The relationship between organizational commitment and nursing care behavior.

INTRODUCTION: Nursing care encompasses physical, emotional, mental and social needs, in order to improve a patient's health and wellbeing. Caring is the central core and the essence of nursing. The important issue of care is access to proper care and increasing patients' satisfaction. Job performance of nurses is affected by many factors including organizational commitment. This study aimed to determine the relationship between organizational commitment and nurses caring behavior.
METHODS: In this cross-sectional study, 322 nurses from selected Hospitals of Shahid Beheshti University of Medical Sciences in Tehran were randomly selected and enrolled in the study in 2015. The self-reported data by nurses were collected through demographic characteristics questionnaire, Meyer & Allen organizational commitment model and Caring Behavior Inventory (CBI). Data were analyzed with SPSS statistical software version 20, using t-test and ANOVA.
FINDINGS: The majority of nurses (63%) were female. The mean score and standard deviation of organizational commitment and caring behavior of nurses were 74.12±9.61 and 203.1±22.46, respectively. The results showed a significantly positive correlation between organizational commitment and caring behavior (p=0.001).
CONCLUSION: In this study the caring behavior of nurses with higher organizational commitment were significantly better than the others. Managers and nurse leaders should pay more attention to improve organizational commitment of nurses, in order to improve nurses' performance.

1. Introduction

Nursing care with the aim of improving patient’s health not only is concerned with the physical needs of a patient, but also encompasses the entire mental, spiritual and social needs of the patient (1). The theoretical foundations of nursing are based on the understanding of care and caring behavior (2). Since the 1980s, nurses in western countries have moved from theory to practice and emphasized nursing care as the heart of care practice (3). As a consequence of conscious care behavior, the quality of care increases the sense of security in patients, and reduces patients’ anxiety. (4). Cowin & Warelow believe that a deep understanding of the concept of care and putting it into action, has an important effect on the quality of services provided by nurses, and more importantly, on understanding nursing practices (5). Care is the core of these practices, and has an important role in determining patients’ satisfaction with the experience of hospitalization (6). The results of studies on understanding caring behavior, suggest that there is no similar understanding of care in various other societies (5). Although the concept of care, philosophically speaking, is the mission of many organizations and health institutions, nursing care in the health system still remains as a complex concept that has no precise definition (7). Although it is generally appreciated by nurses that care is the core concept of nursing, the attention to this concept is very low and even declining (8). Two main aspects of care are physical-technical and psycho-social aspects. A study by Christopher & Hegedus in 2000, showed the psycho-social aspect as the most important aspect of caring behavior, while studies in Iran show that nurses pay more attention to the physical-technical aspect of care in comparison to psycho-social aspect (5). Nurses’ job performance as one of the most important professions within the hospital, is affected by several factors, particularly organizational commitment (9). Organizational commitment is an important variable in understanding employee behavior that has potentially serious effects on the performance of the organization, and ignoring it has been harmful for the organization (10, 11). Failure to research and study the employees’ commitment to the organization, leads to a huge increase in costs due to staff turnover and recruiting new employees, low performance as well as establishment of precise and complicated control mechanisms (12). The result of a study showed that there was significant relationship between organizational commitment and staff turnover, so that increasing organizational commitment leads to reducing turnover. (13). Organizational commitment results in increased effort, motivation, job satisfaction, lower absenteeism from work and increased retention in the organization (12, 14). Organizational commitment has been considered by Allen and Meyer as a mental connection between an employee and an organization that causes fewer employees to voluntarily leave the organization. Organizational commitment has three components; normative, continuous and emotional commitment (15). “Emotional commitment” represents the desire and attachment of the individual to the organization, identification with the organization and willingness to participate actively in it. “Continuance commitment” shows the individual subjugation to the organization and the costs of leaving the organization, which is presented in two forms of the absence of suitable job opportunities and loss of experience. “Normative commitment” has been described as a sense of loyalty to the values and goals of the organization (16). Studies show that committed employees are more loyal in their behavior (17). Organizational commitment can bring about a sense of satisfaction, belonging, affiliation and attachment of employees to the organization, more favorable job performance, and financial success, and can increase the effectiveness and efficiency of the organization (13). A researcher, during his study and work as a nurse, witnessed differences in nurses’ caring behavior from different aspects such as communication and care given to patients, and employment experience and skills; and these differences raised the question in his mind, whether those who have a higher organizational commitment would have a better caring behavior to patients or not. For this purpose, a literature review was performed and a study which measures the correlation between these two variables was not found in the country. Therefore, the aim of this study was to investigate nurses’ organizational commitment and their caring behavior in selected hospitals in Tehran.

2. Material and Methods

This 2015 cross-sectional study was performed on nurses working in selected teaching hospitals of Shahid Beheshti University of Medical Sciences in Tehran including Shohada Tajrish, Loghman Hakim, Imam Hossein and Ayatollah Taleghani hospital. The sample size for this study was 350 of which 322 questionnaires were returned for a rate of 92%. Inclusion criteria for nurses working in surgical and internal wards were as follows: history of at least one year work experience, at least a bachelor’s degree in nursing, working in the sector as a nurse during the conduction of research (not including supervisors or matron), have full consent to participate in this research. In this study, three instruments including nurses’ demographic information questionnaire (such as age, gender, etc.), Allen & Meyer organizational commitment questionnaire consisting of 24 questions and Caring Behavior Inventory were used, to collect data. In the Organizational Commitment Questionnaire, eight items were used to measure each of the three components of emotional, continuance, and normative commitment. The participants showed their agreement with each of the items, using the Likert scale ranging from 1 = Strongly Disagree to 5 = Strongly Agree. The minimum and maximum score was between 24 and 120 for a total organizational commitment and organizational commitment scores for each aspect were between 8 and 40. Caring Behavior Inventory which was designed 1981 by Wolf, based on Watson Care Theory in 1986 was used for the first time in this study, for measuring nurses caring behavior. The list had 42 items and five subscales including respect to others (12 items), assurance of human presence (12 items), communication and positive attitude (9 items), knowledge and professional skills (5 items) and attention to other’s experiences (4 items). Items were based on the 6-point Likert scale, ranging from 1=never to 6=always. To measure the average of each subscale, the scores of each subscale were summed and the total score was divided by the number of items. To calculate the average (index of caring behavior), scores of all items were summed and then divided by 42. In addition, the minimum and maximum scores of caring behavior index were 42 and 252, respectively. The score of each subscale was between score 1 to 6. This means that the scores achieved in each of the subscales are divided by the number of items for each subscale. In this study, qualitative content validity method was used in order to determine the validity of organizational commitment and caring behavior. In this method, factors such as difficulty levels, clarity, simplicity and relevance were assessed by 15 members of the Faculty of Nursing and Midwifery at Shahid Beheshti University of Medical Sciences. Additionally, face validity of instruments was evaluated by surveying ten nurses who had the inclusion criteria and were not enrolled in the study (were not among the study population). Moreover, internal consistency was used, to determine the reliability of organizational commitment, and caring behavior questionnaires, and Cronbach’s alpha was calculated, so that twenty nurses were excluded from the subject group and were considered as the control group. The questionnaires were then completed by the group and the amount of Cronbach’s alpha was calculated. The amount of Cronbach’s alpha for organizational commitment and Caring Behavior Inventory was 0.81 and 0.97, respectively. Quota and convenient sampling (based on the number of nurses in each hospital) method was used to select the eligible subjects who had the inclusion criteria. The permission of the management of each hospital was obtained for sampling. Then the objective of the research was explained to the nurses and after obtaining their oral and written informed consents, the organizational commitment and caring behavior questionnaires were given to the nurses in each shift to be completed and returned by the end of the shift or the following shift. The research units were free to fill the questionnaires and the information was recorded anonymously and kept confidential. Data were analyzed by IBM© SPSS© Statistics version 20 (IBM© Corp., Armonk, NY, USA) using t-test and ANOVA to achieve the objectives of the study.

3. Results

A total number of 322 people were enrolled in the study. The majority of nurses (63%) were women. The minimum age was 21 and maximum age was 56, with an average of 32.04±7.84. Most nurses (126 cases, 39.1%) were contract employees, 172 nurses (53.4%) worked rotating shift, and 224 nurses (69.6%) had less than 5 years of work experience in their current hospital. Most nurses were working in an internal ward (65 people, 20.2%) and surgical ward for males (58 people, 18%). A total of 227 people (70.5%) were only working in the hospitals where sampling was performed. Minimum and maximum score of organizational commitment was 38 and 103 respectively, with the average score of 74.12±9.61. Post hoc test results showed a significant difference in the mean score of commitment between the three aspects of organizational commitment (p<0.005) and based on that, “continuance commitment” with an average of 25.70 was greatest and “normative commitment” with an average of 23.67, was the lowest subscale of organizational commitment. The minimum score of nurses’ caring behavior was 96 and the highest score was 24 with an average score of 203.1±22.46. Post hoc test results showed that there is no statistically significant relationship between the mean scores of subscales of respect to others and assurance of human presence; assurance of human presence and attention to others experiences; knowledge and professional skills and attention to others’ experiences. The lowest score was related to the subscale of communication and positive attitude (4.72). The data show that there was a significant positive correlation between emotional and normative commitment with caring behavior (p=0.005), but there was no statistically significant correlation between continuous commitment and caring behavior (p=0.368). In total, there was a significant positive correlation between organizational commitment and caring behavior (p=0.001). In addition, regression analysis showed that marital status and organizational commitment remain as predictor variables of caring behavior in the model (p<0.005).

4. Discussion

This study aimed to determine the correlation between organizational commitment and caring behavior of nurses working in Shohada Tajrish, Loghman Hakim, Imam Hossein and Ayatollah Taleghani Hospitals, in the city of Tehran. Based on the obtained results, the mean score of organizational commitment of nurses was 74.12 (ranging from 38 to 103), which shows the commitment of nurses in the hospitals was in a moderate level. Also, “continuance commitment” with an average score of 25.70 and “normative commitment” with an average score of 23.67, accordingly had the greatest and lowest score among subscales of organizational commitment. According to the study by Seyyed Gheibi et al. which was carried out on nurses working in Shiraz University affiliated hospitals, the score of continuance and normative commitment were 4.05 and 3.14 respectively. Considering the mean score of organizational commitment (52.57%), the nurses’ commitment was moderate, which was consistent with our results (11). Delgoshaei et al. showed that the mean score of organizational commitment of employees and managers of teaching hospitals of Hamadan University of Medical Sciences was 78.48, and that emotional (27.18) and normative commitment (25.31) had the maximum and minimum score among subscales of organizational commitment. In this research, the moderate level of commitment was in line with the present study (18). Rahmanzadeh et al. (10) reported an average level of organizational commitment (80.9%) in nurses working in hospitals affiliated to Tehran University of Medical Sciences. In line with our study, normative commitment had the lowest score (38.9%) and continuous commitment had the highest score (42.4%). In addition, Mahmoudi-Rad et al. (19) reported a mean score of 95.01 for organizational commitment of nurses working in Valiasr hospital in Birjand while the lowest score was related to emotional commitment (30.46) and the highest score was related to continuous commitment (32.88). Total score of organizational commitment was in the average rating level that is consistent with present study. Furthermore, the results of other studies by Nabizadeh et al. (20), Radabadi et al. (21), Golden and Veiga (22), and Yaghoubi et al. (23) were in line with our research. However, Lavasani et al. (24) showed that the nurses’ commitment in Tehran was higher than average and in contrast; Hadizadeh- Talasaz et al. (25) reported a low level of organizational commitment among midwives. The discrepancy between the reported results can be due to the difference in environments, study population, time of the study, sample size and instruments. The average score of nurses caring behavior was 203.1 (from a minimum of 42 to a maximum of 252), which also shows that the nurses caring behavior is very favorable. This finding is in line with the results of studies by Joulaei et al. (26) and Hajinejad et al. (27). It should be noted that in this study, the nurses’ perspective was investigated whereas in other studies, patients’ perspective has been examined. Sayed Al-shohadaei et al. indicated a low level of nurses caring behavior (28) which was in contrast with the results of this study. Working in different wards (internal, surgical, cancer etc.) could be a good reason to justify the differences. Professional knowledge and skills and attention to others experiences had the highest score among subscales. These findings are consistent with the results of studies by Sayed Al-shohadaei et al. (28), Haji-Nejad et al. (27), Wolf et al. (29) and Roper et al. (30). Given the importance of the knowledge and skills in providing quality care which has been proven by several studies, it can be said that proper educational planning, appropriate and effective teaching practices and strengthening the knowledge and skills of nurses is very important. According to the results, there was a significant positive correlation between organizational commitment and caring behavior of nurses. This means that with increased commitment, nurses caring behavior has improved. This has been verified by several studies. For instance, Dehghanizadeh concluded that organizational commitment is a strong predictor for nurses’ job performance (9). In addition, Kim et al. noted that nurses’ job satisfaction is one of the most important factors affecting organizational commitment, and he believes that higher commitment leads to a lower turnover of nurses (31). Anis et al. regarded the organizational commitment as an effective factor in preventing nurses’ turnover (32). Additionally, Gutierrez et al., and Al-Aameri believe that organizational commitment has positive and direct association with the level of nurses’ job satisfaction and faculty members of nursing schools (33, 34). Alipour et al. and Al-Hawajreh in their studies, indicated that attention and enhancing organizational commitment is a convenient way to reduce occupational stress among nurses (35, 36). In a study conducted by Seyedghibi et al., it was found that organizational commitment can be a predictor of nurses’ moral sensitivity and can increase it (11). In a study by Ahmad et al., conducted on 110 Bankers in ten banks of Pakistan, it had been shown that increasing organizational commitment can improve the employees’ performance (37). This has also been indicated by Tolentino on university staff in Malaysia (38). Furthermore, Fu et al. showed a direct impact of organizational commitment on employees’ performance in an insurance company in China (39). According to various studies on nurses in different hospital wards, communities and environments and in different countries, the positive effects of organizational commitment and positive relationship between this issue and caring behavior, performance, job satisfaction and reducing employees’ turnover can be inferred.

5. Conclusions

In summary, the findings showed a significant positive correlation between organizational commitment and caring behavior, so that by increasing organizational commitment, nurses caring behavior improves. Practical significance of this finding is that nurses and healthcare providers can pay more attention to the organizational commitment among nurses, in order to provide the necessary conditions and to take further steps for improving caring behavior among nurses. It is recommended that regular conferences and meetings should be held, with the participation of nurses in various hospitals around the country, in order to provide introductory and training programs for nurses to increase organizational commitment. Performing a complementary research on nurses for educating organizational commitment with interventional methodology could open many interesting avenues for future research on this topic.