Organizational Commitment and its Predictors among Nurses Working in Jimma University Specialized Teaching Hospital, Southwest Ethiopia

Background: The idea of organizational commitment has intuitive appeal because of the relationship of commitment to turnover, absenteeism, and organizational performance. All of these are important to healthcare executives who are attempting to stabilize a nursing workforce in the presence of a growing nursing shortage. Objective: The objective of the study was to determine the level of organizational commitment of nurses and its predictors among Jimma University specialized teaching hospital nurses, Southwest Ethiopia. Methods: Institution based cross-sectional study design was conducted in Jimma University Specialized Teaching Hospital from March 2 to March 18, 2016 and systematic sampling technique was used to select a total of 242 study subjects. Data were collected using self-administered questionnaire and entered to Epi data version 3.1 and analyzed using SPSS version 16 software. One-way analysis of variance, independent sample T-tests and Multivariable linear regression analysis was conducted to identify predictors of organizational commitment and significance was checked at p<0.05. Results: The respondents mean score of organizational commitment was 70.45 ± 8.22 and only 72 (32.9%) of the nurses score high level of organizational commitment. The independent t-test and One-way analysis of variance result revealed educational status and working ward were significantly associated with organizational commitment. The multivariable linear regression showed that perceived organizational support (ß=0.482, p<0.001), interpersonal relationship (ß=0.303, p=0.008), job satisfaction (ß=0.059, p=0.027), transformational leadership behavior (ß=0.165, p<0.001), educational qualification (ß=-1.860, p=0.02) and working ward (ß=-0.585, p=0.018) were significant predictors of organizational commitment among nurses. Conclusion: The organizational commitment levels of nurses were low. Job satisfaction, perceived organizational support, transformational leadership behavior, interpersonal relationship, and working in ICU and OR are significant predictors of organizational commitment. Recommendation: Human Resource Management, CEO and Nursing Leaders of JUSTH shall participate nurses in managerial decision making, using improved communication skills and give appreciation for their contributions to the organization. Citation: Israel B, Kifle W, Tigist D, Fantahun W (2017) Organizational Commitment and its Predictors among Nurses Working in Jimma University Specialized Teaching Hospital, Southwest Ethiopia. Prim Health Care 7: 262. doi: 10.4172/2167-1079.1000262


Introduction Background
Organizational commitment is defined as "the relative strength of an individual's identification with and involvement in a particular organization" [1]. Others described as employee's belief in the goals of the organization and determination to remain a part of the organization [2]. It is further conceptualized by the following three factors: "a) a strong belief in and acceptance of the organization's goals and values; b) a willingness to exert considerable effort on behalf of the organization; c) a definite desire to maintain organizational membership". It could also be referred to as the extent to which an employee develops an attachment and feels a sense of allegiance to his or her employer [3].
As cited by Mullins [4], committed employees in any organization must possess three major characteristics: sense of belonging to the organization, sense of excitement in the job and confidence in management leadership. One of the challenges facing modern organization involves maintaining employee commitment in the current working environment [5,6]. Studies have reported that nurses were more content with their work if they were committed to the believes, values and practices in the organization [7,8]. However, they are uncomfortable with job satisfaction, perceived organizational support, transformational leadership behavior and level of education [9].
Health service delivery is affected by human resources, service delivery system and infrastructures and cannot function effectively without sufficient, skilled, motivated and supported in health system performance [10,11].
Nowadays, in hospitals Nurses, are the largest group of professionals and that carry out the overall hospital activities, play an important role in determining the quality and cost of healthcare in their organizations' performance [12,13]. Nursing shortage is a major problem in the healthcare setting throughout the world and it is b/c of high turnover rate in the healthcare industry and this is significantly related with organizational commitment of nurses [14]. Researches on staff nurses suggested that organizational commitment indirectly influences turnover through its direct effect on antecedents of turnover, such as intent to leave [15,16]. Contemporary studies have continued to report a statistically significant relationship between organizational commitment and turnover behaviors in staff nurse populations [17].
In order to deal with nurses' turnover, most of the healthcare organizations increase the recruitment and retain nurses to maintain adequate staffing. Although increasing recruitment of nurses may help to offset the problem of nursing shortage in the short term, retaining them may be the best strategy in the long term because a healthcare objective is to maintain high quality of care at reduced costs. Among the factors that contributed to high retention, organizational commitment has been found as an antecedent [18][19][20].
Nurses enumerated different major factors that contribute to their commitment to the organization: perceived organizational support, transformational leadership behavior, relationships and interaction opportunities for learning, job satisfaction, a plan to retire from the organization, monetary benefits, patient care, co-workers, cultural factors, and job security, were related with level of organizational commitment [2,21,22].
There is a lack of research specifically related to level of organizational commitment and factors that predict nurses' commitment to the organization in Ethiopia. This study addresses this gap by identifying predictors of organizational commitment among staff nurses. It is also important for other researchers as a base who wants to investigate in different health institutions. This research might also offer managers insight into strategies for practices to improve nurse's organizational commitment, staff retention, job satisfaction, and performance.
The outcomes of this assessment would help to Jimma University, JUSTH administrators, and FMOH in drafting policies and guiding principles of nursing leadership in Ethiopia as well as for nursing leaders and staff nurses in providing information to confirm their organizational commitment and to examine factors associated with it. The objective of this study is to assess organizational commitment and its predictors among nurses working in Jimma University Specialized Teaching Hospital, southwest Ethiopia from March 2 to March 18 ( Figure 1).

Methods and Materials
The study was conducted in JUSTH, Jimma, Oromia Regional state from March 2-March 18, 2016. Jimma is the town of Jimma zone which is one of 18 zone of the Oromia Regional State found at 352 km from Addis Ababa, the capital city of Ethiopia, in the South western part of the country. There are two public hospitals found in the town which are called JUSTH and Shenen gibe hospital.
Jimma University specialized teaching hospital is one of the oldest public hospitals in the country. Geographically, it is located in Jimma city 352 km southwest of Addis Ababa. Currently it is the only teaching and referral hospital in the southwestern part of the country, providing services for approximately 15000 inpatient, 160000 outpatient attendants,11000 emergency cases, and 4500 deliveries in a year coming to the hospital from the catchment population of about15 million people.
Jimma university specialized teaching hospital is committed to reduce morbidity, mortality, disability and improve health status of the local people through providing a compressive package of high quality curative, preventive, promotive and rehabilitative health service to the public and providing clinical education to the next physicians, nurses, medical laboratory technologists, pharmacists and other clinical and public health students in collaboration with respective stakeholders It has a total of 1448 servants from which 861 are technical staffs and the remaining 587 are supportive staffs. From the technical staffs 242 physicians, 497 nurses, 45 midwives, 53 pharmacist, 48 laboratory technologist, 7 psychiatric nurses, 5 ophthalmic nurses, 2 dental nurses, 8 radiographer and the remaining 4 are M.Sc. Nurses professionals.
Facility based cross-sectional study design was employed. Sample size was determined using single population estimation formula with assumption of 95% confidence interval, 5% and considering the 50% proportion. Considering non-response rate of 10%, final total sample sizes was 242 and simple random sampling technique using lottery method was employed.
All Nurses who are served for six months or more in the hospitals at the time of the study and willing to participate was included and who were not available during data collection time due to Annual leave, maternal leave and sick leave were excluded.

Data collection procedures
To collect the data, self-administered structured questionnaire was used. Some of our tools were developed after review of different literatures [24].

Instrument
The organizational commitment scales was adopted from Stephen Jaros and originally it was developed by Meyer and Allen's [25] three-component model of organizational commitment, The job satisfaction and interpersonal relationship items was adapted from and these items will be answered on a five-point Likert scale with response options ranging from 1 (very dissatisfied) to 5 (very satisfied) and the perceived organizational support items was adopted from Format for the 8-itemSurvey of Perceived Organizational Support developed by Robert and Rubin [28] and this is also on a five point liker scale and the transformational leadership behaviors items was adopted [24][25][26][27][28][29].

Data analysis procedure
Data were checked for completeness, reversely coded items were backed, edited and entered into EpiData version 3.1 and exported to SPSS version 20.00 for analysis. The data were explored using descriptive statics such as frequencies to clean data. Scatter plots, skewness and kurtosis were examined to determine the shape of the data distribution.
On the basis of this information, data were determined to be fairly normally distributed, so no transformations were required but 3 items were found to be an outlier for organizational commitment score and left out of respective analysis. One-way analysis of variance (ANOVA) and independent sample T-tests were used for comparing organizational commitment scores across the categories. For descriptive purpose data driven classification was done on perceived organizational support, job satisfaction, interpersonal relationship and transformational leadership behavior score in to two (two tiles), i.e., good/poor perceived organizational support, satisfied/unsatisfied job satisfaction, good/poor interpersonal relationship and good/poor transformational leadership behavior.
Simple linear regression was done to see the independent effect of predictors on the dependent variables and multiple linear regression analysis was conducted to identify final predictors of organizational commitment after controlling other independent variables. Variables p ≤ 0.25 in simple linear regression were entered in the final model. Participant's characteristics, perceived organizational support, job satisfaction, interpersonal relationship and transformational leadership behavior were entered independently.
Finally, variables with P ≤ 0.05 were assumed to be statistically significant. The assumptions in linear regressions (linearity, normality and multicollinearity) were checked.

Data quality assurance
Five percent of the questionnaires were pre-tested in Shenen gibe Hospital to assess the reliability, clarity, sequence, consistency and understandability and the total time it takes to finish the questionnaire before the actual data collection. To check the reliability and validity of questionnaires for each category the Crohnbach alpha was employed, for organizational commitment (0.83), perceived organizational support (0.819), for job satisfaction (0.87), relationship and interaction (0.88) and transformational leadership behavior was (0.85). Then after, the necessary comments and feedbacks were incorporated in the final tool. Training was given for the data facilitators on the objectives of the study and the way of collection.

Ethical consideration
Ethical clearance and approval to conduct the research was obtained from Jimma University College of health science, Ethical Review Board. Then a letter was secured from the university to respective hospital management to gain support for the study. Prior to administering the questionnaires, the aims and objectives of the study were explained to the participants and personal consent was obtained from study participant after explaining the objective of study. They were also told that participation is voluntarily and confidentiality and anonymity will be ensured throughout the execution of the study as participants were not required to disclose personal information on the questionnaire.

Socio-demographic characteristics of the study participants
Out of the 242 distributed questionnaires 222 were collected from the respondents (9 questionnaires were unfilled, 3 questionnaires were not returned and 8 questionnaires were incomplete) giving the response rate of the study to be 91.7%. 3 outliers excluded from the analysis. From the study participants, 112 (51.1%) were male and 107 (48.9%) females. The participants' age ranged from 20 to 57 years with a mean age of 26.53 ± 5.057 years. One hundred thirty two (60.3%) were single and 87 (39.7%) married.
Regarding educational qualification, 114 (52.1%) of nurses were bachelor degree holders and only 2 (0.9%) were masters. They had work experience ranging from 1 year to 33 years with a mean of 4.33 ± 4.87years and 211 (96.3%) of them worked <10 years. Their monthly salary ranges from 1254 EBR to 8000 EBR with a mean of 2648.21 ± 1132.956 EBR.

Level of organizational commitment among nurses
The respondents mean score of organizational commitment was 70.45 ± 8.22, ranging from (44-99). From the given organizational commitment items (based on tertiale analysis); 71 (32.4%) of the respondents scored low level of organizational commitment; value ranging from (44-66), (34.7%) of them scored moderate level of organizational commitment; value ranges from (67-73) and only 72 (32.9%) of the nurses scored high level of organizational commitment; value ranges from (74-99) ( Figure 2).
From the organizational commitment scale items" I think that people these days move from company to company too often "had maximum score frequency for agree (80 times) but this organization has a great deal of personal meaning for me had a minimum frequency of strongly agree ( Figure 3).
Mean score were compared between marital status, educational status and sex category using independent sample t-test in relation to the "organizational commitment scale"-i.e. a higher score indicates a higher level of organizational commitment, and the result showed that diploma holder mean score 72.0194 (SD=6.8599) was significantly higher than the mean of BSC degree and above holders mean score 69.0603 (SD=9.07101 at t=2.696 and p=0.008).
But, there were no significant mean difference seen between sex and marital status ( Table 2).
Also mean scores were compared using one way ANOVA among different working ward groups of nurses. Organizational commitment mean score differed significantly among the six ward groups =7.726, p<0.001 (Table 3).

Associations of organizational commitment and independent factors
In the perceived organizational support assessment items 116 (53%) of the respondents fail to have good perception of organizational support. The top two factors with which the respondents strongly disagree from the perceived organizational support were "The organization really cares about my well-being "and "The organization cares about my general satisfaction at work". The top two strongly agree were" The organization fails to appreciate any extra effort from me" and "The organization takes pride in my accomplishments at work".
In job satisfaction assessment items (50.7%) of the respondents were not satisfied. The top two factors with which the respondents strongly disagree from the job satisfaction items were" "I am satisfied with the amount of pay I receive in comparison with people in other occupations" and" I am satisfied with the degree to which I am fairly paid for what I contribute to this organization". The top very satisfied was" I am satisfied with the amount of time spent talking with my patients".
In interpersonal relationship assessment items (52.5%) of the respondents were satisfied. "I am satisfied with the relationship I have with other health-care workers" was the top to be described as very satisfied and very dissatisfied.
In transformational leadership behavior assessment items (51.6%) of the respondents were fail to have good perception of transformational leadership behavior. The top two factors with which the respondents strongly disagree from the transformational leadership behavior items were "Our immediate boss re-examines assumptions" and "rewards our    achievement". The top strongly agree was "our immediate boss has my respect" (Table 4).

Initial model of predictors of organizational commitment among nurses
Fifteen predictors (including five dummy variables) were entered independently to see their independent effect on level of organizational commitment and out of these perceived organizational support, level of job satisfaction, level of relationship and interaction, transformational leadership behavior and working in ICU and OR ward were found to have a significant association with level of organizational commitment among nurses ( Table 5).

Predictors of organizational commitment among nurses
Variables with p-valve ≤ 0.25 in bivariate analysis were entered in the final model. In the model perceived organizational support, relationship and interaction, job satisfaction, transformational leadership behavior, educational status, working wards (ICU&OR and surgical ward) and salary were entered through enter method (Table 5).
Perceived organizational support was found to have a positive association with organizational commitment and it explains slightly over 22.6% of the variance in bivariate analysis. For a unit increase in mean perceived organizational support organizational commitment score increases by .482 times at p<0.001; those nurses who have positive perceived organizational support have increased level of organizational commitment than those nurses with negative perceived organizational support.
Relationship and interaction was also shows a positive association with organizational commitment and it explains slightly over 20.7% of the variance in bivariate analysis. For a unit increase in relationship and interaction organizational commitment score increases by 0.303 times at p=0.008.Those nurses who have a good relationship and interaction have increased level of Organizational commitment than those who have not a good relationship and interaction.
Job satisfaction was also having a positive association with organizational commitment and it explains about 33% of the variance in bivariate analysis. For a unit increase in job satisfaction organizational commitment score increases by 0.059 times at p=0.027. Satisfied nurses have increased level of organizational commitment than those who were not satisfied.
Perceived Transformational leadership behaviors of managers have a positive association with organizational commitment and it explains 31.2% of the variance in bivariate analysis. For a unit increase in perceived transformational leadership behavior of managers organizational commitment score increases by 0.165 times

Discussion
This study was carried out with the aim of determining the level of organizational commitment and its predictors among nurses. The study findings point to low level of organizational commitment among the studied nurses which is not similar as compared with findings in other studies [2,20]. Only about 72 (32.9%) of the nurses had a high level of organizational commitment. A number of factors might explain this low level of organizational commitment. These are related to perceived organizational support, relationship and interaction, job satisfaction, perceived transformational leadership behavior and other work related factors and they are discussed in the following sections.
The result of the current study revealed low level of organizational commitment among nurses which was inconsistent with studies done in Malaysia using Meyer and Allen organizational commitment scale [25]. This discrepancy might be due to poor working environment and the attention given to nurses is low by the hospital management.
It's known that low level of organizational commitment leads to negative outcomes including increased staff turnover and decreased productivity of the organization [14,15]. It also affects retention of experienced nurses which serve the organization well and this may in turn affect the organization's objective of maintaining high quality of care at reduced costs [17][18][19]. In our countries 5 year health related GTP where health care organizations are required to strive to deliver quality of care and improve patient satisfaction and as a whole achieve the health related goals of the plan the importance of committed and devoted health personnel is very important. But, we cannot achieve all these goals by having nurses with low level of organizational commitment which takes the majority of health team in any health care settings.
With the increment of committed nurses to their organization, their roles will expand and as a result work environment will also change; the quality of nursing application in the hospital will increase and patient care will be enhanced. So, Jimma University Specialized Teaching Hospital may implement different strategies to increase organizational commitment among nurses.
Qualification of nurses was not a significant predictor of organizational commitment. Even if qualification is not a predictor of organizational commitment there is a significant mean difference between the two groups (BSc and above holders have lower organizational commitment score than diploma holders with p=0.008). This finding was inconsistent with that of a previous study conducted in USA and Tanzania and both stated that the nurses with higher educational levels showed a higher level of organizational commitment and the discrepancy might be no role difference between the two categories (the same job description) and this leads to BSC holders have lower scorer than diploma holders [9,13].
Working ward was a significant predictor of organizational commitment. Organizational commitment score decreases for those working in Intensive Care Unit (ICU) and Operation Theatre Room (OR) than other wards, their scores being 0.3620 times lower than those nurses working in other wards (p=0.004). This finding is consistent with that of a study conducted in Jordan that stated nurses working in ICU showed lower level of organizational commitment [30]. In our situation the benefit gained from working in ICU and OR is much less when compared to the burden they face and it might be this reason that contributes to this phenomenon.
So it is important to develop strategies that foster organizational commitment of nurses working in these highly burdened wards (units).
Perceived organizational support is another significant predictor of organizational commitment (p<0.001). The overall R square of 0.226 indicated that over 22% of the variance in organizational commitment could be explained by perceived organizational support. This result is consistent with a study conducted in Slovenia and USA showed that perceived organizational support was significant and substantial predictor of organizational commitment explaining much of the variance in organizational commitment [2,9].The possible explanation is that, , if employees didn't feel empowered by their managers, they will likely have more negative working relationships with managers, which would be expected to negatively influence trust, increase conflict and lead to lower employee commitment toward the organization.
In the present study, there was no significant difference in organizational commitment score with nurse's age and experience which was inconsistent with the finding in Tanzania revealing both age and experience statistically significantly associated with organizational commitment. The findings of their research shows that the young (20-30 years) group nurses are more committed than the elder ones and in addition, less experienced nurses (1-10 years) showed to be more commitment [13]. The reason behind this discrepancy might be in our context the less experienced and younger nurses are always striving to get better job and they repeatedly move from one organization to the other compared to the older most of them have a family and not want to leave the organization.
The other findings from this study were transformational leadership behavior which was found to be significant predictor of organizational commitment at (p<0.001). The overall R square of 0.315 indicated that slightly over 31% of the variance in organizational commitment could be explained by transformational leadership behavior in bivariate analysis. The result of this study was consistent with researches done in Slovenia and USA which showed Significant positive correlation between organizational commitment and transformational leadership behaviors [2,9].This might be if nurses are believed that they are not treated well by their immediate leader they believe they are not part of the organization and not devote their time for the organization.
Job satisfaction was also found to be significant predictor of organizational commitment at (p=0.027).When mean job satisfaction increases by 1 unit mean organizational commitment is increased by 0.058 times. The result of this study is consistent with research done in Malaysia showing components of job satisfaction could explain 33% of variability in the organizational commitment among nurses in state hospitals of Malaysia [20]. The major reasons might be longer shift work, lack of motivation, insufficient resources and supplies, poor infrastructure, and inadequate human power.
The other finding from this study was relationship and interaction which was found to be significant predictor of organizational commitment (p<0.001). The overall R square of 0.333 indicated that over 33% of the variance in organizational commitment means score could be explained by relationship and interaction. Those nurses who have satisfied with their relationship and interaction scores 0.291 times more on organizational commitment score than from the unsatisfied ones (p=0.01) and this is consistent with the findings in Slovenia (r=0.730, p<0.001) [2].The possible explanation might be collaborative and trusting relationships with supervisors and co-workers have consistently been linked to organizational commitment specifically among nurses.
This study also showed that marital status and sex is not a predictor of organizational commitment in JUSTH, Which was consistent with the study conducted in kingdom of Saudi Arabia, showed that there was no significant relationship between organizational commitment and these two variables [12].

Limitations of the study
The finding of this study is limited to teaching hospital. Therefore the finding may not be generalized to nurses working at health centers, district hospitals and referral hospitals. There is also limitation of literature on this topic in our country because of this reason comparison of the results was done with other countries where the health institutions setup, health policy and other factors are quite different. Since it is organizational research there is also social or cultural desirable bias.

Conclusion
The results of this study indicate that the organizational commitment levels of nurses are at a low level and factors associated with this were; working wards, perceived organizational support, interpersonal relationship, job satisfaction and transformational leadership behavior. The finding of this study adds a small but essential piece to the puzzle of how to increase organizational commitment of nurses in Ethiopia.

Recommendations
Nursing director, Human Resource Personnel and CEO's of the hospital should develop various strategies to increase organizational commitment of nurses. It will be important if Human Resource Management, CEO and Nursing Leaders of JUSTH shall involve(participate) nurses in, decision-making processes and establish appropriate reward systems as such measures can result in the increment of level of commitment of nurses to the organization. The hospital management must give necessary support to nurses how they are important to this organization through close supervision, meetings and give appreciation for their contributions to the organization.
Hospital management must reform and continuously improve hospital organization through the effective use of leadership within teams and using improved communication skills. So, the hospital management should take necessary measures for the optimal provision of intrinsic and extrinsic job rewards to make their core workforce highly satisfied and committed. Further research is needed to examine the predictive ability of other variables such as empowerment on organizational commitment. As a general recommendation; these findings indicate that leaders in Jimma University, Jimma University Specialized teaching hospital and Ministry of Health should initiate policies and encourage programs for the development of organizational commitment of nurses.