Figure 1 visualizes the proposed conceptual model of this study. As seen at the foot of Fig. 1, the elements in the conceptual model are grouped into three different categories, Appraisal—Response—Outcome (ARO) that are connected in a specific directional manner as shown by the arrows between them. On the top of the figure, each of the three categories is labeled with names reflecting the content and focus in each category. The category Response (R) is named “individual-level resource” and is represented as the most central concept in this study, that is, work engagement (WE). Furthermore, the category Appraisal (A) is named as “Organizational-level resources” and is represented by the concepts (i) internal market-oriented culture (IMOC) and (ii) collaboration climate (CC). It is notable to recognize that the term “resource” is used to label both organizational- and individual-level types of resources. The term “resource” signals something that is not static but dynamic and consequently varies, either positively or negatively, as time passes. Further, because a “resource” is dynamic, it also implies that a “resource” is potentially changeable or manageable. As seen in Fig. 1, the appraisal of the two organizational-level resources (referring to IMOC and CC) is directly linked to the response in the individual-level resource (referring to nurses’ WE). Three types of Outcomes (O) are linked to WE in this study. The category Outcomes (O) is named “organizational goals” and is represented by the three concepts (i) service quality of care (SQC), (ii) job satisfaction (JS) and (iii) turnover intention (TI). In the following, each concept and linkage in Fig. 1 are elaborated in detail.
Figure 1 Conceptual model to examine precursors and outcomes of WE
Work engagement (WE)
The concept of WE originally comes from positive psychology, which focuses on the positive resources and strengths of humans, rather than their limits . Specifically, in this study WE is defined as “positive fulfilling, work-related state of mind” [19, p. 74]. Moreover, this positive work-related state of mind embraces three interconnected types of feelings, namely, absorption, vigor and dedication. Absorption is about employees’ level of interest and engrossment or immersion of employees in their work so that the sense of time is lost . Vigor reflects the workers’ level of energy and mental resilience while performing their work. Dedication describes how involved employees are in the sense of significance, inspiration and challenge . It is important to note that work engagement is a “… state of mind” [19, p. 74]. Defining the WE as a “state of mind” and not a “trait of a person” means that WE, compared with the relative stability of a trait of a person, is dynamic. This dynamic feature implies that all “ingredients” of the internal resource pool of individual employees’ WE (referring to absorption, vigor and dedication) are potentially changeable and something that can fluctuate, both positively and negatively within a certain timeframe.
As indicated in the previous discussion and visualized in Fig. 1, WE is a response (R) and an individual-level resource. WE is heterogeneously distributed among individual employees in organizations. WE is a variable that can be described as a motivational-like variable with the potential to positively “improve … organizational outcomes” [21, p. 2]. In the next section, three outcomes of WE are proposed.
The outcomes of work engagement (WE)
“It is pivotal to study which job resources can enhance … organizational outcomes” [21, p. 2]. WE is, as visualized in Fig. 1, an individual-level resource that is suggested to be linked to three different types of outcomes, namely, (i) turnover intentions (TI), (ii) job satisfaction (JS) and (iii) service quality of care (SQC). All outcomes of WE represent desirable organizational goals that healthcare organizations want to achieve.
Turnover intentions (TI)
The concept of TI is “particularly useful in nursing studies because of their effectiveness in predicting actual turnover” [23, p. 191]. In this study, TI refers to nurses’ psychological response to conditions in organizations  and consequently their reflection about whether they should stay with the organization by which they are employed. As such, TI reflects an important “cognitive step in the decision-making process” [25, p. 23] about leaving the organization.
Previous research has suggested that WE is negatively related to TI. When employees experience a positive state of mind characterized of vigor, dedication and absorption, referring to those elements embraced by the concept WE, this should lead to a more favorable evaluation and thoughts of their workplace and thus be associated with decisions or intention to not leave the organization in which they are employed. Previous research on nurses supports the existence of a negative relationship between WE and turnover intention. For example, in their study, Moloney et al. , including 2876 nurses working in New Zealand as respondents, the findings reveal that nurses’ WE is directly negatively linked to the intention to leave the organization. Rodwell et al.  also found in their study of 459 nurses across Australia a directly negative linkage between nurses’ WE and nurses’ intention to leave the organization. Similar to the two aforementioned research studies, Wan et al.  found, when performing a study among 778 nurses employed in a hospital in China, a significant negative relationship between nurses’ WE and TI. In line with the aforementioned research findings, it is expected to find a similar negative relationship between nurses’ WE and TI among those nurses included in this study (referring to nurses from Norway). Therefore, the following hypothesis is proposed:
Work engagement (WE) is negatively related to turnover intentions (TI)
Job satisfaction (JS)
According to Tomietto et al. , job satisfaction (JS) requires “strategies … to enhance job satisfaction … one of the most challenging topics in nursing research” [21, p. 2]. In this study, WE is suggested to be one such strategy to achieve JS. Therefore, as seen in Fig. 1, JS is proposed to be one outcome of nurses’ WE. In this study JS is about the “extent to which employees [nurses] like their jobs” [28, p. 13]. JS is a cognitive concept regarding nurses’ job satisfaction. Specifically, JS refers to nurses’ global assessment of their job .
Although JS has generally been included in several previous studies on nurses, it seems that relatively few of these have examined the specific link between WE and JS. For example, in their extensive review of antecedents and effects of work engagement by Keyko et al. , the authors only reported four previous studies examining this linkage among professional nurses. Of these four studies, two studies identified a significant relationship between WE and JS. One study found a nonsignificant relationship between WE and JS. One study was qualitative. Consequently, there is a need for more research on this topic that specifically focuses on the domain of nursing. In general, it seems that previous research most often has identified a positive relationship between WE and JS . It is reasonable to assume a similar pattern and relationship between these concepts among nurses. Both WE and JS are work-related concepts. As noted in the previous discussion, WE is defined as a motivational concept characterized by feelings of vigor, dedication and absorption in employees’ work role. Consequently, when positively experienced, these three “ingredients” of WE should lead employees to have more favorable thoughts and feelings about their job. It is difficult to imagine a situation where an employee (e.g., a nurse) has a high level of WE and at the same time dislikes/hates his/her job and thus has low JS. Clearly, there is probably variation in the level of both WE and JS among nurses. However, in line with previous research  on this topic, this study assumes that professional nurses’ WE is positively related to their JS. This reasoning leads to the second hypothesis in this study:
a: Work engagement (WE) is positively related to job satisfaction (JS).
Previous research has found that the JS of nurses is directly linked to TI among nurses . However, in this study, it is also suggested that JS functions as a mediator between WE and TI. Consequently, this represents a complementary “route” to TI compared with what was proposed in hypothesis one. In addition, to have a direct impact on TI, it is also assumed that there is some inner mechanism in humans that explains why there exists a relationship between WE and TI. In this study, this inner mechanism in humans refers to JS. JS does not arise by itself or occur in isolation. JS is always triggered or created by someone or something. In this study, “something” refers to nurses’ WE. As discussed in the second hypothesis, previous research on WE suggested its impact on JS [14, 29]. Based on this, when nurses experience a positive WE, their JS will be positively affected. Further, when JS increases because of an increase in WE, it is reasonable to assume that this next also will lower the level of TI among nurses. To the authors’ knowledge, no previous research has examined JS as a mediator between WE and TI. However, it is interesting to note that in the study by Tomietto et al. , the authors actually conceptualize nurses’ JS as one potential mediator between nurses’ WE and nurses’ TI. Nevertheless, the authors did not make any empirical test of whether JS was operating as a mediator. Consequently, this study is the very first study to test whether JS is operating as a mediator between WE and TI. The aforementioned reasoning can be expressed by this formal hypothesis:
b: The relationship between work engagement (WE) and turnover intention (TI) is mediated by job satisfaction (JS).
Service quality of care (SQC)
The best level of SQC to patients is a highly desirable organizational goal for hospital organizations to achieve. Frontline nurses make a considerable contribution to the total “service package” regarding SQC that patients receive or experience during their stay at a hospital. According to Chen et al., this group of frontline workers “tend to have the longest and closest contact with patients” [30, p. 1]. In this study, the concept of SQC refers to nurses’ perceptions of the overall quality of services provided. SQC is studied from an employee perspective and not from a patients’ or “customer” perspective. Although this is a subjective in contrast to an objective way to capture the content of SQC, it follows from how previous research sometimes has studied service quality both within and outside healthcare and other contexts [2, 31]. Moreover, previous research also suggests that there exists a “psychosocial closeness” between providers’ and receivers’ perception of service quality . Consequently, parallel to how SQC is studied and defined in previous research, it is assumed in this study that frontline workers are capable of considering whether their level of quality of services is of high or low standard or lies within a zone that “customers generally perceive as acceptable” [33, p. 208].
There are many examples in the literature that employees’ WE is positively associated with a variety of types of job performances such as innovative behavior , work effectiveness , productivity , patient satisfaction , innovative capability , creative strategy generation  and market orientation  among several other types of performance concepts. In the extensive systematic review of studies on WE by Keyko et al. , the authors identified seven different types of performance and care outcomes associated with WE. Among this group, two outcomes of WE, referred to in the paper as perceived care quality  and quality care , are relatively similar to the concept of SQC in this study. In both cases, WE was positively associated with service quality. Similar to previous research, it is expected to find the internal resource pool embraced in WE (referring to vigor, dedication and absorption) of an individual as something that positively contributes to frontline employees to work more intensively and goal-oriented to provide excellent service quality to hospital patients. In contrast, a negative WE would have a negative impact on SQC. However, in this study, a positive perspective of the association between WE and SQC is considered. Consequently, it is expected that the more WE increases the more positively it drives SQC. The assumption about the association is formulated by this hypothesis:
Work engagement (WE) is positively related to service quality of care (SQC).
Precursors to work engagement (WE)
In Fig. 1, precursors to WE are suggested to be (1) collaboration climate (CC) and (2) internal market-oriented culture (IMOC). Consequently, the discussion in focus is whether the appraisal of CC and IMOC, representing two organizational-level resources, promotes or causes a response in the individual-level resources of employees referred to as WE in Fig. 1. This is discussed in the following.
Collaboration climate (CC)
An organizational climate is about employees’ shared perceptions of their organization. This shared perception of climate varies from strongly negative to strongly positive. The literature emphasizes the significance and value for organizations to focus on organizational climate. For example, in the research undertaken by Kieft et al., the authors found that “it is important to develop and maintain collaborative working relationships with professionals, including those in their own field” [39, p. 5]. Consequently, there are good reasons to include collaborative climate (CC) and how frontline employees perceive and appraise this organizational-level resource. However, in an organization, there are a variety of alternative aspects to focus on when studying a collaborative climate. Therefore, it is necessary to identify aspects that are both relevant and specific for the phenomenon in focus. Consequently, “climate is best regarded as a specific construct having a referent” [40, p. 1278]. The literature suggests several ways to study organizational climate. For example, D’Amour et al. suggest four ways to analyze cooperation in healthcare organizations . In this study, CC is about two work-related concerns regarding interdepartmental collaboration in the health organization. Specifically, CC refers to frontline employees’ perception of interdepartmental (i) conflict and (ii) connectedness, which both are suggested in previous research [42, 43]. The first climatic aspect of “conflict” of CC is about whether there exist tensions, caused by inconsistency regarding actual and desired responses between departments in the organization. The second climatic aspect, “connectedness,” focuses on whether there are formal and informal contacts across departments in the organization. This latter aspect intends to reveal frontline employees’ perceptions of whether departments are operating dependently or independently from each other. The two aspects of CC represent and reflect frontline employees’ perceptions of the supportive work environment or what alternatively can also be labeled as the internal service climate in an organization .
According to the job demands-resources (JD-R) model, WE is fostered by job resources . In this study, CC represents this organizational level of resource in the JD-R model that promotes or fosters WE among frontline employees. According to Wan et al., “a supportive work environment … offers various resources to foster employees’ willingness to dedicate their efforts and abilities to job tasks” [8, p. 1334]. Although it seems that no study has examined the link between the (work environmental factor) CC and WE specifically, previous research has found that the work environment, in general, is positively associated with WE. For example, the work environment has been found to be associated with WE among nurses . Furthermore, research has found that perceptions of organizational climate are linked to employees’ attitudes . Consequently, based on the JD-R model and findings in previous research there are good reasons to expect CC to be positively associated with WE. Therefore, the following hypothesis is proposed:
Collaboration climate (CC) is positively related to work engagement (WE).
Internal market-oriented culture (IMOC)
In Fig. 1, internal market-oriented culture (IMOC) is considered as an organizational-level resource. Organizational culture is, according to Banaszak-Holl, said to “pervade all aspects of organizational life” [47, p. 462]. Organizational culture is a “stable element deeply rooted in employees’ mentality” [48, p. 585]. Moreover, organizational culture embraces norms that “provide the rules for behavior” [49, p. 2]. Of the different components an organizational culture consists of, norms and behavior are the two most observable components . In this study, organizational culture refers to frontline employees’ perception of norm-based behavior regarding the IMOC in the organization. As such, as also noted in Slåtten et al., IMOC “focus on more tangible or visible aspects of organizational culture that frontline employees of hospitals experience or observe daily” [17, p. 160]. The basic idea with the concept of IMOC is to treat employees in organizations as customers. Parallel to external customers, it is important to treat these internal customers (referring to employees) in the best possible way. Consequently, IMOC focuses on employees’ perception of whether managers’ norm-based behavior in the organization is oriented toward satisfying the needs and wants relevant to employees’ working conditions . Three systems constitute the norm-based behavior concept of IMOC: (i) internal-market intelligence generation, (ii) internal-intelligence dissemination and (iii) response to internal intelligence . The three systems are closely connected and represent a logical flow of information from system one to system three. The first system is about management-related activities to collect information regarding the needs and wants of employees. The second system is about management interpretation and understanding of employees’ needs and wants. Finally, the third system is about the willingness and capability of the management in an organization to take steps to perform real actions and actively do what is necessary to satisfy the needs and wants of their employees. All systems of IMOC are interconnected. However, system three (referring to “response to internal intelligence”) is probably the most visible part employees experience or observe in their day-to-day work and thus most prominently brings IMOC to “life” in the organization.
Organizational culture “strongly influences employee behaviors” [50, p. 1] and thus is an employee-impacting instrument to create the desirable and necessary behavior in an organization. Previous research within healthcare organizations has found organization culture associated with such areas as job satisfaction, leadership behavior, turnover intention, organizational attractiveness (, , ). Regarding this and specifically referring to IMOC, Slåtten et al. state, “IMOC is a type of organizational culture affecting frontline employees” [17, p. 161]. The core of IMOC is about management ability to satisfy needs and wants with a specific focus on employees’ work role. With this in mind, it is reasonable to assume that when IMOC is perceived by employees as something good, it should positively influence employees’ vigor, absorption and dedication, which all are embraced in the concept of employees’ WE. The association between IMOC and WE is also supported in the JD-R model. The JD-R model  highlights that different resources in the work environment can promote or act as motivational factors for employees’ dedication and efforts (or what this study refers to as WE) to perform work tasks . In this study, IMOC is termed an organizational-level resource. Therefore, based on the JD-R model and previous research, IMOC should have an impact on employees’ WE. This reasoning leads to the following hypothesis:
a: Internal market-oriented culture (IMOC) is positively related to work engagement (WE).
Although IMOC is expected to be directly associated with WE, it is also assumed that this relationship is mediated through the concept organizational climate, in this study represented as CC. Accordingly, it is proposed that two “routes” exist from IMOC to WE. In the literature, the concept of climate and culture are often suggested to be closely related. Regarding conceptual closeness Carlucci noted, “… culture and climate are similar concepts” [48, p. 585]. Although they at first hand seem to be rather similar, they diverge. Culture is about relatively stable and deeply rooted norm-based behavior while climate is more “superficial elements such as employees’ reactions, opinions and tendencies” [48, p. 585]. Therefore, the climate is a surface manifestation of culture . Based on this it is expected that when employees perceive IMOC in a positive manner this would have a positive impact on the organizational climate of CC. Moreover, when CC increases, because of IMOC, this next should have a positive impact on employees’ WE. To the authors’ knowledge, no previous research has examined this specific linkage. However, two arguments support this idea. First, IMOC as defined in this study focuses on managers’ norm-based behavior and their orientation toward satisfying the needs and wants in employees’ work role. Consequently, the norm-based behavior of management, manifested in IMOC, models the “correct standard” of organizational climate for all employees such as how CC should be in the organization. As such, and based on social learning theory , employees learn appropriate behavior from their managers as significant role models. When IMOC and CC are perceived as positive, this should significantly increase employees’ WE. The second argument supporting a linkage between the three variables can be found in the JD-R model. IMOC and CC are both based on the JD-R model, suggested to be resources. In Fig. 1, they are both labeled as organizational-level resources. However, as indicated in the aforementioned discussion, IMOC is critical for CC in the organization. Thus, the resources of IMOC serve as necessary input or “ingredients” to positively build and increase the CC resources. Consequently, when the (resources in) CC increase because of a positive impact of (the resources in) IMOC, this should next lead to a positive increase in employees’ absorption, vigor and dedication which all are embraced in the concept of WE. Thus, IMOC and CC are expected to work in tandem to strengthen employees’ WE. The assumption about WE as a mediator between IMOC and CC can be formulated by this formal hypothesis:
b: The relationship between internal market-oriented culture (IMOC) and work engagement (WE) is mediated by collaboration climate (CC).
WE as a mediator between IMOC, CC and SQC, TI and JS
As visualized in Fig. 1, WE is suggested to play a role as a mediator between the two organizational-level resources (IMOC and CC) and the three organizational goals (SQC, TI and JS). WE, labeled as an individual-level resource, is expected to play a central key role. Consequently, WE is assumed to function as the mediating mechanism that binds or ties the suggested variables together to a whole.
As noted in the previous discussion, IMOC and CC are closely related concepts. Because of their close relationship and association, it is reasonable to assume that the two concepts should work in the same direction depending on how employees appraise or perceive them. As Trus et al. noted, “culture and climate represent a social context … that constrains and promotes certain behaviors and interactions” [53, p. 55]. This study takes a positive perspective when studying the social context of IMOC and CC. Consequently, rooted in the assumption of the close relationship between IMOC and CC, it is expected to find both as positive promoters to employees’ WE. Moreover, when WE increases, because of employees’ positive perception or appraisals of IMOC and CC, this should next also lead to several positive job-related outcomes and thus an achievement of organizational goals such as increased SQC, JS and reduced TI of employees in the organization.
The assumption of the mediating role of WE is summarized in these two final hypotheses:
Work engagement (WE) functions as a mediator between internal market-oriented culture (IMOC) and a) service quality of care (SQC), b) turnover intention (TI) and job satisfaction (JS).
Work engagement (WE) functions as a mediator between collaboration climate (CC) and a) service quality of care (SQC), b) turnover intention (TI) and job satisfaction (JS).