A hierarchical model of the internal relationship marketing approach to nurse satisfaction and loyalty.pdf

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European Journal of MarketingA hierarchical model of the internal relationship marketing approach to nurse satisfaction and loyalty

James W. Peltier John A. Schibrowsky Alexander Nill

Article information:To cite this document:James W. Peltier John A. Schibrowsky Alexander Nill, (2013),"A hierarchical model of the internal relationship marketingapproach to nurse satisfaction and loyalty", European Journal of Marketing, Vol. 47 Iss 5/6 pp. 899 - 916Permanent link to this document:http://dx.doi.org/10.1108/03090561311306967

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A hierarchical model of theinternal relationship marketingapproach to nurse satisfaction

and loyalty James W. Peltier

Department of Marketing, UWW Institute for Sales Excellence,University of Wisconsin-Whitewater, Whitewater, Wisconsin, USA, and

John A. Schibrowsky and Alexander Nill Department of Marketing, University of Nevada-Las Vegas,

Las Vegas, Nevada, USA

Abstract

Purpose – The purpose of this study is to empirically test a hierarchical model of the antecedents of nurse job satisfaction and loyalty based on the internal marketing literature. Specifically, the studyaims to investigate the degree to which structural, social, and financial bonding activities influencenurses’ job satisfaction and retention.

Design/methodology/approach – Following a review of the literature, the model was tested via asurvey of 200 nurses from three US health care institutions.

Findings – The study resulted in key findings pertaining to the hierarchical nature of structural,social, and financial bonding activities and their impact on job satisfaction and loyalty.

Practical implications – Service industries that depend on front-line employees to deliver high

quality services are provided with innovative suggestions to improve job satisfaction and loyalty of their employees by employing an internal marketing approach. The study provides organizations withempirical evidence regarding the synergistic effects of bonding activities.

Originality/value – To t he best of t he aut hors’ knowl edge , t hi s i s t he fi rst t ime ahierarchical/sequential model of the impact that relationship bonds have on satisfaction andretention of health care staff has been empirically tested. The findings that structural bonds have botha direct and indirect impact on job satisfaction and loyalty are of value for interested academicsworking in this area and are relevant for companies trying to improve job satisfaction and loyalty of their employees.

Keywords Internal marketing, Nurses, Job satisfaction, Health care, Empirical research, Job loyalty

Paper type Research paper

1. IntroductionEmployee retention is critical to the long-term success of any organization and acommitted employee base is especially relevant in the global health care communitywhere the retention of caregivers is increasingly important in light of a world-wideshortage of nurses (World Health Organization, 2008). The global nursing gap is due inpart to a widening supply-and-demand chasm caused by a host of macro-level factorsincluding an increase in the total number of health care workers needed around theworld, the aging of the nursing population leading to an unprecedented number of

The current issue and full text archive of this journal is available at

www.emeraldinsight.com/0309-0566.htm

Nursesatisfaction and

loyalty

899

Received 10 November 2009Reviewed 10 August 2010

24 August 20106 January 2011

28 May 2011Accepted 14 August 2011

European Journal of Marketing

Vol. 47 No. 5/6, 2013

pp. 899-916

q Emerald Group Publishing Limited

0309-0566

DOI 10.1108/03090561311306967


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nurses retiring in the next ten years, and enrollment caps brought on by a deficiency in

the number of nursing school faculty (Buerhaus et al., 2009; Royal College of Nursing,

2009).

Beyond these structural supply-side issues, Aiken’s et al. (2001) study of nurses in

the US, Canada, England, Scotland and Germany put a spotlight on the high level of

job dissatisfaction and burnout that exist within the nursing profession. This trend has

continued over the past decade, causing nurses to leave the health care field at an

alarming rate (Poghosyan et al., 2010). As a result, the global nursing shortage is

approaching a crisis level, with expected shortfalls reaching approximately 260,000 in

the US by 2025 (Buerhaus et al., 2009), 60,000 positions in Canada by 2022 (Canadian

Nurses Association, 2009), 40,000 in the UK by 2012 (World Health Organization, 2009)

and massive shortages in other nations in the European Union and around the world

(van der Heijden et al., 2009).

The failure to fill vacant nursing positions triggers a host of negative consequences

for the nursing staff, the organization, and patients. First, inadequate staffing

contributes to job stress due to an increased workload, work schedule inflexibility, and

burnout (Lim et al., 2010) and leads to higher levels of nurse dissatisfaction with their

job. Second, an under-employed and over-worked nursing staff compromises patient

care and leads to more medical errors, increased hospital stays, increased visitations by

chronically ill patients, and greater patient mortality (Chaguturu and Vallabhaneni,

2005).

Given that it is hard to increase the supply of new nurses entering the profession,

the most logical approach to this crisis is to find ways to increase the job satisfaction

and retention of existing nurses (Laine et al., 2009). In response, research is emerging

that investigates how “internal marketing” can be utilized to create a loyal nursing

staff, one that is fully committed to meeting organizational goals and patient needs(Chang and Chang, 2007; Peltier et al., 2008; Tsai and Tang, 2008).

In a recent European Journal of Marketing article, Vasconcelos (2008) noted that

broadening the internal marketing construct to investigate workplace satisfaction has

value for employers and customers and that the failure to do so could negatively

impact the organization’s supply of human capital. To date, limited research exists that

has examined the use of internal marketing practices to identify the underlying

dimensions of nurse satisfaction and loyalty (Chang and Chang, 2009). Virtually

ignored is research that develops and tests comprehensive frameworks of the ordered

and sequential relationships between antecedent variables (Peltier et al., 2008). This

study is designed to help fill this gap by developing and empirically testing a

theoretical framework of the antecedents of nurse job satisfaction and loyalty, andattempts to answer three questions:

(1) How do structural, social, and financial bonding activities impact nurses’

satisfaction with their job and their commitment to the organization?

(2) Is there an ordered relationship between these internal bonding constructs and

nurse satisfaction/loyalty?

(3) Do these relationships hold in cross-cultural settings?

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2. Background literature: internal marketing, job satisfaction and loyaltyInternal marketing is based on the principle that organizations that treat theiremployees as they would “valued” customers are likely to impact the satisfaction andloyalty of this key organizational resource (Lings and Greenley, 2005; Mudie, 2003;

Bowers and Martin, 2007). Internal marketing is seen as a way to communicateorganizational values that can be leveraged to create a positive workplace atmosphere(Naude et al., 2003), leading to organizational and marketing success (Lings andGreenley, 2009, 2010). Within a health care context, internal marketing efforts havebeen found to increase patient service quality (Tsai and Tang, 2008) and create a senseof belongingness to the organization (Bellou and Thanopoulos, 2006).

2.1 Bonding activitiesDeveloping relational bonds with employees is a primary way to impact employee jobsatisfaction and customer service (Ballantyne, 2003). Structural, social and financialbonds have been identified as antecedents to building long-term marketing

relationships with health care staff (Berry, 1995; Peltier et al., 2008). Commitment toan organization is expected to be at highest when all three types of relationship bondsexist (Peltier et al., 2008). Empirical support indicates that the strength of the relationalbonds of physicians (Goldstein and Ward, 2004), nurses (Peltier et al., 2003, 2004) andother care givers have toward the organization impact their job satisfaction and loyaltyto the institution.

2.2 Job satisfaction and employee loyalty Job satisfaction has been defined as an attitudinal reflection of how people like ordislike their jobs (Spector, 1997). In their comprehensive review of the literature, Brownand Peterson (1993) found that role perception and organizational variables were

highly correlated with job satisfaction. This is in line with Melten et al. (2005) whoproposed process integration as a way to raise employee satisfaction in the health careindustry. Job satisfaction among health care workers is of great interest sincenumerous studies indicate that job satisfaction and retention are related to jobperformance (Christen et al., 2006).

It is clear that nurses are key determinants of health care quality and patientsatisfaction. Compared to doctors, nurses and support staff are truly frontline serviceproviders with patients, supplying the overwhelming number of contacts with bothpatients and their families (Choi et al., 2005). As such, nurses and support staff havebeen regarded as the single most important determinant of perceived service qualityand customer (patient) satisfaction (Paswan et al., 2005).

3. Direct effects of internal marketing on satisfaction and loyaltyThe nursing literature is increasingly investigating how job satisfaction and loyaltyare impacted by intra-organizational relationships (Peltier et al., 2008; Willem et al.,2007). Underdeveloped is research that examines how bonding activities areinterrelated and how these antecedent variables directly and indirectly impact jobsatisfaction and loyalty. Based on a review of the literature we next present our directand indirect hypotheses related to financial, social and structural bonds.


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3.1 Financial bonding activities and job satisfaction/loyalty3.1.1 Financial package. One way to build employee relationships is through asatisfactory financial package and is based on the belief that greater financialincentives lead to greater job satisfaction and less turnover (Bowers and Martin, 2007).

The financial package includes salary, overtime pay, and fringe benefits in the form of health insurance, retirement benefits, etc. (Murrells et al., 2005). As the financialpackage improve, individuals are more likely to feel that the organization is committedto them, values their contribution, and cares about their well being:

H1a. Nurses’ perception of the financial package will be positively related to jobsatisfaction and loyalty.

3.1.2 Job support . Job support has been defined in terms of organizational practices andstructures that provide opportunities for growth, learning, and movement within theorganization (Stewart et al., 2010). Laschinger et al. (2004) found workplaceenvironments with greater access to information, support, and opportunities to learnand grow over time experienced higher levels of nurse satisfaction. Education andtraining opportunities promote feelings of self-worth and professional growth (Kingand Grace, 2006) and have been correlated with job satisfaction and loyalty (Cooper,2009):

H1b. Nurses’ perception of job support will be positively related to job satisfactionand loyalty.

3.2 Social bonding activities and job satisfaction/loyaltySocial bonds are developed through personal interactions with customers/employees.The same types of activities are important for building social bonds with internalcustomers. Horizontal communication structures within nursing units and

communication between nurses and physicians are expected to be key precursors toworkplace satisfaction (Willem et al., 2007). In this regard, internal marketing must beviewed in terms of an emotional orientation, one that is based on empathic awarenessby employees and management that permeates across the organization (Ahmed et al.,2003; Ahmed and Rafiq, 2003).

3.2.1 Communication with other nurses and care giver . Health care researchsuggests that positive communications between nurses and other members of thehealth care team lead to improved job performance, increased job satisfaction, andbetter quality of care (Rosenstein and O’Daniel, 2005; Peltier et al., 2003, 2004).Teamwork, shared values, cooperation, friendliness, and a supportive workenvironment are all important antecedents of nurse satisfaction and retention(Miller, 2006). In our theoretical framework we distinguish between the

communications nurses have with other nurses and health care providers fromthose that they have with physicians:

H2a. Nurses’ perception of the relationship they have with other nurses andsupport staff will positively impact job satisfaction and loyalty.

3.2.2 Communications between nurses and physicians. Nurse-physician relationshipbuilding is an essential in creating a positive work environment and is an importantantecedent to nurse satisfaction and loyalty (Peltier et al., 2003, 2004). Conversely,

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negative interactions between nurses and physicians lead to lower satisfaction and agreater propensity to leave the organization (Rosenstein and O’Daniel, 2005):

H2b. Nurses’ perception of the relationship they have with physicians will

positively impact job satisfaction and loyalty.

3.3 Structural bonds and job satisfaction/loyaltyStructural bonding activities create collaboration between organizational members. Inhealth care, collaboration in patient care decisions provides a sense of “empowerment”and is linked to improved patient outcomes and an enhanced sense of accomplishmentat work (Patrick and Laschinger, 2006). Despite the benefits associated withempowerment, nurses report high levels of dissatisfaction concerning the extent towhich they feel empowered in the care giving process (Nedd, 2006). Althoughempowering structural bonding activities take multiple forms, we focused on controlover care and job flexibility.

3.3.1 Control over care. A major barrier to the recruitment of individuals into the

nursing profession is the perception that nurses play a subservient role and have littleinput into health care decisions (Chaguturu and Vallabhaneni, 2005). Nurses’perception of the amount of input they have in the care of patients is correlated withfeelings of empowerment, and leads to job satisfaction and loyalty to the organization(Laschinger and Finegan, 2004; Nedd, 2006). Aiken et al. (2001) found that nursesworking in organizations that support autonomy and control were more satisfied withtheir jobs and experienced less burnout. A growing body of research supports arelationship between structural empowerment, nurse job satisfaction, and loyalty tothe organization (Laschinger and Finegan, 2004):

H3a. Nurses’ perception of control over care will positively impact their jobsatisfaction and loyalty.

3.3.2 Job flexibility. Job flexibility refers to the coordinated decision making betweennurses and supervisors with regard to scheduling the length of work shifts, daysworked, and total hours worked. Job flexibility is viewed as a means of increasingnurse empowerment (Wright and Bretthauer, 2010). Studies show that allowing nursesflexibility over their work schedules increases their ability to balance job and familycommitments and to adjust income as they wish (Holtom and O’Neill, 2004). Thisflexibility gives nurses control over how they deal with the emotional and physicaldemands of the job (O’Brien-Pallas et al., 2004). Laine et al. (2009) found in their studyof ten European countries that nurses concerned about involuntary changes in workschedules are more likely to leave the organization and/or the profession:

H3b. Nurses’ perception of job flexibility will positively impact their job

satisfaction and loyalty.

3.4 The hierarchical impact of bonding activitiesIn this study, we were particularly interested in the hierarchical structure between thethree types of bonding activities. Recent empirical research in the marketing andnursing literature suggests that structural bonds have the greatest direct impact on jobsatisfaction (Peltier et al., 2008; Wagner et al., 2010). We hypothesize that nurses’perceptions of their level of empowerment and autonomy will not only have a direct


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impact on job satisfaction and loyalty, but will also have an indirect effect as well byinfluencing their level of satisfaction with social and financial bonding activities. Wealso posit that the nurses’ perception of their empowerment in care provision and jobflexibility (structural bonding activities) significantly impact their perception of the

relationships they have with physicians, other nurses and support staff (social bonds):

H4. Nurses’ perception of control over care will positively impact their perceptionof the relationship they have with physicians ( H4a ) and other nurses andsupport staff ( H4b ).

H5 . Nurses’ perception of job flexibility will positively impact their perception of ( H5a ) the relationship they have with physicians and ( H5b ) other nurses andsupport staff.

Along these same lines, we posit that as nurses feel more empowered they tend to viewtheir financial package and job support activities in a more favorable light (Stewartet al., 2010):

H6 . Nurses’ perception of control over care will positively impact their perceptionof ( H6a ) the financial package and ( H6b ) job support.

H7 . Nurses’ perception of job flexibility will positively impact their perception of ( H7a ) the financial package and ( H7b ) job support.

There is also recent support that social bonds have a greater impact on job satisfactionand loyalty than do financial bonds (Peltier et al., 2008). Based on our earlierdiscussion, we would expect that as the work environment becomes more supportive,cooperative, and friendly, nurses will tend to be more satisfied with the job’scompensation package and job support activities:

H8 . Nurses’ perception of the relationship they have with other nurses andsupport staff will positively impact their perception of ( H8a ) the financialpackage and ( H8b ) job support.

H9. Nurses’ perceptions of the relationship they have with physicians willpositively impact their perception of ( H9a ) the financial package and ( H9b )

job support.

Together, the preceding hypotheses form the “Internal relationship marketing model of nurse job satisfaction and loyalty” displayed in Figure 1.

4. Methodology4.1 Survey construction

To test the proposed model and related hypotheses, data were collected via a survey of US nurses. A three-step procedure was employed to construct the questionnaire. First,the nurse loyalty, internal marketing and relationship marketing literatures werereviewed to identify possible topics. Next, 20 interviews were conducted with staff nurses and supervisors at the target hospitals and clinics to identify questionnairecontent. Third, the questionnaire was pre-tested and modified as needed. Thequestionnaire was finalized and approved by the participating hospital. The finalsurvey contained 29 questions related to financial, social, and structural bonds, six

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Figure 1.An internal relationship

marketing model of nurse job satisfaction and

loyalty


loyalty

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overall satisfaction and loyalty measures, and three demographic items. All of thebonding questions used a five-point scale ranging from 1 ¼ very dissatisfied to5 ¼ very satisfied.

4.2 Data collectionThe study was administered to 242 nurses at a not-for-profit US hospital and its twoclinics. A communication was sent to nurses describing the purpose of the study andwhy their involvement was important. The survey was distributed via the in-housemail system to all full time nurses at these organizations. To encourage candidresponses, completed surveys were returned in a sealed envelope to a confidentialreturn box. A total of 200 questionnaires were returned for an 82.6 percent responserate. As expected given the high response rate, the sample was nearly identical to theoverall population of nurses.

4.3 Model testing procedures

The structural model was evaluated using the process proposed by Diamantopoulos andSiguaw (2000), and Jöreskog (1993). First, the structural model based on the hypotheseswas defined and specified. The basic approach was a two-step procedure (Anderson andGerbing, 1988), where the purified measures were determined prior to specifying andestimating the model. Next the model (displayed in Figure 1) was estimated with thesummated measures (items parcels approach) using the SPSS structural equation modelingsoftware, Amos 19.0. The fit of the model was evaluated using the measures proposed byBlunch (2008, p. 117), specifically the overall chi square value for the structural model, thegoodness of fit index (GFI), the adjusted goodness of fit index (AGFI), the root mean squareerror of approximation (RMSEA), and the probability of close fit index (PCLOSE). Asrecommended by Blunch (2008, p. 98), Diamantopoulos and Siguaw (2000), Olobatuyi(2006, p. 127) and others, we assessed the model fit using the modification indices.

5. Results5.1 MeasuresThe multiple indicants representing the six measures related to the financial, social, andstructural bonds were evaluated according to the principles outlined by Nunnally (1978)and detailed by Churchill (1979). The items were subjected to a principle componentsexploratory analysis employing a Varimax rotation to determine the degree to which theitems represented unique measures. Five of the 29 bonding questions were dropped due tolow ( ,0.40) or multiple factor loadings. As predicted, the items resulted in six uniquemeasures. Next, the items were subjected to an item to total correlation analysis todetermine if any items with low item to total correlations needed to be removed to increasereliabilities. Finally, the coefficient alpha for each of the measures was computed as an

indicator of the measure’s reliability. All measures were found to be at satisfactory levelsof reliability. Table I contains the individual items for each of the bonding measures, thefactor loadings, and their estimated reliabilities.

The six item measure of overall job satisfaction and loyalty was evaluated separatelyand included five overall satisfaction questions related to level of job stress, unit,relationships with physicians, relationships with nurses, and satisfaction with job.Loyalty was measured via overall likelihood of staying (five-point likelihood scale). Thecoefficient alpha was 0.90.

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C a r e

c o n t r o l

C

o m m w i t h n u r s e s a n d

c a r e g i v e r s

F i n a n c i a l

p a c k a g

e

C o m m . w i t h

p h y s i c i a n s

J o b fl e x

S u p p o r t /

g r o w t h

F r e e d o m t o d o y o u r j o b a

s y o u s e e b e s t

0 . 7 3

A b i l i t y t o p r o v i d e t h e b e s t p o s s i b l e c a r e t o

p a t i e n t s

0 . 7 3

I n p u t i n t o y o u r s p e c i fi c p

a t i e n t

r e s p o n s i b i l i t i e s

0 . 7 2

A m o u n t o f i n p u t y o u h a v

e i n c a r e d e c i s i o n s

0 . 6 7

I n p u t i n t o y o u r p a t i e n t l o

a d a s s i g n e d t o y o u

e a c h s h i f t

0 . 5 8

C o h e s i o n o f t h e n u r s i n g s t a f f

0 . 7 9

Y o u r r e l a t i o n s h i p w i t h n u r s e s

0 . 7 5

C o m m u n i c a t i o n a m o n g n

u r s i n g s t a f f

0 . 7 4

Y o u r r e l a t i o n s h i p s w i t h s u p e r v i s o r s

0 . 5 2

C o m m u n i c a t i o n w i t h o t h e r m e m b e r s o f

h e a l t h c a r e t e a m

0 . 4 9

C o m m u n i c a t i o n b e t w e e n

a d m i n i s t r a t i o n a n d

y o u r s e l f

0 . 4 6

T o t a l i n c o m e e a r n e d

0 . 8 9

H o u r l y w a g e t h a t y o u r e c e i v e

0 . 8 6

H e a l t h i n s u r a n c e b e n e fi t s

0 . 6 1

R e t i r e m e n t b e n e fi t s

0 . 5 8

C o m m u n i c a t i o n b e t w e e n

p h y s i c i a n s a n d y o u

0 . 8 3

H o w w e l l p h y s i c i a n s l i s t e

n t o w h a t y o u h a v e

t o s a y

0 . 7 8

Y o u r r e l a t i o n s h i p w i t h p h y s i c i a n s

0 . 7 7

N u m b e r o f h o u r s y o u w o

r k e a c h s h i f t

0 . 7 7

W o r k s c h e d u l e fl e x i b i l i t y

0 . 7 1

A b i l i t y t o d e t e r m i n e h o w

m u c h o v e r t i m e y o u

w o r k

0 . 6 3

C o n t i n u i n g e d u c a t i o n / t r a i n i n g o p p o r t u n i t i e s

0 . 7 4

O n - t h e - j o b t r a i n i n g

0 . 7 4

A m o u n t o f r e c o g n i t i o n t h

a t y o u r e c e i v e

0 . 4 6

V a r i a n c e e x p l a i n e d ¼ 6 3 . 8 % ( % )

1 2 . 9

1 2 . 6

1 1 . 4

1 0 . 8

8 . 4

7 . 7

C o e f fi c i e n t A l p h a

0 . 8 6

0 . 8 3

0 . 7 6

0 . 8 6

0 . 6 5

0 . 7 2

Table I.Model dimensions and

measures


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5.2 Structural model The fit of the model was evaluated using the fit statistics described in section 4.3. Theresults are shown in Figure 1. In total, these various fit measures suggested that themodel might benefit from some modifications. Although not hypothesized a priori, we

anticipated the need to account for the relationships of the variables within each of thebonding levels. The modification indices confirmed this premise, suggesting that the“fit” would be improved if the model accounted for these associations. We thus addedcorrelated error terms between the two structural, social, and financial bond measures.By adding these correlated terms in our model the overall Chi Square improved from0.7 to 52.6 and the goodness of fit improved from 0.933 to 0.999. This is consistent withthe theoretical model and our original thought that additional relationships were likelyto exist between these bonding levels. Finally, since they were not statisticallysignificant, we eliminated the paths from job flexibility to communications withphysicians and from communications with physicians to financial package. The finalmodel is shown in Figure 2

When these various paths were modified, the model fit improved significantly. Theresults are shown in Figure 2. When comparing these fit statistics with those of theoriginal model there were substantial improvements across all five measures. The overallchi square value for the structural model improved considerably as did the GFI and theAGFI. In addition, the RMSEA was reduced to 0.001 and the PCLOSE improved to 0.809.In summary, these fit measures suggested that the modified model was a good fit of thedata. In reviewing the estimates for the individual coefficients, most remained virtuallyunchanged, suggesting that the model was stable and not significantly altered by themodifications. The revised model along with the fit statistics are displayed in Figure 2,and the individual parameter estimates are shown in Table II.

We then compared the modified model shown in Figure 2 to a variety of potentialalternative competing models. First, we compared this model to non-nested models

where the paths between the various bonding activities were reversed. Based on themeasures proposed by Blunch (2008, p. 117) for non-nested models, we found that noneof the alternative models performed as well as the modified model. Subsequently, wecompared the modified model to nested models where the direct and indirect pathswere eliminated from the model. Based on the chi square difference compared to thechange in degrees of freedom, along with Akaike Information Criterion (AIC),Consistent Akaike Information Criterion (CAIC) and the expected value of thecross-validation index (ECVI) (Blunch, 2008, p. 117; Diamantopoulos and Siguaw, 2000,p. 136) none of the investigated models proved to be a better fit of the data compared tothe modified model.

Our final two evaluations of the model included investigations of its parsimony andcross-validity. To evaluate parsimony we first reviewed the related measures

suggested by Blunch (2008, p. 118). The AGFI was sufficiently high and the AIC andthe CAIC measures for the proposed model were lower than either the independence orsaturated models, providing evidence of model parsimony. All of the proposedstructural paths were significant indicating that they each add value to the explanatoryvalue of the model. Eliminating any of them would reduce the fit of the model,suggesting that it is parsimonious in its current form.

Our ability to assess the cross validity of the model was limited due to a sample sizethat did not allow for the use of split samples. Instead, we evaluated the cross-validity

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using the one sample measures suggested by Blunch (2008, p. 117). We first reviewed

the EVCI, AIC and the CAIC for the proposed model compared to the independent and

saturated models and found that in each case they were lower for the proposed model

than for either of the alternatives. Next, we investigated Hoelter’s critical N and found

it to be sufficiently high ( .200), which also provided some evidence of cross-validity

(Blunch, 2008, p. 117). Finally, we ran a cross validation simulation. The simulation

only produced 4/500 permutations ( p-value ¼ 0.008) that fit the data better or as well

as the proposed model, providing more evidence of cross-validity.

Figure 2.Final structural equation

model of the internalrelationship marketing

model of nurse satisfactionand loyalty


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H y p o t h e s i s F r o m

T o

C o e f f

S E

C R

p - v a l u e *

H 1 a

F i n a n c i a l p a

c k a g e

!

J o b s a t i s f a c t i o n a n d l o y a l t y

0 . 0 6 3 0 . 0 3 5 1 . 8 0 9

0 . 0 5

H 1 b

J o b s u p p o r t

!


0 . 5 7 8 0 . 1 8 9 3 . 0 6 3

0 . 0 0 1

H 2 a

C o m m u n i c a t i o n w i t h o t h e r n u r s e s a n d c a r e g i v e r s

!


0 . 2 3 2 0 . 0 6 4 3 . 6 0 7

0 . 0 0 1

H 2 b

C o m m u n i c a t i o n w i t h p h y s i c i a n s

!


0 . 1 3 8 0 . 0 6 4 2 . 1 4 1

0 . 0 1

H 3 a

C a r e c o n t r o l

!


0 . 1 0 9 0 . 0 4 9 2 . 2 3 5

0 . 0 1

H 3 b

J o b fl e x i b i l i t

y

!


0 . 1 6 2 0 . 0 6 1 2 . 6 2 9

0 . 0 1

H 4 a


!

C o m m u n i c a t i o n w i t h p h y s i c i a n

s

0 . 3 3 7 0 . 0 4 2 7 . 9 9 3

0 . 0 0 1

H 4 b


!

C o m m u n i c a t i o n w i t h o t h e r n u r

s e s a n d c a r e g i v e r s 0 . 3 3 4 0 . 0 4 8 7 . 2 1 8

0 . 0 0 1

H 5 a


y

!

C o m m u n i c a t i o n w i t h p h y s i c i a n

s

N S

H 5 b


y

!

C o m m u n i c a t i o n w i t h o t h e r n u r

s e s a n d c a r e g i v e r s 0 . 1 2 3 0 . 0 7 0 1 . 7 5 4

0 . 0 5

H 6 a


!

F i n a n c i a l p a c k a g e

0 . 1 9 3 0 . 0 9 2 2 . 0 9 1

0 . 0 5

H 6 b


!

S u p p o r t

0 . 0 6 1 0 . 0 1 8 3 . 3 3 0

0 . 0 0 1

H 7 a


y

!


N S ( 0 . 0 7 )

H 7 b


y

!

J o b s u p p o r t

0 . 0 4 5 0 . 0 2 3 1 . 9 0 2

0 . 0 5

H 8 a


!


0 . 4 0 8 0 . 1 2 2 3 . 3 4 6

0 . 0 0 1

H 8 b


!

J o b s u p p o r t

0 . 1 0 2 0 . 0 2 3 4 . 3 4 3

0 . 0 0 1

H 9 a


!


N S

H 9 b


!

J o b s u p p o r t

0 . 0 4 6 0 . 0 2 4 1 . 9 1 7

0 . 0 5

N o t e s : * O n e t a i l e d t - t e s t

Table II.Model estimates for theinternal marketing modelof nurse job satisfactionand job loyalty

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5.3 Hypotheses testing We evaluated individual coefficients to test the hypotheses. In each case the sign of thecoefficient was correct, and using a one tailed t test, 15 of 18 of the originally proposedstructural paths were found to be significant; on path was marginally significant (see

Table II). The two notable exceptions were H9a and H5a. Specifically, satisfaction with job flexibility did not impact communications with physicians and communicationswith physicians did not influence satisfaction with the financial package. Although notshown in Figure 2, the path from job flexibility to job support was marginallysignificant.

This study produced findings concerning the magnitude of the effects and thehierarchical nature of the antecedent variables. While all six of the antecedent variableshad a statistically significant impact on job satisfaction and loyalty, the actualmagnitude of the effects were very different. To investigate the actual size of theeffects, the direct, indirect and total standardized effect sizes were calculated using themethod proposed by Hayduk (1988) and Olobatuyi (2006). The effect sizes areinterpreted as the magnitude of the standardized unit change in the dependent variable

given a one standardized unit change in the independent variable (Olobatuyi, 2006,p. 134). Table III displays the effect sizes.

While communications with other nurses and caregivers produced the largest directeffect (0.237), control over care had the largest total effect (0.412) on job satisfaction andloyalty, Conversely, the financial package was found to result in only a 0.105 change inthe measure of job satisfaction and loyalty. While we leave it to the reader to interpretwhether or not the individual effect sizes are meaningful in practice, we do note that allof the total effect sizes with the exception of the financial package resulted insubstantive changes in the measure of job satisfaction and loyalty.

6. Discussion of results

Our findings corroborate the work by Laschinger and Finegan (2004) and Nedd (2006)concerning control over care and the findings of Laine et al. (2009) pertaining to jobflexibility and job satisfaction. The results also support the previous work of Miller (2006),Rosenstein and O’Daniel (2005), and others concerning the impact of the nurses’perception of their relationships and communications with physicians, nurses and othercaregivers on job satisfaction and loyalty. Finally, the results support the previousfindings that the financial package and job support are directly related to nurses’ job

VariableNo. of items

Directeffect

Indirecteffect

Totaleffect

Control over care 5 0.156 0.256 0.412

Job flexibility 3 0.148 0.053 0.201Communications with physicians 3 0.132 0.025 0.157Communications with other nurses and caregivers 6 0.237 0.087 0.324

Job support 3 0.202 0.202Financial package 4 0.081 0.105

Note: Effect sizes based on standardized coefficientsSource: Olobatuyi (2006, pp. 135-36)

Table III.The direct and indirect

effects of the dependentvariables on job

satisfaction and loyalty


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satisfaction and loyalty (Cooper, 2009; King and Grace, 2006; Laschinger et al., 2004). Alsoas hypothesized, we found that a hierarchical relationship between structural, social, andfinancial bonding activities existed. The study established support for the relationshipsforwarded by Peltier et al. (2008) and Wagner et al. (2010) that nurses’ perceptions

pertaining to the structural bonds (control over care and job flexibility) impact their viewsabout the social bonds (relationships with physicians, other nurses and caregivers) whichaffect their assessment of the financial package and job support. As Table II indicates, thestrongest relationships existed between control over care and communications withphysicians, nurses and other caregivers. To the extent that nurses feel empowered to dotheir job in the way they see as best, they are more satisfied with the relationship theyhave with the physicians, supervisors, other nurses, and members of the health care team.In turn, they are more satisfied with their financial package and job support. All of thisleads to increased job satisfaction and loyalty.

This study also reaffirms and extends earlier findings regarding the importance of jobsupport activities (Chang and Chang, 2007, 2009; Tsai and Tang, 2008) andcommunications (Chang and Chang, 2007, 2009), and builds on the work of Willemet al. (2007), supporting their findings regarding the significant negative impact of centralization (to the degree to which it negatively impacts the nurses’ ability to have asay in care decisions and job flexibility) and importance of autonomy and interactions.However, our results differed from theirs regarding the importance of the dimensions of

job satisfaction. While Willem et al. (2007, p. 1016) found that “pay was not important inthe study of organizational structures and job satisfaction relationships,” they did reportthat the nurses in their study, “considered pay as the most important dimension of jobsatisfaction, followed by autonomy and interaction” (Willem et al., 2007, p. 1015). Ourstudy found that the financial package, though significant, was the least impactful on jobsatisfaction and loyalty. More research needs to be done in this area.

In summary, this study developed and tested a comprehensive model of nurse

satisfaction and loyalty with ordered relationships between the antecedent variables.The results imply that the individual factors are not separable or substitutable, butrather synergistic, which intimate that a combination of financial, social and structuralbonding activities is a more effective approach to increasing job satisfaction andloyalty among nurses. Although these relationships need to be investigated acrossdifferent settings, the results provide insights for both practitioners and academics.

7. Managerial implicationsThe results from this study provide a number of innovative suggestions for serviceindustries in general and the health care industry that depends on front line employeesto deliver high quality services specifically.

First, the organization needs to empower its employees by allowing them some

control and flexibility over their jobs. As our study found, the empowerment of nursesin terms of more control over care and job flexibility improved their evaluation of almost all the other aspects of their jobs. Second, our findings suggest that theorganization needs to enhance social bonds by providing an atmosphere that promotescommunication and teamwork. Our study revealed that nurses who maintain opencommunication lines and positive relationships with other care givers up and down thechain of command are more satisfied with their jobs and feel in a better position toprovide quality services. Third, the organization needs to realize that job satisfaction is

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not just a function of the financial package. That is, there is a synergistic value of financial, social and structural bonding activities and a multiplicative value of socialbonding on financial bonds. Our study suggests that investing in structural bondingand social bonding activities pay compounded dividends in terms of improving job

satisfaction, loyalty and retention. Fourth, and possibly most importantly, health careorganizations need to implement an internal relationship marketing program (Ahmedet al., 2003; Peltier et al., 2008). We advocate that all service organizations that rely onskilled employees to provide high quality services must be both customer andemployee centered. In other words, a true stakeholder orientation (Greenley and Foxall,1997) that addresses the interests of multiple stakeholder groups by applying itsmarketing and communication competencies towards the satisfaction of customers andemployees might increase overall system performance. Service providers need tobecome proactive internal marketers and develop communication programs directedtoward their employees.

In summary, service providers need to develop strategic plans with a mission andgoal dedicated to improving service quality and the work environment for its

employees. The internal relationship marketing model proposed in this study providesa framework to build relationship bonds with employees and communicate with thempertaining to the service quality being delivered.

8. Limitations and future research directionsThis study provides a starting point for research on the application of the internalrelationship marketing model to the nursing profession. It should be noted that thisstudy was conducted at a small number of health organizations located in theMidwestern US. In addition, many of the nurses were relatively satisfied with their jobs.The results might be different in a less positive situation or in a different geographiclocation. More research needs to be conducted across different countries and settings to

determine the model’s generalizability across a variety of health care organizations.Given these limitations we propose a number of future research directions. First, wewould like to extend this work to other staff employees at health care organizations.Second, we believe that this model should be investigated across a variety of healthcare related job sites. Finally, a longitudinal study is needed to determine if ahealth care organization can employ this internal relationship marketing approach toactually impact perceptions about quality, job satisfaction and loyalty.

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Corresponding authorAlexander Nill can be contacted at: [email protected]

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