Organizational commitment and turnover intention among rural nurses in the Philippines: Implications for nursing management.

OBJECTIVES: The unrelenting migration trend of Filipino nurses to other countries has threatened the quality of patient care services in the country. This study explored the extent of nurses' organizational commitment and turnover intention in the Philippines. Furthermore, predictors of nurses' organizational commitment and turnover intention were identified.
METHODS: A cross-sectional research design was adopted for this study. Two hundred nurses from nine rural hospitals in the Central Philippines were asked to participate in the study and 166 nurses responded (an 83% response rate). Two standardized instruments were used: the Organizational Commitment Questionnaire and the Six-item Turnover Intention Inventory Scale.
RESULTS: Findings revealed that Philippine nurses were moderately committed (3.13 ± 0.24) to and were undecided (2.42 ± 0.67) whether or not to leave their organization. Nurses' age (P = 0.006), gender, (t = -2.25, P = 0.026), education (t = 2.38, P < 0.001), rank(t = 4.38, P < 0.001), and work experience (t = 2.18, P = 0.031) correlated significantly with organizational commitment, while nurses' age (P = 0.028) and education (t = 1.99, P = 0.048) correlated significantly with turnover intention. An inverse relationship was identified between the organizational commitment and turnover intention (r = -0.22, P = 0.005).
CONCLUSION: The findings of this study highlight the need for formulation and implementation of interventions to promote life-long commitment in nurses and to reduce turnover rates.

Introduction

Nurses are considered the heart of health care organizations and keeping nurses in the organization remains a challenge for nurse administrators. Therefore, organizational measures must be instituted in order to ensure highly committed and dedicated nursing workforce and promote nurse retention. This is necessary to ensure the continuity of quality patient care and services [1], organizational efficiency, performance, and productivity [2,3].

Organizational commitment is broadly defined as an individual employees' strong emotional linkage to the organization and consists of three dimensions: (1) affective commitment, (employees' emotional connection to the organization); (2) continuance, (perceived costs related to exit from the organization); and (3) normative commitment, (moral duty to stay in the organization) [4]. A myriad of individual factors predicting organizational commitment in nurses have been identified such as age [5], gender [6], academic degree [5], years of work experience [7], and job tenure [7]. In an integrative review conducted by Vagharseyyedin [8], factors contributing to nurses' organizational commitment were integrated and grouped into four (4) main categories: (1) nurses’ traits and characteristics, (2) administrative behaviors and styles, (3) discernment of the organizational setting, and (4) characteristics of the job itself and the workplace setting.

A clear link between organizational commitment and job outcomes is well documented in the literature. Higher levels of organizational commitment were contributed to work effectiveness and job engagement in nurses, increased job performance, reduction in burnout [6,9,10], reduction in absenteeism and nurse turnover, and a decrease in work fatigue [11].

Turnover intention refers to the employees' voluntary retraction from the organization and profession [12]. There can be many consequential impacts on the organization as turnover may lead to low productivity in nurses [2], poor nursing care [1], and added costs to the organization [13]. Numerous variables, both individual and organizational, have been found to influence nurses' turnover intention. Individual – related variables included: age [3,14], gender [15], and work tenure [[16], [17], [18]]. Organizational variables included: the number of hospital beds [3], insufficient job orientation [3], job stress, the practice environment, inadequate management support [19], a poor workplace environment [20], poor staffing levels [21], the actual place of work [3], and insufficient career opportunities [3]. In a prospective study by Rudman, Gustavsson, & Hultell [22], nurses’ decisions to leave their profession were linked with their burnout experience. Other factors included: ineffective relationships with other nurses or staff members including nurse managers, the practice of intimidation and harassment in the workplace, ineffective working relationships with physicians, and a limited leadership support [3,23].

Earlier studies have supported the relationship between organizational commitment and the nurses’ desire to leave the organization as well as the profession. For instance, Omar, Mohamed, Majid, Halim, & Johari [24] found the affective dimension of work commitment to be strongly linked to the intention to leave among Malaysian nurses while Al-Hussami, Darawad, Saleh, & Hayajneh [25] identified a strong link between work quality, health perceptions, and normative organizational commitment. Similarly, in one study involving nurses in Korea, higher levels of organizational commitment and job burnout were identified as strong predictors of turnover intentions [26]. In China, nurses who were satisfied and reported a higher degree of job commitment tended to stay in their current position [27].

The Philippines is the world's largest nurse exporter with nearly 90% of Filipino nurses working overseas [28,29]. The Philippine Overseas Employment Administration [30], an agency that monitors deployment of Filipino workers abroad, reported a high number of professional nurses emigrating from 2004 to 2010. Filipino nurses' decision to migrate relates to a myriad of factors such as low incomes, lack of benefits, lack of opportunities and professional growth, high patient-nurse ratios, and poor enforcement of nursing laws [28,31]. This will have negative consequences on the ability to provide effective health care services for this country. The loss of those nurses who have significant amounts of experience and expertise who can mentor new nurses will impact the provision of effective patient care by increasing the workloads in the healthcare facilities leading to a negative impact on the nursing workforce [32].

The Philippine nursing community has identified that many qualified nurses leave the country or their current jobs. This adds considerably to the current nursing shortage and difficulties in managing safe and effective patient care. The situation is even more significant in rural areas where many nurses struggle related to appropriate salaries, heavy workloads, lack of opportunities for professional growth, and a poor work environment [28,32,33]. This is further aggravated by a serious shortage of healthcare workers, nurses in particular, as many nurses prefer to work in urban areas where most healthcare facilities are located and the pay is considerably competitive [33]. All these could adversely affect work performance, work satisfaction, work commitment, and ultimately increases the intention to leave their jobs.

In addition, few research studies have been focused on the reasons for nurse migration and the extensive turnover in the Filipino nurses [31]. Those in nursing management need to study these issues and focus on interventions that can be put into place to assist with nurse retention and decrease of turnover in the various organizations. Therefore, this study is an update of the work completed by Lorenzo et al. [31] and is aimed to explore the following questions: (1) what is the extent of a rural nurses' organizational commitment and turnover intention? (2) Is there a significant association between nurses' characteristics organizational commitment and turnover intention? and (4) is there a significant association between nurses' organizational commitment and nurses’ turnover intentions?

Methods

Research design

This study utilized a cross-sectional approach using two standardized instruments: the Organizational Commitment Questionnaire (OCQ) and the Turnover Intention Inventory Scale (TIIS).

Samples and settings

Stratified random sampling was utilized in this study. Using the Sloven's formula [(n = N/(1 + Ne2)] the minimum estimated sample size was 160 (n = 283, e = 5%). During the four months of data collection, 200 nurses from nine hospitals in the rural areas in the Central Philippines were recruited to participate and 166 nurses responded, with a response rate of 83%. The following criteria were used in recruiting respondents: (1) a licensed staff nurse, (2) working in the hospital setting for more than 3 months, (3) and obtained consent to participate in the study. Respondents were approached during their break time and were asked to participate in the study.

Instruments

The questionnaires that used in this study were all authorized.

The OCQ [4] was used to examine nurses' commitment to the health care organization. The questionnaire is a 23-item scale which is categorized into three distinct dimensions (affective, continuance, and normative) and was developed primarily to analyze the employees' magnitude of perceived connection and attachment to the organization. In accomplishing the questionnaire, respondents rated each OCQ items using a 5-point likert scale which ranged from 1 (strongly disagree) to 5 (strongly agree). The composite score was categorized into three points: low organizational commitment (1.00–2.33), moderate organizational commitment (2.34–3.66) and high OC (3.67–5.00). The OCQ showed a high internal consistency, with a statistical value of 0.82–0.91 (Cronbach's α) as previously reported [34]. In the current study, the Cronbach's α coefficient for the entire instrument was 0.91. Cronbach's α for the three (3) OCQ dimensions ranged from 0.89 to 0.92.

The TIIS [35] was used to examine turnover intention among nurses. The scale is 6-item scales which elicit nurses' intent to quit or vacate their current job because their efforts are not valued. Sample items are: ‘I will probably not stay with this organization for much longer’, and ‘I sometimes put in less effort in my work than I know I can’. The respondents accomplished the questionnaire by reporting the extent of their agreement on each TIIS items using a 5-point Likert scale which ranged from 1 (strongly disagree) to 5 (strongly agree). The Cronbach's α of the TIIS was 0.92 as reported by the original authors [34]. In the current study, the Cronbach's α was 0.88.

Data collection process

The Health and Ethics Committee of Samar State University approved the study protocol. Permissions to conduct the study were granted by each of the hospital's Chief Nurse. Prior to the questionnaire distribution, the researchers explained the nature, risk, and benefits of the study. Additionally, consents were obtained from individual respondents prior to data collection. To ensure anonymity of the respondents, code numbers were assigned on each questionnaire instead of real names. The researchers personally administered the questionnaires to the respondents during their free time. Data gathering took place during the months of September 2015 to December 2015.

Data analysis

Statistical Package for the Social Sciences (SPSS) version 22 (SPSS Inc., Chicago, IL, USA) were used to analyze the data collected. Descriptive statistical tools such as the percentage, weighted means, and standard deviations were used to describe the responses of the respondents. Inferential statistics such as stepwise multiple linear regressions and Pearson r coefficient correlations were used to identify correlations between selected variables. To compare selected variables, one way analysis of variance (ANOVA) and independent t-test were used.

Results

Out of one 166 nurses who participated in this study, the majority of the respondents were female (n = 131, 78.9%), within the age bracket of 20–29 years old (n = 112, 67.4%), and with a baccalaureate degree (n = 159, 95.8%). Table 1 shows the completed profile of the respondents. Based on the total scores, the mean scores for the OCQ was 3.13 ± 0.24. Ranking the OCQ subscales revealed “affective commitment” as the highest rated subscale (3.33 ± 0.44), while “continuance commitment” (2.82 ± 0.48) was the lowest rated subscale. The total mean score for the TIIS were 2.42out of a possible mean score of 5 and fell under the category ‘neutral or undecided’ (Table 2).

Table 1

Nurses' characteristics (n = 166).

Characteristics	n(%)
Gender
Male	35 (21.1)
Female	131 (78.9)
Age(years)
20–29	112 (67.4)
30–39	27 (16.3)
≥40	27 (16.3)
Education
Baccalaureate	159 (95.8)
Master's degree	7 (4.2)
Monthly Income (US Dollar)
< 100	122 (73.5)
≥ 100	44 (26.5)
Work Experience(years)
1–5	112 (67.5)
> 5	54 (32.6)
Rank
Staff Nurse Position	141 (84.9)
Managerial Position	25 (15.1)
Hospital Category
Public	122 (73.5)
Private	44 (26.5)
Hospital Level
Primary	15 (9.0)
Secondary	125 (75.3)
Tertiary	26 (15.7)
Hospital bed capacity
25	36 (21.7)
50	37 (22.3)
75	32 (19.3)
100 and above	61 (36.7)
Plan to leave the current organization
Yes	93 (56.0)
No	73 (44.0)

Table 2

Responses on the turnover intention inventory scale (TIIS).

TIIS Items	Mean ± SD
I will probably not stay with this organization for much longer	2.92 ± 1.01
Lately, I have taken an interest in job offers in the newspaper	2.80 ± 1.17
I often think about quitting	2.58 ± 1.03
I sometimes put in less effort in my work than I know I can	2.30 ± 0.90
Sometimes I postpone important duties for an unlimited period of time	2.20 ± 0.87
I do not work hard in my job	1.72 ± 0.76
TIIS Mean Score	2.42 ± 0.67

Table 3 displays the association between nurse characteristics, organizational commitment, and turnover intention. Independent t-test analysis showed significantly higher organizational commitment mean scores in female nurses (t = -2.25, P = 0.026), nurses' with master's degree (t = -2.38, P = 0.019), nurses with more than 5 years of work experience (t = 2.18, P=0.031) and those with managerial positions (t = 4.38, P < 0.001). Results of the ANOVA indicated a significant difference in organizational commitment scores according to the nurses' age. Nurses with ages greater than 40 years had significantly higher organizational commitment mean scores when compared to nurses with ages that range from 20 to 29 years (P = 0.006). With regards to turnover intention, independent t-test revealed higher TIIS scores in nurses with a baccalaureate degree (t = 1.99, P = 0.048) and with ages that ranged from 20 to 29 years (P = 0.007) and 30–39 years (P = 0.028).

Table 3

Association between nurse characteristics, organizational commitment, and turnover intention.

Characteristics		Organizational Commitment			Turnover Intention
		Mean ± SD	Statistical test	P	Mean ± SD	Statistical test	P
Gender	Male	3.05 ± 0.29	t = 2.25	0.026	2.32 ± 0.72	t = 0.93	0.353
	Female	3.15 ± 0.22			2.44 ± 0.66
Age (years)	20–29	3.09 ± 0.23	F = 5.22a	0.006	2.48 ± 0.61	F = 5.14b	0.007
	30–39	3.18 ± 0.23			2.52 ± 0.82
	≥40	3.24 ± 0.27			2.05 ± 0.65
Educational level	BS	3.12 ± 0.24	t = 2.38	0.019	2.44 ± 0.65	t = 1.99	0.048
	MA/MS	3.33 ± 0.19			1.93 ± 0.96
Monthly Income (US Dollar)	<100	3.12 ± 0.23	t = 0.83	0.406	2.45 ± 0.66	t = 0.93	0.354
	≥100	3.15 ± 0.26			2.34 ± 0.70
Rank	Staff nurse position	3.09 ± 0.22	t = 4.38	<0.001	2.42 ± 0.66	t = 0.14	0.887
	Managerial position	3.31 ± 0.25			2.40 ± 0.72
Work experience (years)	1–5	3.10 ± 0.24	t = 2.18	0.031	2.49 ± 0.66	t = 1.86	0.064
	>5	3.18 ± 0.23			2.29 ± 0.68
Hospital category	Public	3.11 ± 0.25	t = 1.13	0.261	2.41 ± 0.70	t = 0.25	0.803
	Private	3.16 ± 0.20			2.44 ± 0.59
Hospital level	Primary	3.19 ± 0.18	F = 0.69	0.504	2.34 ± 0.54	F = 0.41	0.667
	Secondary	3.11 ± 0.25			2.41 ± 0.71
	Tertiary	3.14 ± 0.21			2.52 ± 0.56
Hospital bed capacity	25	3.12 ± 0.20	F = 0.57	0.633	2.42 ± 0.71	F = 0.41	0.746
	50	3.08 ± 0.27			2.40 ± 0.72
	75	3.15 ± 0.20			2.53 ± 0.59
	100 and above	3.14 ± 0.26			2.37 ± 0.66

Note: aPost Hoc Tests (Bonferroni): ≥40 years old vs 20–29 years old (P = 0.009).

bPost Hoc Tests (Bonferroni): 20–29 years old vs ≥ 40 years old (P = 0.007) & 30–39 years old vs ≥ 40 years old (P = 0.028).

Pearson product moment correlation was utilized to determine whether a significant relationship exists between the two variables (organizational commitment and turnover intention). The analysis revealed an inverse correlation between the two variables (r = −0.22, P = 0.005).

Discussion

Organizational commitment and its associated factors

Organizational commitment is an important management element that determines nurses' work performance, productivity, and impact of organizational effectiveness [6,9,10]. In this current study, nurses perceived “moderate commitment”, with higher scores observed in the “affective commitment subscale.” This suggested that the study's nurses have strong emotional attachment to their organization and to the work that they do. The OCQ mean score in the current study is significantly low compared to other studies conducted in India [36] and Canada [37], but higher when compared to other Asian countries such as China [38] and Malaysia [39]. This may be due to cultural variations across different countries in terms of organizational commitment perceptions and the diversity of assessment scales used in different studies.

Several nurse demographics have been mentioned to influence organizational commitment such as age, gender, academic degree, years of work experience, and job tenure [[5], [6], [7]]. In the present study, nurses' rank, gender (being female), education (having master's degree), age (greater than 40 years), and work experience (greater than 5 years of work experience) were associated with increased organizational commitment.

In the current study, nurses who held higher positions (nurse manager position) had significantly higher organizational commitment scores than those who were staff nurses. In the Philippines, nurses who occupied higher positions receive comparably higher wages and adequate compensation, greater career opportunities, and have greater involvement in decision making as compared to those nurses who hold staff nurse positions [31,33]. These factors are known to increase work commitment in nurses [36]. Such commitment and job satisfaction were also explained by Sikorska-Simmons [40] and Laschinger, Finegan, & Shamian [41] as a product of higher involvement in decision making when a nurse assumed a higher level position in an organization. Higher organizational commitment in nurses with master's degree may be explained by the fact that nurses who have more education usually occupied positions of higher status and were more involved in decision-making in the organization.

In agreement with the assumptions by Allen & Meyer [4] where commitment in an individual progress over time as a product of self-reinforcement, the current study showed that experienced nurses tended to report higher organizational commitment compared with those young nurses and nurses with fewer years of work experience. This result coincides with the previous studies highlighting a clear and positive connection between work experience and work commitment [38]. Certainly, these findings call for a greater need of management interventions to retain these groups of nurses.

According to Meadus & Twomey [42], the nursing profession requires life-long commitment and dedication, characteristics that are dominant among females; thus they may have more commitment to their careers. In the current study, there is a positive and significant link between organizational commitment and female nurses reporting higher levels of work commitment. This finding supported the previous work of Mrayyan and Al Faouri [43] where female nurses’ were reported to be more committed to work than their male counterparts. However, when interpreting the results, caution should be exercised as the number of specific gender participants may inappropriately represent the findings.

Turnover intention and its associated factors

Nurses in the current study were ‘undecided’ whether or not to leave their organization with more than 50% of nurses (n = 93) reporting an intention to leave. This finding corroborates with previous studies demonstrating a moderate level of turnover intention of nurses [19,44,45]. Studies conducted in Asia also yielded similar results. For instance, Lee et al. [7] found turnover intention at a moderate level which is comparable to this study.

Previous studies conducted using the cross-sectional and longitudinal designs identified nurses' age and an academic degree as important factors in explaining turnover intention among nurses [16,18]. In the current study, nurses who were less than 40 years old and those with a baccalaureate degree had a higher turnover intention when compared with younger nurses and those with master's degree. An explanation to this may be that younger nurses having much shorter stay in the workplace may have not invested emotionally to the organization as compared to older and experienced nurses. Additionally, new and younger nurses are faced with many issues such as low pay and salaries, significant workloads, lack of appropriate staffing levels, and the inability to strive for advancement in the profession where they consider leaving. These factors, when not satisfied, may decrease work motivation, satisfaction, work commitment, and eventually drive them to leave their organization [39]. Furthermore, nurses who had a baccalaureate degree had a higher turnover intention than those nurses with a master's degree. Again, low salaries and a lack of professional development opportunities along with massive workloads could explain these findings. In addition, the local situations in most rural hospitals in which baccalaureate nurses are exposed to dismal working conditions and limited career opportunities contributes to turnover decision-making employment [31,46,47].

The results suggest that there needs to be a more focused approach by hospital administrators and their attention to those working in the nursing profession so as to assist with decreasing turnover of the nurses and continuality of the delivery of safe and effective nursing care. This may include development of an effective staffing plan, formulation and implementation of professional education programs, providing of adequate organizational support, and the provision of a positive working environment. Other measures may include review and revision of salary and pay policies, and formulation of career planning activities. Hsu, Chiang, Chang, Huang, & Chen [48] found a fair reward system is an effective incentive to increase satisfaction and commitment especially in experienced nurses. Therefore, enhancing the reward system in nurses may be helpful to reduce turnover intention. Previous studies suggested that nursing administrators could possibly assist in the area of nurse turnover by reviewing of policies and procedures related to improvement of the work environment and staff moral/satisfaction, adjusting of pay scales, and facilitating of appropriate staff promotions [49,50].

Consistent with previous research, this study’ authors found an inverse relationship between organizational commitment and turnover intention in nurses. This seemed to suggest that highly committed nurses tend to be satisfied and contented with their jobs and would want to stay longer in their positions. The finding is consistent with previous studies [51,52]. For instance, Yasmin & Marzuki [51] and Sato et al. [52] found the affective and normative domains of work commitment as highly influential to nurses intention to leave their organization. Organizational commitment in nurses maybe enhanced by improving nurses’ work environment through adequate staffing levels, enhancing hospital resources, providing of good patient-nurse ratios, offering of career opportunities, and having open forums for staff-administration communication.

Limitations of the study

Although this study is one of the earliest studies exploring organizational commitment and TIIS among Filipino nurses, it has a few limitations that need to be addressed and carefully considered when generalizing the findings. This study was conducted only in one region in the Philippines excluding nurses from other regions which could have affected the results and generalization of the findings. An additional limitation was the utilization of a self – report scales which might have limited the actual responses of the respondents. It may have been beneficial to have incorporated a longitudinal research design considering the nature of the variables being studied.

Conclusion

To the best of the study's researchers, this is one of the earliest studies ascertaining the extent of and factors associated with organizational commitment and turnover intention in a group of nurses in the Philippines. Therefore this study contributes to the growing literature on organizational commitment and turnover intention among nurses in a Philippine context. It can be inferred in this study that nurses were moderately committed to the organization and were undecided whether or not to leave their organization. Nurses' age, gender, education, rank, and work experience correlated significantly with organizational commitment, while nurses' age and education correlated significantly with turnover intention. Furthermore, nurses' organizational commitment correlated negatively with turnover intention. These findings may provide useful insights for policy makers, hospital administrators, and nursing administrators in the Philippines by formulating and implementing empirically tested interventions that would improve nurses' commitment and promote retention.