The Influence of Competent Managers on Employee Retention, Job Satisfaction and Well-Being in the Healthcare Industry - A Scoping Review

Introduction

One of the significant challenges facing healthcare systems worldwide is the shortage of healthcare workers. After the recent COVID-19 pandemic, employee turnover rates have accelerated.¹ It is predicted that by 2030, there will be a shortage of 10 million healthcare workers worldwide.² High employee turnover places a significant burden on healthcare organisations struggling to remain competitive while providing personalised, high-quality care to patients.³ Turnover is costly, not only increasing the budget for recruiting and training new employees but also generating indirect costs, such as lower profits and reduced organisational effectiveness.^4,5 Moreover, high employee turnover negatively impacts patient satisfaction^3,6 quality of care⁷ and leads to disruptions in the continuity of care.⁸ High turnover also results in reduced staff productivity because there are limited people available to complete the required tasks.³ This increased workload can lower the morale of existing workers, increase staff dissatisfaction and burnout, leading to additional turnover among the remaining employees.⁹

Table 1 Key Concepts and Keywords Used for Literature Search

Considering the negative consequences associated with high employee turnover, urgent action is necessary to enhance healthcare workers’ retention, job satisfaction, and reduce burnout. As part of this effort, scholars have increasingly recognised the critical role that healthcare managers play in ensuring employee success and quality of care.^10,11 Employees working in an environment where they are supported and valued are less likely to experience high levels of stress and burnout and therefore, will remain in their jobs.^12,13 Previous literature has established that individuals in management positions must not only be good managers, who can set processes and structures, but also effective leaders, who can create a vision and inspire action.¹⁴ Over the years, different leadership styles have evolved, and numerous publications have recognised that leadership style is a key element for improving employee outcomes.¹⁵ In recent years, the transformational leadership style is highly recommended by previously published literature^15,16 and is associated with higher job satisfaction,^16,17 decreased intention to leave,¹⁷ and a lower burnout rate.¹⁸ It emphasizes creating and enacting change to boost followers’ motivation and morale, utilising idealised influence, personalised consideration, inspiring motivation, and intellectual stimulation to achieve superior results.¹⁹ Transformational leaders inspire their followers to look beyond their self-interest and work for the interest of their team and organisation.¹⁵ In addition to transactional leadership and laissez-faire leadership, which have been in the literature for many years, growing evidence on the benefits of authentic leadership and servant leadership has also emerged.^20,21 Authentic leadership is characterised by leaders who have an honest, transparent, and ethical approach, striving for symmetrical, trusting, and close leader–follower relationships that promote the open sharing of information and consideration of employees’ viewpoints.^15,20 Servant leaders are empathetic, share power, put the needs of others first, and help followers develop and optimise performance by concentrating on performance planning, day-to-day coaching, and are willing to learn from others, forsaking personal advancement and rewards.^21,22

Effective health managers are required to possess competencies consisting of the skills, knowledge, and attitudes necessary to deliver superior performance as required by their roles.^22–24 Internationally, competencies required for health managers to perform their managerial tasks have been well-researched^25,26 A recent systematic review used the validated MCAP tool to confirm seven core leadership and management competencies, including communications, professionalism, leadership, knowledge, change, resources and evidence-informed decision-making.²⁷ However, competencies are context-specific, and the demonstration varies according to management levels, positions, and geographical contexts in which these competencies must be demonstrated.²⁸ Management competency development should include clear competency requirements in the context in which these competencies must be demonstrated, and specific consideration should be given to hospital types, management levels and positions²⁹ Recently, professional management institutions have adopted a competency-based approach to guide the development and training of the health management workforce. These include the Healthcare Leadership Model by the NHS Leadership Academy (UK) (NHS Leadership Academy, 2013), the Australasian College of Health Service Managers Competency Framework (Australia),³⁰ the Health Leadership Competency Model (US),³¹ and the IHF Leadership Model by the International Hospital Federation (Switzerland).³²

Despite the increasing interest and investment in conducting management competency studies in different countries in the past two decades,²⁸ a quick desktop review confirmed the lack of systematic understanding of the link between competent managers and employee retention, job satisfaction and well-being in the healthcare industry. The existing literature has primarily examined the impact of effective leadership or various leadership styles on select measures such as job satisfaction,^15,33 well-being,^13,34 work engagement³⁵ performance³⁶ and patient-related outcomes.^37,38 A deeper understanding of how management competencies contribute to enhancing healthcare employees’ job satisfaction, staff retention, and psychological well-being.

The need to have a competent management and leadership workforce has been increasingly recognised. Literature has confirmed the importance of competence in supporting the high performance of employees³⁹ and guiding health managers’ recruitment, training, performance appraisal and succession planning (Rasa, 2020). Competence can be defined as the combination of skills, knowledge, and capacity to perform tasks expected by organisations.²²

Aims and Importance

This scoping review was conducted to identify, synthesise, and evaluate studies that examine the relationship between competent managers and leadership and job satisfaction, staff retention, and the well-being of employees in the healthcare setting in order to answer the following two research questions:

1. Do competent health managers improve healthcare employees’ job satisfaction, staff retention, and psychological well-being?
2. If so, how do health managers’ competency impact job satisfaction, staff retention, and psychological well-being?

Materials and Methods

Design

This review was conducted following the steps specified in chapter 11 of the JBI guidance for scoping reviews including: (1) defining a clear objective and research questions, (2) Applying PCC framework, (3) developing a protocol, (3) conducting a systematic search, (4) screening results according to eligibility criteria, (5) data extraction and (6) writing up evidence to answer research question.⁴⁰ The search results are reported according to the PRISMA Extension for Scoping Reviews (PRISMA-ScR).⁴¹

Eligibility Criteria

Inclusion Criteria

1. Papers included at least two of the key concepts.
2. Papers presented empirical studies conducted in the health context.
3. Papers are published from the year 2000 onwards and in English language.

Specific Exclusion Criteria

1. Papers that have not gone through a peer review process.
2. Papers published before the year 2000 and not in the English language.

Papers that presented the results of systematic/scoping/rapid reviews, commentaries, book reviews and opinion articles were included in the abstract screening but excluded from data extraction.

Data Source and Search Strategies

The current review searched the following databases where published health services management research is most indexed: Medline, Scopus, Emcare, Web of Science and Emerald Management. Database search was carried out in January 2024 using the combination of key concepts and keywords as detailed in Table 1. Key concepts were connected using the Boolean term “AND” while the Boolean term “OR” was used for the keywords.

Study Selection Process

Results of keywords/key concepts in the search were imported into the EndNote software, and duplicates were removed. First, SK performed an independent title and abstract screening to check for the potential inclusion of papers. The abstracts were then transferred to Covidence software, which allowed authors SK and ZL to screen the titles and abstracts of the articles independently. When there are conflicts in the decision made by SK and ZL, a review was then conducted by BF. Once the agreement was reached between SK and ZL, SK performed a full-text review of the articles according to the inclusion criteria. The final decision on papers to be included for data extraction was based on an agreement between SK and ZL. This procedure was completed for a total of 39 full texts. The results of the search and selection of studies are detailed in Figure 1.

Figure 1 PRISMA flow diagram of the study selection process.

Figure 2 Benefits and positive impact of competent managers.

Data Extraction

The authors developed a data extraction form to record and organise information and confirm the relevance of included papers. Data of five papers were extracted by SK into a Microsoft Excel sheet 2019 (Microsoft, Redmond, WA) For ZL to check for consistency and accuracy followed by discussions between ZL and SK before the completion of data extraction of all identified papers. The authors extracted general information on each study (eg, authors, year of publication, context, study type, aims, cadre of health professions, and management level) and specific information related to the research question (benefits of competent managers). All information on individual, team and organisation benefits reported in the publications, including those derived from results (empirical) and from the interpretation of results (opinion-based) was extracted. This allowed the authors to give a broad overview of the research question.

Critical Appraisal

In line with the scoping review framework, a critical appraisal of the paper was not conducted.⁴²

Synthesis

The authors conducted a descriptive analysis of the characteristics of the included studies (Appendix 1) as well as an inductive thematic analysis of benefits that occur to competent managers. Inductive thematic analysis was carried out according to the steps outlined by previously published literature.⁴³ Once data extraction was completed, keywords were identified from the data. The keywords were developed into codes and then organised into levels based on their shared characteristics. The results are presented in Tables 2 and 3.

Table 2 Benefit Codes Generated During the Thematic Analysis Process

Table 3 Strategies for Developing Competent Managers

Results

Literature Search

The PRISMA flowchart (Figure 1) details the review process and search results. An initial search conducted in 2023 generated 8825 publications, and after removing duplicates, 4560 publications were included for title screening. Abstract screening of 4265 publications resulted in 117 studies being included for full-text review. The full-text review confirmed the inclusion of 39 papers in data extraction and analysis.

Descriptive Synthesis

All papers were published between 2006 and 2023. Most of the papers (74%, n=29) were published after 2016. 13 (33%) studies were conducted in Asia (India, Indonesia, Iran, Japan Jordon, Saudi Arabia, and Turkey), 11 (28%) were completed in Europe and in the Americas (USA and Canada), followed by three (10%) in Africa (Nigeria, Uganda and a study conducted in Ethiopia, Kenya, Malawi and Mozambique). Only one (3%) study was conducted in Oceania (Australia).

All of the studies included health managers working in different health settings. Most papers included managers working in hospitals (n=36, 91%), and one (3%) paper included managers working in social service agencies. Two (6%) papers did not specify the organisation the managers were working in, but they were recruited because they were members of professional bodies such as the American Society of Radiologic Technologists (ASRT) or through national surveys. More than half of the papers (51%, n=20) included all levels of managers (frontline, middle and senior managers). 11 (28%) of the papers involved frontline managers and one (3%) paper each included middle managers and senior managers only. The other 6 (15%) papers did not specify the level of management.

Managers were from the following different medical professions:

• Twenty-three papers (59%) included managers from the nursing profession.
• Eight papers (21%) targeted all managers, regardless of their profession.
• Four (10%) papers involved managers from the allied health professions (10%, n=4), including radiology (2 papers), community health care workers (1 paper), and housekeeping and dietary service workers (1 paper).
• Two papers (5%) involved physicians and healthcare managers.

From a methodological standpoint, 31 (79%) of the studies used a quantitative method, 3 (5%) studies included qualitative methods, three (5%) utilised experimental methods, and 2 (5%) used mixed methods.

Impact of Competent Managers

All of the papers included in data extraction mentioned the benefits of “good management” and/or “competent managers”. Hence, such benefits were also included in data extraction.

Management and Job Satisfaction

Twenty papers confirmed that competent management improves employee job satisfaction.^{44–47,56–58,63,66–69,71,73,77–81,83} The results emphasise the importance of managerial competencies in increasing employees’ job satisfaction. The behaviour of managers towards their staff is also a crucial determinant of job satisfaction.^57,58,66,67 The results further confirmed the positive impact of leadership on employees’ job satisfaction. Three leadership styles, authentic, transformational, and transactional, were specifically mentioned by these papers.^{45,46,48,56,59,72,73,78,79,83} With one exemption, laissez-faire leadership qualities were found to be associated with reduced levels of job satisfaction.^78,83

Management and Employee Retention

This scoping review confirmed that competent managers are instrumental in retaining healthcare employees. Analysis of eight papers has shown that competent managers improved staff retention by increasing job satisfaction, affective commitment, and teamwork. Managers who are supportive and build effective workplace networks increase employees’ affective commitment, which in turn lowers employees’ turnover intention.^53,56–62

Management and Well-Being

The findings of this review clearly demonstrate that competent managers are instrumental in managing stress at the workplace, reducing burnout and improving the psychological well-being of employees. Analysis of five papers highlighted that managers who are supportive and assist their followers in dealing with ethical issues protect them from the onset of emotional exhaustion.^{49,54,63–65} The review also highlighted that an authentic leadership style was vital in creating a positive working environment, increasing the coping self-efficacy and confidence of staff and lowering burnout.^{49,54,63–65}

Strategies for Developing Competent Managers

Thirty studies discussed or recommended strategies for improving management and developing competent managers. Hence, data relevant to strategies were also extracted and analysed.^{46,50–52,55,61,67,70,73–76}

Discussion

This scoping review confirms the positive influence of competent managers on job satisfaction, retention, and well-being of employees in the healthcare sector based on the results of empirical studies. The review also confirmed a range of benefits that competent managers can bring to employees, patients and the healthcare organisations. The review findings suggest that competent health managers are critical to employee and organisational success as illustrated in Figure 2.

Skills, Behaviours and Leadership Styles of Competent Managers

The results of this review highlighted the essential skills, behaviours, and leadership styles that competent managers should possess, enabling them to generate positive outcomes for employees, patients, and organisations. Competent managers should have the ability to effectively develop long-term plans, set goals and communicate goals and vision to their employees⁵⁵ They should also be able to successfully manage teams, workload, resources, and solve workplace conflicts.⁶⁵ Managers should be effective leaders who can collaborate well with their team, think critically, and foster a healthy working environment.^{55,57,65–68,70,77} Managers who are supportive of their subordinates and support the development of staff through mentoring are vital in improving employee outcomes.^{53,60–62,64} Managers with effective leadership skills and who demonstrate positive leadership behaviours can improve employee outcomes. Therefore, managers need to commit to continuous improvement in their managerial skills and address the skill gaps. In addition, healthcare organisations should be very clear about the managerial and leadership skills required of their health managers and dedicate resources to developing managers if gaps in skills and behaviours are recognised.

The role of three leadership styles - authentic, transformational, and transactional was highlighted in recent empirical evidence in improving employees’ job satisfaction, well-being and retention^{45,46,56,59,72,73,78,79,83} Leadership is context-sensitive and situational; hence, a single leadership style may not be suitable for all situations. Leadership styles can be applied differently in various situations to produce different benefits and outcomes. Managers and leaders should have the ability in adapt their leadership style to meet the abilities, willingness, and situational demands of team members⁸² Thus, regular training should be provided to assist health managers in recognising their leadership styles and to develop flexibility to adapt their leadership style to suit the situation.⁸⁴

Developing Competent Managers

The papers included in this review discussed several strategies in four different levels for improving management and developing competent managers. The results of this review reinforce that developing a competent health management workforce requires a holistic approach, with system-level investment, support, recognition, and collective efforts to promote the development of management competencies. Health managers need an empowering environment where their personal development is reinforced by efforts from and collaborations between health organisations, higher education institutions, and health systems.⁸⁵

From the health systems’ perspective, political will and support are required to improve and develop the capacity of managers.^68,70 There is a need to develop national partnerships and policies to build health management capacity.⁷⁰ These may include policies that recognise the importance of acquiring core management and leadership competencies and support the development of competency-based educational programs in healthcare management.⁸⁶ Healthcare organisations are instrumental in creating a supportive environment conducive to good management practices in two ways: the first is by adopting sound human resource management (HRM),^49,50,55,68 and the second is by committing resources to providing continuous onsite training and professional development interventions to support the development of managers.^{49–51,55,57,63–65,70–75,77,79,81} Good HRM policy and practices invest in activities to ensure organisations have an adequate number of employees with the right skills and motivation to achieve the organisation’s goals.⁸⁷ The findings of this review support previous research advocating the need to embed competency frameworks to enhance management capacities and to link the core organisational competencies to the organisation’s internal capabilities, thereby supporting the competence of the workforce.⁸⁸

HR practices of coaching, training and performance appraisal are also vital in developing competent managers.⁵⁰ Training and continuous professional development have long been recognised as essential in expanding the capacity of individuals to be effective in their management or leadership roles.^89,90 Health organisations need cost-effective mechanisms to develop the competency of their managers. The review supports informal or workplace-based training is necessary to develop competent managers.^{49–51,55,57,61,63–65,70–74,77,79,81} Literature⁵¹ highlights that workplace-based training programs should be tailored to the local context in terms of content and learning methods. Workplace-based training can be implemented using flexible, multiple training techniques such as interactive workshops, coaching, action learning, constructive feedback and mentoring.⁶¹ Training programs should also be regularly reviewed and revised to improve targeted management competencies 73. The current review also supports that effective leadership can be promoted through formal health management education.^59,79,80 Since management competencies are context-specific and will continue to evolve, both tertiary institutions and professional bodies must commit to understanding the changing competency requirements and competency development needs of the health management workforce. Higher degree teaching curricula must be regularly reviewed to incorporate newly emerged competency requirements.

Previous studies have confirmed that formal education provides an array of positive outcomes, including improved knowledge of management and leadership roles and responsibilities, improved communication skills, increased participant confidence and job positivity and satisfaction.⁹¹ From the health manager’s perspective, the results indicate that managers should engage in regular reflective practice.⁵⁹ This allows managers to reflect and identify their key managerial strengths and weaknesses, ultimately improving future practice.⁹² De-briefing sessions, self-report questionnaires and mentor feedback can encourage health managers to engage in reflective practice.⁹² Therefore, it is beneficial to integrate self-reflection into the everyday practice of health managers, with feedback from mentors and emphasis on self-evaluation as a means of ongoing monitoring.

Limitations and Further Research

The review only included articles published in English, and hence, relevant articles published in another language may be excluded. Most of the included studies were published in developed countries (North America and Europe), which may indicate that transferability to the context of developing countries requires further research.

Most papers were quantitative (79%) and adopted a survey strategy for data collection, indicating gaps in adopting different methodological approaches. Therefore, further research should be undertaken using mixed methods and qualitative paradigms to give a more comprehensive understanding of the topic. Since more than half of the included studies were conducted on nurses, there is a need to include other healthcare professions in future studies.

Research Implications on Policy and Practice

This review has confirmed various important elements for improving management and developing competent managers. Health managers can enhance their capacity and capability by developing self-confidence in leadership through a collaborative learning process reinforced by efforts from health organisations, higher education institutions, and policymakers. System and organisational level commitment is required to develop policies, structures, and processes that enable the development of competent health managers with the skills and behaviours necessary to perform their job effectively. Training and continuous professional development are essential for enhancing the management capabilities of health managers. There is a need to embed competency frameworks to guide the development and training of health managers.

Health organisations must commit to providing workplace-based training to enhance the capacity of their managers. Since management competencies are context-sensitive and will continue to evolve, it is imperative that professional and tertiary institutions commit to continuously understanding the changing competency requirements and development needs of the health management workforce and regularly review higher degree teaching curricula to incorporate newly emerging competency requirements.

Conclusion

This review has taken an important step in confirming the link between health managers and employee success. The results confirm that competent managers are crucial to enhancing job satisfaction, retention, and the overall well-being of healthcare employees. This review also confirmed a range of other benefits that competent managers can bring to patients and healthcare organisations. These findings suggest that competent health managers are critical to employee and organisational success. The review also highlights that managers must possess a range of leadership skills, display positive leadership behaviors and have the ability to adapt their leadership styles in order to generate positive outcomes for employees, patients, and organisations. Therefore, dedicating resources to develop a competent health management workforce is critical. This review confirms the importance of joint efforts and collaboration between governments, health organisations and higher education institutions to systematically enhance the capabilities of hospital managers. Health managers should be provided the opportunities in and encouraged to participate in both formal and informal management training. Equally important is the system and organisational level support in developing policy, structure and process that builds management capacity and supports managers. Since management competencies are context-specific and will continue to evolve, both tertiary institutions and professional bodies should continue their efforts in understanding the changing competency requirements and competency development needs of the health management workforce. Higher degree teaching curricula must be regularly reviewed to incorporate newly emerged competency requirements.