Quality of the leader-member relationship and the organizational commitment of nurses

2 Escola Superior de Enfermagem de Lisboa, Lisboa, Portugal. ABSTRACT Objective: To understand the perception of the quality of leadership relationships and the organizational commitment of nurses, and to analyze the influence of this relationship quality. Method: Cross-sectional and correlational study, with a quantitative approach, using a non-probability convenience sampling with 408 nurses. The data were collected through questionnaires at Central Hospital in Lisbon, between January and March 2013. The statistical analysis of the data was carried out using IBM® SPSS® Statistics 19 software. Results: Three hundred forty-two questionnaires were considered valid. The quality of the leadership relationship was satisfactory, and the nurses were poorly committed to the organization. The quality of the leadership relationship was statistically correlated with organizational commitment: there was found a moderate association to affective commitment (rs=0.42, p<0.05), a low association with the normative commitment (rs=0.37, p<0.05), and a very low association with the calculative commitment (rs=0.14, p<0.05). Conclusion: Leadership exerts influence on organizational commitment. An opportunity to improve the quality of the leadership relationship between nurses and their leaders was found, with the consequent possibility of developing organizational commitment.


INTRODUCTION
All organizations are made up of people and depend on them to achieve their goals of carrying out planning, organization, management, and control, so that they are viable and fulfill their missions.In all organizations, it is fundamental to develop environments that promote well-being, involvement, and retention of professionals.In the area of healthcare, these aspects are especially important to ensure performance quality and safe care practices.Today, deep and substantial organizational changes can be seen, which may interfere with the relationship of professionals to organizations, especially recent legislative reforms in Portugal's healthcare, and cultural changes based on economic interests, which sometimes, overcome issues regarding individuals in the world of work.In the context of these changes, leadership is considered essential (1) .Through leadership, it is possible to develop and influence the organizational climate, and contribute to the team's motivation, the commitment of collaborators, and trust in the organization (2) .
Leadership, from the perspective of the leader-member exchange (LMX) theory, has as a focus the interpersonal relationship between leader and collaborators, suggesting that leaders establish unique relationships with each member (3) , thus determining high-quality (in-group) or low quality (out-group) relationships.High-quality or non-contractual relationships are characterized by the development of a partnership based on reciprocity, non-contractual behaviors, mutual trust, respect, affection, and solidarity.In low-quality relationship or contractual relationships (4) , leaders act as hierarchical supervisors, and the relationship is based on contractual functions (5) .
According to the role theory, this approach presupposes that the relationship is developed over time (4) and, in spite of the quality of the relationship being mostly determined by the leaders, the collaborators also have the power to influence this process (3) , that is, the collaborators have a dynamic and active role.
Some studies have shown a positive relationship between the LMX quality of relationship and some important results for collaborators and the organization, especially job satisfaction (6) , performance (7) , and affective organizational commitment (5) .
There is evidence that the commitment of professionals may be an important explanatory variable for the results of organizations (8)(9) .The underlying idea is that the creation of bonds with the organization implies an active participation of collaborators in organizational life and a desire to give something of themselves, with the purpose of contributing to the organization's success.It is of utmost importance that nurses are organizationally committed, since commitment maximizes the positive behavior of productivity (10) , and consequently all these dimensions will be reflected in quality care.
Several researchers have studied organizational commitment.Initially, it was conceptualized as an unidimensional construct; however, some authors (8) recognize that organizational commitment, defined as a psychological bond that links the individual to the organization, has multidimensional characteristics.The model developed by these authors shows various connections to the organization, with three components of this model defined as follows: affective commitment (AC), calculative commitment (CC), and normative commitment (NC).
Affective commitment is seen as the emotional bond to, identification with, and involvement of employees in the organization.It is influenced by positive experiences at work, perceptions of support and justice, and job satisfaction.Collaborators with high affective commitment do not see their jobs as an obligation; they share the organization's values by establishing positive relationships with it and remain in it because it is their desire.
Calculative commitment is about the awareness of costs associated with leaving the organization (8) .This awareness may be due to two factors.The first is related to the perception of loss of investment in the organization in case a collaborator leaves it, and the second to the perception that there is no alternative to move to another organization.This connection is established when collaborators feel dissatisfied, wronged, and without opportunities to develop their own potential.Collaborators with high instrumental commitment present poor motivation and lower levels of performance, satisfaction, and involvement with their jobs (11) .
Normative commitment refers to feelings of loyalty, debt, and moral obligation toward the organization, that is, it is seen as a sense of obligation to remain in the organization, because it is the right attitude.It is developed through socialization and increases when there is a feeling of debt to the organization.Collaborators with high normative commitment work hard at their jobs (8) , share organizational values, trust their leaders, and feel valued by the organization (11) .
According to the above, any organization seeks collaborators with high affective and normative commitment, for which reason it is necessary to know the contours of the organizational commitment.In spite of some studies showing the relationship with the leader having a positive influence on organizational commitment (11) , other studies disagree with this aspect (5) , and there are few studies with healthcare professionals, especially nurses.In light of this, it is of utmost importance to know the organizational commitment of nurses and the existing relationship between the leader-member exchange and the organizational commitment of nurses.
Therefore, the following guiding questions emerge: What is the quality of the leadership relationship perceived by nurses?What is the level of organizational commitment of nurses?Is there an association between the perception of the quality of the leadership relationship of nurses and their organizational commitment?Based on these guiding questions, the aim of this study was to analyze the quality of the leadership relationship and organizational commitment of nurses, and to analyze the influence of the quality of the leadership relationship on the organizational commitment of nurses.

METHOD
A cross-sectional and analytical study with a quantitative approach was carried out in 15 admission units of the Central Hospital in Lisbon (medicine, neuroscience, cardiology, cardiothoracic surgery, and vascular surgery areas).The inclusion criterion for nurses was having worked in the admission unit for more than one year, in order to study stable relationships with the leader (12) .All nurses who met this criterion (n=408) were invited to participate in the study, which led to 342 valid questionnaires, corresponding to a 2% sampling error.
The data collection instrument was the questionnaire made up of evaluation instruments previously validated for the Portuguese population: The LMX-7 scale, or Leader Member Exchange, version for collaborators (13) , made up of seven statements (for example, "Your reliance on your boss is so strong that you would defend his position even in his absence.").Responses were based on a Likert-type scale, with five positions, from "rarely," "nothing," "none," "I totally disagree," and "extremely ineffective" (1) to "often," "much," "very high," "I totally agree," and "extremely effective" (5).A value of 2.5 was considered a cutoff point.
The organizational commitment scale developed by Meyer & Allen (14) , made up of 19 statements (for example, an item regarding affective, normative, and continuance commitment, respectively: "This organization has a great personal meaning for me"; "Even if it is an advantage for me, I feel that it would not be right to leave this organization at this time"; "I believe that there are very few alternatives to think about leaving this organization.").Responses were based on a Likert-type scale, with seven positions: "I totally disagree" (1), "I moderately disagree" (2), "I slightly disagree" (3), "I do not agree nor disagree" (4), "I slightly agree" (5), "I moderately agree" (6), and "I totally agree" (7).A value of 3.5 was considered a cutoff point.
The statistical analysis of the data was carried out with IBM® SPSS® Statistics 19 software.The statistical tests were carried out using a 0.05 significance level.
To verify the normality of the sample, the Kolmogorov-Smirnov test was used, with a Lilliefors correction; because the significance level presented values lower than 0.05, it led to the rejection of the normality of the sample.
In order to evaluate the psychometric properties of the instruments, a factor and internal consistency analysis of the instruments were carried out through calculation of Cronbach's Alpha coefficient, using a value higher than 0.80 as a good indicator.
Spearman's rank correlation coefficient was used to verify the association between the quality of the leadership relationship and organizational commitment.
All ethical aspects in studies of this nature were considered, such as authorization by the authors who validated the instruments used was obtained.Authorization was also granted by the healthcare ethics committee of the hospital where the study was carried out; and along with the questionnaire a free and informed consent was also provided, with an explanation of the research objectives, and assurance of data confidentiality and participant anonymity.

RESULTS
Of the sample of 408 nurses, 347 questionnaires were returned, and a response rate of 85% was obtained.Three hundred forty-two questionnaires were considered valid.
As expected, the sample had a prevalence of women (80.5%), and most were single (55.1%).Regarding academic degrees, most nurses interviewed had bachelor's degrees (63.8%), and with respect to the employment relationship with the organization, there was a prevalence of open-ended contracts (96.5%).The nurses' ages ranged from 23 to 59 years, and their length of time in the profession ranged from one to 39 years, with a mean of eight years, which confirms their professional experience.Their length of time in the organization also ranged from one to 36 years, and their length of time in their units ranged from one to 34 years, with a mean of 6.6 years, which confirms their stability at work.
The factor analysis showed that the LMX-7 instrument saturated only in one factor, which gives support to a unidimensional construct.With regard to the organizational commitment scale, it is distributed into three components according to the literature, and since it was adapted and validated for the Portuguese population, the items and the validated components were fully accepted (15) .The scales presented good internal consistency, with the exception of the calculative component of organizational commitment.Thus, the Cronbach's Alpha values were 0.90 for LMX-7, 0.80 for affective commitment, 0.83 for normative commitment, and 0.65 for calculative commitment.
With regard to the relationship with the leaders, the mean and median were above the cutoff values (3.24 and 3.28, respectively), and the item that obtained the lowest value was the provision of feedback by the leaders (mean of 2.79; median of 3).The values of affective and calculative commitment were also above the cutoff values.Normative commitment presented the lowest values and a higher dispersion in responses (Table 1).The analysis of the correlation table (Table 2) showed that the quality of the relationship with the leader was statistically correlated with organizational commitment, www.ee.usp.br/reeuspQuality of the leader-member relationship and the organizational commitment of nurses Rev Esc Enferm USP • 2017;51:e03263 presenting a moderate association with affective commitment (r=0.42,p<0.05), a low association with normative commitment (r=0.37,p<0.05), and a very low association with calculative commitment (r=0.14, p<0.05).

DISCUSSION
Nurses consider the quality of their leadership relationship satisfactory.This result is similar to that of other studies (9) , and regardless of the various contexts in which the studies were carried out, the leadership relationship in the perspective remains at a median level (16) .The results obtained through the LMX-7 suggest that it is important to incorporate greater feedback from nurse leaders.Feedback stands out as a skill required from nurse leaders, which is acquired through dialogue (17) .Through feedback, leaders recognize the potential of each member of the team, encouraging shared responsibility and professional autonomy (18) .By using it, leaders strengthen and develop the team's performance quality (19) .Feedback in the form of compliments, in addition to providing a positive organizational climate, promotes organizational commitment (20) .
With regard to commitment, this displays different levels.Therefore, nurses are moderately committed from the affective and calculative points of view, and poorly committed from the normative point of view, which shows that organizational commitment is poor.Considering that commitment has repercussions in organizational dynamics, especially in interactions with the members of the team and users, in addition to being able to maximize efficiency and organizational effectiveness, taking measures so that calculative commitment is reduced is of utmost importance.The measures must focus on valuing nurses, treating them with justice, and consistent practices of socialization.The results corroborate other studies (11) with regard to the prevalence of affective commitment; however, the same does not apply to other components.The fact that calculative commitment is greater than normative commitment may suggest that the current social and economic context promotes this type of commitment.There is a general perception of a lack of alternative jobs in other healthcare organizations, forcing nurses to remain in their organization because "they need to" (14) .However, the restructuring of the National Health Service, in addition to other measures, have caused the merger of some units, thus creating instability and dissatisfaction among professionals.This situation may lead to a feeling of weaker obligation and moral duty toward the organization.The results obtained suggest a double relationship toward the organization, that is, that nurses feel emotionally connected to the organization, nourishing feelings of loyalty, affection, and belonging (9,14) , but at the same time, they feel dissatisfied, wronged, and without opportunities to develop their own potential (11) .
There is a positive influence from leadership on commitment.The results corroborate other studies, in which the quality of the leader-member exchange (LMX) has a positive effect on collaborators' commitment (9,21) .Therefore, individuals who perceive their LMX relationship to be of high quality are more committed to accept the goals of the organization where they work, which suggests that, in order to strengthen nurses' commitment, the quality of the leadership relationship between nurses and leaders must be considered.This influence varies in several components of organizational commitment; the strongest is in the affective and normative components.Therefore, when there is a perception of a good relationship with nurse leaders, nurses easily develop affective bonds and feelings of moral duty toward the organization.These results are similar to those of an integrative literature review, which showed that nurses' perceptions of leadership style and management behaviors are considered determinants of organizational commitment (22) .
It is important that nurses develop a consistent organizational commitment, because when they are feeling involved and identify with the organization, positive behaviors that go beyond what is formally required are promoted, and this is reflected in the quality of care provided.The results obtained highlight the important role of nurse leaders, who have an essential role in ensuring the implementation of the mission, values, and principles defined by the top management (13) , and their ability to influence nurses' involvement and identification with the goals of the organization, conciliating them with the needs of the team.

CONCLUSION
The perception of the quality of the leadership relationship was found to be satisfactory, allowing us to state that it is possible and desirable that nurse leaders establish high-quality leadership relationships, establish and develop relationships of trust and loyalty, and increase the feedback provided to nurses who are part of the team.
The organizational commitment of nurses is based on affective and calculative components, and the implementation of measures in order to reduce the effect of the calculative component is necessary.
The data obtained with this sample suggest that there is a positive association between the quality of the leadership relationship and organizational commitment, and it may be said that the relationship that is established between nurse leaders and nurses is essential for the development of organizational commitment.Through leadership behaviors, it is www.ee.usp.br/reeuspRev Esc Enferm USP • 2017;51:e03263 possible to improve the organizational commitment of nurses with its consequences for individuals and organizations.The conclusions of this study pertain only to this sample and are not representative of nurses, which is considered a limitation.
Further studies with nurses in different healthcare organizations and the use of more comprehensive variables that influence the organizational commitment of nurses are suggested, especially organizational culture and the perception of organizational support.
** Mean value according to the Likert scale from 1 to 7.