Nurses’ Perception of Management Styles and Factors Influencing Retention of Nurses in Ghana: A Cross-Sectional Survey

: Retention of health professionals in the health sector in Ghana is crucial to address the human resource needs of the health sector and to promote an 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 the retention of nurses in Ghana. 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 analyzed using STATA statistical software Version 14.2. Statistical significance was set at 0.05. Females dominated the study (68.89%). Most of the respondents (19.70%) strongly agreed that Nurse Managers exhibited a participatory management style. However, the majority (52.71%) of the respondents intended to leave their current facility. Nurses’ intention to leave was higher in a public hospital (55.45%) compared to the private hospital (45.95%). Salary and rewards were the major (39.53%) extrinsic factors that influenced the retention of nurses at work and self-motivation was the major (27.91%) intrinsic factor that contributed to nurses’ retention at work. Most of the respondents strongly agreed that managers practiced a participatory management style. Benevolent authoritative management style was statistically significant with nurses’ intention to leave.


Introduction
Background Healthcare management is a complex but dynamic task that requires trained and experienced professionals to provide seethe services needed (Bhattacharya and Ramachandran, 2015). Healthcare operates with its most valued asset; the health workforce, where nurses of any specialty play a major role in caregiving (Rad and Yarmohammadian, 2006). Baumann et al. (2006) described retention of employees as the "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 (Seber, 2012). It builds a strong relationship between the manager and the health professional, creates room for dependability in the professional, provides the opportunity to gain more experience and advance professionally (Aboshaiqah et al., 2014). 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 (WHO, 2013). 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 an 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 (Duffield et al., 2014). The shortage is a result of aging health workers, high labour turnover of health professionals, and the fast-growing world population (WHO, 2013). Another triggering report discussed at the annual meeting of the WHO African Region held in Victoria Falls, Zimbabwe noted a shortage of skilled health professionals in Africa (WHO, 2017). 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 of 2015.
Many studies have been done to identify factors that influence nurses' retention at work. These findings suggest that intentions to stay and retention of nurses are multifactorial (Brown et al 2013). One factor that has been identified to promote staff 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 (Nwadukwe and Court, 2012). According to Likert and Likert (as cited in Nassar et al., 2011), 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 the healthcare system. Retention of nurses has attracted many concerns and one theoretical view has been on job satisfaction as a factor influencing nurse retention (Lui et al., 2011). Job satisfaction is classified to be associated with intrinsic or internal factors and external factors. The intrinsic factors include employee goals and their alignment to organizational goals, self-motivation, and personal values and the extrinsic or external factors include leadership style, managerial relations, salary, the opportunity for professional advancement, and work environment (Warburton et al., 2014).
Ghana, on the other hand, experienced massive nurses' attrition from 2000 to 2006 which was associated with a poor salary. However, the attrition rate was reduced in Ghana upon the introduction of the Single Spine Salary Structure (SSSS) in 2012 (Antwi and Philips, 2013). In Ghana, the Health Sector Fact and Figures (2017) saw a nurse per 542 populations. Although there is a lack of consistent statistics supporting labour turnover among nurses in Ghana, Akatsi Government Hospital recorded several nurses taking transfers to other facilities outside the municipality over the last 2 years (ASMHDAR, 2020). Also, St Paul's Hospital recorded quite a significant number of nurses resigning from the organization according to the HRM, within 2020. Irrespective of efforts made by hospital administrators and nurse managers to retain registered nurses, turnover 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 skilled registered nurses to ensure productivity and quality health care.
Management styles are the philosophies that the manager utilizes on the capabilities of the employees in order to achieve established organizational goals (Nwadukwe and Court, 2012). 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 the performance of those activities to attain organizational goals.

Exploitative Authoritative Management Style
The exploitative authoritative style of management is a style where decisions are solely made by the manager. This style may be used when an organization is large and most employees are seen as less competent therefore have to be coerced to perform their responsibilities. In another way, this style is noted to promote productivity if a task needs to be accomplished within the shortest possible time (Giltinane, 2013). According to Grimsley, this style is associated with a manager who exploits the employees and mostly where the employees are unskilled and have no union representative for indirect participation and advocacy on their behalf pushing them to work extra with demeaning incentives.

Benevolent Authoritative Management Style
The Benevolent Authoritative Management Style has been described as a style of management that is 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 (Basak and Govender, 2015).

Consultative Management Style
The consultative style encourages the employees' involvement in decision-making and fosters voluntary cooperation (Shah Mohammadi, 2015). 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 (2016), the participatory style is employed by a manager who involves the employee in decision making concerning the organization and 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 the issue at hand and are well versed in the organizational culture. This management style is perceived as positively associated with a high level of employees' job satisfaction, promotes involvement, enhances problem-solving and empowers the employees, and encourages autonomy and creativity (Rolková and Farkašováa, 2015).

Extrinsic and Intrinsic Factors
Determinant of nurses' retention at workplaces 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, the 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 (Warburton et al., 2014). These factors are internal and turn to motivate the individual and determine their commitment to work. They influence how the individual reacts to the situation and can be adjusted by the individual to promote job satisfaction. Intrinsic factors include personal values and interests, personal goals that match with those organizational goals, selfmotivation, and psychological response to work among workers (Darkwa et al., 2015;Dovlo, 2003).

Methods
This study employed a quantitative approach using a cross-sectional survey design to collect data from 135 nurses about their perception of their nurse managers' leadership styles and how these styles influence their staff retention at work. The study was carried out in two hospitals in the volta region of Ghana. Hospital A (Akatsi Government Hospital) is a government-owned hospital while Hospital B (St Paul's Hospital) is a privately owned hospital. 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 population in each hospital. All Nurses who were not on duty during the survey were excluded from the study. Data were analyzed using STATA statistical software Version 14.2. Statistical significance was set at 0.05.

Results
In assessing management styles employed by managers in both facilities, the 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%).
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 to 3. Half (50.37%) were single, (47.41%) were married and a proportion (2.22%) were divorced. The majority (48.89%) of the respondents had no child. The longest years of service of the respondent was above 5 years (32.59%) with the majority (46.67%) with Diploma Certificate.
Respondents were asked about their intention to leave their current workplaces. The majority (52.71%) of the respondents responded positively (YES) and (47.29%) responded negatively (NO). Intention to leave was higher in public hospitals (55.45%) compared with 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 4years.
Respondent's perception was sought on extrinsic and intrinsic factors influencing retention of nurses. Among the extrinsic factors influencing nurses' retention, the majority (39.53%) of the respondents strongly agreed to salary and rewards and a conducive working environment (35.66%) as extrinsic factors influencing retention of nurses. Also, (34.88%) of the respondents strongly agreed to opportunities for career advancement, Job Security (33.33%), and promotion (32.56%) as extrinsic factors contributing to the intention to stay.
The majority (27.91%) of the respondents strongly agreed to self-motivation and professional autonomy (22.48%) as intrinsic factors contributing to the 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 being retained at work.  Source: Author's Survey, 2020

Discussion
The study assessed nurses' perception of four management styles; Exploitative Authoritative style, Benevolent Authoritative style, Consultative style, and Participatory style proposed by Likert and Likert (1967). The study found that the majority (19.70%) of the nurses strongly perceived their managers to have exhibited a participatory management style in both hospitals. This finding was remarkable but contradicts a study by Nassar et al. (2011) which found nurses' perception of their managers in some private hospitals in Egypt as consultative, where nurses' ideas were sought but were not trusted completely by their managers.
The 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 (Kossivi et al., 2016). This evidence may be related to the fact that the majority of the respondents had worked for more than five years and maybe were more acquainted with their managers and the health systems. Rad and Yarmohammadian (2006) highlighted the fact that this style of management is more applicable where the employees are matured in the organization and well informed coupled with the manager's competence in the organizational operation. Presumptuously, the finding of this study showed that nurses were well experienced, was involved in decision making, and had good relationships with their managers.
A proportion (12.12%) of respondents also perceived their managers to have practiced a consultative style where they were engaged in decision making only in specific situations while the general policies were determined by the nurse manager. Few nurses also perceived their managers as benevolent and exploitatively authoritative. Managers were 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, they may not promote innovation and may decrease the morale of employees hence turnover intentions (Giltinane, 2013). The reason for the low response 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 (Cole et al., 2014). This brings about job satisfaction hence a higher likelihood of retention (Lephalala et al., 2008). The study shows that employees have diverse opinions about their managers and there is a need for managers to develop a good and 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 nurses' intention to leave their current facilities. It was found that the 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 (2015) proved otherwise when they identified job dissatisfaction among nurses working in 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 were found to be the most (39.53%) contributing factors. This was in agreement with the findings of (Rad and Yarmohammadian 2006, Willis-Shattuck et al., 2008and Getie et al., 2013. This result, however, contradicts a study by Kwansah et al (2012) in three regions in Ghana which reported a lower response rate for financial incentives as a motivator in rendering healthcare services among health professionals. The findings by Kwansah et al. (2012) were concluded based on the fact that, though a good salary is important, it was not recognized as the most important motivating factor for retention even in rural areas.
'Conducive environment' was also strongly acknowledged among nurses who work in the private hospital compared with those who worked in the public 18 hospital. Apparently, the private facility has modernized buildings and a serene environment compared to the public hospital which may be the source of motivation. A proportion of respondents also strongly agreed to the opportunity for career advancement as an extrinsic factor that contributed to the 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 and many universities have sprung up offering flexible courses. This finding was similar to the findings of (Kossivi et al., 2016) who found an opportunity for educational advancement to promote retention. However, a study by (Agyei-Baffour et al., 2011) in Ghana found a lack of opportunity for further education as the reason for health professionals' lack of motivation to work in 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 the retention of nurses at the workplace. Cole et al., (2014) found self-motivation significantly associated with job satisfaction and concluded that this factor promotes a sense of responsibility, ownership hence better performance. Notwithstanding, this current study confirms selfmotivation 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 (Lephalala et al., 2008) in England which proved autonomy as nurses' desire to be retained. The majority of the respondents were in their Middle Ages with youthful exuberant and with over five years of working experience and so, will desire autonomy in practice. Autonomy in practice is possible with appropriate and available resources to perform the nursing duties (Cole et al., 2014).
Lastly, individuals had their personal goals for choosing an institution or accepting job appointments where job satisfaction was achieved when these personal goals were congruent with that of the organization. A study by Mehta et al. (2014) noted that some personal goals such as the opportunity for career development, quality time for family, 'fat pay check', and better benefits influence 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.

Conclusion
The study found that the majority (52.71%) of respondents had the intention to leave their current place of work soon. Intention to leave was higher in public hospitals (55.45%) compared with private (45.95%). Most of the respondents strongly perceived their managers as exhibiting a participatory management style. However, a proportion also perceived their managers as exhibiting consultative, exploitative authoritative, and benevolent authoritative management styles. Salary and rewards were the most extrinsic factor that influenced the retention of nurses at work and self-motivation was the most intrinsic factor that contributed to nurses' retention at work.

Limitation of the Study
A cross-sectional study was used for this study which can infer a relationship between variables but are not sufficient to set the direct cause. Researchers have acknowledged that and recommend further investigations and future studies in this area.

Recommendation
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, good Reward systems should be instituted in all facilities coupled with equal opportunity for all nurses to develop themselves professionally and academically.