A nursing shortage: Building organizational commitment among nurses / Practitioner application

The nursing workforce of the next decade is forecasted to be driven by increasing demand and decreasing supply of registered nurses, second only to aging of that workforce; that impact on healthcare organizations is unprecedented (Buerhaus 1999). Therefore, healthcare administrators must work harder to promote and develop methods for building organizational commitment among nurses, and among other clinicians, before that imminent shortage occurs.

Organizational commitment (OC) is defined as "the strength of an individual's identification with, and involvement in, the goals and values of the organization," a strong desire to maintain membership in the organization, and a willingness to exert considerable effort to serve the organization (Porter et al. 1974). OC is broader and more complex than job satisfaction and is separate from commitment to the profession (Fletcher and Williams 1996; Scoble 1991; Tong 1991). According to Katz and Kahn (1978), work activities are self-rewarding when they are expressions of the individual's ego or central values. Despite multiple studies and literature on OC, no research exists that describes employees' perceptions of their own OC, which is critical in validating quantitative research and understanding this concept. Therefore, this qualitative study was undertaken to identify and describe staff nurse views of their commitment and lack of commitment to their employing organization as well as the personal and organizational factors that influence their response.

BACKGROUND

Studies have shown that OC is a global measure of employees' attitudes about the organization (McCaul, Hinsz, and McCaul 1995). An analysis of nine studies revealed that OC is principally measured as an affective dimension (Dunham, Grube, and Castaneda 1994) and is influenced by job characteristics, structural elements, work experience, and employee characteristics (Mowday, Porter, and Steers 1982).

job characteristics that correlate with OC include customer focus (Crosby, Grisaffe, and Marra 1994) and availability of flex time for women with family responsibilities (Scandura and Lankau 1997). Structural elements that correlate with OC include leadership and age of the organization (Glisson and Durick 1988); style of management (Zeffane 1995); use of systems (Fletcher and Williams 1996; Levy and Williams 1998); manager leadership skills (McNeese-Smith 1995, 1996); organizational communication (Varona 1996); and human resource practices of staffing, staff development, rewards, and communication (Kirsch 1990; Wimalasiri 1995). Work experience characteristics that correlate with OC include job satisfaction (DeConinck and Stilwell 1996; Mathieu 1991; McNeese-Smith 1995, 1996; Morrison 1997; Tett and Meyer 1993); satisfaction with benefits (Ward and Davis 1995); sense of equity (Scandura and Lankau 1997); realistic expectations of the job (Werbel, Landau, and DeCarlo 1996); participation in decision making; and low role conflict (Boshoff and Mels 1995). Organizational commitment of women managers is related positively to promotional opportunities and is negatively related to perceived differential treatment, which favors males (DeConinck and Stilwell 1996).

Employee characteristics that correlate with OC include occupational identification (Witt 1993); a propensity for commitment (Lee et al. 1992); internal locus of control (Werbel, Landau, and DeCarlo 1996); selfperception of personal competence (Mathieu and Zajac 1990); age, developmental stage, and job stage (McNeese-Smith 2000; McNeese-Smith and van Servellen 2000); and career stage (Allen and Meyer 1993; Cohen 1991, 1993). Having children does not decrease OC among women managers (Korabik and Rosin 1995).

Commitment to the organization among nurses, and among other healthcare professionals, may be decreasing as organizations reorganize for greater cost effectiveness (Corser 1998). In fact, nurses may question why they should have commitment to the organization if they do not feel commitment from their employer. According to Shore and Wayne (1993), employee perception of organization support is strongly related to employee commitment. OC is the primary buffer against stress and job displeasure (King and Sethi 1997), especially during consolidation of work units (Begley and Czajka 1993). Stress increased job displeasure only when OC was low. Additionally, researchers found that employees with high OC are more likely to practice "organizational citizenship behaviors"-defined as voluntary actions that benefit the organization (Williams and Anderson 1991).

Highly committed employees also experience positive affectivity in other areas of their lives, including family and nonwork activities (Romzek 1989).

Lack of a sense of organizational support will have long-term deleterious effects on organizational financial status, as lack of OC is associated with lower job satisfaction (Blegen 1993; McNeese-Smith 1995, 1996); poorer performance (Meyer et al. 1989); higher absenteeism and tardiness (Dahlke 1996); and turnover (Cohen 1993; Lee and Mowday 1987; Lum et al. 1998). The relationship of low OC to turnover is stronger among white-collar employees (Cohen and Hudecek 1993) including nurses (Farrell and Petersen 1984).

However, Mayer and Schoorman (1998) found that employees may be committed to the organization for pay and retirement plan reasons (continuance commitment) but may not be committed to organizational values (affective commitment). Job performance was found to be lower among employees with continuance commitment, compared to those with affective commitment (Meyer et al. 1989). Nurses with continuance commitment may be a liability to an organization, while nurses committed because of congruity with mission and values of the organization are an asset (Corser 1998).

Nursing researchers found relationships between OC and job satisfaction, nurse perception of care quality, and anticipated turnover (DeGroot, Burke, and George 1998). Acorn, Ratner, and Crawford (1997) found significant relationships between job satisfaction and OC, and between decentralization and OC of first-line managers. Researchers from the University of Western Ontario found moderate to strong relationships between nurse perceptions of jobrelated empowerment and OC among acute care hospital nurses (McDermott, Laschinger, and Shamian 1996; Wilson and Laschinger 1994). Nurse perceptions of their manager's power positively influenced their perceptions of their own empowerment. Other researchers, using path analysis, reported lower turnover and higher OC among nurses given realistic job previews as a randomly assigned intervention at the time of hire (Hom et al. 1998).

METHOD

Semistructured interviews were conducted to gather nurse views of their OC, or lack of OC, and factors that affect these outcomes. Data were content analyzed into nine categories, with themes within each category, using an inductive process (Waltz, Strickland, and Lenz 1991; Weber 1990). This research was part of a larger qualitative study that analyzes influences on staff nurse job satisfaction (McNeese-Smith 1999) and productivity (McNeeseSmith, in press), as well as nurse manager influence on these staff nurse outcomes (McNeese-Smith 1997).

Setting and Sample

The setting was a large Los Angeles county hospital associated with a major university. The hospital primarily serves a low-income population, particularly Latinos. A purposive sample of 30 staff nurses was recruited by letter. In an attempt to reflect a representation of staff nurses in this acute care hospital, the nurses were selected from six units including Obstetrics/Gynecology, Pediatrics, Operating Room/Recovery, Medical, Surgical, and Intensive Care.

Twenty-eight participants were female and ranged in age from 31 to 59, with an average age of 43. Highest degrees held were as follows: nursing diploma (7 or 23.3 percent); associate degree (7 or 23.3 percent); baccalaureate degree (13 or 43.3 percent); and graduate degree (3 or 10 percent). Twenty (67 percent) obtained their nursing education in a country other than the United States. The majority of the participants were Filipino (18 or 60 percent), while others were Asian (6 or 20 percent); Caucasian (2 or 6 percent); African American (2 or 6 percent); and Latino (2 or 6 percent). Their years of RN experience averaged 16 years and 11 years in the current hospital site. Nineteen (63 percent) had dependent children, while six (20 percent) had dependent elders. Twenty-seven (90 percent) identified themselves as the primary source of income for their family.

Instrument

A semistructured interview guide was created for identification of conditions or factors that create OC or lack of OC. Interview questions were based on a review of previous research on the topic, and a panel of seven experts in nursing human resource issues was consulted to ascertain content validity. A total of 22 questions were asked, seven of which concerned OC and lack of OC. Organizational commitment was defined to the nurses as their longterm identification with and involvement in the goals and values of the organization. Examples of interview guide questions were:

"When you are feeling very committed to this hospital, what conditions or situations make you feel that way?'

"In relation to lack of organizational commitment, what is it about you personally, including your personality, motivation, home, background, or culture, that decreases your commitment to this hospital?"

Eighty to 100 percent agreement from the expert panel was achieved on the criteria for each question, and the panel's feedback was used to revise the interview guide. A pilot study of two "practice" interviews was done in the research setting to determine that procedures and instruments were usable and the interview could be completed in 30 to 60 minutes to minimize time loss for nurses.

Procedure

Semistructured, audiotaped interviews were done in private rooms by the researcher only Predefined questions and probing questions were used to clarify responses. Interviewing continued on all shifts, over a six-week period, until saturation of the data was experienced.

FINDINGS

Categories and themes that emerged from the analysis, together with direct quotes from the participants, are highlighted below (see Figure 1 for the number and percentage of nurses who cited each category).

Factors That Affect OC

Nurses enumerated nine major factors that contribute to their commitment to the organization: (1) personal factors, (2) opportunities for learning, (3) job satisfaction, (4) a plan to retire from the organization, (5) monetary benefits, (6) patient care, (7) coworkers, (8) cultural factors, and (9) job security.

1. Personal factors. This category was the most frequently mentioned cause of OC, and the responses brought out two themes. "Meets home and family needs" was the first theme identified: "I live close by so my family knows they can count on me. I have both children and elderly parents." "I'm not ambitious, I just want to do a good job and raise my two children."

The second theme identified was "prefers stability to change." Four nurses said they were not the type to move around: "I am a person of stable habit." "My kids are small and I am the primary bread winner, so I don't see myself moving around." Other nurses revealed that they choose to work out problems in their current jobs rather than move to a new set of problems in another facility: "This is the kind of job I have. It is stressful, and I have to deal with that." Another nurse profoundly described how her attitude affects her commitment: "Little problems are not going to go away. It's the way you handle it that makes a bad day or a good day."

2. Opportunities for learning. This factor of commitment brought out three themes, the first of which was being in a "learning environment." Nurses admitted to liking the variety of patients and diagnoses they encounter in a county university hospital, the opportunity to learn with medical students and residents, and the ability to ask questions: "This hospital gives you a chance to learn, and you can move around through different wards." "I worked in a private hospital, but I didn't like it. It was routine and there wasn't the constant chance to learn."

The second theme was "modern technology and change offering new skills," such as use of computers: "We have lots of improvements. We started our pediatrics intensive care unit, so that's a nice experience." The third theme was "continuing education and schooling." Nurses said opportunities to pursue higher education and continuing education are important because the nursing profession is occupying more expansive roles in the healthcare industry: "We have case managers, clinical nurse specialists, nurse practitioners, and discharge planners, so nursing is being stretched." "My manager sends me to school and I just finished a program.... That makes me more valuable to this facility. Education is top priority to me."

3. Job satisfaction. Many nurses reported that being happy with and challenged by their jobs contributes to their OC: "I am part and parcel of this organization. If someone says something good about this hospital, I am proud to be part of this organization." "I like the system here. Nurses have a lot to say."

4. A plan to retire from the organization. Nurses from all age groups disclosed that they desire or intend to retire from the organization, which is reason enough to develop OC. Three themes emerged from this category; the first was "satisfied and planning to retire from the organization." Nine nurses were very positive about the hospital, yet looked forward to retirement in the near or distant future: "I plan to retire from here at age 55." "If nothing goes wrong I will stay here until I retire."

Meanwhile, other nurses described their commitment in relation to theme two-"longevity": "I am going to work here as long as they want me. I have worked here almost 8 years." "I have learned to like it already I've been here 21 years." On the other hand, two nurses introduced a third theme"dissatisfied but planning to retire from the organization" because of the number of years they had already put into the organization: "I've been here [so many] years, and the company has put me through school twice already so in that way I am committed to the organization ... and to my department.'

5. Monetary benefits. Nurses discussed the relationship between their pension plans and salary and their OC: "When I see my benefits, I say, 'Oooh, I've accumulated that?' " "We get regular raises." "Our pay is comparable to private hospitals." "I am divorced, so I must think of my retirement."

6. Patient care. Three themes emerged from this factor; the first theme was "pleasure in giving good care": "Patients are like my customers, and [they] need our help." One nurse said her commitment stems from being able to work in both the clinic and the hospital with high-risk patients, while another described satisfaction in achieving good outcomes as the source.

The second theme was "working with an interesting variety of patients": "I like the patients. Some are bad, some are nice, but [working with them is] part of the job." "I enjoy the multicultural variety." The third theme was a "desire to serve humanity": "[I like] to lessen suffering and to serve. This hospital is situated [in a place] where so many people really need [our help]."

7. Coworkers. Some nurses said that their close relationships with coworkers-as friends, as a support system, and as family-contribute to their OC: "My best friend is here, and our friendship developed at work." "We maintain a very good working environment and we are supportive of one another." I like my coworkers and the physicians as well. We have a good rapport with the surgeons and anesthesiologists."

8. Cultural factors. Four nurses believed that their cultural backgrounds influence their commitment; two themes emerged from this category. The first was "creating a better life for self and family": Life is hard in the Philippines, so it inspires me to work hard [in this country]. I want my children to have nice living conditions. . . "

A second theme was "work values": "Maybe having an Oriental work ethic, it was an attitude that you worked for the company until you died. If there's problems in the organization, you're part of the problem and you need to solve it

9. job security. Nurses also said that being secure about not losing their jobs is a factor in their OC: "Job securitythat's number one. Private hospitals are laying off right now." "Security is important to my commitment, especially with the job market now."

Factors That Affect Lack of OC

Nurses identified eight categories that contribute to their lack of OC: (1) conflict with personal needs, (2) lack of learning, (3) lack of appreciation/fairness, (4) inadequate monetary benefits, (5) patient care, (6) poor relations with coworkers, (7) career developmental stage, and (8) lack of job security Six of these categories are direct opposites of those categories that create and promote OC. Many were discussed by only one to four nurses.

1. Conflict with personal needs. Ten nurses cited personal reasons for their lack of OC, and two themes emerged from this category. The first was "family needs": "I had to quit before to care for my ill mother." "I definitely would like to be with my parents who are considering moving to another state."

The second theme was "deteriorating neighborhood." Two nurses mentioned the increase of gangs and crime in the surrounding area, and one expressed the frustration: "Sometimes

I have a feeling I would like to go somewhere else, but then there's no other place to go." Several nurses also mentioned hypothetical situations that could create a lack of commitment, but no clear theme emerged from them:

"If I felt discrimination." "If I were very tired," and "If something terrible happened and I had to leave to save face."

2. Lack of learning. Several nurses said they cannot feel committed "if there is no new learning, and boredom sets in."

3. Lack of appreciation/fairness. Four nurses discussed having decreased commitment when they feel a lack of appreciation of their efforts or lack of fairness shown. Three themes emerged from this category; the first was "lack of appreciation from physicians": "When you work with a difficult surgeon you can feel like quitting." The second theme was "lack of appreciation from the organization": "When you are frustrated, you want to quit or retire. It's not fair [that] they don't appreciate you." Lack of appreciation from managers is reported elsewhere (McNeeseSmith 1997). The third theme was "unfair politics" as explained by two nurses: "The promotion system is not fair. People get hired or promoted because they have pull." "[There's] too much politics in this hospital. If you know the right people you get invited to do things."

4. Inadequate monetary benefits. Two nurses perceived that pay and benefits at this facility were lower than elsewhere: "Compared with another hospital, it's not as good." "My pay and benefits are less [here] than at other hospitals."

5. Patient care. Nurses described difficult patient-care situations that affect their lack of OC. Two themes were identified; the first was "difficult or repetitive patient care": "Sometimes we have very difficult patients. I don't want to face this problem. . . "Sometimes the redundancy of the work makes me feel like I want to do something else." One nurse switched [to another unit] from the ICU when she became "burned out," which solved that problem. The second theme was "overload and/or stress" associated with overwhelming patient care. One nurse admitted to feeling uncommitted "when I am overloaded, and one of my coworkers gets sick. I work like a chicken without a head." Another nurse said: "If I had another choice-- another job that's less stressful, I might do that."

6. Poor relations with coworkers. Two nurses stated that not getting along with coworkers could decrease their OC: "If I have a bad time with my coworkers, I feel less committed." Another complained about coworkers, hired by the county, who receive money but do not do their job: "I hope if there is a layoff, they pick the right people who don't do their job."

7. Career developmental stage. One nurse articulated her view on changing focus to challenge and grow one's career: "Sometimes ... you need to change if you're bored or stressed out. Try another specialty."

8. Lack of job security. One nurse expressed her fear as a crucial factor in her lack of OC: "Lately there has been talk about layoffs, [and we ask] how stable is this job? Before I commit myself, [I ask first] will this job support me when I'm 40, when I'm 45?"

DISCUSSION

Two studies published in 2000 (McNeese-Smith 2000 and McNeese-Smith and van Servellen 2000) reported that the strongest predictor of nurse job disengagement is lack of OC. In this study, thirty staff nurses stated that their OC was related to personal factors such as meeting family needs, job satisfaction, opportunities for learning, monetary benefits, and a desire to retire from their current organization. A majority of these nurses verbalized affective commitment-a continuing desire to maintain membership in the organization and a willingness to work hard for the organization. Except for job satisfaction, the major themes related to OC were extraneous to the job itself. Lack of OC was most frequently identified as caused, or potentially caused, by a conflict with personal needs. Problems with difficult patient care and lack of appreciation/fairness were the next most frequently identified causes.

Personal factors, including proximity to home and a preference for stability rather than change, was the category identified most often as creating OC. Most of these nurse participants were the primary source of income for their families and had children and/or parents under their care. The nurses' emphasis on meeting family needs indicates that an organization that is flexible and supportive of its employees' personal needs could reap long-term commitment, as reported by Scandura and Lankau (1997).

In a qualitative study on job satisfaction (McNeese-Smith 1999), 77 percent of those interviewed identified patient care as the most important cause of job satisfaction. In relation to OC, patient care is discussed by only 30 percent of the nurses interviewed; however, job satisfaction is identified as a contributor to the nurses' OC. Therefore, good patient care appears to lead to job satisfaction, which then contributes to OC. This hypothesis is consistent with the path analysis of Hom et al. (1998), the meta-analysis of Blegen (1993), and the findings of Tett and Meyer (1993). Several nurses reported that stress was just part of their job, and it seemed that their commitment buffered that stress, as reported by Begley and Czajka (1993) and King and Sethi (1997).

Opportunities for learning were identified by 40 percent of the nurses as a cause of commitment, which was impressive given that the nurses were not cued for this response. This response is important because it is relatively inexpensive for the organization to provide good learning opportunities, and continued education may benefit the employer as well as the nurse. It appears to be a cost-effective way to reap organizational commitment, even in times of financial pressure.

While four nurses related their OC to their Filipino and/or Asian cultural mindset, it is unknown whether or not the fact that 67 percent of these nurses were from another country affected their OC. Leininger (1991) described cultural values of loyalty to the employer that are similar to the statements of the Filipino and Asian nurses in this study. Nurses in this study hospital had significantly higher scores in OC than nurses, primarily U.S.-born Caucasians, in two Seattle study hospitals (McNeese-Smith 1995).

The nurses in this study were influenced by the layoffs occurring in private hospitals, and one nurse verbalized concern about the organization's commitment to her, which is similar to that described by Corner (1998) and may predict the concerns of more nurses in the future. It also appeared that some nurses who were dissatisfied and angry at the organization were committed to staying because of their retirement plans and their reluctance to go elsewhere (continuance commitment), as described by Mayer and Schoorman (1998). Other nurses also mentioned their disapproval of "county" employees who stay for the money but don't do their job.

Criteria for judging content analysis in qualitative studies include validity of the coding scheme and of the data. Information gained from these interviews revealed a pattern that seems congruent with the reality of nursing practice in an acute care setting and is consistent with the researcher's experience. Categories and themes are understandable and may be applicable to other settings. The views of these nurses tend to confirm the findings about OC in quantitative research. However, generalizability of these results is limited by the nonexperimental methodology; the setting; and the relatively small sample, which was ethnically diverse and whose job longevity was unusual. In spite of these limitations, the study provided a perspective missing from current research and nursing literature.

The findings from this research have implications for nursing practice, healthcare administration, and education, particularly as we face the nursing shortages of the future. As administrators consider the enormous costs of turnover and a limited supply of nurses, they should create effective strategies for retaining long-term affestive commitment of skilled nurses.

Suggestions from this study and the author's years of experience as a nurse administrator include the following: Expect all members of the administrative team to spend two hours each month working with a nurse or other clinician to better understand the mission of the organization and the roles of care providers.

2. Create a performance improvement team to develop a strategic plan to increase organizational commitment, and job satisfaction, and reduce turnover.

3. Make flexible scheduling, which supports personal needs and continued education, a priority.

4. Hire, evaluate, and support the nurse executive, other administrators of departments with nurses, and other nurse administrators on their ability to build a satisfied, committed staff.

5. Encourage staff to seek learning experiences both within the organization and on their own.

6. Promote equal opportunity for nurses of all ethnic and cultural backgrounds.

7. Build interdisciplinary respect and positive interdepartmental relations, including between nurses and physicians and other clinicians.

The evidence from the words of these nurses in this study can provide insight for administrators to use in strategizing direction for building a committed nursing workforce.

Acknowledgment

Thanks to the staff nurses, managers, and administrators who participated in and supported this study. Special gratitude is expressed to Ms. Margaret Nazarey, MSN, nursing administrator of Harbor-- UCLA Medical Center. Lastly, thanks to Mr. William McNeese-Smith and Ms. Patricia Carter for coding assistance and the UCLA Faculty Research Oriented Group, especially Dr. Adeline Nyamathi. This study was funded in part by a UCLA School of Nursing Research Grant.