A study of the relationship between job satisfaction, organizational commitment and turnover intention among hospital employees

Health Services Management Research 21: 211 227. DOI: 10.1258/hsmr.2007.007015 # 2008 Royal Society of Medicine Press A study of the relationship between job satisfaction, organizational commitment and turnover intention among hospital employees Ali Mohammad Mosadeghrad*, Ewan Ferlie and Duska Rosenberg *Health Policy and Management, School of Health, Tehran University of Medical Sciences, Iran; School of Management, Royal Holloway University of London, UK The purpose of this descriptive, co-relational and cross-sectional study was to gain a better understanding of the relationships between job satisfaction and organizational commitment of employees, and their impact on turnover intention at Isfahan Hospitals, Isfahan, Iran, in 2005. Data were collected by the distribution of two questionnaires among 629 employees of these hospitals through a stratified random sampling method. The results of the paper indicate that hospital employees are moderately satisfied with their jobs and committed to their organization. Employees job satisfaction and organizational commitment were closely inter-related and correlated with turnover intention (P, 0.001). The positive correlation between the two was expected, but there was also unexpected correlation with turnover intention. This may be due to external factors, such as job market conditions, which may influence perceived opportunities for career advancement elsewhere. The impact of such external factors is outside the scope of this study, but will have to be investigated in further research. As job satisfaction and organizational commitment have strong correlation with turnover, it is very important to reinforce them by applying the right human resource policies. Introduction Organizations are social systems where human resources are the most important factors for Ali Mohammad Mosadeghrad BSc MSc, Lecturer, Health Policy and Management, School of Health, Tehran University of Medical Sciences, Iran and Doctoral Researcher, School of Management; Ewan Ferlie MA PhD, Professor (Management), School of Management; Duska Rosenberg MA PhD, Professor (Information and Communications Management), School of Management, Royal Holloway University of London, Egham, Surrey TW20 0QS, UK Correspondence to: Ali Mohammad Mosadeghrad Email: m.mosadeghrad@rhul.ac.uk effectiveness and efficiency. Organizations cannot succeed without their employees efforts and commitment. Employees satisfaction with their jobs and commitment to their organizations has been viewed as major determinants of organizational effectiveness. 1 Job satisfaction and commitment are critical to retaining and attracting well-qualified personnel. Concerns about employees job satisfaction and organizational commitment are just as, or even more, critical in the knowledge-based sectors, such as the health-care industry as they are in other business sectors. These factors are especially important in professionalized and 211

Health Services Management Research service-based organizations, such as hospitals where long-term specialist training and retention issues are highly important. Employees who experience job satisfaction are more likely to be productive and stay on the job. 2 Job dissatisfaction has been found to be a strong and consistent predictor of intention to leave as well as turnover. 3 6 Employees job satisfaction is also found to be positively related to patient satisfaction in health-care settings. 7 Employees commitment is a valuable asset in an organization. Research has shown that increased commitment improves employees job satisfaction, motivation, performance and creativeness, and reduces absenteeism and turnover. 8 10 Justification for the need to investigate employees job satisfaction and organizational commitment is exemplified in the seemingly observed relationship between the lower levels of job satisfaction and commitment, and negative symptoms of absenteeism, grievance expression, tardiness, low morale and high turnover. Job satisfaction and organizational commitment are important indicators to managers because of the desire to retain a stable and committed workforce. Researchers are keenly interested in understanding the factors that influence an individual s decision to stay or leave an organization. Iran s health system is passing though a period of transformation. Since early 2000 the Ministry of Health has been working on a comprehensive health-care reform programme, especially in hospitals. One of the aims of this reform programme is to strengthen health-care management. However, human resource management is still not what it should be and the human aspects relating to employee satisfaction and organizational commitment, which affect productivity, are neglected. There are a small number of research studies in the literature that have examined the associations between job satisfaction, organizational commitment and turnover intention. Most of these studies have been based on data collected in Western countries and, also, limited to health-care employees. However, where job satisfaction has been found to be a direct predictor of turnover, organizational commitment has not been analysed. This study aims to overcome this by focusing on issues such as employee attitudes, like satisfaction and commitment, and the extent to which these factors contribute to their intention to leave the organization. There are no known studies related to the links between these subjects in the health-care organizations of Iran. The results of this research will allow a better understanding of the relationship between employees job satisfaction and their organizational commitment, and their impact on turnover intention. The results will also enhance our understanding of the determinants of these two important employee attitudes. It is anticipated that a better understanding of these issues and their relationships can aid further research, pinpoint better strategies for recruiting, promotion and training of future hospital employees, particularly in Iran but probably in other societies as well. Literature review Organizational commitment Organizational commitment reflects a multidimensional psychological attachment of an individual to the organization, 11 which plays a positive role in retention of members in the organization. Meyer and Allen 12 defined organizational commitment as: A psychological state that characterizes the employee s relationships with the organization and has implications for the decision to continue membership in the organization. Meyer and Allen 12 differentiated organizational commitment into three components: affective, continuance and normative commitment. Affective commitment refers to employees perceptions of their emotional attachment to their organization and its goals. 13 Employees with high affective attachment to organization have strong motivation to contribute to the organization goals because they see them as theirs. 14 According to Kate and Masako, 11 individual and organizational factors may influence the level of affective commitment. Individual factors include, for example, factors such as personality, values orientation, education or age, while organizational factors include believing that employee s roles and job goals are clearly defined and receive management support. Continuance commitment represents cognitive attachment between employees and their organizations because of the costs associated with leaving the organization. 13,11 It is based on the 212

Relationship between job satisfaction, organizational commitment and turnover intention assumption that individuals do not leave an organization if they would lose their benefits, take a pay cut, incur job search expenses and risk of being unemployed. 15 The level of investment employeeshaveaccumulatedinanorganization and lack of alternative jobs outside the organization are the most important factors that may lead to continuance commitment. If employees believe that fewer work opportunities exist outside their organizations, the perceived costs of leaving current organizations will be higher, and they will develop a stronger sense of continuance commitment to their organizations. 16 Finally, normative commitment refers to typical feelings of obligation to remain with an organization. 13 Normative commitment is based on an ideology or a sense of obligation; employee feels obligated to stay with the organization because it is the moral and right thing to do. Factors that may influence the level of normative commitment are education, age and related factors. 11 Normative commitment could be based on organization investment in an employee who then feels a moral obligation to stay with the organization, based on employee s social or cultural norms and believes that one should be loyal to one s organization. Job satisfaction Job satisfaction is an attitude that people have about their jobs and the organizations in which they perform these jobs. Job satisfaction is defined as the extent to which people like or dislike their jobs. 17 It is an employee s affective reaction to a job, based on a comparison between actual outcomes and desired outcomes. Job satisfaction is generally recognized as a multifaceted construct that includes employees feelings about a variety of both intrinsic and extrinsic job elements. Intrinsic elements of job satisfaction, derived from internally mediated rewards, such as the job itself and opportunities for personal growth and accomplishment; and extrinsic elements of job satisfaction, resulting from externally mediated rewards such as satisfaction with pay and benefits, company policies and support, supervision, co-workers, job security and chances for promotion. 18 Job satisfaction, organizational commitment and intention to leave A positive association between job satisfaction and organizational commitment has been consistently reported by studies. 19 22 The links between organizational commitment and job satisfaction are complex and it is not clear whether satisfaction is a precursor to commitment or whether commitment influences one s level of satisfaction. The dominant view in the literature supports the causal precedence of 23 25 satisfaction over commitment. There is also evidence indicating that high levels of commitment to the organization cause job satisfaction. 26,27 Several other studies have concluded that a reciprocal effect exists between satisfaction and commitment. 28,29 A fourth group of studies finds no evidence of causal relationship in either direction. 30 Numerous studies have reported that job satisfaction 31,32 and organizational commitment are negatively related to turnover 33 35 intention. According to Tett and Meyer, 8 organizational commitment and job satisfaction are different, and each contributed uniquely to turnover intentions. Job satisfaction correlated more strongly with turnover intention, whereas organizational commitment had the strongest correlation with actual turnover. The theoretical framework of the study There are a variety of individual, social, cultural, organizational and environmental factors that can influence a person s level of job satisfaction and organizational commitment. Individual factors include age, gender, marital status, personality, education, intelligence and abilities. Social factors include relationships with coworkers, group working and norms, and opportunities for interaction. Cultural factors include underlying attitudes, beliefs and values. Organizational factors include organization structure, policies and procedures, supervision and styles of leadership, management systems, and working conditions. Finally, environmental factors include economic, social, technical, political and governmental influences. This study aims to investigate the role of individual, social, and organizational factors, and employees level of job satisfaction, organizational commitment and turnover intention with a sample of Iranian hospital employees. It was not possible to examine all aspects of this hypothesized model within the confines of the present study. Thus, the study is confined to testing hypothesized relationships between job satisfaction, organizational 213

Health Services Management Research commitment and turnover intention, and the other relevant variables, which relate to job satisfaction and commitment. As shown in Figure 1, the relationship between job satisfiers and employees outcomes is moderated by individual and cultural factors. The initial hypothesis is that job satisfaction is positively related to organizational commitment, which is negatively related to turnover intention. Therefore: Hypothesis 1: The greater the employees job satisfaction, the greater their organizational commitment or vice versa. Hypothesis 2: The greater the employees job satisfaction and commitment, the lower their turnover intention. Methodology The study utilized descriptive correlation design and cross-sectional survey methodology. Purpose and objectives The purpose of this paper is to examine the relationships between job satisfaction, organizational commitment and turnover intention among hospital employees in Isfahan, Iran. This survey investigates possible causes for low levels of job satisfaction and commitment as precedents for turnover and decision to leave the workforce. This study also focuses on revealing homogeneous demographic characteristics these employees exhibit, which affect their satisfaction and commitment level and turnover intention. Setting Hospital care in Iran is provided by a network of regional hospitals located in the main cities. This includes government-financed Ministry of Health hospitals (MOH), the Social Security organization-affiliated hospitals (SSO) and private hospitals. 36 The study was carried out in six hospitals: three public MOH (two teaching and one non-teaching), one SSO (semipublic hospital) and two private hospitals. The six hospitals of the study were selected to represent the three dominant hospital-care systems in Iran. Participation At the time of the study (2005), these hospitals employed 2411 full-time employees. Seven Figure 1 Hypothesized relationship between job satisfaction, organizational commitment and turnover intention 214

Relationship between job satisfaction, organizational commitment and turnover intention hundred and forty employees were selected for this research after a pilot study using the following formula (N ¼ 2411, d ¼ 0.03, z ¼ 1.96 and s ¼ 0.50). Employees who had less than six months of work experience were excluded from this study. n ¼ NZ2 S 2 Nd 2 þ Z 2 S 2 Instruments A survey instrument was designed to measure and identify demographic characteristics, levels of job satisfaction and commitment among employees of hospitals and their intention to leave the organization. A cover letter briefly explained the purpose of the study and the mechanisms to maintain confidentiality. Further explanations were given when requested. The respondents received and answered the questionnaires at their work place. Participation was voluntary. The questionnaire consisted of three sections as follows: Section 1 Demographics: As hospital employees deal with very specific tasks on a daily basis, there may be a link between individuals demographic characteristics and their job satisfaction to a particular type of work. Therefore, demographic data on employees were also gathered. The questionnaire gathered data relative to participants : (a) gender; (b) marital status; (c) age; (d) years working in the hospital; (e) education level; (f) employment status; (g) department they work in; and (h) monthly salaries received. We chose these characteristics based upon a review of related literature. Section 2 Job Satisfaction Scale: A selfdeveloped questionnaire was used to assess the level of job satisfaction among hospital employees according to nine subscales. First, the domains of job satisfaction were defined. To accomplish this, a literature review was conducted to identify the dimensions of job satisfaction. 17,37,38 From each study, a list of dimensions was created. Using a Delphi technique, the organizational behaviour and management experts opinions were used in completing this list. The nine most common job satisfaction domains were chosen for inclusion in the questionnaire. These included: salaries and benefits, recognition and promotion, management and supervision, co-workers, task requirement, organization policies, working conditions, nature of the job and job security (Table 1). This questionnaire had 36 items (4 items in each domain). A further four items were also included in the questionnaire: employees asked about their overall job satisfaction, ability to do their job well, intention to leave the organization if they received a good offer from other health-care organizations and if they would recommend the hospital to others for work. The questionnaire utilizes a Likert-type scale with six response alternatives ranging from Strongly disagree (weighted 1) to Strongly agree (weighted 6) for each of the 40 items. In part II of the questionnaire, employees were asked to specify the importance of those nine dimensions of job satisfaction according to their personal interests on a six-point scale from less important (weighted 1) to very important (weighted 6). Section 3 Organizational Commitment Scale. This variable was measured using Meyer and Allen s 12 Organizational Commitment Scale, which contains three six-item components: affective, continuance and normative commitment (Table 2). Ratings were completed on a six-point scale from Table 1 Definition of job satisfaction dimensions Salaries and benefits: remuneration, pay and fringe benefits for the work done Recognition and promotion: the opportunity to advance; achievements Management and supervision: competence of supervisor and way the boss handles employees Co-workers: relationships with co-workers; quality of interactions Task requirement: what employees need to do their job well, such as education, resources and some degree of autonomy Organization policies: satisfaction with organization policies and rules Working conditions: all facets of the work environment, safety Nature of the job: job identity, meaningful work; level of responsibility and authority and Job security: steady employment of the job 215

Health Services Management Research Table 2 Definition of organizational commitment dimensions Affective commitment: psychological attachment to organization; Continuance commitment: costs associated with leaving the organization; and Normative commitment: perceived obligation to remain with the organization strongly disagree (weighted 1) to strongly agree (weighted 6). The translation followed an established forward backward translation procedure, with independent translations and counter-translation. Access and ethical approval Ethical approval of the study was gained from the Isfahan Medical University s Research Ethics Committee. The main ethical issues involved in this study were respondents rights to self-determination, anonymity and confidentiality. For this reason, respondents were given full information on the nature of the study through a letter, which was distributed with the questionnaire. The questionnaire data were kept confidential and respondents were assured of their right to withdraw at any time. The names of the respondents were not recorded and so all the data were rendered anonymous. Pilot study A pilot study was undertaken to test the relevance and clarity of the questions, and to refine them as needed to avoid misunderstanding. A small sample of 40 randomly selected hospital employees, who were not included in the sample, received the questionnaires. The questionnaires were found to be understandable, acceptable and could be completed in about 15 min. Validation of research instruments Content and face validity were established by a panel of experts consisting of management and organizational behaviour experts. The panel was asked to review the content of the items in each of the instruments and determine if the items were within the linguistic capabilities and understanding of hospital employees in Iran. The panel was also asked to eliminate items or questions they found to be irrelevant to the Iranian culture and make suggestions on how to simplify the items that were not relevant. After some modifications were made, the instruments were resubmitted to the experts. The experts unanimously recommended the use of the modified instruments for this study. Reliability of research instruments Internal consistency reliability was measured by Cronbach s coefficient a as 0.9210 for job satisfaction questionnaire and 0.8383 for organizational commitment questionnaire. The results in Table 3 show that the values of Cronbach s a derived for the constructs ranged between 0.70 and 0.89, indicating a high reliability of the scales. Acceptability of research instruments Acceptability was assessed in terms of refusal rates and rates of missing responses. A total of 629 (85%) hospital employees filled in the questionnaires. Organization-specific response rates Table 3 Internal consistency analysis Constructs Number of items Salaries and fringe 4 0.81 benefits Recognition and 4 0.80 promotion Management and 4 0.73 supervision Co-workers 4 0.78 Task requirement 4 0.70 Working conditions 4 0.72 Nature of work 4 0.74 Organization policies 4 0.72 Job security 4 0.70 Overall job satisfaction 40 0.92 Affective commitment 6 0.86 Continuance 6 0.71 commitment Normative 6 0.89 commitment Overall organizational commitment 18 0.83 Cronbach s a 216

Relationship between job satisfaction, organizational commitment and turnover intention varied from 87% to 94%. Missing data analysis showed that 90.3% respondents had no missing values for the entire set of 58 items. Data collection Stratified random sampling method was used. Data collection was undertaken in the last two weeks of October 2005. Informed consent was obtained from all subjects following receipt of information on the purpose of the study, assurances of anonymity and confidentiality. Data analysis All data were analysed using the statistical package for the Social Sciences (SPSS 11, SPSS for Windows, V 11 [SPSS, Inc]). Appropriate statistical procedures were used for description and inference. The missing values were checked prior to further statistical analysis. In order to normalize the Likert 1 6 scales for each domain of job satisfaction and organizational commitment questionnaires, the sum of raw scores of items in each domain was divided by the number of items in each domain and for overall job satisfaction and commitment, sum of raw scores of items were divided by 40 and 18, respectively. The possible justified scores varied between 1 and 6. Scores of 2 or lower on the total scale indicate very low, scores between 2 and 2.99 indicate low, scores between 3 and 3.99 indicate moderate, scores between 4 and 4.99 indicate high and scores of 5 or higher indicate very high job satisfaction or commitment. The differences between groups were tested with the chi-square, independent t-test, Mann-Whitney and Kruskal-Wallis tests. The correlation coefficients were calculated to evaluate the relationship between variables. Forward conditional logistic regression analysis was used to identify the most important predictor domains in global satisfaction and commitment. Data were presented as the mean + standard deviation (SD) and percentage (P, 0.05 were considered as significant). Results Characteristics of the respondents As described in Table 4, over half of the respondents were women (54.3%) and over three-fourths (78.8%) were married. Most (63.8%) had at least a college degree. Just over half (56.9%) had a monthly income,2,000,000 Rials (poverty line in Iran in 2005; equivalent to 250 US$). A total of 51.4% of employees had permanent employment. In public, semi-public and private hospitals, 52.2%, 89% and 19.5% of employees, respectively, had permanent job contracts. The age of these hospital employees ranged from 18 to 73, with an average age of 35.29 + 8.58 (mean + SD). Nearly three-fourth of respondents (71.9%) were,40 years old. The average age of the employees in public, semipublic and private hospitals was 37, 34 and 33 years, respectively. On an average, employees had 12.2 years of work experience, respectively. Job satisfaction Total job satisfaction of the respondents was measured on a six-point scale, where 6 stood for highly satisfied and 1 for highly dissatisfied. Overall, hospital employees were satisfied with their job showing a mean score of 3.51 + 0.74 (moderate satisfaction) compared with the possible range of 1.20 5.61. Approximately, 1.6, 23, 45, 28.8 and 1.6% of hospital employees had, respectively, very low, low, medium, high and very high satisfaction with their job. Within the nine items of the Job Satisfaction Scale, the three dimensions of the job with which respondents were most satisfied were: co-workers, nature of the job and task requirement. Respondents were least satisfied with the salaries and benefits, working conditions, recognition and promotion and job security (Table 5). As indicated in Table 5, co-workers, salaries and benefits, management and supervision, nature of job and job security were the most important facets of job satisfaction from the points of view of the employees. The differences in the gap scores (perception minus expectation, P 2 E ¼ gap) for all the nine dimensions of job satisfaction were studied. This gap was more in salaries and fringe benefits, working conditions, and recognition and promotion, and less in nature of work, task requirement and coworkers dimensions of job satisfaction. The differences between values of employees job satisfaction in different hospitals were statistically significant (P, 0.05). 217

Health Services Management Research Table 4 Percentage of participants and the mean score of their job satisfaction and commitment Demographic parameters Percent of sample Job satisfaction Organizational commitment Mean SD Mean SD Gender Male 45.7 3.59 0.68 4.03 0.66 Female 54.3 3.44 0.78 3.93 0.70 Marital status Single 21.2 3.38 0.70 3.77 0.64 Married 78.8 3.54 0.72 4.03 0.69 Education Illiterate 0.5 4.17 0.70 4.21 0.49 Under diploma 8.5 3.67 0.74 4.36 0.77 Diploma 27.2 3.50 0.68 3.97 0.68 Post-diploma 16.9 3.66 0.69 4.15 0.59 Bachelor s degree 40.6 3.41 0.79 3.81 0.69 Master s degree or GP 4.7 3.56 0.67 3.84 0.50 Doctoral degree 1.6 3.54 0.81 4.34 0.49 Area of work Managerial and clerical 19.1 3.73 0.75 4.15 0.59 Ancillary or logistic 17.1 3.75 0.74 4.13 0.72 Therapeutic 51.2 3.31 0.66 3.86 0.71 Diagnostic 12.6 3.69 0.72 3.99 0.57 Age (years), 20 0.7 4.48 0.78 3.91 1.13 20 30 34.9 3.40 0.72 3.81 0.66 31 40 36.3 3.56 0.75 4.01 0.70 41 50 24.4 3.53 0.73 4.10 0.65. 50 3.7 3.86 0.64 4.27 0.66 Tenure (years), 1 (6 months 1 year) 6.4 3.28 0.78 3.83 0.67 1 5 23.1 3.35 0.74 3.77 0.71 6 10 21.4 3.59 0.75 3.94 0.59 11 15 16.2 3.48 0.69 4.02 0.71 16 20 11.4 3.78 0.61 4.29 0.65 21 25 14.6 3.44 0.78 4.00 0.64 26 30 6.4 3.64 0.63 4.13 0.69. 30 0.5 4.45 0.08 4.84 0.38 Received wages (in Rials), 2,000,000 56.9 3.48 0.76 3.93 0.69. 2,000,000 43.1 3.57 0.71 4.04 0.66 Employees job satisfaction in private hospitals was higher than public and semi-public hospitals. The differences between values of employees job satisfaction in these hospitals were statistically significant (P, 0.01). In private hospitals, employees have more satisfaction with co-workers, and less satisfaction with wages and benefits. Employees in social security hospital are more satisfied with salaries, benefits, recognition and promotion than their colleagues in public and private hospitals, but they are less satisfied with working conditions (Table 6). SSO provides more benefits to employees. Health-care services in SSO hospitals are free of charge for people under SSO insurance programme. Therefore, these hospitals are always overcrowded. Furthermore, customers in these hospitals have a kind of ownership sense and are more demanding than patients in other hospitals. 218

Relationship between job satisfaction, organizational commitment and turnover intention Table 5 The mean score of employees expectation and perception about job satisfying factors (on a 6-scale) Job satisfying factors P E P E Salaries and fringe benefits 2.57 5.01 22.44 Recognition and promotion 2.88 4.85 21.97 Management and supervision 3.84 4.96 21.12 Co-workers 4.54 5.15 20.61 Task requirement 4.17 4.76 20.59 Working conditions 2.59 4.86 22.27 Nature of work 4.37 4.94 20.57 Organization policies 3.24 4.80 21.56 Job security 3.11 4.89 21.78 Overall job satisfaction 3.51 4.91 21.40 When the participants were stratified by the type of hospitals, teaching or non-teaching hospital, there were significant differences in the total job satisfaction scores (P, 0.05). It was 3.43 + 0.68 in the teaching hospitals and 3.57 + 0.78 in the non-teaching hospitals. The differences were because of working conditions and management and supervision dimensions of job satisfaction (Table 7). The employees job satisfaction in therapeutic and diagnostic departments was lower than administrative and ancillary departments. A statistical significant association was seen between employees job satisfaction and their area of work or specialty (P, 0.001). The mean score of employees job satisfaction in the cash office (4.46), medical equipment office (4.35), administrative office (4.34), secretarial unit (4.10), material supply department (4.08) and computer centre (4.01) were high and in cardiology ward (2.89), pathology department (2.97), psychiatry ward (2.99), obstetrics ward (3.04), urology ward (3.20), medical records department (3.27) and paediatrics ward (3.30) were low. There was a strong correlation between the job satisfaction of employees and their gender, marital status, age, years of work experience, organizational position, type of employment ( permanent or contract employment) and salaries received (P, 0.05). As regards differences according to age and seniority, we observed a curvilinear relationship: scores were higher for the lowest and highest ages and seniority ranges. There was statistically significant correlation (reverse) between job satisfaction of employees and their graduation levels (P, 0.05). Supervisors or managers represented 15.7% of our sample. Supervisors job satisfaction was found to be significantly higher (m ¼ 3.64) compared with their staff (m ¼ 3.48). Job satisfaction appeared to increase with the level of hierarchy. In order to determine the main factors that cause satisfaction and/or dissatisfaction with work, the relationship between total job satisfaction and job satisfying factors was analysed. Calculations of Spearman s ratios revealed the strongest correlation between total job satisfaction and such characteristics as management and supervision, recognition and promotion, job security and task requirement. On the other hand, working conditions and coworkers had less significant effect on employees job satisfaction, respectively. As Table 8 Table 6 The mean score of employees job satisfaction in public, semi-public and private hospitals (on a 6-scale) Job satisfying factors Public hospital Social security hospital Private hospital P E P E P E P E P E P E Salary and fringe benefits 2.35 4.94 22.59 3.24 4.99 21.75 2.53 5.20 22.67 Recognition and promotion 2.84 4.99 22.15 3.05 4.72 21.67 2.95 4.72 21.77 Management and supervision 3.77 4.88 21.11 3.88 5.07 21.19 4.05 5.04 20.99 Co-workers 4.55 5.21 20.66 4.41 5.14 20.73 4.64 4.99 20.35 Task requirement 4.08 4.57 20.49 4.18 4.80 20.62 4.49 5.22 20.73 Working conditions 2.59 4.74 22.15 2.49 4.67 22.18 2.67 5.36 22.69 Nature of work 4.39 4.91 20.52 4.16 4.87 20.71 4.50 5.11 20.61 Organization policies 3.20 4.76 21.56 3.23 4.64 21.41 3.30 5.05 21.75 Job security 3.11 4.87 21.76 3.07 4.71 21.64 3.14 5.13 21.99 Overall job satisfaction 3.45 4.87 21.42 3.56 4.84 21.28 3.63 5.09 21.46 219

Health Services Management Research Table 7 The mean score of employees job satisfaction in teaching and non-teaching hospitals (on a 6-scale) Job satisfying factors Educational hospitals Non-educational hospitals P E P E P E P E Salary and fringe benefits 2.39 4.85 22.46 2.68 5.11 22.43 Recognition and promotion 2.77 4.95 22.18 2.94 4.81 21.87 Management and supervision 3.67 5.01 21.34 3.99 4.93 20.94 Co-workers 4.47 5.21 20.74 4.60 5.11 20.51 Task requirement 4.01 4.69 20.68 4.32 4.81 20.49 Working conditions 2.66 4.68 22.02 2.55 4.98 22.43 Nature of work 4.42 4.94 20.52 4.35 4.94 20.59 Organization policies 3.20 4.85 21.65 3.25 4.76 21.51 Job security 3.10 4.76 21.66 3.12 4.97 21.85 Overall job satisfaction 3.43 4.88 21.45 3.57 4.93 21.36 shows, this relationship was statistically significant in all the cases (P, 0.001). The mean score of employees satisfaction of job factors, organizational factors and social factors were 4.37, 3.20 and 4.54 credit from 6, respectively. The results of the simultaneous multiple regression model indicate that organizational, social, job and individual factors overall explained 98.8% of the variance in employees job satisfaction. Organizational factors explained the largest amount of the variance (94.3%), followed by job, social and individual factors. With regards to organizational factors, management and supervision explained the largest amount of the variance, followed by promotion, task requirement, security, and salaries and benefits. Organizational commitment Employees were moderately committed to their organizations, with a mean global score of 3.98 + 0.68 on a six-scale. The overall scores ranged from 2.05 to 5.67 (possible range 1 6). Organizational commitment was low, medium, high and very high in 9.1, 41.7, 43.7 and 5.5% of hospital employees. The mean score of affective, continuance and normative commitment were 3.86 + 1.12, 3.97 + 0.73 and 4.13 + 0.64, respectively. The employees organizational commitment in therapeutic and diagnostic departments was less than administrative and ancillary departments. The differences between values were statistically significant (P, 0.001). Total organizational commitment scores were not different among the six hospitals (P ¼ 0.54). Some demographic variables were related to one or more of the three commitment measures. Significant differences were obtained between employees organizational commitment and their marital status, age and years of work experiences, type of employment and salaries received (P, 0.03). Married (as opposed to single) employees have shown more affective, continuance and normative commitment. Age and tenure were related to affective and normative commitment. A negative association was seen between employees organizational commitment and their educational levels (r ¼ 20.156, P, 0.001), such that those with fewer years of education revealed more continuance commitment. This could be explained by external factors, if there are fewer opportunities for finding suitable or better jobs outside the organization. In correlation analysis between organizational commitment and its three dimensions, affective, continuance and normative commitment, respectively, had positive and the highest effect on employees organizational commitment in that order. The results of the simultaneous multiple regression model indicate that organizational, social, job and individual factors overall explained 44.7% of the variance in employees organizational commitment. Organizational factors explained the largest amount of the variance (33.3%), followed by job, individual and social factors. With regards to organizational factors, management and supervision explained the largest amount of the variance, followed by organization policies and job 220

Relationship between job satisfaction, organizational commitment and turnover intention Table 8 Inter-correlations between job satisfaction, organizational commitment and intention to leave the organization 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1. Overall job satisfaction 2. Salaries and fringe benefits 3. Recognition and promotion 4. Management and supervision 0.648 0.785 0.642 0.794 0.423 0.626 5. Co-workers 0.578 0.238 0.282 0.506 6. Task 0.743 0.362 0.474 0.615 0.567 requirement 7. Working conditions 0.549 0.304 0.370 0.333 0.198 0.258 8. Nature of job 0.675 0.295 0.425 0.457 0.447 0.577 0.296 9. Organization 0.610 0.330 0.487 0.411 0.222 0.372 0.390 0.315 policies 10. Job security 0.773 0.415 0.563 0.606 0.358 0.494 0.507 0.429 0.551 11. Organizational 0.637 0.332 0.433 0.510 0.441 0.508 0.244 0.561 0.372 0.436 commitment 12. Affective 0.690 0.341 0.474 0.546 0.564 0.543 0.292 0.565 0.437 0.501 0.923 commitment 13. Continuance 0.326 0.185 0.210 0.310 0.229 0.271 0.069 0.299 0.145 0.273 0.690 0.453 commitment 14. Normative 0.328 0.140 0.187 0.203 0.308 0.290 0.149 0.397 0.153 0.231 0.669 0.525 0.303 commitment 15. Intention to 0.452 0.233 0.284 0.303 0.212 0.290 0.209 0.233 0.382 0.348 0.436 0.462 0.245 0.198 leave 16. Recommending 0.617 0.406 0.488 0.467 0.287 0.424 0.299 0.349 0.368 0.396 0.435 0.497 0.245 0.149 0.431 the organization for work to others Correlation is significant at the 0.05 level Correlation is significant at the 0.01 level 221

Health Services Management Research security. Employees characteristics explain a lower degree of variation in commitment. This is primarily the result of the effect of the employee s age and education. Relationships between job satisfaction, organizational commitment and intention to leave Table 8 shows the correlations between these three variables. As can be seen, there is a positive correlation between job satisfaction and organizational commitment (rs ¼ 0.637, P, 0.001) indicating that those employees who are more satisfied with their job are also more committed to the health-care service. This study observed an asymmetric relationship where satisfaction had a stronger effect on commitment than the reverse. The relationship running from satisfaction to commitment is much stronger than the relationship running in the other direction. The positive correlation between intention to leave and organizational commitment (rs ¼ 0.436, P, 0.001) and job satisfaction (rs ¼ 0.452, P, 0.001) indicates that those who are less satisfied with their job are less committed to their organization. The influence of external factors needs to be investigated further, particularly with respect to normative and continuance commitment. Furthermore, correlation analysis revealed that job satisfaction dimensions such as nature of the job, management and supervision, task requirement, co-workers, job security, and recognition and promotion had more effect on employees organizational commitment. Nature of the work, co-workers, and management and supervision had the most effect on affective commitment. Management and supervision, nature of work and job security had the most effect on continuance commitment. Finally, nature of the job and co-workers had the most effect on normative commitment. On the other hand, affective commitment had more effect on employees job satisfaction. Employees job satisfaction and commitment are significant predictors of turnover intention. The results of the simultaneous multiple regression model indicate that together, these two variables explain 22.5% of the variance in employees turnover intention. Job satisfaction explained the largest amount of the variance (19.2%) followed by commitment. Figure 2 Relationship between job satisfaction, organizational commitment and turnover intention Organizational factors explained 14% of the variance in employees turnover intention (Figure 2). Factors that have a significant impact on intention to leave are affective commitment, job satisfaction, organizational policies, job security, management and supervision, recognition, amount of salaries received and the department in which the employees work. Factors that have a significant impact on recommending the hospital to others by employees as a good place for work are job satisfaction, affective commitment, recognition and promotion, management and supervision, amount of salaries and task requirement. Discussion This study set out to assess the degree of job satisfaction and organizational commitment among Iranian hospital employees and examine the relationships between those variables and employees turnover intention. From the results of this study, the job satisfaction level of hospital employees can be seen to be in a medium scale, mainly because of salaries and benefits, working conditions, recognition and job security. It is recommended that particular attention be given to improve employees job satisfaction by addressing these issues at the managerial level. This study confirmed a positive relationship existing between job satisfaction and organizational commitment. Findings revealed that employees who were more satisfied with their job had higher levels of organizational commitment. The result supported Hypothesis 1 that job satisfaction is positively related to organizational commitment. This finding is consistent with the findings of other previous studies 20 22 in health-care settings. Furthermore, job satisfaction and commitment were significantly 222

Relationship between job satisfaction, organizational commitment and turnover intention associated with employees intention to leave. The results do not support Hypothesis 2 that there is a negative relationship between turnover intention and employees job satisfaction and commitment. This may be due to external factors, such as job market conditions and workforce mobility, which may influence perceived opportunities for career advancement elsewhere. Several researchers have concluded that employees job satisfaction generally and in health-care organizations is shown to be correlated with age, gender, marital status, number of children, educational level and work experience (years). 37 44 In this current study, variables such as employees age, gender, marital status, work experience years, organizational position, education level, type of employment and salaries received, and benefits were seen as having significant effects on their job satisfaction. A higher level of job satisfaction in illiterate employees may be due to the fact that most of these individuals are old and have been working in the hospitals for many years. Therefore, they are receiving higher pay because of their length of service and the privileges that this brings. Also, they do not do difficult jobs in hospitals. However, their younger colleagues who do not have higher education, have to do the hard and nonprofessional jobs in hospitals, such as working in the laundry, cleaning patients rooms and so on. The U-formed relationship between age and seniority and job satisfaction requires two kinds of explanation. Among younger employees, a higher level of satisfaction may be due to the fact that inexperienced employees have fewer duties and responsibilities, less pressure and fewer demands from colleagues. They may also be less exposed to work-to-family conflicts. Among older employees, higher satisfaction could be explained by a better knowledge of hospital working, by benefits linked to seniority and by fewer external demands. It is also possible that older employees refocus their priorities to factors outside the work setting, such as family and/or planning for retirement. The current study showed that promotion opportunities were another significant predictor of job satisfaction and organizational commitment among study participants. The greater the chances are for advancement within the organization, the higher it is likely to be the level of organizational commitment and job satisfaction expressed by the employee. This finding is consistent with other studies that have shown that the opportunity for personal and professional growth and achievement is one of the best predictors of job satisfaction and organizational commitment. 40,43,45 Unfair promotion policies perceived by employees may negatively impact their organizational commitment. It is therefore, recommended that managers provide equal promotion opportunities for employees. Management should put in place localization programmes and initiatives that would promote employees to key positions and increase their involvement in decision-making. Such steps will help to increase the level of job satisfaction and commitment. Tenure was significantly related to affective and normative commitment. When the experience increases, commitment will rise as well; but there is an exception in employees with one to five years of work experience. Employees in the first year of their job career are highly committed to their organization, especially because of continuance and affective commitments. The employees enter their organizations with great expectations, but when they realize that they may have overestimated what they might be able to achieve, their commitment may decrease. Marital status was related to commitment, especially affective commitment, as married employees demonstrated more emotional attachment than single employees. This could again reflect a tendency for married employees to be more family-oriented and see the organization as a kind of family provider, as opposed to single employees who, being more self-oriented, may view the employing organization only as a source of income and therefore feel less emotionally attached to it. Education also showed a significant negative correlation, such that those with fewer years of education revealed more normative commitment. These findings are also consistent with several studies in which education was found to have an inverse relationship with organizational commitment. 34,46 Amount of salaries was correlated with continuance commitment. Employees with permanent contracts notified higher levels of job satisfaction and organizational commitment than temporary 223

Health Services Management Research employees. These findings suggest that types of employment may have an independent effect on employees job satisfaction. Further research is necessary to overcome various shortcomings of this study, and to assess the role either job security or level of income and social protection. This study also demonstrates that those employees who work with patients had less job satisfaction and as a result less commitment. Employees working in cardiology, psychiatry, pathology, obstetric, urology and paediatric wards had less satisfaction. Job rotation could possibly be a good strategy for improving job satisfaction of these employees. Lower levels of job satisfaction in employees working in the medical record department is likely due to the specific nature of the jobs they perform. Automation is not used in these hospitals and these employees have to perform their tasks manually. Documentation, repetition of duties and low salaries are the most important sources of dissatisfaction of employees in this department. It is recommended that management use job enrichment as a motivational strategy to satisfy these employees. Another major finding as the cause of employee job dissatisfaction is the lack of respect and recognition they receive from hospital management. Recognition and respect are highly important, especially for employees who are in direct contact with patients, families, peers and other health-care team members. Respect and recognition from managers for good performance is vital in increasing job satisfaction and is central to boosting commitment. It is interesting to mention that employees expectations about their jobs in private hospitals are greater than in public and semi-public hospitals. Type of organization shapes the employees expectation. Employees in public hospitals know about the limitations and difficulties in their organization, so will modify their expectations and demands. The strongest direct predictors of intention to leave, based on this study, are low organizational commitment (particularly affective commitment), lack of job satisfaction and its dimensions (especially organizational policies), lack of job security, and management and supervision. Thus, managers should try to improve employees commitment by increasing their job satisfaction and thus reduce their intention of leaving the organization. Conclusions In a cross-sectional study, the relationship between employees job satisfaction and organizational commitment, and their turnover intention in Isfahan Hospitals, Isfahan, Iran were explored. This study revealed a positive relationship between employees job satisfaction and organizational commitment, and a relationship between job satisfaction, commitment and intention to leave the organization. This research has found that job satisfaction and organizational commitment appear to be predictors of turnover intention but moderating factors, such as individual and cultural characteristics, play a significant role in both turnover intention and actual turnover. The findings show that hospital employees are moderately satisfied with their jobs. Factors that may influence the level of employees job satisfaction are demographic variables of gender, age, marital status, education, years of work experience, organizational position, monthly salary, type of employment, type of hospital, employees organizational commitment (and its three dimensions) and the nine subscales of job satisfying factors, as indicted in Table 5. Management and supervision, recognition and promotion, job security and task requirement are the best predictors of job satisfaction among hospital employees. Specific job satisfaction dimensions indicate that highest dissatisfaction level occurs in the area of working conditions, salaries and benefits, recognition and job security. Thus, areas of dissatisfaction can be interpreted as signals that change is needed. The findings also revealed that hospital employees are moderately committed to their organization. Factors that may influence the level of employees organizational commitment are demographic variables of gender, age, marital status, education, years of work experience, monthly salary, type of employment, employees job satisfaction (and its nine dimensions) and the three subscales of organizational commitment dimensions. Affective, continuance and normative commitment are the best predictors of organizational commitment among hospitals employees. Implications for management There are several practical implications that can be derived from our findings. As job 224