RESEARCH

Cultivating Retention: Exploring Transformational Leadership Dynamics in Military Nursing through Qualitative Inquiry

Nickalous Korbut, United States Military Academy

Melissa Miller, TriService Nursing Research Program¹

Joel Cartwright, United States Military Academy

Janice Agazio, The Catholic University of America

Lidilia AmadorGarcia, United States Military Academy²

ABSTRACT

Background: The shortage of nurses heightened the need to retain nurses in the workforce, particularly within military treatment facilities (MTFs). Despite quantitative analyses on factors affecting nurse retention, qualitative aspects of nurses’ free-text responses in routine surveys remain unexplored.

Objective: This study explored the impact of leadership, using qualitative data from the 2016 and 2018 Military Nursing Practice Environment Surveys, through the lens of the transformational leadership theory on preventable nurse attrition within the military health system (MHS).

Methods: Free-text responses from 1372 nurses in MTFs were analyzed using thematic content analysis methodology.

Results: Leadership emerged as the most prevalent concern, with 647 comments referencing leadership’s impact on preventable loss. Analysis revealed 25 leadership subcodes, highlighting negative sentiments about manager and executive leader presence and engagement, lack of acknowledgment, and ineffective communication, constituting 61.3% of negative comments.

Conclusions: This study highlighted the importance of leadership in nurse retention within the MHS. The findings align with Bass’s transformational leadership theory, emphasizing the need for idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration. Dissatisfaction with leadership trends resonates with the four pillars, suggesting that adopting a transformational leadership culture could positively impact MHS nurse retention. The recommendations include enhancing leadership visibility, improving communication channels, and fostering a supportive environment to address nurse dissatisfaction and prevent turnover.

Keywords: Nursing, Retention, Leadership, Transformational Leadership, Military Health System

 

 

The global shortage of nurses, estimated at 5.9 million by the World Health Organization (2020), has brought the issue of nurse retention to the forefront. A 2023 report by the Government Accountability Office published a “Key Insights: Health Care Staffing,” report highlighting that of 70 military installations, 85% reported a shortage of nurses (Warner, 2023). Given that the Military Health System (MHS) recruits its nursing workforce from the same pool of candidates as the civilian sector, which is also grappling with shortages, military leadership has responded to staffing shortages within military treatment facilities (MTFs) by implementing measures such as re-engaging retired nurses and rapidly onboarding new and contract staff (U.S. Department of Defense, 2020). The Army Nurse Corps routinely survey active-duty and civilian government service nurses, exploring various factors. These include job satisfaction, potentially preventable loss, intent to leave, and evaluating the practice environment using the Practice Environment Scale of the Nursing Work Index (Lake, 2002). The qualitative aspects of nurses’ free-text responses on routine surveys have remained unexplored, and this article uses the 2016 and 2018 Military Nursing Practice Environment Survey (MNPES) to research into how cultivating a transformational leadership culture can impact MHS nursing retention. Based on the qualitative data, the concepts from Bass’ theory on transformational leadership (Bass, 1985) appear lacking within the MHS and could help improve retention among military nurses. Bass’ theory emphasizes the capacity of leaders to drive inspiration and personal development among employees (Mengyue et al., 2023).

Bass delineated four critical characteristics of transformational leadership—the four I’s—that encompass idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration (Bass & Avolio, 1993). Idealized influence pertains to followers’ recognition and alignment with leaders’ values and goals, shifting focus from self-interest to collective objectives (Lai et al., 2020). Leaders who lead through idealized influence act as role models within their organizations, thus building a trusting relationship to embrace change (Kariuki, 2021). Trust is an essential element in the relationship that transformational leaders have with their followers and can determine the commitment of their employees (Givens, 2008). Inspirational motivation involves leaders effectively communicating a vision and motivating subordinates toward desired goals (Lai et al., 2020). Jyoti and Bhau (2015) explained the importance of relational identification. Employees with solid relational connections with their leader are motivated to fulfill their role expectations because of increased meaning within the workplace. This becomes challenging if leaders struggle to communicate effectively with their nursing staff to build a relationship. A leader’s vision and developing a shared purpose are crucial to inspirational motivation (Jyoti & Bhai, 2015). Intellectual stimulation encourages subordinates to seek solutions that exceed expectations (Gabel, 2013). Finally, individualized consideration denotes leaders providing personalized support tailored to followers’ needs (Lai et al., 2020). Adopting these transformational leadership principles could lead to a more supportive work environment, thereby improving nurse retention within the MHS.

Studies across sectors, including religious organizations, industries, technology, and laboratories, have demonstrated the effectiveness of transformational leaders possessing these four traits (Givens, 2008). A review of leadership research revealed that transformational leadership has much empirical evidence to support its effectiveness regarding multiple objective and subjective leadership outcomes. In response to employee organizational commitment, Hoch et al. (2018) found that transformational leadership was positively correlated with organizational and affective commitment in their transformational leadership meta-analysis research. Another meta-analysis by Bishop et al. (2023) examined 28 studies to assess the impact of transformational leadership on diverse leadership outcomes. Their meta-analysis used measures to differentiate the influence of transformational leadership at the individual, team, and organizational echelons. The findings highlighted transformational leadership’s effect on employee satisfaction (r = 0.34), organizational commitment (r = 0.33), and team cohesion (r = 0.32), which are all retention factors worth noting as more effective than other leadership styles. There was a positive correlation between healthcare employee retention and transformational leadership in a 2016 study that examined supervisor transformational leadership behaviors and employee turnover intentions (Sow et al., 2016).

Based on the effectiveness of transformational leadership, this study recommends the development of transformational leadership through initiatives like training, coaching, and mentoring due to the qualitative responses of the MHS nursing staff. The article “Qualitative Research and the Study of Leadership” points out that examining leadership through qualitative means is beneficial as it provides a more comprehensive range of contextual variables based on people’s experiences (Bryman et al., 1988). Karin Klenke (2016) published a book titled Qualitative Research in the Study of Leadership, which provides a framework for conducting qualitative interview studies in leadership research. However, this study is unique in considering MHS nurses’ survey responses and providing transformational leadership recommendations.

This study investigates coded comments from over 1372 nurse free-text comments in the 2016 and 2018 MNPES, which revealed a predominant concern—leadership within the organization and its impact on preventable loss (Miller et al., under review). Leadership was the largest coded category, encompassing 647 comments referencing leadership concerns as a factor in their retention status.

Method

We analyzed free-text responses from Licensed Practical Nurses and Registered Nurses across the Army, Navy, and Air Force who are actively involved in direct patient care at military medical treatment facilities (MTFs). The 1372 free-text comments that were analyzed came from the over 6000 respondents who answered the last free-text comment in the survey, “Is there anything else you would like to comment on?” This study is representative of the over 11,000 nurses within the MHS who were offered to complete the survey on a volunteer basis. Table 1 depicts the demographic breakdown of respondents. The focus was on frontline nursing staff, excluding leadership roles, nurse practitioners, and other nursing specialists. This exclusion aimed to minimize potential bias, acknowledging the distinct perspectives that leadership roles and varied nursing specialties might bring to the study. By concentrating on staff nurses primarily engaged in direct patient care, our study sought to capture a more homogeneous set of perceptions within the military nursing environment.

Table 1
Demographics

Service branch	Service type	Role	n	%
Air Force	Military	RN	8	0.58
Navy	Military	RN	11	0.81
Army	Military	RN	433	31.56
		LPN	67	4.88
	Civilian	RN	534	38.92
		LPN	319	23.25
Total			1372	100
RN: registered nurse; LPN: licensed practical nurse.

The MNPES was the data collection instrument that assesses various facets of the nursing practice environment, and the demographic data provide insights into the distribution of respondents across the military services and nursing roles. During the data processing phase, de-identified free-text comments were extracted. This study utilized a content analysis methodology with NVIVO Release 1.7.1. A descriptive-analytical framework was utilized to categorize comments, identify themes and word patterns, and assess sentiment frequencies (Elo & Kyngas, 2008).

The comments were coded and categorized based on prevalent themes and the frequency of respondents’ opinions and views among the free-text responses. Reliability and validity were increased by ensuring each comment was reviewed by at least two research team members. Two teams within the research group independently coded 140 responses for cross-validation, ensuring consistency (>90%) before advancing to the subsequent coding phase. Each team then focused on specific data segments, allowing for a more detailed analysis. Regular collaborative meetings were held to discuss findings, resolve coding discrepancies, and refine the schema. This approach facilitated the exploration of complex patterns and themes related to job satisfaction, intent to leave, and potentially preventable loss among military nurses. The process continued until saturation, with a final agreement consistently above 90%. See Miller et al. (under review) for a complete description of the method and results.

Results

Among the 1372 free-text responses, the parent code leadership emerged as the most prevalent, resulting in 25 leadership subcodes. This prevalence signifies its importance as a factor susceptible to preventable loss among nurses within the MHS. A closer examination yielded the development of 10 subcodes that specifically addressed comments about nurses’ perceptions of manager/supervisor leadership versus executive-level leadership. Table 2 outlines the distribution of the 630 leadership responses across the 25 subcodes in descending order by a percentage of positive and negative comments. There are 17 general leadership comments coded, which did not fit within the subcodes and are not included in Table 2.

Table 2
Leadership Subcodes

Subcode	Negative comments
	n	%
Manager negative presence & engagement	82	26.8
Executive negative presence & engagement	66
Manager lack of acknowledgment response to employees	63	20.6
Executive lack of acknowledgment & response to employees	51
Manager’s ineffective communication	52	13.9
Executive ineffective communication	25
Policy management	35	6.3
Favoritism	29	5.2
Mistreatment & bullying	28	5.0
Unit leave management	27	4.8
Participation in decision-making	24	4.3
Hostile environment	20	3.6
Toxic Leadership	16	2.8
Lack of accountability	14	2.5
Lack of collaboration (teamwork)	13	2.3
Lack of standard operating procedures dissemination	4	0.7
Lack of standard operating procedures	3	0.5
Subcode	Positive comments
	n	%
Manager positive presence & engagement	38	65.3
Executive positive presence & engagement	13
Positive leadership	11	14.1
Positive collaboration (teamwork)	8	10
Manager effective leadership communication	3	5.1
Executive Effective Leadership communication	1
Policy management (positive)	3	3.8
Positive environment	1	1.2

There was a notable difference between the negative and positive comment categories. There were 17 subcodes for negative responses and only eight for positive comments. The total negative responses reached 552 segments, much more than the 78 positive responses.

Leadership Trends

The three largest coded categories were presence and engagement, lack of acknowledgment and response to employees, and ineffective communication. Due to the number of responses, those were further divided by references to managers or executive leadership.

Presence and Engagement

The category exhibiting the most prevalent leadership feedback was manager and executive presence and engagement (n = 199). From a negative perspective (n = 148), numerous comments highlighted a perceived lack of leadership presence. One statement emphasized the need for managers to allocate more time to daily challenges within the clinics: “Managers need to spend more time in the clinics, observing and understanding daily challenges.” A similar sentiment was echoed regarding the executive leadership team. Their remarks included “Chain of Command is rarely visible within our work area” and “I do not even know the name of our Deputy Commander of Nursing, and their presence in our clinic is almost nonexistent.” One suggestion emphasized the need for managers to enhance their visibility by conducting regular visits within their clinics: “Managers should be more visible on the units, rounding regularly.” Leadership’s lack of physical presence emphasizes a disconnection between staff and their leadership. While most of the comments were negative, roughly 25% had positive sentiments toward the presence of their manager and executive leadership (n = 51).

Acknowledgement and Response to Employees

The second most prevalent category, acknowledgment and response to employees, encompassed 20.6% (n = 114) of the total negative comments. At the executive level, a trend surfaced within comments echoing the feeling of being unheard. One respondent summarized this frustration: “Our concerns are continuously expressed but met with no assistance or concern.” Similarly, a nurse expressed the absence of effective communication to agreed-upon plans, “There is a lack of solid communication and follow-through.” Among the managerial comments (n = 63), nurses overwhelmingly criticized their leadership’s lack of response to discussed concerns. One respondent highlighted the repeated dismissal of suggestions, stating, “Our ideas are consistently squashed, making it immensely challenging to feel heard.” Insufficient acknowledgment from leadership demonstrates a general feeling of being unheard in times of difficulty.

Ineffective Communication

The third largest theme was nurse’s dissatisfaction with leadership communication (n = 77). Among the 77 segments, nurses felt their manager’s communication lacked the most (n = 52). One nurse’s remarks highlight this: “Decisions are made, and those directly affected by them are the last to find out and often find out late after problems have already occurred.” Another recurring response was unheard nurses: “No one truly sits down and talks about the issues with us.” Among the executive-level comments on ineffective communication (n = 25), there was a sense among nurses of being uninformed. Multiple words echoed this sentiment: “Policies are set in place without any discussion, communication, or training” or “Communication is all but absent; I do not feel supported and have not for many years by the nursing leadership of this hospital.” When nurses feel uninformed about workplace changes and disconnected from decision-making processes, it can lead to increased dissatisfaction and a higher likelihood of seeking opportunities elsewhere.

These three categories—Presence and Engagement, Lack of Acknowledgment and Response to Employees, and Ineffective Communication—constitute more than half (61.3%) of the negative survey comments. Notably, 14.1% of the total comments were of nurses commending their leadership team. These comments suggested that positive leadership traits are being demonstrated across the MHS; however, the high percentage of negative comments engulfs the positive comments and offers potential areas for improvement.

Discussion

Nurses are the backbone of the MHS due to their multifaceted roles within MTFs (Jackson et al., 2022). Therefore, retaining nurses is vital to delivering high-quality, consistent healthcare. Concerns should be addressed to combat the negative sentiment among nurses within the MHS, as evidenced by the survey data. Bass and Avolio’s four pillars of transformational leadership outlined in their book Transformational Leadership and Organizational Culture (1993)—idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration—provide a framework for analyzing the impact of negative leadership traits on nursing retention within the MHS. Throughout this discussion, we will compare how dissatisfaction with their current leadership trends resonates with the four pillars of Bass’s transformational leadership theory.

Idealized Influence

A leader’s ability to influence their nurses’ behaviors requires leaders to embody the behaviors they seek within their nurses. The survey results demonstrated that nurses believe that idealized influence is lacking within the presence and engagement survey results. Overall, nurses reported that their leaders were distant and disengaged from the daily clinic demands. Leaders cannot expect their nurses to feel connected to the organization and inspired to come to work each day if they are not demonstrating similar behaviors. To address this issue, leaders must strive to be more visible and accessible to their staff. In a healthcare setting, this can be achieved by participating in team meetings, engaging with nurses during clinic rounds and fostering more face-to-face interactions. An engaged leader has a better chance of inspiring their employees when their involvement is felt within the clinic. Leaders lead, by example, by embodying the values they expect from their nurses and actively engaging among their teams, which can create change to a more committed and inspiring workforce (Kariuki, 2021).

Inspirational Motivation

Motivating employees requires leaders to establish personal relationships with their employees by helping them realize their full potential. Nurses voiced dissatisfaction with their leaders’ communication, sensing that decisions were made without their input or prior discussion. These actions can leave nurses uninformed, unheard, and disconnected from leadership, fostering disengagement. Leaders cannot create a sense of shared understanding unless employees feel connected to them. Presence and engagement are fundamental for cultivating this connection, but effective communication is equally important in establishing shared meaning. MHS leaders can reassess the communication channels through which information is disseminated to their nurses. Regular town hall or department meetings led by leadership, including all hospital/department employees, will ensure policies, updates, and organizational information sharing. These gatherings allow nurses to voice their concerns and feel empowered, fostering shared understanding within the organization. This approach aims to cultivate a more connected and inspired nursing staff, enabling them to comprehend the “why” behind their leaders’ intentions.

Intellectual Stimulation

The concept of intellectual stimulation in nursing leadership ties into the issue of nursing retention. When nurses feel their innovative thoughts and expertise are not valued, it impacts their commitment to their roles (Kamalaveni et al., 2019). This discontent was the third most prevalent coded survey response labeled “acknowledgment and response to employees.” Nurses seek an environment where their contributions are valued, and their ideas are encouraged. Nurses’ responses within the survey overwhelmingly expressed that their concerns were ignored by the lack of response to their needs, or that their ideas were dismissed. When acknowledgment is absent, it can lead to dissatisfaction, which drives them to seek employment elsewhere.

Encouraging a culture of inclusion by incorporating nurses’ insights at all levels is crucial. Actively involving nurses in decision-making empowers them and aligns their interests with the organization’s goals. Creating venues/meetings for idea exchange and investing in continuous education develops an environment conducive to growth. Empowering nurses to lead change initiatives they are interested in can increase commitment to the workplace. Recognizing expertise reinforces nurses’ sense of worth and encourages further engagement. Due to intrinsic motivation, nurses who experience intellectual stimulation can exhibit higher job satisfaction and commitment. Leaders are pivotal in fostering an intellectually stimulating environment that ensures a more fulfilling and engaging workplace for nurses.

Individualized Consideration

Individualized consideration requires personalized support for the unique needs of each employee (Lai et al., 2020). The presence and engagement category highlights how a leader’s physical presence is essential for personalized support. The negative feedback from the survey demonstrates a concern in leadership’s understanding of their nurses’ day-to-day challenges. Comments revealed that nurses’ desire for increased presence among their leadership aligns with the foundation of individualized consideration. Accessible leaders can understand the needs of their nursing staff and can offer personalized support. In addition, the second most consistent theme of “acknowledgment and response to employees” highlights the significance of leaders attending to their employees. Nurses expressed frustration at feeling disregarded despite articulating their concerns. A leader’s lack of acknowledgment of their employees impacts that leader’s ability to support them at the individual level. Individualized consideration consists of leaders responsive to their staff, ensuring each concern is heard with leader support and coaching (Khan et al., 2020).

Limitations

This study’s limitations included the use of cross-sectional data, which limited the breadth and scope of the analysis. However, the broad prompt provided rich data for analysis of nursing team personnel’s perceptions regarding their turnover intentions. In addition, open-ended questions tend to be negatively biased; however, given the survey’s focus on intent to leave, this bias likely had little impact on our findings (Poncheri et al., 2008). Future studies should include more significant numbers of Air Force and Navy nurses and all resource personnel.

Conclusion

The importance of retaining nurses within the MHS cannot be overstated due to their essential roles in delivering quality healthcare. The survey results emphasize the need to address the negative sentiments among MHS nurses. There was a difference in 522 negative comments and 78 positive comments related to leadership. The Four Pillars of Transformational Leadership by Bass is a framework that MHS leaders could adopt to demonstrate how leadership traits can positively impact potentially preventable loss trends within the 2016 and 2018 survey responses. The most prevalent trends from the survey are lack of presence, acknowledgment, and effective communication, which are issues that make nurses feel undervalued and unheard, leading to increased turnover and impacting patient care. Leaders can help reverse the negative sentiment among MHS nurses by creating a more supportive, engaged, and empowered MHS nursing workforce.

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