Nurses Perception of Management Styles and Factors Influencing Retention of Nurses in Ghana: A Cross-Sectional Survey
Background: Retention of health professionals in the health sector in Ghana is crucial to address human resource needs of the health sector and to promote efficient and effective healthcare system. Nurses are one of the key professionals whose role in the healthcare industry cannot be underestimated. This study assessed nurses' perception of management styles and factors influencing retention of nurses in Ghana.
Methods: A cross-sectional quantitative descriptive survey was conducted among 135 Nurses at Akatsi Government Hospital and St Paul's Hospital in the Akatsi municipality of Volta region of Ghana using a simple random sampling in selecting participants. A structured questionnaire was used to collect data from the participants. Data was analysed using STATA statistical software Version 14.2. Statistical significance was set at 0.05.
Results: Females dominated the study (68.89%). Most of the respondents (19.70%) strongly agreed that Nurse Managers exhibited participatory management style. However, majority (52.71%) of the respondents intended to leave their current facility. Nurses' intention to leave was higher in public hospital (55.45%) compared to the private hospital (45.95%). Salary and rewards was the major (39.53%) extrinsic factor that influenced retention of nurses at work and self -motivation was the major (27.91%) intrinsic factor that contributed to nurse's retention at work.
Conclusion: Most of the respondents strongly agreed that managers practiced participatory management style. Benevolent authoritative management style was statistically significant with nurses' intention to leave.
Nurses, Perception, Management Styles, Factors, Retention, Ghana
Healthcare management is a complex but dynamic task which requires trained and experienced professionals to provide services needed . The healthcare operates with its most valued asset; the health workforce, where nurses of any specialty plays major role of caregiving . Baunaun, et al.  described retention of employees as “maintenance of an appropriate supply of personnel to meet the health needs of any given population”. Retention could be of many advantages to the health professionals, the organization and the clients who patronize healthcare services . It builds a strong relationship between the manager and the health professional, create room for dependability in the professional, provide the opportunity to gain more experience and advance professionally [5,6]. Retention of nurses is a means by which organizational culture is handed down to the newly trained nurse.
Nurses are one of the key professionals whose role in the healthcare industry cannot be underestimated. As such, their retention is crucial to the growth and survival of the healthcare industry. Global health force shortage is predicted to reach 12.9 million by the year 2035, which currently stands at 7.3 million and if not addressed will lead to devastating implications for the health sector . Also, registered nurses' (RN) labour turnover has been on the rise globally. This is evident in a study conducted in the USA in 137 hospitals from 26 states. The study recorded 18.2% turnover rate at an estimated cost of $4.4-7.0 million lost in an average hospital (Nursing Solutions Inc, 2018). The situation remains unchanged with high labour turnover in New Zealand, Canada and Australia . The shortage is as a result of aging health workers, high labour turnover of health professionals and the fast growing world population . Another triggering report discussed at the annual meeting of WHO African Region held in Victoria Falls, Zimbabwe noted shortage of skilled health professional in Africa . This report cited an average of 1.3 health workers to 1000 population which was found as a challenge and was below the recommended 4.5 per 1000 population by the Sustainable Development Goals (SDGs) in Africa as at 2015.
Many studies have been done to identify factors that influence the nurses' retention, but they have been unable to establish a singular factor. One factor that has been identified to promote staffs' retention in the health industry is the management style used by the managers. Management styles are the methods the managers use throughout the organization to achieve the organizational goals . According to Likert and Likert (as cited in Nassar, et al., ), management styles are classified into four kinds and these styles are; exploitative authoritative, benevolent authoritative, consultative and participatory management style. These management styles play critical roles in personnel's empowerment, job satisfaction and commitment of employees to the organization hence their relevance to healthcare system. Retention of nurses has attracted many concerns and one theoretical view has been on job satisfaction as a factor influencing nurse retention . Job satisfaction is classified to be associated with intrinsic or internal factors and external factors. The intrinsic factors include employee's goals and its alignment to organizational goals, self -motivation and personal values and the extrinsic or external factors include leadership style, managerial relations, salary, opportunity for professional advancement, and work environment .
Ghana on the other hand, experienced massive nurses' attrition from 2000 to 2006 which was associated with poor salary. However, the attrition rate reduced in Ghana upon introduction of single spine salary structure (SSSS) in 2012 . In Ghana, the Health Sector Fact and Figures  saw a nurse per 542 populations. Although there is lack of consistent statistic supporting labour turnover among nurses in Ghana, Akatsi Government Hospital recorded several nurses taking transfer to other facilities outside the municipality over the last 2 years . Also, St Paul's Hospital recorded quite a significant number of nurses resigning from the organization according the HRM, within 2020. Irrespective of efforts made by hospital administrators and nurse managers to retain the registered nurses, turnover still persists. To curtail the issue of labour turnover coupled with increasing population growth (2.7% per annum in Akatsi Municipality) with its increasing demand for health care, there is a need to identify strategies to retain the skilled registered nurses to ensure productivity and quality health care.
Management styles are the philosophies that the manager utilize on the capabilities of the employees in order to achieve established organizational goals . These philosophies are applied throughout the organization to ensure effectiveness and efficiency. According to the authors, these styles are the extent to which the manager progressively leads the subordinates and the distinct ways by which he involves them in decision making in performance of those activities to attain organizational goals.
• Exploitative authoritative management style: Exploitative authoritative style of management is a style where decisions are solely made by the manager. This style may be used when organization is large and most employees are seen as less competent therefore have to be coerced to perform their responsibilities. In other way, this style is noted to promote productively if task needs to be accomplished within the shortest possible time . According to Grimsley, this style is associated with manager who exploits the employees and mostly where the employees are unskilled and have no union representative for an indirect participation and advocacy on their behalf pushing them to work extra with demeaning incentive.
• Benevolent authoritative management style: Ackon  in his book 'Management of Healthcare Organisations in Developing Countries', described this style of management as permissible where the manager seeks the ideas of the employees but the final decision lies with the manager. Communication is mostly downward where inputs of the employees are not mostly taken into consideration.
• Consultative management style: Consultative style encourages the employees' involvement in decision making and foster voluntary cooperation . This style is perceived as ideal as the employees' ideas, suggestions and concepts are considered during decision making by managers.
• Participatory management style: According to Kossivi, et al. , participatory style is employed by manager who involves the employee in decision making concerning the organization and also with issues that may affect them directly. He further stated that, this style is a good choice of style where the employees have adequate knowledge about issue at hand and well versed in the organizational culture. This management style is perceived as positively associated with high level of employees' job satisfaction, promote involvement, enhances problem solving and empowers the employees and also encourages autonomy and creativity .
Extrinsic and Intrinsic Factors
Determinant of nurses' retention at work places has been described to be driven by either extrinsic (outside the individual or organizational factors) or intrinsic (individual or personal) factors . Extrinsic factors were identified as work environment, salary and incentives, opportunity for professional advancement, and promotion. Intrinsic factors on the other hand are individual factors that are inherent and are controlled by the individual rather than the working organization . These factors are internal and turn to motivate the individual and determine their commitment to work. They influence how the individual react to situation and can be adjusted by the individual to promote job satisfaction. Intrinsic factors include personal values and interest, personal goals that matches with that of organizational goal, self-motivation and psychological response to work among workers [22,23].
A cross-sectional quantitative descriptive survey was conducted among 135 Nurses at Akatsi Government Hospital and St Paul's Hospital in the Volta region of Ghana using a simple random sampling in selecting participants. A structured questionnaire was used to collect data from the participants. The sample size was estimated using an online epi info software open calculator. A Non-response rate of 10% was added and a proportional allocation was made according to the nurse's population in each hospital. All Nurses who were not on duty during the survey were excluded from the study. Data was analyzed using STATA statistical software Version 14.2. Statistical significance was set at 0.05.
Ethical approval for the study was obtained from the Ghana Health Service Ethical Review Committee with the assistance of the Kwame Nkrumah University of Science and Technology, School of Public Health, Kumasi. However, local permission and approval for the study was required and obtained from the Management of the two Hospitals as well as eligible participants. Participation was voluntary, assured anonymous identity and respondents were able to withdraw at any stage without any penalty.
Females dominated the study (68.89%) and the majority (35.56%) were between the age group of 26-30 years as presented in Table 1. Half (50.37%) were single, (47.41%) were married and a proportion (2.22%) were divorced. Majority (48.89%) of the respondents had no child. The longest years of service of respondent were above 5 years (32.59%) with majority (46.67%) with Diploma Certificate.
In assessing management styles employed by managers in both facilities, Majority (19.70%) of the respondents strongly agreed that, their managers practiced participatory management style, consultative management style (12.12%), exploitative authoritative (9.85%) and benevolent authoritative (6.82%) (Table 2 and Table 3).
Respondents were asked about their intention to leave their current work places. Majority (52.71%) of the respondents responded positively (YES) and (47.29%) responded negatively (NO). Intention to leave was higher in public hospital (55.45%) compared with the private (45.95%). However, among those who intend to leave soon (52.71%), 17.05% replied leaving in less than 1 year, followed by 13.18% in 1 year, 11.63% in 2 years, 7.75% in 3 years and 3.10% in 4 years.
Respondent's perception was sought on extrinsic and intrinsic factors influencing retention of nurses. Among the extrinsic factors influencing nurses' retention, majority (39.53%) of the respondents strongly agreed to salary and rewards, and conducive working environment (35.66%) as extrinsic factors influencing retention of nurses. Also, (34.88%) of the respondents strongly agreed to opportunity for career advancement, Job Security (33.33%) and promotion (32.56%) as extrinsic factors contributing intention to stay.
Majority (27.91%) of the respondents' strongly agreed to self -motivation, and professional autonomy (22.48%) as intrinsic factors contributing to retention of nurses. Personal reasons (20.93%) and 'my goal in alignment with organizational goal' (19.38%) were also identified as intrinsic factors contributing to nurses to be retained at work.
The study assessed nurses' perception on four management styles; Exploitative Authoritative style, Benevolent Authoritative style, Consultative style and Participatory style proposed by Likert . The study found that majority (19.70%) of the nurses strongly perceived their managers to have exhibited participatory management style in both hospitals. This finding was remarkable but contradicts a study by Nassar, et al.  which found nurses' perception on their managers in some private hospitals in Egypt as consultative, where nurses' ideas were sought but were not trusted completely by their managers.
Participatory style was perceived by nurses as a good choice of style, where the employees were engaged in decision making concerning the organization, similar to the findings of . This evidence may be related to the fact that majority of the respondents had worked for more than five years and may be more acquainted with their managers and the health systems. Rad and Yarmohammadian  highlighted the fact that, this style of management is more applicable where the employees are matured in the organization and well informed coupled with manager's competence in the organizational operation. Presumptuously, the finding of this study showed that, nurses were well experienced, were involved in decision making and had good relationship with their managers.
A proportion (12.12%) respondents also perceived their managers to have practiced consultative style where they were engaged in decision making only in specific situation while the general policies were determined by the nurse manager. Few nurses also perceived their managers as benevolent and exploitatively authoritative. Manager was perceived to be dictated and there was either little or no involvement of nurses in decision making. Although these styles are known to promote productivity in the shortest possible time, it may not promote innovation and may decrease morale of employees hence turnover intentions . The reason for the low respond to these styles may be due to nurses' preference for autonomy. Nurses' desired professional autonomy where they can make decisions and practice independently with their skills and knowledge, provided resources are available with little or no dictation from the manager [5,6]. This brings about job satisfaction hence higher likelihood of retention . The study shown that employees have diverse opinions about their managers and there is a need for managers to develop a good and a balanced working relationship with their subordinates to help organize them to achieve productivity, teamwork and job satisfaction to keep them at work.
This study also explored nurse' intention to leave their current facilities. It was found that majority (52.71%) had the intention to leave their current place of work in the shortest possible time. However, this finding was most common among nurses working in the public hospital compared to the private. Rispel, et al.  proved otherwise when they identified job dissatisfaction among nurses working in the private hospitals due to higher workload, poor pay and strict working conditions hence higher intention to leave the private sector.
Assessing the extrinsic and intrinsic factors that influenced nurses' intention at work, salary and reward was found to be the most (39.53%) contributing factor. This was in agreement with the findings of [2,27,28]. This result however, contradicts a study by Kwansah, et al.  in three regions in Ghana which reported lower response rate for financial incentive as a motivator in rendering healthcare services among health professionals. The findings by Kwansah, et al. was concluded based on the fact that, though good salary is important, it was not recognized as the most important motivating factor for retention even in the rural areas.
'Conducive environment' was also strongly acknowledged among nurses who work in the private hospital compared with those who worked in the public hospital. Apparently, the private facility has modernized building and serene environment compared to the public hospital which may be the source of motivation. A proportion of respondents also strongly agreed to opportunity for career advancement as an extrinsic factor which contributed to retention of nurses. This clearly shows the enthusiasm among nurses recently towards further education. This may be due to the fact that the tertiary education system in Ghana has become more flexible where many universities have sprung up offering flexible courses. This finding was similar to the findings of  who found opportunity for educational advancement to promote retention. However, a study by in Ghana found lack of opportunity for further education as the reason for health professionals' lack of motivation to work in the rural areas.
Intrinsic factors such as 'self-motivation' (27.91%), professional autonomy ((22.48%), personal reasons (20.93%) and 'my goal in alignment with the organizational goals' (32.56%) were identified as contributing factors to retention of nurses at the work place. Hee, et al. found self-motivation significantly associated with job satisfaction and concluded that this factor promotes sense of responsibility, ownership hence better performance. Notwithstanding, this current study confirms self-motivation as the major intrinsic factor toward retention. A proportion of respondents also noted professional autonomy to have influenced their intention to stay longer at their place of work. This finding agreed with a study by  in England who proved autonomy as nurses' desire to be retained. Majority of the respondents were in their middle ages with youthful exuberant and with over five years working experience and so, will desire autonomy in practice. Autonomy in practice is possible with appropriate and available resources to perform the nursing duties [5,6].
Lastly, individuals had their personal goals for choosing an institution or accepting job appointment where job satisfaction was achieved when these personal goals were congruent with that of the organization. A study by Mita  noted that, some personal goals such as opportunity for career development, quality time for family, 'fat pay check' and better benefits influences retention among nurses. Therefore, a fair opportunity for these benefits in an organization in alignment with the employees' desires, will surely bring job satisfaction hence, the intention to stay longer.
The study found out that majority (52.71%) of respondents had the intention to leave their current place of work soon. Intention to leave was higher in public hospital (55.45%) compared with the private (45.95%). Most of the respondents strongly perceived their managers as exhibiting participatory management style. However, a proportion also perceived their managers as exhibiting consultative, exploitative authoritative and benevolent authoritative management styles. Salary and rewards was the most extrinsic factor that influenced retention of nurses at work and self-motivation was the most intrinsic factor that contributed to nurse's retention at work.
Hospital managers should be able to identify the specific motivation and retention needs of nurses so as to develop strategies to meet their needs in order to keep them at work. Secondly a good Reward system should be instituted in all facilities couple with equal opportunity for all nurses to develop themselves professionally and academically.
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Augustine Kumah, MPH, Department of Quality and Public Health, Nyaho Medical Centre, Accra, Ghana.
© 2022 Kumah A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.