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Internal Marketing and theAntecedents of Nurse Satisfactionand LoyaltyJames W. Peltier a , Lucille Pointer b & John A.Schibrowsky ca College of Business and Economics, University ofWisconsin-Whitewater , Whitewater, WI, 53190 E-mail:b University of Houston-Downtown , One Main Street,Suite 1058N, Houston, TX, 77002 E-mail:c University of Nevada , Las Vegas, Box 456010, 4505Maryland Parkway, Las Vegas, NV, 89154 E-mail:Published online: 22 Oct 2008.
To cite this article: James W. Peltier , Lucille Pointer & John A. Schibrowsky (2006)Internal Marketing and the Antecedents of Nurse Satisfaction and Loyalty, HealthMarketing Quarterly, 23:4, 75-108, DOI: 10.1080/07359680802131582
To link to this article: http://dx.doi.org/10.1080/07359680802131582
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Internal Marketing and the Antecedentsof Nurse Satisfaction and Loyalty
James W. PeltierLucille Pointer
John A. Schibrowsky
ABSTRACT. Employee satisfaction and retention are critical issues thatinfluence the success of any organization. Yet, one of the most criticalproblems facing the worldwide health care industry is the shortage ofqualified nurses. Recent calls have been made within the traditional nurs-ing literature for research that utilizes marketing and business models tobetter understand nurse satisfaction and retention. The purpose of thisstudy is to develop scales that can be used to empirically test a model ofthe proposed antecedents of nurse job satisfaction and loyalty which havebeen used widely in the internal marketing and the relationship-marketingliterature. Specifically, the study will investigate the degree to whichstructural bonding, social bonding, financial bonding activities, and qual-ity of care impact how well nurses are satisfied with their job and theircommitment to the organization. The results show that quality of caremost impacted nurse satisfaction and loyalty, followed by structural, so-cial, and financial bonds. Article copies avail-able for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH.E-mail address: [email protected]> Website: http://www.HaworthPress.com> © 2006 by The Haworth Press. All rights reserved.]
James W. Peltier is Professor of Marketing, Irvin L. Young Professor of Entrepre-neurship, College of Business and Economics, University of Wisconsin-Whitewater,Whitewater, WI 53190 (E-mail: [email protected]).
Lucille Pointer is Assistant Professor of Marketing, University of Houston-Down-town, One Main Street, Suite 1058N, Houston, TX 77002 (E-mail: [email protected]).
John A. Schibrowsky is Professor of Marketing, University of Nevada, Las Ve-gas, Box 456010, 4505 Maryland Parkway, Las Vegas, NV 89154 (E-mail: [email protected]).
Health Marketing Quarterly, Vol. 23(4) 2006Available online at http://www.hmq.com
© 2006 by The Haworth Press. All rights reserved.75doi:10.1080/07359680802131582
doi:10.1080/07359680802131582
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KEYWORDS. Internal marketing, relationship marketing, health care,quality, retention, loyalty, satisfaction, nurse
Employee satisfaction and retention are critical issues that influencethe success of any organization. Both of these outcome variables are es-pecially important in the health care industry where staffing demandsimpact the overall quality of care that patients receive (Gebbie andTurnock 2006). Yet, one of the most critical problems facing the world-wide health care industry is the shortage of qualified nurses (Ross et al.2005). This shortage is due in most part to an overarching imbalance ofsupply and demand attributed to demographics, qualifications, avail-ability, and importantly, the willingness to do the work (Robert WoodJones Foundation 2002). This shortfall is expected to become even morecritical in the future as the total demand for nurses outpaces the numberentering the workforce (Joint Commission on Accreditation of HealthCare Organizations, JCAHO 2002). The crisis is extreme, with the U.S.Department of Health and Human Services expecting a shortage of al-most 800,000 nurses by 2020, a vacancy rate of 29%, nearly four timesthe current rate of 8% (USDHHS Health Resources and Services Ad-ministration 2004).
Contributing to the nursing shortage is the fact that qualified nursesare leaving the nursing field at an alarming rate due to high levels ofjob dissatisfaction (O’Brien-Pallas et al. 2006). Aiken et al.’s (2001)comprehensive study of hospital nurses in the United States, Canada,England, Scotland and Germany found that over 40% of the nurses sur-veyed were dissatisfied with their jobs and over 20% planned job changeswithin the year. At a time where an aging population is contributingto increased patient volume, the “total” number of nurses needed is ex-pected to increase as more facilities are built to accommodate the grow-ing marketplace for health care services, which will only serve toexacerbate the nurse shortage problem (Waters 2003).
A number of interrelated problems are created when health care facil-ities have an inadequate number of nurses. First, job stress rises whenthe nursing staff must bear the burden of an increased work load due toinadequate staffing and work schedule inflexibility (Hays et al. 2006).This in turn leads to high levels of job dissatisfaction associated withpoor scheduling practices, unrealistic workloads, mandatory overtime,and administrators’ perceived lack of responsiveness to nurses’ concerns(Cohen 2006). From a patient-safety outcome perspective, an under-staffed and over-worked nursing staff compromises patient care in the
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form of increased medical errors, higher nurse-patient ratios, lower pa-tient survival rates, an increase in the average length of hospital stay,and more return visits for chronically ill patients (Aiken et al. 2002;Buerhaus et al. 2005; Chaguturu and Vallabhaneni 2005; Needlemanet al. 2002). Moreover, dissatisfied nurses are a major contributing fac-tor to negative perceptions patients have about the quality of care thatthey receive (Kaldenberg and Regrut 1999). Combined, the nursingshortage clearly impacts the state of the U.S. health care system and itsresolution is of great importance to the society’s long-term well-being(Buerhaus et al. 2006).
Since the supply of nurses entering the workforce is unlikely to in-crease in the near term, one of the best strategies at the organizationallevel for reducing the nursing shortage is to limit the nurse attrition rate(Robinson et al. 2006). As a consequence, many health care facilities arestarting to place a higher priority on the cultivation of nurse loyalty andretention (Anthony et al. 2005; Holtom and O’Neill 2004). Loweringnurse attrition has the added benefits of reducing recruitment and trainingcosts, and maintaining a more productive and experienced nursing staff(Wilson 2005). Waters (2003) argued that many of these turnover costsare much greater than most hospitals realize in that “full” replacementcosts are four to six times higher than what is typically estimated. Giventhe costs of having to continually recruit and train nurses to replace thosewho leave, one of the primary objectives of any health care organizationshould be to devise efficient and effective strategies for enhancing theiroverall job satisfaction and loyalty to the organization. Unfortunately, al-though reducing nurse attrition is an important and common goal, rela-tively few health care organizations have effective retention programs inplace (Nogueras 2006; O’Brien-Pallas et al. 2006).
One solution to the nurse retention dilemma is for health care organi-zations to adopt a “relationship-marketing” approach to nurse loyaltyand retention. From a customer satisfaction perspective, relationship-marketing theory contends that nurse loyalty can be addressed in termsof “customer-based” satisfaction principles (MacStravic 2002). In-grained in this philosophical perspective is the tenet that “replacing”lost customers is more costly and creates greater havoc than working tokeep satisfied customers (Reichheld 1993). In this regard, a paradigmshift is needed that advocates that health care organizations treat theiremployees as a significant “customer group” and a critical organiza-tional asset (Gifford et al. 2002; Gombeski et al. 2004; Kelemen andPapasolomou-Doukakis 2004; Peltier et al. 1999). Importantly, astutehealth care managers will identify critical switching costs that minimize
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motivation for leaving (Malhotra and Mukherjee 2003) and that maxi-mize exit barriers (Murrow and Nowak 2005).
Inherent in any relationship-building effort is the need for health careinstitutions to follow the guiding principles of what has been termed in-ternal marketing (Peltier et al. 2003). Broadly defined, internal market-ing integrates “marketing, human resources management, and alliedtheories, techniques and principles to motivate, mobilize, co-opt, andmanage employees at all levels of the organization to continuously im-prove the way they serve external customers and each other” (Joseph1996, p. 55). Internal marketing presumes that organizations have a va-riety of internal stakeholder groups and that those firms which treat theiremployees as they would customers are well positioned to positivelyimpact the satisfaction and loyalty of this all-important organizationalresource (Peltier and Scovotti 2004). As part of the customer relation-ship perspective, it is important for employers to consider the needs ofworkers across all stages of the employee life-cycle, from new hire toseasoned veteran (Scovotti and Peltier 2005). A key outcome of suc-cessful internal marketing is the creation and communication of cor-porate-wide values designed to convey a sense of commitment to theorganization’s service providers (Hogg et al. 1998), who in turn areseen as champions of the organization (Bellou and Thanopoulos 2006).Organizations with a high degree of internal marketing orientation (IMO)have ongoing processes in place for producing value for their employ-ees through the effective management of the relationships between em-ployees, supervisors and management (Gounaris 2006).
Unfortunately, many health care institutions lack the strategic insightfor designing and implementing research programs to address the roleof nurses in the care-giving process, and how their satisfaction and loy-alty impacts patient care, patient satisfaction, and profitability (Cooperand Cronin 2000; Peltier et al. 2003; Woods and Cardin 2002). Despitethe clear benefits of developing customer-focused staffing initiatives,only recently have health care researchers begun to direct attention tothe use of relationship marketing, internal marketing and related busi-ness-oriented concepts to explore ways to improve job satisfaction andnurse loyalty (Bevolo 2004; Brown et al. 2006; Melten 2005; Peltieret al. 2004). Moreover, while there is growing interest in exploring thenurse satisfaction and retention issue, little research has actually fo-cused on scale development and validation (Lings and Greenley 2005;Murrels et al. 2005), particularly within the relationship marketing andinternal marketing literature (Brown et al. 2006; Gombeski et al. 2004;Peltier et al. 2003, 2004).
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Recent calls have been made within the traditional nursing literaturefor research that utilizes marketing and business models to better under-stand nurse satisfaction and retention (Brown et al. 2006; Greenawalt2001; Mee 2005; Woods and Cardin 2002). The purpose of this studyis to develop scales that can be used to empirically test a model of theproposed antecedents of nurse job satisfaction and loyalty which havebeen used widely in the internal marketing and the relationship-mar-keting literature. We further expand the antecedent variables to investi-gate whether nurses’ perception of perceived quality affects satisfactionand commitment. Specifically, the study will investigate the degree towhich structural bonding, social bonding, financial bonding activities,and quality of care impact how well nurses are satisfied with their joband their commitment to the organization. We begin first with a discus-sion of the internal and relationship-marketing constructs, present outmodel and hypotheses, and present the results from a large scale studyof nurses in three health care organizations.
INTERNAL MARKETING AND RELATIONAL BONDS
Internal Marketing
According to Ballantyne et al. (1995), internal marketing comprisedmarketing activities done within the firm that channel staff attention tothe internal activities that need to be changed in order to enhance exter-nal performance. Gröonoos (1990) suggested that internal marketing isabout developing motivated and customer-minded employees at all lev-els of the organization including the frontline employees. From a supplyand demand perspective, Melten et al. (2005) conceptualize employeesas consumers of internal resources generated and supplied by otherswithin the firm, with the ultimate focus being on ways to use these re-sources to improve the job characteristics that contribute to long-termcommitment to the organization. The implied assumption driving inter-nal marketing is that satisfied employees will perform their jobs betterand impact customer satisfaction (Berry 1983).
Previous research investigating the conceptual underpinnings of theinternal marketing construct can be categorized into four categories(Hwang and Chi 2005):
1. Treating employees as an important internal customer;
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2. Similar to external marketing efforts, to develop an employee cus-tomer orientation behavior through promotional and communica-tion efforts designed to create awareness and a positive outlooktoward the employer;
3. Human resource management orientation related to efforts to en-courage and improve employees’ focus on providing external cus-tomers with superior service;
4. Internal exchange relations examining how employees effectivelyinteract with other organizational members for achieving com-mon goals.
More recently, internal marketing has been conceptualized as orga-nizational citizenship behavior. An overarching goal of organizationalcitizenship behavior is to ensure that employees contribute to the healthcare institution through an enhanced sense of belonging and, therefore,to the nursing staff’s corresponding self-esteem (Bellou and Thanopoulos2006). By harnessing the power of the health care staff for communicat-ing organizational value, the entity has the ability to create a unifiedbrand equity that is not only useful for external marketing, this identitycan be leveraged to create a work-based atmosphere that unifies internalstaff members regardless of their years of tenure (Berthon et al. 2005;Gombeski 2004; Woods and Cardin 2002). A key component of an or-ganization’s internal branding efforts is the notion of relational internalmarketing. Bell et al. (2004) defined relational internal marketing interms of coordinating relationships and tasks via the “process of initiat-ing, maintaining, and developing the relationships between employees,their management, and the organization, for the purposes of creating su-perior value for customers” (p. 114).
Although there is growing conceptual acceptance of the boundariesof internal marketing, there are surprisingly few suitable instruments formeasuring its impact on important organizational consequences such asstaff retention, staff attitudes and satisfaction, and compliance (Gounaris2006; Lings and Greenley 2005). From the perspective of the nurseworkforce, the strength and direction of internal relationships could bemeasured in terms of nurses’ interactions with other nurses, supervisors,physicians, management, and other health care support staff (Peltier et al.2003, 2004). Undeniably, internal marketing in a health care environ-ment is complex and requires a clear understanding of the myriad ofpossible interpersonal interactions that take place amongst caregivers,all of which contribute to the level of satisfaction, commitment and
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loyalty that internal and external customers have for the organization(Peltier and Scovotti 2004; Scovotti and Peltier 2005).
Relationship Marketing
Relationship marketing was first conceptualized as a way to attract,maintain, and enhance customer relationships in services industries andgrew out of the realization that the marketing of services needed a dif-ferent approach than what had been used to market physical goods(Berry 1983). Building on this definition, Gonroos (2000) conceptualizedrelationship marketing as the “process of identifying and establishing,maintaining, enhancing, and when necessary terminating relationshipswith customers and other stakeholders, at a profit, so that the objectivesof all parties involved are met, where this is done by a mutual giving andfulfillment of promises” (p. 98). Relationship marketing is seen as a par-adigm shift away from viewing organization-customer interactions asone-time exchanges to a marketing orientation encompassing long-termcommitments afforded to the seller as a reward for collaborative part-nerships (Bonnin et al. 2005). Viewed this way, customer acquisitionis only a first step in the relationship-building process, with the strengthof the relationship being a function of the quality of interactions that ac-cumulate as the buyer-seller partnership unfolds (Peltier et al. 1998).Mutually beneficial supplier-customer relationships are seen as a keysustainable advantage, one that is integral to the long-term financial suc-cess of an organization (Danov et al. 2003).
In contrast to relational marketing, which recognizes the importanceof motivating external customers to seek a relationship with an organi-zation, internal marketing emphasizes the equally important need formanagement to see the organization as a free market existing of a supplychain of internal suppliers and customers (Bonnin et al. 2005). Com-bined, relationship marketing and internal marketing utilize a customerfocus that seek to enhance employer-employee partnerships by viewingloyalty as a logical outcome of training and motivational programs de-signed to increase customer and employee satisfaction, generate posi-tive word-of-mouth, reduce turnover, and at its apex, to provide highquality service (Bonnin et al. 2005; Cooper and Cronin 2000; Peltieret al. 1997; Rafiq and Ahmed 2000). Given “the long-term and interac-tive nature of the relationship-building process, “the recruitment andhiring of nurses should be viewed as the initial stage of the relationshiplife-cycle, with the ultimate goal being to strengthen situations where
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the relationship is strong and convert indifferent nurses into loyal advo-cates” (Peltier et al. 2003, p. 67).
A number of antecedent variables have been identified for buildingstrong internal marketing relationships for health care staffing, includ-ing commitment, trust and relational bonds (Scovotti et al. 2005). Theseinterrelated constructs are developed through repeated interactions be-tween nurses and other parties in the care-giving relationship and sug-gests an orientation consistent with the approach of marketing from theinside out (Woods and Cardin 2002). Kanter (1993) maintained thatwork environments providing access to information, resources, support,and growth opportunities lead to enhanced levels of organizationaltrust, job satisfaction, and loyalty. Based on this seminal work, a grow-ing stream of research is emerging to identify the plethora of antecedentrelationship-oriented variables and their impact on the level of trust andcommitment employees have for the organization (Wilson 2005).
Trust
Trust is an essential ingredient of the relationship-building process,particularly in services industries offering intangible products and whereefficacy claims are often difficult to verify (Berry 1995). Because ser-vice settings typically require more frequent interactions and personalinteractions, establishing a high degree of interpersonal trust is crucialfor achieving positive relational outcomes (Bendapudi and Berry 1997).From an outcome perspective, the psychological need to trust an ex-change partner increases along with the perceived level of risk asso-ciated with how the relationship unfolds over time and the quality ofservice that is rendered (Morgan and Hunt 1994). In harmony with thisrisk perspective, Anderson and Narus (1984) defined trust as a partner’sbelief that the other partner will perform actions that will result in posi-tive outcomes, as well as not take unexpected actions that would resultin negative outcomes. Along these same lines, Moorman et al. (1992)defined trust as a willingness to rely on an exchange partner as the needarises. Nevin (1995) supported these viewpoints and suggested that trustemerges incrementally over time as the number of inter-party exchangesincrease and positive outcomes are established.
A recent report by the Institute of Medicine (IOM) clearly under-scores the importance of having a positive work environment and thebenefits such environments have on patient safety and workforce mo-rale. A major conclusion from that study was that creating, nurturing,and sustaining organizational trust should be one of management’s
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highest priorities (IOM 2004). Unfortunately, the nursing shortage andthe resulting organization changes implemented by management havehelped create a working environment in which nurses have become dis-trustful of management (Spence Laschinger et al. 2004). This perceivedlack of trust has had a number of detrimental effects, most notably withregard to a lessened commitment of nurses to accept organizationalgoals and strategic initiatives (Spence Laschinger and Finnegan 2005).
Commitment
Commitment is a necessary element for sustaining a long-standingrelationship between parties and has been defined as a customer’s long-term orientation toward a relationship (Hennig-Thurau et al. 2002).Moorman et al. (1992) defined commitment as an enduring desire tomaintain a valued relationship. Loi et al. (2006) found that organiza-tional commitment was negatively related to intention to leave and waspartially mediated by the relationship between perceived organizationsupport (POS) and turnover intention. In terms of nurse satisfaction,Spence Laschinger and Finnegan (2005) and Spence Laschinger et al.(2006) uncovered a direct link between job satisfaction, trust, and orga-nizational commitment.
Commitment to an organization and/or a relationship is multidi-mensional and has been conceptualized trough a variety of interrelatedconstructs likely to influence employee satisfaction, retention, andperformance:
1. Affective Commitment: Refers to employees’ emotional attach-ment to the organization and the extent to which they identify withthat organization (Johnson et al. 2006). Affective commitment isbased on emotional factors which hold parties together and is sim-ilar to Moorman et al.’s (1992) conceptualization of the strengthof a relationship.
2. Normative Commitment: Associated with the degree to which anemployee feels obligated to maintain the relationship (Malhotraand Mukherjee 2003).
3. Calculated or Continuance Commitment: The desire to maintainthe relationship based on an analysis of the costs versus the ben-efits of maintaining the relationship (Fullerton 2003). From acost-benefit perspective, commitment to an organization directlyimpacts profitability through greater efficiencies, cost reductions,
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and increased revenues across the customer life-cycle (Berry1995; Peltier et al. 2002).
Bonding Activities
While the positive relationships between trust, commitment andcustomer loyalty have received empirical support in the services mar-keting and industrial marketing literature, this stream of research is un-derdeveloped from an internal marketing perspective. One area that isreceiving increased attention for explaining the strength of employee-employer relationships is the investigation of relationship bonds. Earlyresearch on relationship marketing identified three types of relationshipbonds for developing loyal customers: financial, social, and structuralbonds (Berry 1995). Turnbull and Wilson (1989) view these bonds aspositive interpersonal relationships between employees in a buyer andseller organizations.
Although not well documented, trust in and commitment to an or-ganization are expected to be at their highest when all three types ofrelationship bonds exist (Wang et al. 2006). From an organizational per-spective, researchers investigating the strength of the relationship pa-tients have with health care providers (Peltier, Boyt and Schibrowsky1999a, 1999b, Peltier et al. 2001, 2002) showed that satisfaction andloyalty were enhanced in the presence of strong relational bonding ac-tivities. Specific to internal marketing efforts, empirical support sug-gests that the strength of relational bonds of physicians (Cochran andPeltier 2003; Peltier et al. 1997), nurses (Peltier, Boyt and Westfall1999; Peltier et al. 2003, 2004) and other care givers have toward the or-ganization impact job satisfaction and loyalty to the institution. Becauseimproving retention is an important mechanism for reducing the nurseshortage and satisfied nurses are more likely to remain with their currentemployer, the relationship bonding constructs will be evaluated aspredictors of job satisfaction.
Job Satisfaction and Employee Loyalty
Job satisfaction is a widely studied concept in many different occu-pational areas including the health care industry. Much of the ongoinginterest in job satisfaction is based on the belief that job satisfactionis highly related to employee loyalty, job performance and retention(Christen et al. 2006). Job satisfaction has been defined as an attitudinalreflection of how people like or dislike their jobs (Spector 1997). Nelson
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(2006) contends that the biggest determinant of whether health care em-ployees stay or voluntarily quit a job is dissatisfaction with their em-ployment situation. In an extensive review of the literature, Brown et al.(1993) found more than 30 constructs linked to job satisfaction. Thesefactors were grouped into four major categories: work outcomes, indi-vidual differences, role perception, and organizational variables. Theiranalysis showed that the variables related to role perception had thehighest average correlation with job satisfaction followed by organiza-tional-related variables. The results suggest that employees need cleardirections regarding their work environment and that the task and jobdesigns should be given a higher priority among employees. Job designissues could be conceived as being similar to aspects of the job whichfacilitate the development of structural, social, and financial bonds.This is consistent with Melten et al. (2005) and their discussion of pro-cess integration as a way to support internal employees and foster em-ployee satisfaction. Although there is a burgeoning body of literatureinvestigating issues related to nurse satisfaction and retention, rela-tively few measurement instruments have assessed scale validity andreliability (Murrells et al. 2005). Almost nonexistent is scale validityand reliability assessments utilizing the internal marketing and relation-ship-marketing constructs.
Quality Perception of Employees and Job Satisfaction
Gustafsson et al. (2005) indicated that for services, satisfaction issimilar to a global evaluation of service quality and is comprised of cus-tomers’ perception of how good the service is or whether the servicemeets expectations. The Institute of Medicine (IOM) reported that thequality of care patients’ receive is positively impacted by the extent towhich nurses are active and empowered members of the health care pro-vision process (IOM 2004), a finding corroborated by Armstrong andLaschinger (2006). Numerous studies have found that firms whoseproducts or services are rated as offering superior quality enjoy severaladvantages including increased customer satisfaction and loyalty, lowermarketing costs, larger market shares (Beloucif et al. 2004). Beloucifet al. (2004) reported that quality relationships are based on trust, com-mitment and satisfaction, with service quality being the key compo-nent in the ultimate strength of the relationship. Quality and service areseen as major selection criteria for patients choosing among health pro-viders, and patient satisfaction is an important indicator of health carequality (Al-Mailam 2005).
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Although there is a growing consensus that quality of care impactspatient satisfaction and that nurses satisfied with their work environ-ment provide higher quality care (Buerhaus et al. 2005), only recentlyhave researchers reversed the relationship to investigate whether per-ceptions nurses’ have of the quality of care an institution provides pa-tients impact job satisfaction and retention (Mrayyan 2005; Wagner2006). This is an important area of investigation from an internal mar-keting perspective in that positive indicators of care quality could serveto promote commitment to the organization through attractive em-ployee branding efforts (Berthon et al. 2005; Gombeski et al. 2004;Woods 2002).
In the next section we conceptualize a model of internal marketingfor evaluating the impact of bonding activities and the perception ofquality of care on nurses’ job satisfaction and loyalty. Specific constructsincluded financial rewards, job support and growth, social relationships,nurse-staff relationships, nurse-physician relationships, control overcare decisions, job flexibility, and perceived quality of care provided.The hypothesized relationships between these variables and job satis-faction are discussed below and are illustrated in Figure 1.
MODEL DEVELOPMENT
Internal marketing, with its inside-the-organization customer focus,leverages employer-employee and employee-employee relationshipsto increase job satisfaction, lower attrition, generate staffing referrals,and like relationship marketing, to positively impact service quality(Ballantyne 2003; Rafiq and Ahmed 2000). Given the customer-basedorientation of the relationship-marketing construct, it offers clear direc-tion for developing conceptual and empirical models of effective inter-nal marketing efforts and how they impact nurse satisfaction and loyalty(Cooper and Cronin 2000; Murrow and Nowak 2005; Peltier et al. 1997,2003, 2004). Because services are often produced and consumed simul-taneously, high levels of customer contact and interaction exists in mostservice settings. The constant organization-customer interactions thattake place underscore the critical importance of ensuring that serviceemployees are motivated to attend to the needs of the customers. As anextension of relationship marketing, internal marketing was proposedas one way to ensure that employees are willing participants in thedelivery of customer service. As the model in Figure 1 indicates, nurse
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satisfaction is dependent on financial bonds, social bonds, structuralbonds, and perceived quality of care. According to the model, financialbonds are conceptualized as including monetary and job support, whilesocial bonds are proposed to be demonstrated by relationships withnurses and other health care workers and relationships with physicians.
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FIGURE 1. Hypothesized Model of the Antecedents of Nurse Satisfaction andLoyalty
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Total Financial Compensationas a Bonding Element and Job Satisfaction
Financial Support: Financial incentives are one simple way to builda relationship bond with employees. These incentives are typically de-signed to provide the right monetary incentives to gain employees satis-faction and loyalty (Murrells et al. 2005). Financial incentives typicallyinclude salary, fringe benefits in the form of health insurance and retire-ment benefits, and the opportunity to make additional income throughovertime pay (Miceli and Mulvey 2000). By adding these together the to-tal monetary value or compensation package can be calculated. As thevalue of the compensation the worker receives escalates, it increases theextent to which workers believe the organization is committed to them,values their contribution, and cares about their well-being (Eisenbergeret al. 1986).
A recent survey of 811 nurses reported that changes in compensationwere the most important thing needed to attract more people into thenursing field (Nursing Spectrum and the Bernard Hodes Group 2003).Although financial compensation is a necessary component of a nurse’sjob environment (Sparks et al. 2005), it is by no means a sufficient ante-cedent to satisfaction and loyalty (Peltier et al. 2003, 2004). Peltier et al.(1997) suggest that loyalty built solely on financial incentives does notprovide a sustainable competitive advantage since employees can belured away by firms offering higher financial rewards. In this regard, anurse’s compensation can increase dramatically by shifting organiza-tional allegiance. As a consequence, financial rewards may serve as amotivation to leave the organization if other types of personal and psy-chological rewards are not present in the job environment (Reineck andFurino 2005; Sparks et al. 2005).
H1a: Nurses’ perception of financial rewards will be positively re-lated to job satisfaction and loyalty.
Job Support: Kanter (1993) posited that having access to organiza-tional resources necessary for accomplishing one’s work leads to morecommitted, satisfied and loyal employees who are able to exercise higherlevels of autonomy and self-efficacy. In a comprehensive and longi-tudinal study, Spence Laschinger et al. (2004) found workplace envi-ronments allowing nurses greater access to information, support, andopportunities to learn and grow over time experienced higher levels ofjob satisfaction. Education and training promote feelings of self-worth
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and professional growth, two key elements for enhancement in the nurs-ing profession (Robinson et al. 2005; Thorpe 2003). Employees who arewell supported will be more satisfied and better at performing their jobsand creating higher levels of customer satisfaction (Gould and Fontenla2006; van der Wiele et al. 2002).
H1b: Nurses’ perception of job support will be positively relatedto job satisfaction and loyalty.
Social Bonding Elements Related to Job Satisfaction
One approach to explaining the employee and employer relationshipis through social exchange theory which refers to how well two partiesinteract and form dependent relationships. Gouldner (1960) referred tosocial exchange as a type of contingent exchanges between parties withexpectations of reciprocity. Through these exchanges, parties developemotional bonds over time through the communication process. Theseties are critical to maintaining the relationship. At the heart of socialexchanges is the amount and nature of communications between ex-change partners. Communication is the facilitating dimension betweenthe members of an organization. Positive communication in the form ofempathy, reflective listening, and supportive comments can enable or-ganization members to share their needs. Melten et al. (2005) empha-sized the need for managers to communicate with contact workers as away to facilitate better consumer satisfaction.
Within a health care organization, social bonding can take manyforms, including social support, connectedness to other staff, caring, em-pathy, information support, assistance, affirmation, and a host of otherrelationship-based communications and interactions between nursesand other health care professionals (Langford et al. 1997; Peltier et al.2003, 2004; Shirey 2004; Underwood 2000). Research has denoted alink between collaboration and the nature of interpersonal communica-tions between caregivers (Bégat et al. 2005). Adequate communicationsbetween these workers are necessary, especially those that enhance in-terpersonal relationships (Peltier et al. 2003, 2004; Taylor and Barling2004). When good communications exist between nurses and othermembers in the health care team, the likely result is higher job perfor-mance, increased job satisfaction, and improved quality of care (Van EssCoeling and Cukr 2000; Manojlovich 2005; Rosenstein and O’Daniel2005). In our model we segment relationships nurses have with other
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nurses and health care providers from those that they have with physi-cians.
Relationship with Nurses and Other Health Care Staff: Social bondscover a much wider array of activities than financial bonds and couldinclude any and all interpersonal interactions that exist within an orga-nization (Peltier et al. 2003; Barney 2002). In an increasingly competi-tive environment for recruiting and retaining nurses, a close team ofmutually committed care givers, including staff at all levels, is neededto ensure a high level of job satisfaction (Bégat et al. 2005; Trofino2003). Teamwork, cohesion, cooperation, friendliness, shared values,and a supportive work environment have all been found to be impor-tant antecedents of nurse satisfaction and retention (Anthony et al.2005; Buerhaus et al. 2005; Miller 2006; Strachota et al. 2003). Yet,workplace incivility and a neglect to show mutual respect are pervasivein many health care organizations (Hutton 2006). In this regard, non-supportive and uncooperative peers negatively impact nurses’ joy ofworking (Manion 2003; Taylor 2001).
H2a: Nurses’ perception of the relationship they have with othernurses and support staff will be positively related to job satisfac-tion and loyalty.
Relationship with Physicians: Specific to nurse-physician relation-ships, superior communications and a more positive working relation-ship are seen as antecedent conditions to nurse satisfaction and loyalty(Budge et al. 2003; Peltier et al. 1999, 2003, 2004; Rosenstein 2002;Taylor and Barling 2004). In contrast, negative interactions betweennurses and physicians, especially those characterized as being highlydysfunctional, lead to lower satisfaction and a greater propensity toleave the organization (Rosenstein and O’Daniel 2005a, 2005b, 2006;Rosenstein et al. 2002).
H2b: Nurses’ perception of the relationship they have with physi-cians will be positively related to job satisfaction and loyalty.
Structural Bonding Elements Related to Job Satisfaction
With regard to the provision of appropriate health care to patients inneed, structural bonding is in part a form of collaboration betweenmembers in the network in which various stakeholder groups acknowl-edge and value the input of others for achieving the desired care goals
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(Stichler 1995). Collaboration among team members provides a senseof “empowerment” and has been associated with improved patient out-comes (Baggs et al. 1999) and an enhanced sense of support and accom-plishment at work (Patrick and Spence Laschinger 2006). Effectiveteams are those that have greater information diversity across care par-ticipants, allow team members to exercise some level of care control,and that have a higher degree of shared values (Jehn et al. 1999). De-spite the benefits of structural bonding, nurses report high levels ofdissatisfaction with the extent to which they feel empowered in thecare-giving process (Nedd 2006). Although structural bonding can takemultiple forms, two that have received recent attention in health care set-tings are perceptions of control over care and job flexibility.
Perception of Control Over Care: Despite increasing financial in-centives for nurses, the nursing profession has lost some of its appealdue to the perception that nurses have inadequate input into health caredecision making (Chaguturu and Vallabhanen 2005; Segio et al. 2006).As such, an essential element for enhancing nurse satisfaction and loy-alty is having an internal culture that values the knowledge, experi-ences, and perspectives that nurses offer to the organization (Cohen2006). Nurses’ perception of the amount of control they have in the carethat patients receive represent feelings of empowerment, which in turnhas been found to enhance respect, and organizational trust (SpenceLaschinger and Finegan 2005). In general, empowerment is an orga-nizational cultural that decentralizes power by involving employees atdifferent levels to become involved in the decision making process(Hardy and Leiba-O’Sullivan 1998; Spreitzer 1997). Kanter (1977)maintained that characteristics of a job can either constrain or encour-age job performance and job satisfaction. Her theory states that whenemployees have access to lines of information, support, resources andopportunity to learn and grow they feel empowered. These lines of powerare sources of structural empowerment and affect among other things,job satisfaction.
There is growing support in the nursing literature that job satisfactionand loyalty are in part a function of the degree of decision autonomy thatnurses have in the provision of care (Nedd 2006; Patrick and SpenceLaschinger 2006). Aiken et al. (2001, 2002) showed that nurses work-ing in environments that promote autonomy and control of hospital prac-tices were generally more satisfied with their jobs and experience lessburnout. An evolving stream of research by Spence Laschinger and col-leagues has found a significant relationship between structural empower-ment, trust, nurse job satisfaction, and commitment to the organization
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(Armstrong and Spence Laschinger 2006; Spence Laschinger et al.2001, 2004, 2006; Spence Laschinger and Finnegan 2005).
Within the relationship marketing paradigm, structural bonds developwhen customers in buyer-seller relationships feel involved in makingdecisions regarding how the exchange process and outcomes unfold(Wang, Liang, and Wu 2006). Peltier and colleagues have found consis-tent support that patients are more satisfied with the care that theyreceive and have an increased likelihood of referring the health care facilityto others if nurses played a role in the care-giving process (Peltier, Boytand Schibrowsky 1999a, 1999b; Peltier et al. 2000, 2001, 2002). Spe-cific to internal marketing, Peltier, Boyt and Westfall (1999) and Peltieret al. (2003, 2004) found that nurses’ perceptions of their working envi-ronment and their likelihood of referring the organization to other nurseswere impacted by the degree of structural bonding that existed in the re-lationship.
H3a: Nurses perception of control over care will be positively re-lated to job satisfaction and loyalty.
Job Flexibility: Kelliher and Riley (2003) indicated that flexibilityin the management of labor allows a better match between supply anddemand of workers and improves efficiency and worker productivity.They distinguish between three types of flexibility: numerical, finan-cial, and function. Functional flexibility refers to re-assigning workersas needed within a firm opposed to specialization of labor. Numericalflexibility deals with the number of workers and the amount of time theywork. Pay flexibility refers to the ability to adjust pay structures in linewith changes in economic and competitive conditions. Each form of jobflexibility has been found to be positively associated with job satisfac-tion (Rosin and Korabik 1991; Kelliher and Riley 2003; Scholarios andMarks 2004).
For the current study, job flexibility encompassed both financial andscheduling forms of job flexibility. Most health care facilities by natureneed nurses 24 hours a day and are likely to have only the minimumnumber of nurses on staff. Studies have reported that many nurses areassigned mandatory overtime and often worked overtime involuntarilyin the sense that they felt they had no choice in the given situation(Steinbrook 2002; Golden and Wiens-Tuers 2005). An increased flexibil-ity in work hours enables nurses to balance more evenly work and familycommitments (Holtom and O’Neill 2004). It also gives them someautonomy to determine how they will accommodate their lifestyle with
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the emotional and physical demands of the job (O’Brien-Pallas, Duffield,and Alksnis 2004), and is expected to enhance job satisfaction (Halfer andGraf 2006).
H3b: Nurses perception of job flexibility will be positively relatedto job satisfaction and loyalty.
Quality, Job Satisfaction, and Loyalty
The link between quality of care and patient satisfaction is well doc-umented. A parallel yet under-researched area of inquiry is whetheremployees’ perception of perceived quality of care is related to theirpersonal satisfaction and loyalty. Employees’ perceptions of job-relatedfactors are posited to have certain psychological effects pertinent to un-derstanding the quality-satisfaction link (e.g., Yoon et al. 2004; Paswanet al. 2005). For example, Reeves and Hoy (1993) found that employeeswho believe that management is committed to service quality enjoyedhigher quality ratings by customers as well. They went on to say thatthis situation may motivate the employees to, in fact, provide higher ser-vice quality. Through their interactions with the doctors, staff and man-agement, nurses should be able to assess the service quality of their healthcare facility. Given this perspective, nurses perceptions of quality ofcare are expected to impact job satisfaction and loyalty (Armstrong andLaschinger 2006; Mrayyan 2005; Wagner 2006).
H4: Nurses’ perception of quality of care will be positively relatedto job satisfaction and loyalty.
Relative Importance of the Relationship Bonds
Each of the three relationship bonds have been found to impact nurses’perceptions of job satisfaction and loyalty. Recent research has tried todetermine whether an ordered relationship exists, and if so, which rela-tional bonds contribute most to the perceived strength of that rela-tionship. Wang et al. (2006) studied buyer-seller relationships in theinformation services industry and found support that structural bondshad the greatest impact on customer satisfaction and loyalty. Pertinentto the current study, Peltier et al. (2003) posited and found support for ahierarchical ordering in nurse-provider relationships, with structuralbonds having the greatest impact on nurse loyalty and satisfaction, fol-lowed by social bonds, and financial bonds. Given the fact that service
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quality is the preeminent focus of the relationship-marketing literature,and the findings of Peltier et al. (2003) and Wang et al. (2006), we positthe following exploratory hypothesis.
H5: Nurse job satisfaction will be most impacted by perceptions ofquality of care, followed by structural, social, and financial bonds.
METHOD
Data were collected in a large Midwestern health care organization.The organization had a multitude of health care centers and clinics. All405 full- and part-time nurses at these organizations received the surveyvia the in-house mail system. To encourage response, the nursing staffswere informed through each institution’s newsletter of the importanceof the study and that they would be receiving the survey the followingweek. To ensure confidentiality and candid responses, completed sur-veys were returned in a sealed envelope to a secured return box. A totalof 309 questionnaires were returned, for a response rate of 76.3%.
Questionnaire Development Process
A multistage process was utilized to develop the questionnaire. First,previous nurse loyalty and internal marketing research was reviewed tohelp identify possible relationship categories. Next, 20 interviews werecompleted with nurse supervisors and staff nurses to uncover relationalareas and job activities that needed to be addressed on the questionnaire.The questionnaire was finalized after a small sample qualitative pretest.Pertinent to the current study, the final questionnaire contained 35 ques-tions related to financial relationships, social relationships, structuralrelationships, care quality, and overall satisfaction measures. All ques-tions used a 5-point scale ranging from 1 = very dissatisfied to 5 = verysatisfied.
Measures
Financial Relationships: Eight-item measure focusing on financialreward questions (i.e., hourly wage, total income earned, promotions),fringe benefits (retirement, health insurance), and activities designed toenhance future earning potential (on-the-job training, continuing educa-tion, recognition).
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Social Relationships: Eight-item measure pertaining to communica-tions and relationships nurses have with one another and other supportstaff (i.e., nursing staff cohesion, relationship with supervisor, commu-nication with other members of health care team) and with physicians(i.e., communication between physician and yourself, how well physi-cians listen to what you have to say).
Structural Relationships: Ten-item measure related to the amount ofcontrol nurses have in care decisions (i.e., freedom to do job as see best,amount of input have in care decisions) and job scheduling (i.e., workschedule flexibility, ability to determine how much overtime).
Quality of Care: Three-item measure consisting of perceptions ofoverall care regarding the nursing staff, physicians, and support staff.
Global Job Satisfaction Measure: Summed six-item measure includ-ing overall satisfaction with nursing staff, unit, physicians, level of jobstress, overall satisfaction with job, and likelihood of referral.
RESULTS
Scale Validation and Purification
An exploratory factor analysis was initially conducted to determinewhether the predicted financial relationships, social relationships, struc-tural relationships, and quality of care dimensions were present in thedata. To enhance internal reliability, items that loaded on more thanone dimension were removed from consideration. Table 1 contains thesolution from the Varimax rotation. As can be seen in Table 1, seven di-mensions emerged as outlined in the literature review. Two financialbonding relationships emerged: Financial Rewards (coefficient alpha =.76) and Job Support and Growth (coefficient alpha = .72). Two socialbonding relationships were also supported by the data: Nurse-Staff Re-lationships (coefficient alpha = .83) and Nurse-Physician Relationships(coefficient alpha = .86). The two structural bonding dimensions in-cluded Care Control (coefficient alpha = .86) and Job Scheduling Flexi-bility (coefficient alpha = .65). Finally, all three of the Care Qualityitems loaded together (coefficient alpha = .90).
The average scores for each of the relationship dimensions and over-all satisfaction are shown in Table 2. Overall, the nurse participantswere satisfied with their job (average satisfaction = 4.2). The nurses hadrelatively high levels of satisfaction with the relationships they havewith other nurses and nonphysician staff (4.5), job support and growth
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TABLE 1. Factor Loadings
CareControl
Nurse-Staff
FinancialRewards
Nurse-Physician
Qualityof Care
JobFlex
Support/Growth
Freedom to do yourjob as you see best
.775
Your specific patientresponsibilities
.746
Your ability to providethe best possible careto patients
.710
Amount of input youhave in care decisions
.710
Your patient loadassigned to youeach shift
.602
Communicationamong nursing staff
.775
Your relationshipwith nurses
.734
Cohesion of thenursing staff
.729
Communication withother members ofhealth care team
.634
Your relationshipswith supervisors
.489
Communicationbetweenadministrationand yourself
.450
Total income earned .898
Hourly wage thatyou receive
.862
Retirement benefits .566
Health insurancebenefits
.503
Communicationbetween physiciansand you
.858
Your relationship withphysicians
.846
How well physicianslisten to what youhave to say
.755
Quality of carenursing staff
.785
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CareControl
Nurse-Staff
FinancialRewards
Nurse-Physician
Qualityof Care
JobFlex
Support/Growth
Quality of care othermembers of healthcare team
.764
Quality of carephysicians
.723
Your ability todetermine how muchovertime you work
.748
Number of hours youwork each shift
.723
Work scheduleflexibility
.623
Continuingeducation/trainingopportunities
.779
On-the-job training .562
The number of breaksyou take and when
.503
Amount of recognitionthat you receive
.484
Variance explained =64.7%
12.1% 11.8% 10.2% 9.3% 7.8% 6.8% 6.7%
Coefficient alpha .86 .83 .76 .86 .90 .65 .72
TABLE 2. Average Dimension Scores
Relationship Category Average Dimension Score
Financial bonds
Financial rewards 3.0
Job support and growth 4.0
Social bonds
Nurse-staff relationships 4.5
Nurse-physician relationships 3.4
Structural bonds
Control over care decisions 3.7
Job flexibility 3.8
Quality of care 4.0
Overall satisfaction 4.2
Note: On a scale of 1-5 where 1 is “very dissatisfied” and 5 was “very satisfied.”
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(4.0), and quality of care (4.0). They were moderately satisfied withjob flexibility (3.8) and control over care decisions (3.7), and were leastsatisfied with financial rewards (3.0) and relationships with physi-cians (3.4).
A regression analysis using factor scores was conducted to test themodel’s hypotheses that each of the relationship dimensions and per-ceptions of quality of care would impact nurses’ feelings about theirjob. Factor scores were used to eliminate any multicollinearity betweenthe independent variables. The regression findings are shown in Ta-ble 3. The overall model was highly significant and explained 63% ofthe variation in global job satisfaction (F = 71.9, p < .001). Equally im-portant, each of the individual hypotheses related to financial relation-ships (H1a and H1b), social relationships (H2a and H2b), structuralrelationships (H3a and H3b), and perceptions of quality of care (H4)had a significant and positive impact on global job satisfaction (all withp < .001).
In addition to examining the directional impact of each of the inde-pendent variables, we were also interested in determining whether thethree relationship categories and care quality had varying degrees of im-portance in explaining job satisfaction and loyalty. An examination ofthe standardized beta coefficients and t-values in Table 3 provides gen-eral support for our hypotheses. Perceptions of quality of care had thegreatest impact on explaining differences in nurses’ level of job satis-faction (std beta = .399, t = 11.3). Similarly, control over care decisions,
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TABLE 3. Regression Results
Hypothesis Std Beta T-Value Significance
Financial bonds
Financial rewards H1a .204 5.8 .001
Job support and growth H1b .250 7.1 .001
Social bonds
Nurse-staff relationships H2a .297 8.4 .001
Nurse-physician relationships H2b .308 8.7 .001
Structural bonds
Control over care decisions H3a .341 9.7 .001
Job schedule flexibility H3b .252 7.2 .001
Quality of care H4 .399 11.3 .001
F = 71.9, p � .001, R2 = .63Note: Dependent variable was nurses’ job satisfaction.
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a structural relationship component, had the second greatest impact onjob satisfaction (std beta = .341, t = 9.7). On the other end of the rela-tionship spectrum, financial rewards (std beta = .204, t = 5.8) and jobsupport and growth (std beta = .250, t = 7.1) had the least impact on jobsatisfaction. Consistent with expectations, social job aspects regardingnurse-staff (std beta = .297, t = 8.4) and nurse-physicians relationships(std beta = .308, t = 8.7) fell between financial and social bonds. Onlyjob schedule flexibility, a structural relationship dimension, failed tomaintain the predicted order.
DISCUSSION AND MANAGERIAL IMPLICATIONS
The findings of this study lead to a number of notable conclusions andmanagerial implications. First, the results of the comprehensive modelindicated that all the relationship activities plus perceived quality of caresignificantly affect job satisfaction. This suggests that all of these fac-tors can be used as valuable tools for increasing job satisfaction and loy-alty. Moreover, the findings demonstrate that the factors are additive,suggesting that managers and administrators should not consider thesefactors to be substitutes for each other. For example, financial rewardsdo not replace job support and growth. Conversely, job schedule andflexibility will not make up for a deficient pay schedule. The traditionalstrategy that a pay increase will solve all the problems associated withjob satisfaction and retention is not supported by these findings. Insteadthese findings suggest that a combination of financial, social and struc-tural bonding activities along with high perceived quality of care is amuch more effective approach to increasing job satisfaction and loyaltyamong nurses. The most satisfied and loyal nurses are those that arecontent with their financial rewards, social bonding relationships andempowerment.
A second significant finding was that the structural bonding and so-cial bonding activities were more influential than were financial bond-ing activities in affecting job satisfaction and loyalty. While bondingactivities designed to improve job schedule flexibility, nurse-staff rela-tionships, nurse-physician relationships, control over care decisions aremore difficult to implement and take longer to cultivate, they potentiallyyield significant improvements in job satisfaction and employee reten-tion. In addition, social and structural bonds are very difficult for com-peting health care organizations to replicate (or guarantee to new hires),which may provide a sustainable competitive advantage and may be
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more effective in reducing defections. For health care organizations thatare truly interested in improving job satisfaction and retention in theirnursing staffs, this provides a great opportunity to differentiate theirorganization from the others in their geographic region. The benefits arelikely to be well worth the effort.
A third significant finding was the relationship between perceivedquality of care and satisfaction. In this study, the perceived overall qual-ity of care provided by the health care organization was the single mostimportant influencer of job satisfaction. While all health care organiza-tions are concerned with the quality of care, this study provides an addi-tional reason to focus on it. The more the nurses perceive that theircolleagues and the health care organization are working to provide qual-ity care, the more satisfied they will be with their jobs and more likelythey are to stay with the organization.
So what does an organization do to foster “perceived quality ofcare?” First, the organization must make an effort to put a quality teamof employees in place. That includes hiring the most qualified nursesand physicians and attracting good support staff members. It should im-plement highly visible quality improvement programs and recognizestaff for all quality improvements. Second, the organization must en-gage in internal marketing, providing its employees with communica-tions that demonstrate the organization’s commitment to quality careand provide examples and other signals of the quality of care providedby the hospital or clinic. Many health care organizations provide highquality care, but lack the internal marketing mechanisms to communi-cate the successes to their employees. A health care firm interested inimproving job satisfaction among its employees cannot rely on the in-formal communication channels to provide that information. After all,past studies have shown that informal communication networks in orga-nizations are much better at disseminating negative rather than positivenews. Health care organizations must become proactive internal mar-keters. Some typical internal marketing tools include: targeted newslet-ters, awards and recognitions, internal advertising and brand building,special events, e-mail alerts, etc. In many instances, this will requirehealth care providers to seek outside help to create such programs.
Similarly, the health care organization must get the same positivemessages about its commitment to the quality of care out to its externalpublics. Nurses are much more likely to increase their perceptions aboutthe quality of care provided by the health care facility when the percep-tions of quality of care by individuals outside the organization improve.It is much easier to have confidence in the organization when patients,
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friends, acquaintances, and the local media mention positive things aboutthe hospital.
Limitations and Future Research Directions
While this study provides insight into employing marketing tech-niques to improve job satisfaction and quality of care, it was conductedat one organization located in the Midwestern United States. Morework, needs to be done to determine the model’s generalizability acrosshealth care organizations and in different locations. In addition, morework needs to be done to improve the measures of nurse loyalty, satis-faction, likelihood of leaving, and levels of bonding in terms of theirreliabilities and validity (Lings and Greenley 2005; Murrels et al. 2005).More work is also needed to identify other potential influencers of jobsatisfaction and loyalty for nurses.
Given these limitations we propose a number of future research di-rections. First, we would like to extend this work to other staff employ-ees at health care organizations. Second, we believe that it is importantto explore whether there are hierarchical relationships between the in-dependent variables in this study. In particular, social and structuralbondings are at a higher level than financial bonding and the role ofquality perception in this overall relationship. Finally, the relationshipsbetween these variables and job retention, internal marketing, and per-ceived quality of care need to be further addressed. Little is knownabout internal marketing especially as it pertains to employee retention.
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