Health Services Management Research > Volume 21, Number 4 > Pp. 262-275

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Influences on the career commitment of health-care managers

Robert C Myrtle ^* , Duan-Rung Chen , Caroline Liu  and Daniel Fahey 

* School of Policy, Planning and Development, and Leonard Davis School of Gerontology, University of Southern California, CA; Institute of Health Care Organization Administration, College of Public Health, National Taiwan University, Taiwan; School of Policy, Planning and Development, University of Southern California, CA; Department of Health Science and Human Ecology, California State University, San Bernardino, CA, USA

Correspondence to: Robert C Myrtle Email: myrtle{at}usc.edu

The health-care field is undergoing rapid and significant transformation. This transformation has led to the breakdown of traditional career paths for managers in the patient care segment of the industry. To our knowledge, there has not been a systematic examination of how these changes have impacted on the career commitment of managers in this segment of the industry. Building on previous research, we examine the effects of employment-related conditions and career experiences on the career commitment of these managers while controlling for the influence of individual characteristics. Specifically we assess the relationship between employment-related conditions, such as job security, position tenure, industry segment, management level and the extent to which their current position meets their career expectations, and their career experiences, including moving from a non-health-care management position, moving from a different health-care sector, their career stage, career patterns and their satisfaction with their career progression. We found that measures associated with the different employment-related experiences had a more significant influence on career commitment than those measures associated with different career experiences.

	Introduction

TOP Introduction Factors believed to influence... Methods Sample and procedure Data and descriptive analysis Findings Discussion References

 
This paper examines the effect of employment-related conditions and career experiences on the career commitment of managers in the USA health-care industry. Like many other industries, the health-care industry has undergone significant transformation and change.^1,2 As the health-care industry has changed, so too have health-care careers.³ Recent research estimates the turnover rate of hospital Chief Executive Officers (CEOs) at 14%.⁴ Other studies report that health-care employees have a workforce commitment rate that is lower than other industries.⁵ This research uses responses from 1215 health-care managers, supervisors and other personnel to study the effect of a number of employment-related conditions and career experiences on the career commitment of health-care managers.

	Factors believed to influence career commitment

TOP Introduction Factors believed to influence... Methods Sample and procedure Data and descriptive analysis Findings Discussion References

 
Traditionally, a career has been viewed as a process of advancement within a single organization.⁶ In recent years, the globalization of the economy has changed the traditional contract between workers and their employers. Although this traditional model of employment and advancement within one organization may still be a reality for some, for an increasingly larger segment of the work force they are more likely to experience changes that cross organizational boundaries or which may not always lead to hierarchical advancement. Thus, with the expansion of downsizing and outsourcing there is a growing awareness of the futility of building a career around a one-employer relationship.⁷ Whether these changes will also lead to changes in one's commitment to their vocation, occupation or career remains to be seen.

Lee et al.⁸ point out that the changes that workers have been experiencing of late have led many to intensify their focus on and commitment to aspects of their working life that they have some degree of control over, namely their careers.^a Blau⁹ has defined career commitment as ‘one's attitude towards one's vocation, including a profession’. London¹⁰ indicates that career motivation should be understood in terms of the relationship between the worker, their work and their work experiences over time. This research examines the relative contributions of these influences on the commitment of health-care managers to their careers. Specifically, we examine how employment-related conditions and career experiences influence the career commitment of managers in the rapidly changing health-care industry.

Employment-related conditions

London¹⁰ and Colarelli and Bishop¹¹ suggest that a number of employment-related conditions have been found to influence career commitment. Research has shown that managers who remain in the same job for a number of years are less satisfied with their careers than those who are more mobile.¹² Thus, we would expect in a rapidly growing and expanding field, position tenure would have a negative relationship with a person's satisfaction with his or her career. However, Lee et al.⁸ in their meta-analysis did not find an association between organizational tenure and occupational commitment. Because career advancement in the health-care industry often involves taking another similar position in a larger organization or a higher level position in a smaller organization, we expect that:

H1: Position tenure will have a negative association with the career commitment of health-care managers.

Chang¹³ observes that people bring a set of expectations to an employment setting. Aryee et al.¹⁴ found that the expected utility of a worker's present job was a predictor of career commitment. Lee et al.⁸ found that occupational commitment was correlated with several job-related factors including work involvement and the nature of the work itself. Therefore, if an individual's perceived expectations for his or her present job is fulfilled, he or she will have higher job satisfaction and ultimately higher career commitment.^15,16 Because the health-care industry is undergoing significant change the nature of work and the historical employment contracts, like that in other fields, is likely to have undergone significant change as well. Whether these changes have had an impact on the conditions of work that attracted a person to a career in the field has not been examined. Thus, we expect that:

H2: The extent to which career-related expectations are satisfied by current work-related activities will have an impact on the career commitment of health-care managers.

Lee et al.⁸ characterizes an occupation as an identifiable and specific line of work with specific knowledge, skills and duties that differentiates it from other lines of work and which can be transferable across settings. They note that while occupational duties are carried out in employing organizations they also note that membership in an occupation is not necessarily linked to a particular employing organization. Although they suggest that occupational commitment is higher for those working in an organization which shares their professional values (e.g. an accountant working in an accounting firm), it is not clear whether these same professionals working different professional settings (e.g. a nurse working in a hospital versus a nurse working in a community clinic) will influence career commitment. With the organizational transformation taking place in the health-care industry, we propose to examine whether the industry segment in which one works has an influence on career commitment.

H3: The industry segment (clinic, hospital, long-term care [LTC], etc.) within which the respondent works will not influence the degree of career commitment expressed by health-care managers.

Darney¹⁷ notes that while the population of the USA has increased by 16% between 1987 and 2000, the number of hospitals has declined by 20%. Dalton and Howard¹⁸ note that in recent years the number of nursing homes in the USA has also declined. These changes have been accompanied by changes in the administrative ranks. In recent years, the hospital administrator turnover rate has been around 15%.¹⁹ In the long-term care field, the turnover rate for administrators has been even higher – higher than 40% at times.²⁰ These changes in the health-care industry can create a sense of uncertainty about one's job security and ultimately their career as a health-care manager. Thus, we would expect that:

H4: Perceived job security will have a positive relationship with the career commitment of health-care managers.

Mathieu and Zajac²¹ found that job level was positively correlated with organizational commitment. Following the line of reasoning put forth by Hrebiniak and Alutto²² we suggest that the position one attains in an organization serves as an objective measure of the achievements they have realized through the time and effort they have invested in their careers. Thus, administrators in senior level positions in an organization can be viewed as having a greater investment in their career than those in more junior positions and would be less likely to consider changing their careers. Hence, we expect that:

H5: The level of the managerial position in an organization will be related to the career commitment of health-care managers.

Career experiences

A number of factors have been found to influence commitment to a person's career. Chang¹³ reports that career changes have been associated with career commitment. She notes that those who have changed their career were less committed to their current career than those who did not change. What is unclear is whether moving from a management position in one industry to a management position in another industry would have an influence on career commitment. If we accept the traditional definition of career change as movement to a new occupation that is not part of a typical career progression²³ then movement between industries could be viewed as a career change and this movement should be negatively related to one's commitment to their current career. Thus:

H6: Movement from a management position in a non-health-care industry to a management position in the health-care industry will be related to the career commitment of health-care managers.

Brousseau et al.²⁴ suggest that careers should be viewed much more flexibly and that there can be multiple career patterns. As such the movement from one segment of the industry to another may or may not be perceived as a career change. Since health-care administrators do move from organization to organization and, more recently, from setting to setting,³ it is uncertain whether one's move from one sector in the health-care industry to another segment in that same industry would have an effect on their career commitment. As a result, we propose to test whether the movements between different sectors of the health-care industry (e.g. from an administrative position in a hospital to an administrative position in a medical group) will have an effect on the career commitment of health-care administrators. We believe that the blurring of the boundaries between the different delivery sectors may lead to increased professional challenges and new career opportunities such that:

H7: Health-care managers who have been able to move between different sectors of the health-care industry will have higher levels of career commitment than those who have not changed industry sectors.

In the past, the existence of a career that was characterized as advancement through the hierarchy made it easier to assess one's progression relative to others. In the health-care field, that progression would be both hierarchical (supervisor, department head, senior management) and lateral (moving from a supervisor role in a small organization to a supervisor role in a larger or more prestigious health-care institution within one industry segment). With the transformations that are occurring in the health field, movement within and between segments are more common.³

Hall²⁵ suggests that the extent to which a person believes they are competent and successful in their career role will have an influence on commitment to that career. Thus, managers who are able to work in multiple segments of the health-care industry are likely to experience opportunities for professional growth and satisfaction. Equally important, their ability to work in multiple sectors may increase their belief that they can be successful as a manager in this rapidly evolving industry. Therefore, we believe that:

H8: There will be a positive relationship between the ability of health-care managers to work in multiple health-care delivery sectors and their career commitment.

Ng et al.²⁶ note that people assess the extent to which they are successful in their careers through a number of different mechanisms including career satisfaction and by comparing their career progression relative to others. Aryee and Tan²⁷ found a significant and positive relationship between career satisfaction and career commitment. We believe that:

H9: Satisfaction with one's career progression will be positively related to the career commitment of health-care managers.

Dagley and Salter²⁸ note that career development is a process that takes place throughout one's working life. Thus, the longer one remains in a career, the greater their investment in that career, hence we expect:

H10: That there will be a positive relationship between career stage and the career commitment of health-care managers.

In Figure 1, we summarize our conceptual model and the specific relationships we propose to test.

View larger version (9K): [in this window] [in a new window]   Figure 1 Relationships being tested

 

	Methods

TOP Introduction Factors believed to influence... Methods Sample and procedure Data and descriptive analysis Findings Discussion References

 
We used correlation analysis to test for the relationships between the hypothesized relationships with career commitment. Hierarchical regression analysis was used to examine the effects of the proposed model on the career commitment of health-care managers. Individual characteristics were treated as control measures and were entered first, followed by employment-related influences and then the measures associated with career experiences.

Individual variables associated with the individual characteristics portion of the model included age, education, ethnicity, gender, marital status and number of children. Employment-related measures included position tenure, the extent to which initial career expectations have been met, the industry segment (ambulatory care, hospital, long-term care and non-service delivery settings), job security and management level. Measures associated with the career experiences portion of the model included holding a management position in a non-health-care setting, changing the industry segment employed in, career pattern, (single-sector career, single-sector change, back and forth sector change and multiple-sector changes), satisfaction with their career progression and their career stage.

Measures

Career commitment was measured by a scale initially developed by Blau⁹ and has been applied in other studies.^{9,14,15,27,29} Sample items in this research include: ‘if I could do it all over again, I would choose a management career in health care’; ‘I would recommend a health-care management career to others’; ‘If I could get a management job outside of health-care that paid the same as my current job, I would probably take it’. The measure was assessed on a five-point scale (ranging from 1, strongly disagree, to 5, strongly agree).

Career pattern. Several studies have noted that careers follow different trajectories.^24,30 In the health field, Fahey and Myrtle³ identified four different career patterns (traditional, change of sector, back and forth movement between two sectors and multiple-sector moves). Respondents were provided with a description of those career patterns and asked to identify the pattern that described their career.

Satisfaction with career progression was measured by a scale computed from two measures. The first asked respondents to rank their satisfaction with their career progression (1, very dissatisfied; 5, very satisfied) and the second asked an assessment of their career progression compared with others with similar backgrounds (1, very much worse; 5, very much better).

Career stage was based on the respondent's selection of a career stage that best described their career. A description of three career phases was offered (establishment, advancement and maintenance) and respondents were asked to indicate the stage that best describes their career at this time.

Changed industry was defined as a move from a management position in a non-health-care industry to a management position in the health-care industry.

Job security was measured by an item that asked the respondent to indicate how secure they felt in their current position (1, quite insecure; 5, very secure).

Industry sector was determined by asking the respondent to identify the sector of the health-care industry (hospital, ambulatory care, long-term care, other health-care sector) in which they were employed.

Management level was based on the position title provided by respondents. The lead investigators separately coded the 19 management titles listed by the respondents into five management levels (executive – CEO; senior management – COO, CFO; mid-level management – director; lower level – department head, and supervisor level). In the few instances where there was a disagreement as to the level, it was resolved by identifying the industry the respondent worked in and comparing their reported job title to the job titles, by level, commonly used in that health-care sector.

Satisfaction of career expectations. Following a method used by Hrebiniak and Alutto,²² the authors constructed a satisfaction of career expectations measure by computing the absolute magnitude of the difference between two scales. The scale was developed from a series of questions that asked respondents to assess the extent to which items derived from the Job Satisfaction Survey (JSS) were important to their entering the health-care field. Later in the questionnaire, respondents were asked about their satisfaction with that same list of items on their current job. Scale items included, autonomy, opportunity for advancement, professional growth, nature of work and job security. A five-point scale (ranging from 1, not important, to 5, very important) was used in this assessment. The JSS was chosen because it was designed to be used by human services workers and it had been demonstrated to have construct validity and reliability with good results in previous research.^31–34

Position tenure was derived from the actual time in months and years that the respondent held their current position.

Employment sector change was measured by comparing the first sector of the health-care industry the respondent worked in with the sector for their current job. If there was a difference between the sector of their first job and the current sector, that was defined as a sector change.

	Sample and procedure

TOP Introduction Factors believed to influence... Methods Sample and procedure Data and descriptive analysis Findings Discussion References

 
Five thousand and eighty-seven questionnaires were mailed out to the membership lists of the American College of Health-Care Executives (ACHE), American College of Health-Care Administrators (ACHCA), the Medical Group Management Association (MGMA) and the American College of Health-Care Administrators (ACHCA) between July and August 2004. All members of the ACHE, MGMA and ACHCA residing in five western states (Arizona, California, Nevada, Oregon and Washington) were mailed questionnaires. Twelve hundred and fifteen responses were received from this single wave, anonymous response survey providing a 23.9% response rate. A comparison of the reported age of the respondents (48.93) and the average age of the membership (49.01) did not seem to indicate a response bias.

	Data and descriptive analysis

TOP Introduction Factors believed to influence... Methods Sample and procedure Data and descriptive analysis Findings Discussion References

 
As is reported in Table 1, 48% (554) were men and 52% (n = 600) were women. Seventy-six percent (n = 749) respondents indicated they were married and 52.5% (n = 577) did not have children. Forty respondents were Asian, 78 were Black, 1001 were Caucasian and 36 were Hispanic. The average age was 48.9 years. Nine percent (n = 108) had not graduated from college, while 18.5% had bachelor degrees (n = 223), 64.1% (n = 772) had masters' degrees and 8.4% (n = 101) had a doctoral degree. Slightly more than 21% (21.5%, n = 259) had held a management position in another field.

View this table: [in this window] [in a new window]   Table 1 Individual and occupational characteristics

 
Upon entering the health-care field, 57.4% (n = 675) found their first position in the hospital/health systems sector. Reflecting the shift of care from hospital-based settings to ambulatory settings, slightly more people were currently employed in the ambulatory care sector (40.4%, n = 467) than in the hospital/health systems sector (39.5%, n = 456). The title of the current position held by most respondents (42.4%, n = 470) was CEO. The average tenure in their current position was 6.5 years. More respondents (37.3%, n = 450) described their career as traditional, (i.e. remain in the same sector without a move to other sectors), while 279 (23.1%) described their careers as having multiple changes, i.e. movement among multiple sectors.

	Findings

TOP Introduction Factors believed to influence... Methods Sample and procedure Data and descriptive analysis Findings Discussion References

 
Findings of the correlation analysis (Table 2) indicated that among the control variables only age appeared to have a small relationship with career commitment (r = 0.103, P 0.000). Two of the employment-related influences were supported and one partially supported. The extent to which initial career objectives on entering the health-care field were met (H2, r = 0.253, P 0.000) and perceived job security (H3, r = 0.227, P 0.000) were associated with career commitment. Two setting measures, hospital-based employment (H3, r = 0.112, P 0.000) and non-health-care based employment (H3, r = –0.066, P 0.022), were found to be related to career commitment. Finally, two of the career experience measures, change from a management position in a non-health care industry to a management position in the health-care industry (H6, r = 0.060, P 0.038) and career satisfaction (H9, r = 0.255, P 0.000), were associated with career commitment. Although these relationships were statistically significant the degree of association was very modest.

View this table: [in this window] [in a new window]   Table 2 Correlations

 
Aside from age, no statistically significant relationships were found between the other individual characteristics, position tenure (H1), management levels (H5), movement between health-care sectors (H7), career mobility (H8), career stages (H10) and career commitment.

Hierarchical regression analysis (Table  3) was used to examine the relative contributions of employment-related conditions and career experiences on career commitment. In step 1, the control variables were entered. Only age was found to have a statistically significant relationship with career commitment (β = 0.081, P 0.007). The lack of a statistically significant relationship between most of the control measures was generally consistent with previous research. Those studies suggested that age would predict career commitment and that education, the number of dependents and gender would not. Not surprising, these measures accounted for 0.015% of the variation in the career commitment measure.

View this table: [in this window] [in a new window]   Table 3 Hierarchical regression

 
Contribution of employment-related measures to career commitment

The employment-related measures were entered in the second step of the analyses. These measures were found to explain an additional 9.7% of the variation with career commitment. As expected, job security (β = 0.170, P 0.000) and the extent to which the current job met the respondent's career expectations (β = 0.187, P 0.000) had an influence on career commitment. Previous research with professionals in settings that shared their professional values compared with professionals in settings that did not share their values suggested that there was a relationship with career commitment.⁸ Such a relationship might exist between the type of sector employing health-care managers and their career commitment had not been studied.

Our research established a negative relationship between the sector the respondent was employed in and his career satisfaction. Hospital (β = –0.256, P 0.000) and clinic (β = –0.212, P 0.000) settings demonstrated the strongest negative relationship with career commitment although a negative association with career commitment was found between all employment settings. Three of the five management levels had a positive effect on career commitment. However, neither of the top management positions (CEO or Senior Level Managers) were found to predict career commitment nor, as was expected, did position tenure have an effect on career commitment.

Contribution of career experiences to career commitment

Measures associated with career experiences dimension of the model increased the predictive power of the model by an additional 2.9%. Only one of the career experience measures was found to contribute to the career commitment relationship. As expected, satisfaction with career progression (β = 0.170, P 0.000) was found to be a predictor of career commitment. However, neither the change of industry nor the career stage of the respondents were found to be predictors of career commitment. This lack of influence between the different career stages and career commitment is in contrast with the findings of previous research exploring the relationships between managers and professionals working in non-health-care settings.¹⁴

	Discussion

TOP Introduction Factors believed to influence... Methods Sample and procedure Data and descriptive analysis Findings Discussion References

 
This research extends our understanding of the influences on careers by examining the career commitment of managers working in the highly dynamic and transforming health-care industry. Many of the influences of career commitment of managers in non-health-care settings were found to apply to managers in the health-care field as well. Interestingly, the changes in the health-care field which have changed the traditional career patterns have not had an impact on the career commitment of health-care executives. None of the career pattern measures (traditional career, single sector change, back and forth between sectors, and multiple sector changes) were found to have an association with career commitment. This suggests that while managers may have an occupation identity as a hospital, clinic or long-term care facility manager, changing this occupational setting does not appear to affect their commitment to their careers as health-care managers and executives. Perhaps, this lack of association with career commitment reflects a realization of the new career realities in the health-care field, namely that the traditional progression within one health-care sector is no longer the only way of experiencing and understanding one's career.

The finding that management level, position tenure and work settings were not associated with career commitment is intriguing. Perhaps the traditional nature of careers in the health-care field may condition this lack of association. For many non-clinical managers, career advancement is likely to involve movement from a position in one health-care organization to a similar position with more responsibilities in another organization or to a higher position in a different organization or organizational setting. Even for those at the top rank of their organization, there are career advancement opportunities which can be realized by moving to a similar position in a larger or more prestigious organization or perhaps taking a senior management position other than CEO in a setting that provides significant personal and professional responsibilities. While rank is important, it may not capture the career pathways of different health-care executives and thus may not be a significant predictor of career commitment.

Following a similar line of reasoning, that position tenure was not associated with career commitment may not be as surprising as, at first, it might appear. While the health-care industry is undergoing significant transformation – consolidation of facilities, joining other organizations to form integrated delivery systems – it is a growth industry which can provide growth opportunities even while some industry consolidation is taking place. Also, management turnover, especially at the top of the organization, is a reality that has existed for some time. Thus, growth opportunities in the industry and the traditional movement of health-care managers from position to position and organization to organization may moderate the effect that position tenure could have on career commitment.

These findings also suggest that career commitment is influenced by a large number of considerations with no single influence or group of influences being particularly influential. It is interesting to note that employment-related conditions were found to have a greater influence on career commitment than a person's career experiences. Rhodes and Doering²³ suggested that employment-related conditions are influential in causing one to consider changing one's job, occupation or career. In this context, the degree to which the current work position is seen as fulfilling one's career aspirations can have both a direct influence on employment-related behaviours and if the cumulative experience in other settings does not provide the degree of opportunities desired, have an impact on one's commitment to their chosen career.

While there are likely to be identifiable influences on career commitment, the transformation of the health-care and other industries suggests that the career patterns of many workers will be increasingly more complex and more individually linked than they have been in the past. This suggests that studies of careers and career commitment will also be more complex and more dependent on how each person defines what their career is, as well as the extent of their commitment to it. If we accept the emerging view that people will have multiple careers, then perhaps the notion of career commitment will have to be re-defined in terms of the extent to which the current occupational choice is meeting the need state of the individual at any particular point in their life cycle. This suggests that future research inquiries will need to focus on understanding how these issues and dynamics shape individuals and how people view, define and evaluate their career.

Although this research adds to our understanding of some of the influences on the career commitment of health-care executives, careers unfold over a life time of occupational experiences requiring a longitudinal study to more fully understand how careers evolve. Also, our sample was limited to the perspectives of health-care managers residing in the five western states and managers and executives in other states may be influenced by factors other than those explored in this study. Finally, while the average age of the respondents and the average age of the membership list were similar, the low response rate and the realization that not all health-care managers and leaders are members of these associations may have influenced these results in ways that we cannot measure.

These limitations notwithstanding, the findings suggest that there are a variety of career patterns that health-care managers experience and that the variation in those patterns are not associated with career commitment. These findings also suggest that employment-related conditions explain more of the variation in career commitment than the respondent's career experiences do. While changing the industry sector might provide different work experiences, those changes did not appear to have an effect on career commitment. Since the transformation of the health-care industry is still evolving, additional research on the changing nature of health-care careers appears to be warranted.

	Footnotes

 
Robert C Myrtle DPA, Professor of Health Administration, School of Policy, Planning and Development, and Professor of Gerontology, Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA 90089-0626; Caroline Liu MPA, School of Policy, Planning, and Development University of Southern California, Los Angeles, CA 90089-0626; Duan-Rung Chen PhD, Associate Professor, Institute of Health Care Organization Administration, College of Public Health, National Taiwan University, Taiwan; Daniel Fahey PhD, Associate Professor, Department of Health Science and Human Ecology, California State University, San Bernardino, CA, USA

a While they point out that career, occupation and profession have been used interchangeably, they use occupation because it is more encompassing than profession and provides a ‘tighter’ work referent than career

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