Internal Marketing and the Antecedents of Nurse Satisfaction and Loyalty

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<ul><li><p>This article was downloaded by: [McMaster University]On: 27 October 2014, At: 08:38Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK</p><p>Health Marketing QuarterlyPublication details, including instructions for authorsand subscription information:</p><p>Internal Marketing and theAntecedents of Nurse Satisfactionand LoyaltyJames W. Peltier a , Lucille Pointer b &amp; 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.</p><p>To cite this article: James W. Peltier , Lucille Pointer &amp; John A. Schibrowsky (2006)Internal Marketing and the Antecedents of Nurse Satisfaction and Loyalty, HealthMarketing Quarterly, 23:4, 75-108, DOI: 10.1080/07359680802131582</p><p>To link to this article:</p><p>PLEASE SCROLL DOWN FOR ARTICLE</p><p>Taylor &amp; Francis makes every effort to ensure the accuracy of all the information(the Content) contained in the publications on our platform. However, Taylor&amp; Francis, our agents, and our licensors make no representations or warrantieswhatsoever as to the accuracy, completeness, or suitability for any purposeof the Content. Any opinions and views expressed in this publication are theopinions and views of the authors, and are not the views of or endorsed byTaylor &amp; Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor andFrancis shall not be liable for any losses, actions, claims, proceedings, demands,</p><p></p></li><li><p>costs, expenses, damages, and other liabilities whatsoever or howsoever causedarising directly or indirectly in connection with, in relation to or arising out ofthe use of the Content.</p><p>This article may be used for research, teaching, and private study purposes.Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expresslyforbidden. Terms &amp; Conditions of access and use can be found at</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>McM</p><p>aste</p><p>r U</p><p>nive</p><p>rsity</p><p>] at</p><p> 08:</p><p>38 2</p><p>7 O</p><p>ctob</p><p>er 2</p><p>014 </p><p></p></li><li><p>Internal Marketing and the Antecedentsof Nurse Satisfaction and Loyalty</p><p>James W. PeltierLucille Pointer</p><p>John A. Schibrowsky</p><p>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:; Website:; 2006 by The Haworth Press. All rights reserved.]</p><p>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:</p><p>Lucille Pointer is Assistant Professor of Marketing, University of Houston-Down-town, One Main Street, Suite 1058N, Houston, TX 77002 (E-mail:</p><p>John A. Schibrowsky is Professor of Marketing, University of Nevada, Las Ve-gas, Box 456010, 4505 Maryland Parkway, Las Vegas, NV 89154 (E-mail:</p><p>Health Marketing Quarterly, Vol. 23(4) 2006Available online at</p><p> 2006 by The Haworth Press. All rights reserved.75doi:10.1080/07359680802131582</p><p>doi:10.1080/07359680802131582</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>McM</p><p>aste</p><p>r U</p><p>nive</p><p>rsity</p><p>] at</p><p> 08:</p><p>38 2</p><p>7 O</p><p>ctob</p><p>er 2</p><p>014 </p></li><li><p>KEYWORDS. Internal marketing, relationship marketing, health care,quality, retention, loyalty, satisfaction, nurse</p><p>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).</p><p>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 (OBrien-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).</p><p>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</p><p>76 HEALTH MARKETING QUARTERLY</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>McM</p><p>aste</p><p>r U</p><p>nive</p><p>rsity</p><p>] at</p><p> 08:</p><p>38 2</p><p>7 O</p><p>ctob</p><p>er 2</p><p>014 </p></li><li><p>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 societys long-term well-being(Buerhaus et al. 2006).</p><p>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 ONeill 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; OBrien-Pallas et al. 2006).</p><p>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 replacinglost 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</p><p>Peltier, Pointer, and Schibrowsky 77</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>McM</p><p>aste</p><p>r U</p><p>nive</p><p>rsity</p><p>] at</p><p> 08:</p><p>38 2</p><p>7 O</p><p>ctob</p><p>er 2</p><p>014 </p></li><li><p>motivation for leaving (Malhotra and Mukherjee 2003) and that maxi-mize exit barriers (Murrow and Nowak 2005).</p><p>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 theorganizations 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).</p><p>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).</p><p>78 HEALTH MARKETING QUARTERLY</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>McM</p><p>aste</p><p>r U</p><p>nive</p><p>rsity</p><p>] at</p><p> 08:</p><p>38 2</p><p>7 O</p><p>ctob</p><p>er 2</p><p>014 </p></li><li><p>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.</p><p>INTERNAL MARKETING AND RELATIONAL BONDS</p><p>Internal Marketing</p><p>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. Gronoos (1990) suggested that internal marketing isabout developing motivated and cust...</p></li></ul>