Leadership in Health Services

Brazilian nursing professionals: leadership to generate positive attitudes and

behaviours
Claudia Affonso Silva Araujo, Kleber Fossati Figueiredo,
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Claudia Affonso Silva Araujo, Kleber Fossati Figueiredo, (2018) "Brazilian nursing professionals:
leadership to generate positive attitudes and behaviours", Leadership in Health Services, https://
doi.org/10.1108/LHS-03-2017-0016
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Brazilian
Brazilian nursing professionals: nursing
leadership to generate positive professionals

attitudes and behaviours

Claudia Affonso Silva Araujo and Kleber Fossati Figueiredo
COPPEAD Graduate School of Business, Federal University of Rio de Janeiro,
Rio de Janeiro, Brazil Received 8 March 2017
Revised 30 July 2017
Accepted 6 September 2017

Abstract
Purpose – This paper aims to identify the kind of work environment that should be offered by hospital
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leaders to their nursing staff in Brazil to generate job satisfaction, organizational commitment and
organizational citizenship behaviour within their field of expertise.
Design/methodology/approach – A survey was applied to 171 nurses and 274 nursing technicians who
work at five private hospitals in Brazil. Both factor analysis and regression analysis were used to analyse the
study model.
Findings – The results indicate that to stimulate positive behaviours and attitudes among nursing staff,
managers should mainly be concerned about establishing a clear and effective communication with their
professionals to ensure role clarity, promote a good working environment and encourage relationships based
on trust.
Research limitations/implications – The limitations of the study are absence of the researcher while
the questionnaires were filled out and the fact that the sample comprised respondents who made themselves
available to participate in the research.
Practical implications – This study contributes to elucidate the factors that can promote a good internal
climate for nursing staff, assisting hospital leaders to face the huge managerial challenges of managing,
retaining and advancing these professionals.
Originality/value – The findings contribute to the body of knowledge in leadership among nursing
professionals in developing countries. Hospital leaders in Brazil should encourage trusting relationships with
nursing professionals through clear, effective and respectful communications, besides investing in team
development and promoting a good working environment.
Keywords Job satisfaction, Work environment, Organizational commitment,
Organizational citizenship behaviour, Internal climate, Nursing professionals, Private hospitals,
Nursing leadership
Paper type Research paper

Introduction
The primary objective of this article is to investigate how to manage nursing professionals
through leadership to generate positive behaviours and attitudes in relation to the hospital
in which they work. The purpose of our research is to identify the kind of work environment
that should be offered by hospital leaders to their nursing staff to generate job satisfaction,
organizational commitment and organizational citizenship behaviour within their field of
expertise. To achieve this objective, a survey was offered to 410 nurses and 1,619 nursing
technicians working inside five private hospitals in Brazil.
The shortages of nursing professionals and also their high turnover have become a Leadership in Health Services
global issue (Jenaro et al., 2010; Robson and Robson, 2016). However, a good internal climate © Emerald Publishing Limited
1751-1879
can reduce turnover, promote work engagement and this way improve the quality of patient DOI 10.1108/LHS-03-2017-0016
 LHS care and motivate these professionals (Jenaro et al., 2010; Lu et al., 2012; Körner et al., 2016).
In this context, creating a positive internal climate for nursing professionals is pivotal to
retaining this valued staff. However, there is no consensus on what factors determine a
positive internal climate among nursing professionals (Utriainen and Kyngas, 2009).
Two trends emerged in the 80s: the first one emphasized psychological factors promoting
a view that work fulfils or allows for the fulfilment of important values for professionals in
the health sector. The second one pointed out factors related to the work environment such
as acknowledgement, adequate team size, autonomy and appropriate facilities for patient
care. Later in the 90s, the satisfaction of nursing professionals started to be regarded as a
complex terminology made up of both objective and subjective factors such as autonomy
nature and level, authority and responsibility, acknowledgement, reward and personal
satisfaction towards the work performed and a perspective of growth in the career. Patient
care was considered paramount for nurse satisfaction (Jenaro et al., 2010; Utriainen and
Kyngas, 2009).
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In this sense, this study is important and relevant because it contributes to elucidate the
factors that can promote a good internal climate for nursing staff besides assisting hospital
leaders to face the huge managerial challenges of managing, retaining and advancing these
professionals.

Theoretical background
Hospitals are institutions characterized by the fact that decision-making powers,
administration and distribution of resources are divided up among an important group of
professionals – physicians, nursing staff, physiotherapists, nutritionists, among others. In
Brazil, nursing activities are performed by different professional categories – nursing
assistants, nursing technicians and nurses (Hausmann and Peduzzi, 2009). Nursing assistants
and technicians have a high-school diploma, while nurses hold the Nursing degree diploma
(COFEN, 2015). According to the Nursing Profile in Brazil, an extensive survey carried out by
the Federal Nursing Council and The Oswaldo Cruz Foundation (Federal Nursing Council –
COFEN, 2015), the nursing team in Brazil is predominantly female, being composed of 84.6 per
cent of women and 80 per cent are technicians and assistants and 20 per cent are nurses while
more than half of the nurses (53.9 per cent), nursing assistants and technicians (56.1 per cent)
are concentrated in the Southeast Region. The three nursing categories are in charge of
integrating the health team and promoting health education, but the limits of the activities of
nursing professionals are defined in Decree No. 94,406/87, which regulates Law No. 7,498/86 on
the professional practice of Nursing (Federal Nursing Council - COFEN, 2013).
The nurses have the exclusive responsibility of managing the nursing service and
activities such as nursing care planning, consulting and auditing, nursing consultation,
nursing care prescription and all the care of greater technical complexity. On the other hand,
it is incumbent upon the nursing technician to execute the tasks related to patient care under
the nurses’ supervision and to assist the nurse in planning care activities for the severely ill
patient and in the prevention and execution of integral health care programmes (COFEN,
2013). In this study, we will focus our analysis on nurses and nursing technicians.
Although each nursing category is in charge of a part of the process, a good healthcare
service results from high task interdependence and work cooperation of all these
professionals in a good work environment (Drach-Zahavy and Somech, 2013; Körner et al.,
2016), which is still regarded as a rhetorical figure rather than a real practice (Körner et al.,
2016). For that reason, hospitals need leaders that can reconcile diverse perspectives to
provide integrated care (Smits et al., 2014). In this sense, to enhance the level of task
interdependence and to improve the quality of care provided to patients, hospital leaders
 should create more opportunities for nursing professionals to interact and promote a Brazilian
positive internal climate that foments teamwork, increases job satisfaction and reduces the nursing
turnover among healthcare professionals (Hayes et al., 2010; Albrecht and Andreetta, 2011,
Drach-Zahavy and Somech, 2013; Chiarini and Bracci, 2013; Chiarini and Baccarani, 2016).
professionals
In addition, several studies have indicated the turnover and intention to leave negative
effects on organizational effectiveness of hospitals such as low morale and an increase in
workload for the nurses who remain on the job, resulting in a poor quality patient care and
patient safety and satisfaction (Sellgren et al., 2007; Park and Kim, 2009). A good internal
climate is crucial to help nurses stay in their jobs, which requires leadership engagement
and organisational support recognised by the nursing staff (Sellgren et al., 2007, Albrecht
and Andreetta, 2011, Robson and Robson, 2016). Furthermore, according to a study
developed by Costa and Marziale (2006) in a public hospital in Brazil, leaders should
promote a good relationship between nursing professionals and physicians to maintain a
good work climate and to reduce dissatisfaction and stress by nursing professionals.
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For these reasons, an effective leadership that acts like a coach by spending time
maintaining group harmony, empowering and mentoring staff, and regularly reviewing the
factors that contribute to a good internal climate for nursing professionals is crucial
(Sellgren et al., 2007; Park and Kim, 2009; Crowne et al., 2017).
According to Park and Kim (2009), leaders should balance efficiency with human relation
aspects of a hospital’s culture that enhance the nurses’ quality of work life and the internal
climate. In this sense, Chiarini and Baccarani (2016) researched three hospitals in Italy to
evaluate total quality management (TQM) and Lean strategy in public healthcare and,
according to them, all the managers interviewed agreed that TQM–Lean can bring other
improvements more linked to human resources such as involvement and awareness of the
staff on the decision-making process, motivation, empowerment and self-responsibility,
group identity, communication among departments and teamwork.
Sellgren et al. (2007), in turn, argue that there is a strong relationship between leadership
behaviour and work climate, and between work climate, job satisfaction and staff turnover.
Besides, Freire and Azevedo (2015) considered the impact of workplace empowerment and
staff nurse perceptions of trustworthiness in their supervisor as determinants of
organizational commitment. For them, an empowering work context was significantly
predictive of the nurses’ affective commitment and on the perceptions of trustworthiness of
the supervisor. Also, the workers who understand that they have access to factors of
empowerment and perceive that they could influence their workplace are in a better position
to establish affective connections with the organization, as well as to view their supervisor
as trustworthy.
Another important concept related to a good internal climate for nursing professionals is
“shared nursing governance” where systems and services are aligned in partnership and
nurses are empowered to go beyond hospital norms and to collaborate with physicians in
operational activities, thus reducing clinical errors (Tuan, 2015). All these leadership
characteristics are in line with what is known as Kantian theory, in which there is more
participation on the part of the followers and leaders foment values such as justice, autonomy
and respect (Bowie, 2000). According to Bowie (2000), Kant rejects instrumental and also most
charismatic theories of leadership and focuses on transformational leadership and the leader as
educator. Therefore, a good leader ought to respect and enrich the autonomy of followers.
Mainly, the Kantian leader turns followers into leaders.
In addition to leadership behaviour, organizational characteristics are key factors in
nurse attraction and retention and many nurses are attracted to work in hospitals with a
“Magnet” status, which is the award given to hospitals that satisfy a set of criteria by the
 LHS American Nurses Credentialing Center (ANCC). In Magnet Hospitals, managerial practices
and environmental characteristics, such as opportunity to influence decisions about
workplace organization and participate in shared governance and employer-paid continuing
education, increase the job satisfaction of nurses and their commitment to the organization,
which in turn decreases nurse turnover and burnout (Hess et al., 2011). Regarding Magnet
hospitals, Abu Raddaha et al. (2012) state that these hospitals distinguish themselves
through the delivery of excellent patient outcomes evidenced by decreased mortality rates,
lengths of stay and needle stick injuries.
Likewise, in a very recent article about role stressors and coping strategies among nurse
managers (NMs) in Western Canada, Udod et al. (2017) pointed out that organizational
practices and structures affect NM stress by creating expectations that cannot be achieved,
responding to continuous organizational change and shifting organizational priorities. Also
in this sense, Hayes et al. (2012), based on a literature review, argue that without adequate
resources and supports to meet workload demands, nurses grow dissatisfied and
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emotionally exhausted, decreasing job satisfaction and Holden et al. (2011) found that nurse
job satisfaction was positively associated with staffing adequacy.

The concept of internal climate for nursing professionals

There are various labels found in the literature reflecting a concern about the human
element in organizations: quality of internal services, quality of life at work, endomarketing,
internal marketing, service climate, work climate, organisational climate and internal
climate. Each one of these constructs has arisen within the most diverse areas of knowledge
such as service management, marketing, human resources, organizational behaviour and
social sciences such as psychology and sociology of health and illness.
In this paper, the construct named internal climate for nursing professionals is defined as
the work environment offered by the organization to these professionals to generate positive
consequences such as greater job satisfaction, organizational commitment and
organizational citizenship behaviour (Schneider, 1994; Schneider et al., 2005; Schneider et al.,
2009).
According to the literature, internal climate for nursing professionals is a
multidimensional construct that involves trustworthiness, higher levels of employee
involvement and empowerment in decision-making, shared governance programmes,
nursing governance, self-managing work team, teamwork, job security, employee training
and development, employee suggestion and recognition systems, rewards, perception of
justice, good work infrastructure, among other characteristics (Rad and Yarmohammadian,
2006; Rondeau, 2007; Sellgren et al., 2007; Park and Kim, 2009; Abu Raddaha et al., 2012;
Tuan, 2015). A broad bibliographical review concerning the health sector was carried out to
identify the internal quality dimensions for nursing professionals. Because of space
limitations, the dimensions that emerged from the literature, its attributes and the authors
who have proposed them are summarized in Table I.

The positive consequences of internal climate for nursing professionals

The direct consequences of internal climate that arise from the literature and that have been
taken into consideration in this study are as follows: job satisfaction (JS), affective
commitment (AC) and organizational citizenship behaviour (OCB).
Job satisfaction may be defined as an employee’s positive emotional state in relation to
their tasks, which derives from aspects related to the characteristics of the work itself, such
as working conditions and workload and from intrinsic characteristics of the person such as
personality, education, age and gender (Utriainen and Kyngas, 2009; Lambrou et al., 2010;
 Dimension Attributes Authors
Brazilian
nursing
Trust Good relationship with the hospital Lu et al. (2007), Rondeau (2007), Sellgren professionals
leaders, clarity about the hospital’s et al. (2007), Laschinger et al. (2009), Park
mission and objectives, effective and Kim (2009), Cortese, et al. (2010),
internal communication, avoidance Albrecht and Andreetta (2011), Lu et al.
of excessive work hours and (2012), Siqueira and Kurcgant (2012),
inflexible schedules, participation Jefferson et al. (2014), Smits et al. (2014),
in the institution decisions, shared Mun et al. (2015), Robson and Robson
governance, high involvement (2016), Chiarini and Baccarani (2016), Udod
practices, respect, maintenance of et al. (2017)
the psychological contract
Justice Fairness and impartiality Lambrou et al. (2010), Hess et al. (2011),
perceived in the leader’s actions, Rogers (2012), Sawbridge and Hewison
non-discrimination (2013), Baptiste (2015)
Pride Pride regarding the profession, the Newman and Maylor (2002), Lambrou et al.
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institution and the characteristics (2010)

of the work per se
Camaraderie Friendly environment good Newman and Maylor (2002), Rondeau
interaction with other (2007), Utriainen and Kyngas (2009), Park
professionals, thus forming a team, and Kim (2009), Hayes et al. (2010), Pitkäaho
absence of physical and verbal et al. (2011), Abu Raddaha et al. (2012),
aggression among team members, Sawbridge and Hewison (2013), Körner et al.
Teamwork (2016); Chiarini and Baccarani (2016)
Work Infrastructure Adequate resources for taking care Newman and Maylor (2002), Lu et al. (2007),
of patients (physical structure, Rad and Yarmohammadian (2006), Ridley
medicines, instruments and (2007), Utriainen and Kyngas (2009), Park
adequate equipment), planning and and Kim (2009), Hayes et al. (2010), Holden
organization of the workspace, et al. (2011), Lu et al. (2012), Hayes et al.
adequate contingent of (2012), Pitkäaho et al. (2011), Drach-Zahavy
professionals, clear and detailed and Somech (2013), Udod et al. (2017)
work manual
Autonomy The amount of job-related Lee and Cummings (2008), Hayes et al.
independence, initiative and (2010), Lambrou et al. (2010), Abu Raddaha
freedom permitted in daily work et al. (2012), Zydziunaite et al. (2015)
activities
Training & Opportunity to develop skills and Rondeau (2007), Hayes et al. (2010),
Development (T&D) to acquire new knowledge Lambrou et al. (2010), Chen and Johantgen
(2010), Johnson et al. (2011), Hess et al.
(2011), Gianfermi and Buchholz (2011),
Drach-Zahavy and Somech (2013),
Pantouvakis and Mpogiatzidis (2013),
Armstrong-Stassen et al. (2015), Mun et al.
(2015)
Reward Recognition of effort put forth, Newman and Maylor (2002), Rad and
&Acknowledgement possibility of promotion and Yarmohammadian (2006), Abu Raddaha
(R&A) professional growth, feedback et al. (2012), Sawbridge and Hewison (2013), Table I.
from superiors, career planning, Drach-Zahavy and Somech (2013), Mun Internal quality
prospects for promotion et al. (2015)
dimensions for
Remuneration & Adequate pay for responsibility of Rad and Yarmohammadian (2006), Curtis
benefits (R&B) services performed, monetary (2007), Lambrou et al. (2010), Abu Raddaha nursing
benefits, bonuses and non- et al. (2012) professionals,
monetary benefits adequate according to the
economic reward literature
 LHS Pitkäaho et al., 2011, Albrecht and Andreetta, 2011). The environment in which the nurse
works will impact job satisfaction (Rad and Yarmohammadian, 2006; Utriainen and
Kyngas, 2009; Hayes et al., 2010; Lu et al., 2012; Abu Raddaha et al., 2012, Udod et al., 2017)
and because of its impact on patient satisfaction, patient safety and quality of care, job
satisfaction is very important in healthcare (Sellgren et al., 2007). Pitkäaho et al. (2011)
labelled the variety of factors contributing to nurse job satisfaction as intra-personal,
interpersonal or extra-personal factors. Intra-personal factors describe those characteristics
that the nurse brings as a person to the job, inter-personal factors are those that relate to
interactions between the nurse and others, and extra-personal factors are those influenced
by institutional or governmental policies. In this sense, the results of a research conducted
by Park and Kim (2009) in Korea indicate that organizational flexibility and human
relationship-oriented culture may be more helpful for improving job satisfaction of nurses
than a stability-oriented and control-centred mood, and Abu Raddaha et al. (2012) state that
leaders should value staff contributions to promote retention and job satisfaction.
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Organizational commitment, in turn, may be defined as a psychological, emotional link

between the employee and the company (Laschinger et al., 2009; Eslami and Gharakhani,
2012). Allen and Meyer (1990, 1996) have proposed an organizational commitment model
composed of three elements:
(1) The Affective Component – emotional bond, identification and involvement with
the organization where the employee stays with the company “because he or she
wants to”;
(2) The Continuity Component – commitment based on costs associated with leaving
the company where the employee stays with the organization “because he or she
has to”; and
(3) The Normative Component – employees remain with the company “because they
feel obligated to”.

The organizational citizenship behaviour (OCB) concept is characterized by spontaneous and

unconditional behaviours engaged by individual personnel beyond the organization’s
officially requested responsibility. This behaviour is beneficial to the organizational system
and can foster its efficiency, yet it is not directly recognized by the formal reward system
(Huang et al., 2010). It entails activities of cooperation with colleagues, protective actions of
the institution, creative suggestions for organizational improvement, self-training for a
better work performance and the creation of a favourable climate for the organization.
Therefore, the concept of organizational citizenship behaviour ensures that employees are
willing to contribute to the hospital as best as possible by enhancing their sense of
belonging to the healthcare organization (Bellou and Thanopoulos, 2006).

Proposed conceptual model and research hypothesis

The literature indicates that an appropriate good and healthy internal climate can generate
positive attitudes and behaviours on nursing professionals. Therefore, the analytical model
proposed in this study (Figure 1) relates the internal climate dimensions presented in Table I
to positive attitudes and behaviours from nurses in relation to the hospital and the following
general hypothesis has been formulated:

H1. Positive attitudes and behaviours from nursing professionals may be explained by
the internal climate dimensions for these professionals.
 Brazilian
Trust nursing
professionals
Justice

Pride
Nursing professionals’
positive attitude and
Camara- behaviours relative
derie to the hospital
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Work
Infrast.

Auto-
nomy

T&D

R&A

Figure 1.
R&B Proposed conceptual
model

Methods
Based on the literature, a standardized questionnaire of 45 items related to internal climate
and 12 related to its consequences was applied to 410 nurses and 1,619 nursing technicians.
From these, 171 nurses (41.71 per cent) and 274 nursing technicians (16.92 per cent) agreed
to participate in the research. All the participants interviewed work at five Brazilian private
hospitals belonging to National Association of Private Hospitals (ANAHP), three located in
Rio de Janeiro state and two located in Rio Grande do Sul.
A five-point Likert scale, ranging from 1 – strongly disagree to 5 – strongly agree, was
adopted. The questionnaires were adjusted and pre-tested before applying the final version on a
large scale. There was an adaptation to the needs of each hospital regarding the best time to
apply the questionnaire and the professionals available for filling it out. The internal consistency
of the scale was verified using Cronbach’s alpha, and the computed values for the items of
internal climate and for the items of positive consequences were 0.956 and 0.878, respectively.
After the fieldwork, the data were entered and personally checked by the researcher.
The multivariate techniques factor analysis and multiple linear regression were applied
to analyse the data by running them through SPSS 22.0. The factor analysis was applied to
the set of attributes of the internal climate and positive consequences in terms of attitudes
 LHS and behaviours for nursing professionals. To verify the adequacy of this technique, the
Bartlett’s test of sphericity and an examination of the Kaiser-Meyer Olkin measure of
sampling adequacy were done. The principal component analysis procedure was used for
extracting the factors. The latent root criterion (eigenvalue > 1) was adopted to select the
factors. A varimax orthogonal rotation was applied to the original factor matrix to facilitate
the interpretation of the factors.
After applying the factor analysis, multiple linear regression was applied to learn more
about the relationship between the internal climate dimensions, extracted from the factor
analysis, and the nursing professionals’ positive attitudes and behaviours. Our objective
was to verify which dimensions of internal climate (independent variables) better explained
the positive attitudes and behaviours for nursing professionals (dependent variable). The
following steps were followed to perform this analysis:

Determination of the PC Index: Twelve variables were analysed as a single
construct called Positive Consequences Index (PC Index), keeping in mind the
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importance of nursing professionals’ positive attitudes and behaviours for the

hospitals. To calculate the PC Index, the percentage of variance explained by each
one of the factors was utilized together with the values of the factor scores for each
one of the respondents. The PC index of respondent i may be represented as follows:
X
m
EFij xVarExpj
j¼1
PBCi ¼ ;
X
m
VarExpj
j¼1

Where: EFij = factor score for respondent i for dimension j and VarExpj = variance
explained by dimension j.

Multiple linear regression analysis using the Enter method: This method is to verify
the contribution of each internal climate dimension (independent variables) to
predict the PC Index. Furthermore, a multiple linear regression analysis using
Stepwise estimation to examine the contribution of each independent variable to the
regression model was applied. The beta coefficient was analysed to verify the
relative explanatory power of the dependent variables. To apply the multiple linear
regressions, an analysis of the outliers was done using Cook’s distance analysis as a
criterion. Also, a graphical analysis of residuals was done to verify the constant
variance, independence, and normality of the error term distribution, and
multicollinearity was avoided by the orthogonal factor rotation. Thus, it was
decided to include a categorical variable “profession” in the regression equation to
allow the distinction between nursing technicians and nurses. The inclusion of the
categorical variables was done using the dummy variable as a predictor (dummy-
prof), coding it 1 if the respondent is a technician and 0 if the respondent is a nurse.

Results and analysis

Demographic profile of the sample
Nurses were 38 per cent of the sample and 62 per cent were nursing technicians. Most of the
nursing professionals (80 per cent) who participated in the survey were female, 48 per cent
aged between 31 and 50, and 65 per cent of them worked in the hospital for up to five years.
 Internal climate dimensions for nursing professional Brazilian
The factor analysis performed on the 45 attributes included in this study indicated the nursing
existence of nine dimensions of internal climate for nursing professionals, which explains
66.04 per cent of the total variance: trust, camaraderie, non-discrimination, work
professionals
infrastructure, role clarity, training & development, remuneration & benefits, relationship with
the doctors and nursing contingent (Table II). A statistically significant Bartlett’s test of
sphericity (p value < 0.01) indicates the presence of sufficient correlations among the
variables to continue with the factor analysis. In addition, the measuring of sampling
adequacy (MSA) value of each variable was greater than 0.80. An examination of the Kaiser-
Meyer-Olkin measure of sampling adequacy suggested that the sample was factorable
(KMO = 0.923) and the observations/variable reason was 9.20 observations for each variable.
Commonalities were also analysed and all values were equal to or greater than 0.500. The
factors were labelled based on the higher loading variables (>0.50) for each factor.
The dimension that clusters the items related to the leaders’ position was denominated
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trust, representing the trust that nursing professionals have in the hospital leaders; the
dimension that groups the items regarding the good relationships among colleagues was
labelled camaraderie; the dimension composed of items dealing with the absence of
discrimination on the grounds of age, gender, or race within the work environment was
called non-discrimination; the dimension that gathers the items related to working
conditions in terms of workspace organization, existence of medication, equipment and
suitable facilities was named work infrastructure; role clarity was the name selected for the
dimension containing the items related to the absence of ambiguity as far as what
management expects from the work performed by nursing professionals; the dimension
representing the items related to the opportunity in career growth and to the managers’
investment in the professional development of their nursing team was named training and
development; the items related to the remuneration and to the benefits given by the hospital
constituted a dimension named remuneration and benefits and the items related to the
doctors’ perspective regarding nursing professionals formed a dimension whose name was
relationship with doctors. Also, nursing contingent was the title that represents the items
related to the size of the nursing team to care for the patients.
As prescribed by the literature, the trust dimension aggregates attributes related to the
leadership’s ability to easily dialogue, give support for the accomplishments of activities,
show concern for the team’s welfare in the work environment, allow participation in hospital
decision-making and respect individual rights (Bowie, 2000; Park and Kim, 2009; Tuan,
2015; Freire and Azevedo, 2015; Udod et al. (2017). Trust in hospital leaders had already
been deemed important to nursing professionals in previous studies carried out by Sellgren
et al. (2007), Hayes et al. (2010), Huang et al. (2010), Siqueira and Kurcgant (2012), Jefferson
et al. (2014), Freire and Azevedo (2015), Chiarini and Baccarani (2016), Robson and Robson
(2016), Udod et al. (2017), among others. On the other hand, the attributes related to role
clarity, which was believed to be part of the trust dimension as stated in the literature
(Cortese et al., 2010; Lu et al., 2012, Mun et al., 2015), constituted a distinct dimension
designated role clarity containing items related to the absence of ambiguity as far as what
management expects from the work performed by nursing professionals.
Camaraderie, also indicated by the literature, characterized by a good relationship
among colleagues, proved to be one of the internal climate dimensions for nursing
professionals in consonance with previous researches (Hayes et al., 2010; Chiarini and
Baccarani, 2016).
In this research, non-discrimination of any sort – on the grounds of age, gender or race
within the work environment – emerged as an independent dimension. According to
 LHS Dimensions Loads

Dimension 1: Trust
The superiors make my job easier 0.668
The superiors care about my well-being at work 0.666
My superiors are accessible and open to dialogue 0.608
The nursing team participates of the hospital decisions 0.587
My individual rights are respected 0.579

Dimension 2: Camaraderie
Communicating with colleagues is easy 0.764
Colleagues help each other 0.746
Everyone celebrates the success of their colleagues 0.740
The work environment is social and friendly 0.729
We seem to be like a “big family” 0.685
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Dimension 3: Non-discrimination
No one is discriminated against by age 0.852
No one is discriminated against by colour 0.840
No one is discriminated against by gender 0.789
No one is discriminated against for the work position 0.632

Dimension 4: Work infrastructure

There is enough equipment to attend the patient 0.801
Policies and procedures facilitate the patient care 0.679
The facilities are adequate 0.675
Medications and instruments are always in the right place 0.637
Training is offered to the nursing team constantly 0.560
There are enough medicines needed to treat patients 0.545

Dimension 5: Role clarity

I know exactly what my superiors expect from my performance 0.795
I know exactly what the physicians expect from my performance 0.720
The work rules are clear 0.670

Dimension 6: Training & Development

There is equal opportunity for career growth 0.584
I have the possibility of professional growth 0.566
The management team invests in my professional development 0.553
I am proud to work in this team because the professionals are the best on the market 0.551

Dimension 7: Remuneration & Benefits

In addition to the gross salary, I earn other benefits 0.807
Bonuses and benefits are fairly distributed 0.787
My salary is according to the market average 0.617

Dimension 8: Relationship with the Doctors

Table II. The physicians support the nursing team 0.742
The physicians respect the nursing professional 0.685
Internal climate
The physicians give autonomy to the nursing professionals to attend the patients 0.616
dimensions for
nursing professional, Dimension 9: Nursing contingent
according to the The number of nurses is adequate to attend the patients 0.780
research The number of nursing technicians is adequate to attend the patients 0.630
 Baptiste (2015), discrimination is a complex phenomenon related to subconscious beliefs Brazilian
about different ethnic, cultural or religious groups. In our research, this dimension includes nursing
the non-discrimination policies as far as positions go. This is probably because nurses
sometimes feel discriminated against by doctors.
professionals
Work infrastructure, present in previous studies carried out in the health sector (Park and
Kim, 2009; Hayes et al., 2010; Lu et al., 2012; Drach-Zahavy and Somech, 2013; Udod et al.,
2017), also arose as an internal climate dimension among nurses in this study. This
dimension groups attributes related to workspace organization, existence of medication,
equipment, and suitable facilities to take care of the patients. This dimension is also
composed of an attribute related to the existence of well-trained workers, indicating that the
technical quality of nursing professionals is part of the work infrastructure for these
professionals. The total number of nursing staff, which was believed to cluster under the
work infrastructure dimension, turned out to constitute an independent dimension called
nursing contingent. It corroborates with the results of previous research as the insufficient
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number of professionals to attend to patients is pointed out as one of the reasons for stress
and dissatisfaction among nursing professionals (Newman and Maylor, 2002; Ridley, 2007;
Abu Raddaha et al., 2012).
The training & development dimension represents the attributes related both to the
opportunity in career growth and to managers investing in the professional development of
their nursing team. This result is in line with previous research by Lambrou et al. (2010),
Johnson et al. (2011), Gianfermi and Buchholz (2011), Armstrong-Stassen et al. (2015), Mun
et al. (2015), among others. Remuneration & benefits also formed an internal climate
dimension for nursing professionals in this study, grouping attributes related to
remuneration and benefits. The research carried out with nursing professionals by Lambrou
et al. (2010), Mun et al. (2015), among others, had already indicated that a suitable
remuneration was highly important for a healthy internal climate.
Lastly, items related to the doctors’ view of nursing professionals formed a dimension
called relationship with doctors. Costa and Marziale (2006) had already pointed out that
physical and verbal aggressions among team members represent one of the causes of nursing
professionals’ dissatisfaction and stress. Therefore, the results of this research reinforce that
in Brazil it is very important to foment a good relationship between nursing professionals
and physicians to create a good internal climate for nurses and nursing technicians. This
result is also aligned with Park and Kim’s (2009) research, which indicated that human
relationship-oriented culture is important to improve the nurses’ job satisfaction.

Dimensions of nursing professionals’ positive attitudes and behaviours

The factor analysis generated a three-factor solution, which together explains 66.18 per cent of
the total variance: compliance, job satisfaction and organizational commitment (Table III). The
observations/variable reason was 34 observations for each variable investigated. The Bartlett’s
test of sphericity presented a p value < 0.01 indicating the presence of correlations among the
variables, and the Kaiser-Meyer-Olkin (KMO) value was 0.846 indicating the sampling adequacy.
The factors were labelled based on the higher loading variables (>0.50) for each factor.
The compliance dimension basically groups the items related to meeting institutional
rules in line with Bellou and Thanopoulos (2006), which state that employees want to
contribute to the hospital as best as possible. Job satisfaction was the designated term for the
dimension representing items related to satisfaction in working at the hospital as mentioned
by Rad and Yarmohammadian (2006), Utriainen and Kyngas (2009), Hayes et al. (2010), Lu
et al. (2012), Abu Raddaha et al. (2012), Udod et al. (2017). Organizational commitment was
the term designated for the dimension representing items related to nursing professionals’
 LHS Dimensions Loads

Compliance
I try to avoid wasteful use of hospital resources 0.803
I try not to miss work 0.793
I try not to be late for work 0.773
I Respect the hospital rules 0.738
I collaborate with my colleagues for the hospital’s goals 0.724

Job satisfaction
I feel happy working in this hospital 0.910
I really like working in this hospital 0.893
Table III. Good work environment 0.853
I intend to stay for a long time in this job 0.553
Dimensions of
nursing Organizational commitment
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professionals’ I attend meetings even if attendance is not compulsory 0.788

positive attitudes and I try to keep myself informed about hospital matters 0.681
behaviours I feel well doing beyond what is specified to me 0.623

interest in the company matters as proposed by Laschinger et al. (2009) and Eslami and
Gharakhani (2012).
As previously mentioned, these three dimensions were analysed as a single construct
called PC Index.

Dimensions of internal climate that best explain nursing professionals’ positive attitudes and
behaviours (PC index)
As can be seen in Table IV, only six of the nine internal climate dimensions proved statistically
significant to explain the PC Index for nursing professionals. Five of them proved statistically
significant to explain the PC Index for nurses: trust, camaraderie, role clarity, training &
development (statistically significant at the level of 1 per cent) and non-discrimination
(statistically significant at the level of 5 per cent); and the dimension nursing contingent is
statistically significant at the level of 5 per cent to explain the nursing technicians’ PC Index.
The coefficient of determination (R2) of 0.412 indicates that 41.20 per cent of total variation of
PC Index is explained by the independent variables considered in this study.
In relation to the dimensions of trust, camaraderieand role clarity, this result is consistent
with previous researches that state that the environment in which the nurse works and
extra-personal factors impact job satisfaction (Utriainen and Kyngas, 2009; Hayes et al.,
2010; Pitkäaho et al., 2011; Lu et al., 2012; Abu Raddaha et al., 2012, Chiarini and Bracci,
2013; Chiarini and Baccarani, 2016, Udod et al., 2017, Crowne et al., 2017, among others).
Also, training & development is mentioned in the literature as important to foment positive
attitude in nurses, such as job satisfaction and retention (Drach-Zahavy and Somech, 2013;
Pantouvakis and Mpogiatzidis, 2013; Armstrong-Stassen et al., 2015; Mun et al., 2015).
Concerning non-discrimination, as previously mentioned, in this study this dimension
includes the non-discrimination policies as far as positions go and, in Brazil, nurses usually
feel discriminated against by doctors. Besides, non-discrimination is part of the justice
dimension that emerged from the literature and that focuses on treating employees fairly,
equally and without discrimination (Hess et al., 2011; Rogers, 2012; Baptiste, 2015).
With regard to the dimension statistically significant to explain the nursing technicians’
PC Index – nursing contingent – this result can be explained by the fact that nursing
 Standardized
Brazilian
Variables Beta t value Significance nursing
professionals
Constant 1.526 0.128
Trust 0.193 2.677 0.008**
Camaraderie 0.261 3.441 0.001**
Non-discrimination 0.172 2.014 0.045*
Work Infrastructure 0.122 1.684 0.093
Role Clarity 0.484 6.476 0.000**
Training and Development 0.364 4.673 0.000**
Remuneration and Benefits 0.058 0.703 0.482
Relationship with the doctors 0.135 1.779 0.076
Nursing contingent 0.121 1.482 0.139
Dummy-Prof 0.071 1.666 0.096
Trust-TEC 0.053 0.740 0.460
Camaraderie-TEC 0.040 0.529 0.597
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Non-discrimination-TEC 0.028 0.336 0.737

Work Infrastructure-TEC 0.011 0.155 0.877
Role Clarity-TEC 0.108 1.483 0.139
Training and Development-TEC 0.090 1.179 0.239
Remuneration and Benefits-TEC 0.044 0.547 0.585
Relationship with the doctors-TEC 0.113 1.502 0.134 Table IV.
Nursing contingent-TEC 0.184 2.285 0.023*
R2 0.412
Internal results of the
R2 adjusted 0.038 multiple linear
regression–enter
Notes: *5% significance level; **1% significance level method

technicians are responsible for performing the tasks related to patient care under the nurses’
supervision (COFEN, 2013). Thus, the number of professionals available to provide patient
care impacts the workload and job satisfaction of these professionals, as pointed out by
Hayes et al. (2012), Holden et al. (2011), among others.
In the stepwise procedure (Table V), nine internal climate dimensions statistically
significant at the 0.000 level explain the dependent variable PC Index: training &
development, role clarity, trust, camaraderie, remuneration & benefits, non-discrimination,
relationship with doctors, work infrastructure and role clarity-TEC. The inclusion of these
nine variables in the regression model allows for the explanation of 70.60 per cent of the PC
Index variance of nursing professionals.
Table V analysis shows that:

The F ratio of 80.891 indicates that, considering the sample used for estimation, it is
possible to explain 80.89 times more variation than it would when using the average
(1% significance level);

Standard errors of the coefficients are low, indicating that the prediction is reliable;

The standardized coefficient (beta) indicates that role clarity and training & development
are the dimensions that most contribute to explaining the nurses’ PC Index; and

The negative beta coefficient role clarity-TEC indicates that this dimension is less
important to explain nursing technicians’ PC Index than to explain nurses’ PC Index.

These results are consistent with the fact that the nursing technicians have no autonomy in
the performance of their duties, while, on the other hand, nurses are responsible for
 LHS Model Variables entered R R2 Adjusted R2 Standard error

1 Training &Development 0.379 0.144 0.141 0.285

2 Role Clarity 0.565 0.320 0.315 0.254
3 Trust 0.642 0.413 0.407 0.237
4 Camaraderie 0.718 0.515 0.509 0.215
5 Remuneration & Benefits 0.751 0.565 0.557 0.205
6 Non-discrimination 0.782 0.612 0.604 0.193
7 Relationship with the doctors 0.811 0.658 0.650 0.182
8 Work infrastructure 0.830 0.689 0.680 0.174
9 Role Clarity-TEC 0.840 0.706 0.697 0.169

Analysis of Variance
Sum of Squares df Mean square F Significance
Regression 20.828 9 2.314 80.891 0.000
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Residual 8.668 303 0.029

Total 29.496 312

Variable entered into Regression Model Variables not entered

Standard Standardized Partial
Variable Coefficient error coefficient t value Significance correlation t value
(Intercept) 0.060 0.011 5.602 0.000
Training & Development 0.153 0.011 0.429 13.620 0.000
Role Clarity 0.307 0.023 0.701 13.109 0.000
Trust 0.101 0.011 0.285 9.051 0.000
Camaraderie 0.114 0.011 0.317 10.086 0.000
Remuneration & Benefits 0.087 0.012 0.236 7.434 0.000
Non-discrimination 0.120 0.014 0.268 8.378 0.000
Relationship with the
doctors 0.065 0.010 0.204 6.472 0.000
Work infrastructure 0.069 0.012 0.185 5.863 0.000
Role Clarity-TEC 0.123 0.029 0.227 4.248 0.000
Nursing contingent 0.004 0.078
Dummy_pf 0.000 0.003
Trust-TEC 0.095 1.661
Camaraderie-TEC 0.053 0.914
Non-discrimination-TEC 0.018 0.311
Work infrastructure-TEC 0.041 0.705
Training &
Table V. Development-TEC 0.061 1.063
Dimensions that best Remuneration &
Benefits-TEC 0.000 0.007
explain nursing
Relationship with the
professionals’ PC doctors-TEC 0.004 0.062
index Nursing contingent-TEC 0.008 0.143

managing the nursing service and activities and for the nursing care planning, respecting
the medical prescription (COFEN, 2013). In this context, role clarity and training &
development are important dimensions for the job satisfaction of nurses and for the perfect
execution of their nursing activities. This result reinforces the findings of previous studies
conducted by Drach-Zahavy and Somech (2013), Pantouvakis and Mpogiatzidis (2013);
Armstrong-Stassen et al. (2015), Mun et al. (2015), among others.
 Conclusion and discussion Brazilian
The dimensions of internal climate for nursing professionals have been investigated, as nursing
well as the dimensions of positive consequences in terms of their behaviours and
attitudes. Based on the literature reviewed, the analytical model proposed relates some
professionals
dimensions of the internal climate to the nursing professionals’ positive attitudes and
behaviours measured by the PC index.
The results have indicated that six dimensions of internal climate contribute to
explaining the nursing professional’s positive attitudes and behaviours measured by the PC
Index: trust, camaraderie, role clarity, training & development and non-discrimination for
nurses and nursing contingent for nursing technicians. These dimensions explain 41.20 per
cent of the total variation of the PC index. Therefore, H1 has been partially confirmed.
Figure 2 presents the final model.
Among the Brazilian nursing professionals interviewed, the dimension that most
contributes to explaining the PC Index is role clarity followed by training & development,
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camaraderie, trust, non-discrimination, remuneration & benefits, relationship with the

doctors and work infrastructure. The results also indicate that role clarity is more important
to nurses than to nursing technicians.
These results indicate a small difference between nurses and nursing technicians
regarding the internal quality dimensions and their impact on the PC Index. For nursing
technicians, nursing contingent proved to be important to foment positive attitudes and
behaviours. This result can be explained by the fact that in Brazil nursing technicians are

Trust

Camara-
derie

Nursing professionals’
Role
Clarity PC Index

T&D

Figure 2.
Dimensions of
Non-discri internal climate that
mination contribute to
explaining the
Nursing nursing
contingent professionals’ PC
index
 LHS responsible for performing the tasks related to patient care, under the nurses’ supervision
and the number of professionals available to provide patient care impacts the workload and
job satisfaction of these professionals. Another aspect to be mentioned is that nursing
technicians have no autonomy in the performance of their duties, while nurses have to
manage and plan the nursing care service according to medical prescription. That is why
role clarity and training & development is so important for nurses.
Considering the three most important dimensions to explain the nursing professionals’
PC Index, hospital leaders should be concerned to establish a clear and effective
communication with these professionals and stimulate physicians to do this to ensure role
clarity among nurses. Leaders should also invest in their professional development and
stimulate a good work environment among the professional staff.
Some methodological limitations must be considered such as the absence of the
researcher when the questionnaires were being filled out, the order in which the questions
were presented (which could have introduced some bias in the responses) and finally the fact
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that the sample consisted of respondents who made themselves available to participate in
the research. Future research could investigate the impact of demographic characteristics
such as gender, age and work experience on the internal quality dimensions for nursing
staff. Furthermore, qualitative exploratory research could be carried out with nursing
professionals that work at private Brazilian hospitals to capture attributes that were not
included in this study. In addition, it would be interesting to replicate this study in public
and university hospitals in Brazil and compare the results, which would probably be quite
different from those found in the present study.
Despite these limitations, this study has important implications for practitioners and
adds value to the literature. For practitioners and managers, this study is relevant because it
contributes to elucidate the factors that can promote a good internal climate for nursing
staff, assisting hospital leaders to face the huge managerial challenges of managing,
retaining and advancing these professionals. For academics, to the best of our knowledge, it
is an original contribution in the context of Brazil and the findings of this research broadens
the knowledge about leadership among nursing professionals in developing countries.

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About the authors

Claudia Affonso Silva Araujo is an Associate Professor of the COPPEAD Graduate School of
Business, Federal University of Rio de Janeiro – COPPEAD/UFRJ. She is also the Area Head of
Operations, Technology and Logistics (OTL) of COPPEAD/UFRJ and Coordinator of the Centre for
Studies in Management of Healthcare – CESS/COPPEAD/UFRJ. She has a Doctorate in Business
Administration (COPPEAD/UFRJ), Masters in Business Administration (COPPEAD/UFRJ) and
Graduation in Economics from The Catholic University of Rio de Janeiro PUC/RJ. She was a visiting
researcher at Maryland University (USA) in 2004. Claudia Affonso Silva Araujo is the corresponding
author and can be contacted at: claraujo@coppead.ufrj.br
Kleber Fossati Figueiredo has a Doctorate in Business Administration from IESE Business School -
Instituto de Estudios Superiores de la Empresa (1987), masters from the COPPEAD Graduate School of
Business (Federal University of Rio de Janeiro) and graduated from Federal University of Rio Grande do
Sul. He is currently the Associate Professor II at the Federal University of Rio de Janeiro (UFRJ), Director
of COPPEAD/UFRJ and Administrative Coordinator of the Centre for Studies in Management of
Healthcare – CESS/COPPEAD/UFRJ. He assesses articles for journals and national and international
events. He was editor of teaching cases RAC – Journal of Management Contemporary (2008-2011). He was
a visiting professor at the Instituto de Empresa in Madrid from 1999 to 2010.

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