and practices can promote organizational commitment, thus contributing to well-being, happiness at work and organizational performance.
Limitations and future studies
The findings of this study have revealed some limitations. Firstly, the transversal methodology used makes it impossible to track the phenomena over time and thus analyze trends. Secondly, as the data were obtained during a period marked by the coronavirus disease 2019 (COVID-19) pandemic, the answers may have been influenced by the very troubling context experienced by these professionals.
Despite these limitations, the results obtained are promising and have strong practical implications; they can constitute a starting point for new studies in the area of commitment and turnover, which is of great concern to leaders and organizations today. In this sense, although this study makes several contributions to a better understanding of the reasons why nurses consider leaving the organization they work for, as well as the difference between nursing professionals in public and private hospitals, future studies may go further in the comprehension of the extent to which the perception of organizational support may mediate the relationship between organizational commitment dimensions and turnover intentions.
Conclusion
The results of this study suggest that there are differences in nurses' turnover intentions: private sector nurses are more likely to leave the healthcare organizations they work for than public hospital nurses. However, nurses in public hospitals perceive lower levels of transformational leadership, organizational support and organizational commitment than those in the private sector. The factor which provides an explanation for the intention to leave the public sector resides in the normative connection with the organization, as well as affective commitment in the private sector. In sum, normative commitment seems to constitute a determining factor in wishing to remain in the public sector and affective commitment in the private sector.
Figures
Demographic characteristics
| Public sector | Private sector | Total | ||
|---|---|---|---|---|
| Gender | Male | 37 (23.3%) | 19 (16,1%) | 56 (20.2%) |
| Female | 122 (76.7%) | 99 (83.9%) | 221 (79.8%) | |
| Age | 23–32 years | 38 (23.9%) | 62 (52.5%) | 36.1% |
| 33–42 years | 80 (50.3%) | 45 (38.1%) | 45.1% | |
| 43–52 years | 30 (18.9%) | 9 (7.6%) | 14.1% | |
| 53–62 years | 2 (1.7%) | 11 (6.9%) | 4.7% | |
| Education | Bachelor degree | 93 (58.5%) | 79 (66.9%) | 172 (62.1%) |
| Postgraduate degree | 42 (26.4%) | 32 (27.1%) | 74 (26.7%) | |
| Master degree | 7 (5.9%) | 24 (15.1%) | 31 (11.2%) | |
| Contractual relationship | Permanent contract | 119 (74.8%) | 89 (75.4%) | 208 (75.1%) |
| Fixed-term contract | 6 (3.8%) | 11 (9.3%) | 17 (6.1%) | |
| Open-ended contract | 33 (20.8%) | 7 (5.9%) | 40 (14.4%) | |
| Temporary basis | 1 (0.6%) | 11 (9.3%) | 12 (4.3%) | |
| Seniority in the organization | <7 years | 65 (40.9%) | 70 (59.3%) | 135 (48.7%) |
| 8–16 years | 47 (29.6%) | 41 (34.7%) | 88 (31.8%) | |
| 17–25 years | 30 (18.9%) | 5 (4.2%) | 35 (31.8%) | |
| >25 years | 17 (10.7%) | 2 (1.7%) | 19 (6.9%) |
Source(s): Authors' own creation/work
Correlations among the study variables
| Mean | SD | 1 | 2 | 3 | 4 | 5 | 6 | 7 | |
|---|---|---|---|---|---|---|---|---|---|
| Transformational Leadership | 2.935 | 0.972 | (0.94) | ||||||
| Perceived Support | 2.690 | 0.848 | 0.649** | (0.92) | |||||
| Overall Organizational commitment | 3.002 | 0.599 | 0.555** | 0.605** | (0.84) | ||||
| Affective commitment | 3.177 | 0.909 | 0.612** | 0.627** | 0.831** | (0.88) | |||
| Normative commitment | 2.654 | 0.897 | 0.482** | 0.527** | 0.852** | 0.644** | (0.87) | ||
| Continuance commitment | 3.282 | 0.755 | −0.054 | −0.023 | 0.339** | −0.031 | 0.062 | (0.70) | |
| Turnover Intention | 2.794 | 1.059 | −0.300** | −0.351** | −0.501** | −0.527** | −0.372** | −0.015 | (0.94) |
Note(s): N = 277. **Significant at p < 0.001 (2-tailed). Scale reliabilities (appear along the diagonal in italics)
Source(s): Authors' own creation/work
Mean scores for all the variables comparing nurses as public servants versus private employees
| Public servants (n = 159) | Private employees (n = 118) | |||||
|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | t | p | |
| Transformational Leadership | 2.799 | 0.982 | 3.117 | 0.933 | −2.721 | 0.007** |
| Perceived Organizational Support | 2.509 | 0.835 | 2.934 | 0.807 | −4.248 | 0.000*** |
| Overall Organizational commitment | 2.915 | 0.585 | 3.119 | 0.602 | −2.832 | 0.005** |
| Affective commitment | 3.055 | 0.947 | 3.341 | 0.832 | −2.609 | 0.010** |
| Normative commitment | 2.483 | 0.874 | 2.885 | 0.878 | −3.774 | 0.000*** |
| Continuance commitment | 3.292 | 0.760 | 3.267 | 0.750 | 0.278 | 0.781 |
| Turnover Intentions | 2.674 | 1.069 | 2.956 | 1.027 | −2.204 | 0.028* |
Note(s): *p < 0.05, **p < 0.01 and ***<0.001
Source(s): Authors' own creation/work
Regression models for turnover intention for nurses as public servants and as private employees
| Nurses as Public servants | Nurses as Private employees | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Unstandardized coefficients | Standardized coefficients | Unstandardized coefficients | Standardized coefficient | |||||||
| Β | Std. Error | β | t | Sig. (p) | β | Std Error | β | t | Sig. (p) | |
| (Constant) | 4.259 | 0.455 | 9.366 | *** | 6.221 | 0.400 | 15.559 | *** | ||
| Transformational Leadership | 0.046 | 0.112 | 0.042 | 0.413 | 0.680 | 0.159 | 0.098 | 0.144 | 1.625 | 0.107 |
| Perceived Support | −0.148 | 0.139 | −0.116 | −1.067 | 0.288 | −0.127 | 0.106 | −0.100 | −1.195 | 0.234 |
| Affective commitment | −0.106 | 0.117 | −0.087 | −0.908 | 0.365 | −0.891 | 0.127 | −0.722 | −7.010 | *** |
| Normative commitment | −0.399 | 0.119 | −0.353 | −3.356 | *** | −0.050 | 0.101 | −0.043 | −0.0494 | 0.622 |
| Continuance commitment | 0.043 | 0.101 | 0.030 | 0.423 | 0.673 | −0.082 | 0.090 | −0.060 | −0.908 | 0.366 |
| Model Summary | R = 0.475, R2 = 0.225, F = 8.898, p < 0.001 Durbin–Watson (DW) = 1.957 | R = 0.733. R2 = 0.538. F = 26.075, p < 0.001 Durbin–Watson (DW) = 1.524 | ||||||||
Note(s): Dependent variable: Turnover intention. *p < 0.05, **p < 0.01 and ***<0.0.001
Source(s): Authors' own creation/work
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Corresponding author
About the authors
Carla Freire is Assistant Professor at the Department of Management, Economics and Management School at the University of Minho, Portugal. She holds a Master's Degree in Human Resource Management and a PhD in Business Administration from the University of Minho. She has taught various general management and HRM courses in undergraduate and graduate programs and supervised numerous MA and PhD theses. She has published several articles and book chapters. Her main research interests centers on HRM, ethics and Corporate Social Responsibility (CSR), leadership and transversal competencies.
Adriano Azevedo is nurse at the hemodialysis center in Viana do Castelo. He holds a Master's Degree in Healthcare Management from the University of Minho and is currently attending a Master's Degree in People with Chronic Illness His main research interests centers on HRM and leadership.