Abstract
Taiwan has significantly fewer senior nursing personnel than many other countries, which can be attributed in part to the prevalence of interpersonal stress and same-sex conflicts that often arise in female-dominated workplaces such as nursing. This study explored how team reflexivity and gender-role attitudes influence the stay intent of female nursing personnel using a cross-sectional design. Results showed group-level team reflexivity has more positive impact on nurses’ stay intent via team-based self-esteem than individual perceived team reflexivity, but traditional gender-role attitudes weaken this impact. Our findings indicate mutual understanding and trust is crucial for nursing teams to function effectively.
Keywords
In Taiwan, nurses’ intention to stay in the workplace is an important issue (Taiwan National Health Research Institution [TNHRI], 2010). According to the Taiwan Union of Nurses Association (Taiwan Union of Nurses Association [TUNA], 2020), there are approximately 160,000 nurses working in the country. However, fewer than half of all qualified nursing staff are employed (TUNA, 2020, January 6). Moreover, the latest survey conducted by TNHRI (2010, December) shows that Taiwan’s nursing personnel has significantly less experience than that of other countries (approximately 6 years in Taiwan vs. 8.6 years in Korea, 14.8 years in Japan, 20 years in New Zealand, 30 years in Malaysia, and 35 years in Denmark). Training for nursing personnel is not limited to classroom-based education, but includes the cultivation of values, skills, and team spirit (Curtin, 1998), all of which are expected to develop gradually in the workplace. The excessively high turnover of nursing personnel results in a waste of staff and other resources, indirectly decreasing the quality of medical care that patients receive, as well as raising healthcare costs, while adding to the possibility of medical negligence and increased mortality rates (Needleman et al., 2011).
Team reflexivity refers to effective information-processing by the team (Schippers et al., 2014). Hsu et al. (2020) pointed out that the lack of effective team reflexivity, which could lead to bullying, is the main contributing factor to decreased stay intent among Taiwanese nurses. Although recent studies have noticed the importance of enhanced information-giving and that socially positive communication can be beneficial for nurses’ morale and can increase stay intent, especially in junior staff (Chao et al., 2021; Olsson et al., 2021; Yeh et al., 2020), there has been no discussion on team reflexivity. The first contribution of the present study is to examine whether there is a direct relationship between team reflexivity and individual stay intent among Taiwanese nurses to fill the research gap.
Besides the issue of team reflexivity, the issue of female roles should also be addressed in research on Taiwanese nurses. One of the contributing factors for high turnover intent in female Chinese nurses is gender-based work-family conflict (Zhang et al., 2020). The stereotype in the Chinese culture is that men are the “breadwinners,” while women are still traditionally viewed as the stay-at-home care givers (Cotter et al., 2011). Thus, female nurses in Taiwan who have more traditional attitudes toward gender roles may care less about their teams’ perceptions of them because they prioritize their family over career. The second contribution of the present study is to discuss the impact of the interaction between team reflexivity and gender-role attitudes on stay intent in female nurses.
Furthermore, team reflexivity has generally been perceived as a group-level construct, with little attention paid to its potential relevance as an individual-level psychological process (Hadi & Chaudhary, 2021; Wang et al., 2022; West, 2000). Based on the self-regulation mechanism theory, lack of effective feedback may decrease team members’ abilities to recognize their own achievements and cause them to leave the team as a result (Zimmerman & Bandura, 1994). Namely, Taiwanese nurses’ stay intent is influenced by how they perceive their team members’ views of them (Hsu et al., 2020). We argue that not only team reflection and feedback but also individual perceptions of it will impact team members’ personal outcomes, notably stay intent and performance. This is the third contribution of this research.
In addition, past studies have utilized the framework of self-regulation mechanism to explore the relationship between individual perceptions and external environments (Bussey & Bandura, 1999; Zimmerman, 1989; Zimmerman & Bandura, 1994). The present study differentiates between two concepts—individual perceptions of an external environment (i.e., individual-perceived team reflexivity) and environmental factors (i.e., team reflexivity), using a cross-level model to extend our understanding of the self-regulation mechanisms. This is the fourth contribution of this study.
How the Self-Regulation Mechanism Affects Nurses’ Stay Intent
Zimmerman (1989) proposed that individuals develop self-regulation mechanisms, which help to explain the interaction between an individual’s psychological needs and their external environment in achieving desired outcomes. Self-regulation refers to an individual’s self-monitoring of their activities and how they use their intrinsic value standards (e.g., self-concept, motivation, or work goals) to adjust and evaluate their behavior (Zimmerman, 1989; Zimmerman & Bandura, 1994). This mechanism as a psychological process describes the dynamic relationship between self-concepts, personal implicit behaviors, and external environments (Zimmerman, 1989). In practice, when facing a problem at work, an employee may try to positively change their situation, but if they cannot maintain the lowest internal value standard, often self-esteem, they may choose to leave the workplace (Chung, 2021; Ohue et al., 2021).
In the 2000s, scholars across the globe became interested in what factors influence turnover and stay intent (Kovner et al., 2009; Wilson, 2006). These were found to be job dissatisfaction, burnout, emotional exhaustion, and workplace stress (Halpern, 2016; Larrabee et al., 2010; Osuji et al., 2014; Scammell, 2016). In Taiwan, past studies have noted that heavy workloads and interpersonal issues (especially relating to conflicts between colleagues and supervisors), among other factors, have contributed to many nurses leaving the profession (Chiu et al., 2017; Ho et al., 2010). Although such research provided useful guidelines for nursing managers at the time, the question of why nurses do not stay in their jobs requires further investigation.
The quality of the relationship between team members and their working environment, especially perceptions of team feedback, is a main factor that contributes to the lack of retention and high turnover rates among nurses (Busca et al., 2021; Chao et al., 2021; Hølge-Hazelton & Berthelsen, 2020; Van Osch et al., 2018; Yeh et al., 2020). An effective communication pattern (i.e., high levels of team reflexivity) can promote team growth, new members’ adaptability, and indirectly increase quality of care and decrease medical errors (Busca et al., 2021; Chao et al., 2021; Chiu et al., 2017; Hsu et al., 2020; Olsson et al., 2021). According to the ideas of self-regulation mechanisms, the benefits that individuals gain from effective communications and reflections in a team (i.e., promoting personal adaptability and growth) can be internal resources used to improve nurses’ team-based self-concepts and thus increase stay intent (Ohue et al., 2021).
In Taiwan, traditional concepts and gender stereotypes are a social pressure that constrain women, weakening their intention to remain active professionally and often leading to a precarious work-life balance for those who do (Zhang et al., 2020; Zimmerman, 1989). Based on the self-regulation mechanism idea, when role conflict (i.e., tradition versus modernity) exists, female nurses try very hard to balance their home and work lives. Gender stereotypes cause working women to feel they have to choose between work and family, especially for those women who have been influenced by the traditional views on gender roles (Lu et al., 2021; Ohue et al., 2021; Soltanpanah et al., 2018; Zimmerman, 1989). Thus, traditional gender roles can diminish the perceived importance of teamwork and contribute to high turnover rates (Jackson et al., 1993; Lu et al., 2021). Lu et al. (2021) highlighted that family-work conflict is an issue affecting Taiwanese women but not men. This means that gender-role expectation is an important social factor affecting modern Taiwanese women and influencing their decisions to continue working.
The purpose of the present study is to explore the relationship between team reflexivity, team-based self-esteem, gender roles, and stay intent via the self-regulation mechanism concept in Taiwanese female nurses. The research model is presented in Figure 1.
Research model.
The Relationship Between Team Reflexivity and Stay Intent
Within the theoretical framework of self-regulation mechanism, team reflexivity and female roles are external environmental factors that impact Taiwanese female nurses (Auzoult, 2021; Lu et al., 2021). Team reflexivity is a group-level construct that goes beyond communication. It is “the extent to which group members overtly reflect upon, and communicate about the group’s objectives, strategies (e.g., decision making) and processes (e.g., communication), and adapt them to current or anticipated circumstances” (West, 2000, p. 296). Effective team reflexivity requires objective reflection on team members’ mutual opinions and the attention and awareness of in-group members, such as the correct control of status, self-monitoring, and evaluation (West & Richter, 2008). Team reflexivity is critical to team performance, as ineffective team reflexivity can lead to poor team information-processing, which can erode in-group trust and cause people to leave the team (Schippers et al., 2014).
In the nursing field, positive social talk and reflections can help junior nurses integrate in a team (Chao et al., 2021). The stressors for Taiwanese nurses mainly derive from nurse-to-nurse interpersonal conflict (i.e., insufficient team reflexivity and poor communication patterns in teams), especially between female nurses (Hsu et al., 2020), contrarily to expectations of female workers from a traditional female role perspective (i.e., cooperative and helpful to others; Sheppard & Aquino, 2017). Further, almost one-third of Taiwanese nurses do not feel sufficiently understood or psychologically supported by their colleagues (Hsu et al., 2020), similar to findings of research on Chinese female nurses (Zhang et al., 2020). Jackson et al. (1993) noted that heterogeneity-related conflict and discrimination in socialization is caused by an ineffective communication pattern characterized by a lack of information exchange and mutual understanding. In the team-building process, individuals are more inclined to enjoy being a part of a group than to be alone in the workplace and can long for positive self-evaluation through mutual understanding and positive reflection (Jackson et al., 1993; Olsson et al., 2021). Thus, not only team reflexivity but also individual perceptions of reflection in a team can strengthen personal values, decrease uncertainty among team members, and increase personal stay intent in a team (Zimmerman & Bandura, 1994). Accordingly, we proposed the following hypotheses: H1a: Team reflexivity is positively related to stay intent. H1b: Individual-perceived team reflexivity is positively related to stay intent.
The Mediating Role of Team-Based Self-Esteem
According to theories of the self-regulation mechanism, people usually maintain or enhance their self-esteem through inter-group comparison to uphold a positive self-concept (Zimmerman & Bandura, 1994). The use of team-based self-esteem as an internal standard can reflect an individual’s perceptions of their environment and influence explicit behavioral displays among Taiwanese nurses (Chang et al., 2019). Thus, team-based self-esteem can be defined as the sense of values and positive self-evaluations achieved through being part of a group (Sharma & Agarwala, 2014). In Taiwan, perceived status and hierarchical relationships in a group are often related to team-based self-esteem, such that individuals who believe they are not valued and feel marginalized within a group have lower team-based self-evaluations than those who perceive themselves as powerful and/or valued within a team, especially in a collaboration-based occupation like nursing (Chang et al., 2019; Sharma & Agarwala, 2014). Therefore, individuals who perceive they have a low status in a group and feel little connection with other team members will use various behavioral strategies to try to improve their status and connect with their team members to enable better self-evaluation (Busca et al., 2021). In the context of perceived team reflexivity, an individual can objectively examine and reappraise their previous actions, the result of the behavior, and the team processes to satisfy their self-esteem needs (Hibbert et al., 2010). Low levels of individual-perceived team reflexivity can contribute to low levels of team-based self-esteem due to feelings of uncertainty and instability (i.e., people are not sure how they fit into a group and do not feel valued within it), which can lead to a low stay intent in a group or a workplace. Therefore, this study proposed the following hypothesis: H2: Team-based self-esteem mediates the relationship between individual perceptions of team reflexivity and stay intent.
Furthermore, Hibbert et al. (2010) suggested that an effective team reflexivity process requires recursion. This means deliberately repeating an original process to confirm whether a goal can be achieved or whether behavior is effective under the premise of an established principle or existing condition. In other words, individuals must actively observe, review, and evaluate the team’s tasks and goals to be able to objectively perceive the team’s response to them (Carter & West, 1998). It is important for a team to actively create an atmosphere of reflexivity and support to foster inclusion and individual growth (Chao et al., 2021; Hibbert et al., 2010; Olsson et al., 2021). This study suggests that team reflexivity is a variable that can affect stay intent by meeting individual employees’ psychological needs (i.e., team-based self-esteem). Hence, this study proposed the following hypothesis: H3: Team reflexivity is positively related to intention to stay via team-based self-esteem.
The Moderating Effect of Gender-Role Attitudes
Nursing is a predominantly female profession: 96.6% of nurses in Taiwan are women (TUNA, 2020, January 6). Despite this, research has predominately focused on the influence of gender-role issues on male nurses (Cho & Jang, 2021). Gender-role attitude are beliefs about the extent to which individuals should conform to traditional gender roles, which prescribe specific behaviors and expectations for men and women, and are distinct from sexuality (Judge & Livingston, 2008). In a traditional gender role, a woman is praised for concentrating exclusively on her family while a man concentrates on his work and does little if any housework or caring in the home (Soltanpanah et al., 2018). The higher the degree to which individuals believe in the veracity of gender-role attitudes, the more they believe that women should bear the responsibility of caring for the family and maintaining the home (Cotter et al., 2011). Conversely, individuals with a more modern outlook tend to believe in equal participation of both genders in both external work and work within the home (i.e., housework; Mason & Lu, 1988). Gender-role attitudes may have a stronger personal influence on women in the nursing profession than on their male counterparts, because females are more likely to feel subject to social normative expectations that constrain their behaviors and core values (Soltanpanah et al., 2018).
When an individual’s behavior diverges from the stereotypical idea pertaining to their physiological gender, a negative emotional state can ensue because the individual’s self-image is inconsistent with socially gendered expectations, such as men should not be nurses or women should not be breadwinners (Jackson et al., 1993; Soltanpanah et al., 2018). The inconsistency between the self-concept and social expectation will affect behavioral performance (Marginson & Bui, 2009), and can trigger depression and anxiety (Wolfram et al., 2009). Livingston and Judge (2008) suggested that women with traditional gender-role attitudes believe that work-family conflict is caused by work-interfering-with-family. Therefore, female nursing personnel who hold more traditional gender-role attitudes are more likely to feel conflicted by the dual pressures of work and home, compared to those with a more modern gender-role attitudes. Due to the struggle between personal roles and social expectations, the positive effect of team support and reflexivity is likely weakened. Thus, this study proposed the following hypothesis: H4: Gender-role attitudes moderate the positive relationship between individual-perceived team reflexivity and self-esteem, such that the relationship will be weakened by high levels of gender-role attitude (i.e., traditional gender-role attitudes).
Methods
Research Subjects and Sample Distribution
This study used convenience single-source sampling to enroll subjects, and distributed questionnaires to various levels of nursing personnel in healthcare institutions. To minimize the potential impact of social expectations on the authenticity of the responses, the researcher distributed the survey questionnaire in person and sealed it in an envelope immediately after completion to ensure confidentiality. To mitigate potential single-source bias, the survey questionnaires included both concrete examples of behavior and abstract conceptual questions, as recommended by Peng (2006). A third party assisted in the design of the survey to avoid researcher bias.
The subjects were 249 nursing staff from 27 departments in 14 healthcare institutions (response rate was 100%). There were no invalid questionnaires requiring deletion. After excluding 25 questionnaires filled in by male nursing personnel, the final sample was 224 female nursing personnel. The mean of the sample size per departments was 8.30 nurses (Median = 9.00; SD = 2.04). The mean age of the subjects was 29.49 (Median = 30.00); the mean seniority was 3.82 years (Median = 4.00); most subjects were married (58.9%); the education level of most subjects was university (60.6%; Median = university); the hospital department which most subjects worked in was the general acute ward (63.4%); the hospital levels of care which most subjects worked in was the would-be medical centers (the level between religion hospital and medical center; 36.2%); the most common medical specialty was surgery (35.7%; see Table 1 for further details). A post-hoc power analysis showed that based on the smallest effect size detected (f2 = 0.15), with 20 predictors and an α level of .05, the achieved power was >.99 (Faul et al., 2009).
Descriptive Statistics (N = 224).
Item has missing data.
Measures
Chinese versions of the questionnaires were provided for all measures. The back-translation procedure was used (Brislin, 1986), with all items measured on a 6-point scale (1 = strongly disagree; 6 = strongly agree).
Team Reflexivity
This study used a version of the team reflexivity scales developed by Carter and West (1998) that is simplified and modified by Li et al. (2018) for samples in Taiwan to measure individual-perceived team reflexivity, with a total of four items. Sample items were: “In this team, we often review the feasibility of our objectives” and “In this team, we regularly discuss whether we are working effectively together.” The Cronbach’s α = .74. Higher scores indicate a higher level of team reflexivity.
Team-Based Self-Esteem
This study used the scale of organization-based self-esteem developed by Pierce et al. (1989) to measure team-based self-esteem, with a total of seven items. Sample items were: “I am important at work” and “I am trusted at work.” The Cronbach’s α = .90. Higher scores indicate a higher level of team-based self-esteem.
Stay Intent
This study used the scale developed by Hunt et al. (1981) to measure stay intent in the workplace, with a total of four items, including two reverse coded ones. Sample items included: “If I were free to choose, I would not continue working for this organization (reverse)” and “It is very unlikely that I would consider leaving this workplace.” The Cronbach’s α = .84. Higher scores indicate a higher level of intention to stay.
Gender-Role Attitude
This study used the scale developed by Paustian-Underdahl et al. (2019) to measure gender-role attitude, which originated from the traditional gender-role orientation scale modified and compiled by Judge and Livingston (2008), which verified that the scale was highly positively correlated with other gender-role orientation scales, such as the traditional-egalitarian sex-roles scale and the attitudes toward women scale. In addition, the scale was not correlated with masculinity in the Bem Sex Role Inventory, and was negatively correlated with femininity, suggesting that the scale did not measure personal traits but an individual’s attitude toward traditional role orientation (Judge & Livingston, 2008), meeting the purpose of this study. The scale had a total of five items. Sample items included: “Women are much happier if they stay at home and take care of children than if they go out to work” and “It is best if the man is the breadwinner and the woman takes care of the home and family.” The Cronbach’s α = .98. Higher scores indicate the individual holds more traditional gender-role attitudes.
Data Analyses
We used structural equation modeling (SEM) in Mplus 8.0 (Muthen & Muthen, 2017) to conduct confirmatory factor analysis on our hypothesized measurement model with four factors (team reflexivity, team-based self-esteem, stay intent, and gender-role attitudes). Our data structure was nested, because each department had different levels of team reflexivity to influence their group members. We used these 27 departments as our cluster/group variable. Following a multilevel SEM (MSEM) approach (Preacher et al., 2010; Wen & Chiou, 2009), we calculated the intraclass correlation coefficient (ICC) and interrater agreement (Rwg) of the outcome and independent variables. ICC 1 was used for evaluating group homogeneity, ICC 2 to supply the reliability of the group means, and Rwg for homogeneity with within-group aggregation (Bliese et al., 2019; Klein & Kozlowski, 2000). After verifying the acceptability of the ICC 1, ICC 2, and Rwg values for the independent variables using Zohar’s (2000) criteria, we used Mplus 8.0 (Muthen & Muthen, 2017) to examine contextual effects, following the approach outlined by Chiou (2017).
Common Method Variance
This study used the factors extracted from unrotated principal component analysis to determine the existence of common method variance. If the eigenvalue of extracted factors is >1, and the explained variance of the first factor is <50%, then common method variance does not exist (Podsakoff et al., 2003). The factors extracted in this study with an eigenvalue >1 cumulatively explained 77.61% of the variance, and the explained variance of the first factor was 34.08%; thus, this study had no common method variance.
Results
Measurement Model
The study’s discriminant validity and intercorrelations are shown in Table 2. The four research variables (team reflexivity, team-based self-esteem, stay intent, and gender-role attitudes) correlated to each other (p < .05), with the exception of the relationship between gender-role attitudes and team reflexivity (r = −.04, p = .53) as well as team-based self-esteem (r = .06, p = .41). We conducted discriminant validity tests of the four variables following procedures recommended by Fornell and Larcker (1981). The average of variance-extracted estimates (team reflexivity = .58, team-based self-esteem = .62, stay intent = .79, gender-role attitude = .92) were greater than the square of correlations between team reflexivity and team-based self-esteem (r2 = .16), team reflexivity and intention to stay (r2 = .05), team reflexivity and gender-role attitude (r2 < .01), team-based self-esteem and intention to stay (r2 = .52), team-based self-esteem and gender role attitude (r2 < .01), and intention to stay and gender-role attitude (r2 = .03). This provides support for discriminant validity. The standardized factor loadings onto the latent variables ranged from .54 to .97, p < .01, indicating the four variables are distinct from each other.
Discriminant and Convergent Validity, and Intercorrelations.
Note. AVE = average of variance extracted.
p < .05. **p < .01.
ICC and Rwg
Results of our analysis showed that the research model is appropriate for aggregating to level 2. ICC 1 was .49 for team-based self-esteem and .31 for team reflexivity. ICC 2 was .89 for team-based self-esteem and .79 for team reflexivity. The average value of Rwg was .94 (ranging from .80 to 1.00, median = 0.96) for team reflexivity.
Structural Model: Individual-Level
Our multilevel structural equation model (MSEM) added an interaction term to the measurement model: gender-role attitude × individual-perceived team reflexivity, with acceptable fit to the data (Hooper et al., 2008): χ2 (30) = 90.09 (p < .01), χ2/df = 3.00, CFI = .97, TLI = .96, RMSEA = .09, SRMR = .09, GFI = .96, NFI = .96.
Standardized regression coefficients are presented in Table 3. In support of Hypothesis 1b, results showed the direct effect of individual-perceived team reflexivity on intention to stay is positively significant (β = .32, p < .01, CI [0.23, 0.53]: bias-correct CI [0.19, 0.44]). In support of Hypothesis 2, the indirect effect of individual-perceived team reflexivity on intention to stay via team-based self-esteem was significant (β = .14, p < .01, CI [0.08, 0.25]: bias-correct CI [0.07, 0.21]). In support of Hypothesis 4, gender-role attitude moderated the indirect effect in Stage 1 (β = −.14, p = .03), such that the relationship between individual-perceived team reflexivity and team-based self-esteem is weakened when there is a high level of gender-role attitude (see Figure 2).
Indirect Effect of Individual-perceived Team Reflexivity on Stay Intent through Team-based Self-esteem and Moderating Role of Gender-role Attitude.
Note. IPTR = individual-perceived team reflexivity; GRA = gender-role attitude.
Moderated effect of gender-role attitude.
Structural Model: Cross-Level
The cross-level model exhibited an acceptable fit to the data (Hooper et al., 2008): χ2 (51) = 92.74 (p < .01), χ2/df = 1.82, CFI = .98, TLI = .97, RMSEA = .06, SRMRWithin = .09, SRMRBetween = .06, GFI = .96, NFI = .96. In support of Hypothesis 1a, there is a direct effect of team reflexivity on intention to stay (B = 1.26, p < .01, CI [0.62, 1.91]: bias-correct CI [0.50, 1.02]). Following the analysis procedure by Chiou (2017), in support of Hypothesis 3, team reflexivity is positively related to stay intent via team-based self-esteem on the group-level model (B = 0.65, p = .02, CI [0.09, 1.21]) and on the cross-level model (B = 0.16, p = .03, CI [0.02, 0.31]), but not on the individual-level model (B = 0.01, p = .33, CI [−0.01, 0.04]). That is, team reflexivity has a contextual effect on stay intent via team-based self-esteem (see Table 4). We provide the coefficients of the direct effects of the research variables in Figure 3.
Results of MSEM of Team Reflexivity on Stay Intent via Team-based Self-esteem.
Note. IPTR = individual perceived team reflexivity; TR = team reflexivity; TBSE = team-based self-esteem; STAY = stay intent.
Results of the direct effects of the research variables in the cross-level model.
Discussion
Discussion and Theoretical Implications
Our results support the research hypotheses and provide theoretical contributions. First, the pertinent environmental factors and individual perceptions of external environments have been discerned, providing new insights into theories of self-regulation mechanism. Second, our findings indicate that team reflexivity can be considered as an individual-level variable for investigating an individual’s internal psychological processes. In the nursing field, both team reflexivity and individual-perceived team reflexivity impact stay intent. The present study found team reflexivity has a more powerful effect on personal self-evaluations than perceived team reflexivity among Taiwanese female nurses. Third, gender-role attitude weakens the impact of team reflexivity. In the following, we discuss our theoretical contributions in detail.
First, this study’s research model utilized the concept of self-regulation mechanisms (Zimmerman & Bandura, 1994). Our findings suggest that individual-perceived team reflexivity has a positive effect on stay intent in a workplace through the enhancement of team-based self-esteem, while the cross-level model reveals that team reflexivity has a positive effect on stay intent through the enhancement of team-based self-esteem when group-level influence is taken into consideration. In this case, the effect of individual-perceived team reflexivity is reduced to an insignificant level. Previous research had shown that self-regulation mechanisms are associated with an individual’s behaviors through their intrinsic personal standards, which are shaped by their perceptions of information, cognition, or emotions (Bussey & Bandura, 1999; Zimmerman, 1989; Zimmerman & Bandura, 1994). The MSEM model in the present study directly shows that the external environment (i.e., group-level and individual perceived team reflexivity) influences an individual’s behavior through an individual’s intrinsic personal standards. Further, the effect of individual-perceived team reflexivity is weakened by group-level team reflexivity, indicating that, compared with individual information or cognition, the external environment has a greater direct effect on the individual. This study demonstrates that the MSEM model can distinguish between the effects of individual perception and external environments on people through the stratification of group and individual levels for research on psychological processes.
Second, the individual-level model demonstrated that team-based self-esteem mediates the relationship between individual-perceived team reflexivity and stay intent. As we expected, individual-perceived team reflexivity can be used as an individual-level variable to impact female nurses’ stay intent via their team-based self-evaluations. Furthermore, the multilevel model showed that team reflexivity has a contextual effect. In addition to enhancing an individual’s team-based self-esteem and increasing their stay intent, team reflexivity at the group level may exert the same effect, which means increasing the team’s overall stay intent. In this case, the effect of individual-perceived team reflexivity (personal perception) is lessened by group-level team reflexivity (the external environment). This is very important in the nursing field and aligns with the results reported by Hsu et al.’s (2020), indicating that a positive team reflection atmosphere has an impact on both an individual’s team-based self-evaluations and their stay intent among Taiwanese female nurses. Our findings are also consistent with the typical image of a Taiwanese female nurse, which places importance on the traditional female gender role, team connection, and maintaining a harmonious work atmosphere (Busca et al., 2021; Jackson et al., 1993; Zhang et al., 2020). As a result, low levels of individual-perceived team reflexivity will lead a female nurse to experience high levels of uncertainty (Rong et al., 2019), and in turn generate behavioral motivations due to the perception of psychological threats; that is, a reduced stay intent (Zimmerman & Bandura, 1994). Conversely, when overall team reflexivity reaches a high level, even if the level of individual-perceived team reflexivity is not high, female nurses may still experience a positive effect; that is, enhanced levels of self-esteem within a team and an increased desire to stay.
Third, as expected, gender-role attitudes can weaken the relationship between individual-perceived team reflexivity and self-esteem; that is, when a female nurse is inclined to believe the traditional notion that men should work outside of the home and women should shoulder the responsibility for household chores, the effect that team reflexivity has on the enhancement of their team-based self-esteem is reduced. This is possibly because female nursing personnel who adhere to traditional gender roles value their family responsibilities and professional roles equally, whereas those who hold more modern beliefs about gender roles may prioritize their career over their families (Hsu et al., 2020; Zhang et al., 2020). With team and family given equal weight, the impact of team reflexivity is weakened for female nursing personnel, with two possible underlying reasons. First, female nurses may experience role conflict. Although the nursing profession is fundamentally similar to the traditional care-giving role of women in a family, there can be a mental struggle for nurses due to potential conflicts between their professional and personal roles, as perceived by their family. For example, when a female nurse working in a cardiac catheterization room is urgently requested to return to the hospital at night to help save a patient, her family members who have no professional background in medicine may question the necessity of doing so and also consider that she is excessively dedicated to work. However, as medical practice requires long-term cooperation and mutual trust within teams to maximize skills and knowledge, the team understands that this woman cannot be randomly replaced by any other and would thus require her to fulfill her work responsibilities. Second, female nurses may experience role stress, which is usually the main cause of conflict. If a female nurse is considered to be more committed to her professional life than to her personal one (e.g., giving her family members inadequate care due to overtime or long shifts; needing to work during school holidays; etc.), a conflict may arise. In addition, when a woman is unable to strike a balance between her professional and domestic roles, both of which are care-based, she may experience escalating stress that may further aggravate conflict in the home (Alhani & Mahmoodi-Shan, 2018; Gordon & Hood, 2021).
Practical Implications
This study offers recommendations for management practice in three areas. First, based on our findings that individual-perceived team reflexivity can increase stay intent through the enhancement of team-based self-esteem and has a contextual effect, managers should promote interaction and cohesion among team members not only through educational training or regular meetings (formal occasions), but also by emphasizing the importance of private social networks (informal occasions), such as recognizing team members’ birthdays, weddings, and other important events, as well as celebrating major festivals. This can likely increase opportunities for interaction among team members and promote mutual understanding and trust (Chang et al., 2019). Team reflexivity extends beyond positive encouragement among team members and includes the constructive correction of improper conduct or speech among team members. Managers should thus provide team members with a supportive and comfortable space where team members can feel reassured to open up to each other and speak freely about anything that may concern them (Hsu et al., 2020). Working as a team allows members to compensate for individual deficiencies, but sometimes a friendly reminder or unsolicited advice may be perceived as criticism or blame. Thus, it is crucial for managers to properly guide team discussions to ensure everyone feels supported, listened to, and valued (Hsu et al., 2020).
Second, our results indicate that team-based self-esteem can be seen as an intrinsic personal value that helps individuals regulate their behavior to adapt to and fit into a working environment. Team-based self-esteem, unlike general self-esteem, refers to self-evaluation within the context of a team (Sharma & Agarwala, 2014). Managers should recognize the differences between these two concepts, because a frontline employee who has a high level of general self-esteem may not have an equal level of team-based self-esteem. For example, a female nurse who believes in her professional abilities and whose family are supportive of her work may experience long-term abusive behavior within her work team and perceives she is not valued by her peers; it is likely, then, that she will eventually decide to leave the team. Hsu et al. (2020) demonstrated this concept in their study. Career counseling may be helpful for frontline nurses in understanding how they are valued at work and in their team (Hsu & Chang, 2019).
Third, our findings suggest the traditional gender-role attitudes held by female nursing personnel may undermine the relationship between team reflexivity and team-based self-esteem. This has important implications. In Taiwan, while nursing personnel have access to plenty job opportunities and earn decent salaries on average (Hsu et al., 2020; Tsou et al., 2021), these benefits may not fully offset the high levels of work stress they experience (Tsou et al., 2021). Further, due to the traditional expectation that women are the primary caregivers in families, some women may enter the nursing profession as a means of earning additional income to support their families rather than solely for the purpose of personal fulfillment or self-actualization (Pien et al., 2021). Thus, managers should strive to understand their team members’ motivations for entering the nursing profession. This includes recognizing whether individuals are primarily driven by a need to support their family or a desire to help others. Additionally, it is important for managers to acknowledge and take into consideration the individual family circumstances of their team members. When faced with role conflicts, people make different choices depending on their unique circumstances and motivations (Hsu et al., 2020; Pien et al., 2021; Tsou et al., 2021). Those who attach greater importance to the traditional female role and/or to helping others may experience family-work conflict (Pien et al., 2021). Women who prioritize family life and traditional values may leave the nursing profession and seek out alternative types of work that align better with their values (Pien et al., 2021). If an employee intends to leave the workforce, a manager’s failure to understand the team member’s self-perceptions and beliefs may increase the likelihood of the employee leaving, potentially eroding trust and confidence in the manager among the broader team (Hsu et al., 2020).
Limitations and Future Research
Although this study offers theoretical and practical contributions through the multilevel model, there are limitations. First, as found in previous empirical research on psychology, the mental state is a process of dynamic equilibrium, fluctuating and altering as an environment changes (Bussey & Bandura, 1999; Zimmerman & Bandura, 1994). Cross-sectional studies can reveal only one state occurring at one moment, instead of fully demonstrating the long-term state of an individual. Although management practices have suggested the presence of the self-regulation mechanism concept (e.g., Chang et al., 2019; Hsu & Chang, 2019), long-term longitudinal research is required to provide further empirical support.
Second, although the MSEM and contextual models helped us clarify the effects that the external environment and personal perception have on individuals in this study, this created a logical problem. When the external environment changes, the individual should develop a corresponding perception, which in turn influences their internal cognitive system in relation to the external environment. In the case of this study, does team reflexivity increase an individual’s perceived team reflexivity and further affect their intention to stay through the enhancement of their team-based self-esteem, or does team reflexivity directly affect team-based self-esteem without taking account of personal perceptions? Even if a team is fully supportive of its members, could individuals still be affected if they are unable to perceive this support? Our model is unable to provide an explanation for these issues. Future research is necessary to explore and address these questions.
Third, this study investigated the effect of gender-role attitude on how team reflexivity affects an individual’s intention to stay at work through team-based self-esteem based on a sample of female nursing personnel. The findings may not apply to women in other industries, however. The medical profession places a significant emphasis on teamwork, and nursing as a profession centers around the concept of care and is often pursued by individuals with family responsibilities, leading to dual caring roles in their lives. In Taiwan, the predominance of women in the nursing workplace has resulted in a culture of solidarity and harmony among nursing teams, rather than competition for resources. Scholars need to consider these premises carefully when conducting further research based upon the results of this study.
Fourth, no control variables were included in our models. This is the first study to explore the effect of both team reflexivity and individual-perceived team reflexivity on nurses’ stay intent. Thus, there is no basis to suggest the inclusion of control variables. Further, given that nursing is a collaborative profession, including in Taiwan, it is important to consider concepts related to team belonging, such as team identity and team cohesion, in a model. Initially, in the first version of this study, we had planned to compare two mediation paths between team-based self-esteem and team belonging perception, based on Maslow’s hierarchy of human basic needs. However, we ultimately decided against it due to the statistical limitations of a cross-sectional design. Future research should explore the role team belonging plays in the relationship between team reflexivity and stay intent.
Finally, the present study aimed to explore the interaction between team reflexivity and gender-role attitude in the individual psychological process, but only focused on a female sample. As previously stated, the present study is the first to explore the impact of the stipulated research variables on stay intent in the nursing field, and including both male and female nurses in our data may complicate the research purpose and results. If we had included men in our data, we would have had to consider the impact of gender difference, as the traditional gender roles for male and female are significantly different. In fact, the present study found that gender-role attitudes among male nurses (M = 4.22, SD = 1.31) are different from those of female nurses (M = 2.57, SD = 0.67). Further, there are relatively few male nurses in Taiwan, which makes it difficult to obtain a statistically reliable and credible result. However, future research should investigate the effect of gender differences from the perspective of male nurses to provide a more comprehensive understanding of a nursing team.
Conclusion
The study provides evidence that team reflexivity has a contextual effect on stay intent via team-based self-esteem among female nurses in Taiwan, and that gender-role attitudes weaken the relationship between individual-perceived team reflexivity and team-based self-esteem through an MSEM model. These findings support the concept of the self-regulation mechanism (Zimmerman & Bandura, 1994), suggesting that managers should put an emphasis on promoting mutual understanding and trust among team members to increase stay intent. The findings also suggest that traditional gender stereotypes indirectly decreases individuals’ stay intent due to role conflicts and stress. Managers should pay attention to their employees’ perceptions of their roles and positions within their team to prevent problems such as employee turnover from occurring and escalating.
Footnotes
Authors’ Note
Wen-Ying Chang is also affiliated to Nanya Nursing home, Taoyuan, Taiwan.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
