Factors Affecting Nurses ’ Perceived Organizational Commitment : A Qualitative Study

Objective: Nurses’ organizational commitment is one of the most important factors that facilitates their professional evolution and influences the method of care provision, quality of care, and patients’ satisfaction. The aim of this study was identified the factors that affect nurses’ perceived organizational commitment. Material and Methods: This qualitative study, conducted on 16 clinical nurses employed in Social Security Hospital of Khorramabad, Iran, during five months from May to September 2015, used deep semi-structured interviews. Purposive sampling method was used for the selection of nurses and the data were analyzed using conventional qualitative content analysis. Lincoln & Guba’s criteria were used to secure data accuracy and stability. Results: Sixteen subcategories, five categories, and three themes were distilled during content analysis process. The abstracted themes included “organizational factors”, “occupational challenges”, and “contributory management”. Conclusion: Our findings showed that numerous factors present in nurses’ profession and work environment may influence the rate of nurses’ interest and commitment in the hospital and the related organization. Hence, nurse managers can foster the promotion of nurses’ organizational commitment through creating the required suitable conditions.


Introduction
Today, attention to organizational human resources and their performance are rendered as one of the most important organizational success in achieving the set goals [1][2][3] .The managers of these organizations also investigate the organizational concern and commitment of the personnel to assess the organization's performance as they believe that organizational commitment plays a vital role in fulfilling the goals of the organization [4][5][6] .
Organizational commitment forms the attitude and approach of the personnel towards the organization and provides managers with useful information on planning, organizing, and increasing efficiency, efficacy, and performance 1,[6][7] .Moreover, a responsible manpower prepares the conditions for the growth and development of the organization [8][9][10][11] .On the contrary, an irresponsible staff would lead to reduced outcome and performance 12 lack of contribution to organizational affairs, lack of occupational motivation 13 , and no inclination for remaining in the organization culminating in work leave and unfulfilled organizational goals 14 .Nowadays, many organizations including hospitals are involved in challenging the diminished organizational commitment of their staff 5,[14][15] .The problem of nurses' reduced organizational commitment manifests itself as issues like decreased motivation and occupational satisfaction [13][14][15] , reduced performance 5,11,16 , that all leading to increased percentage of nursing medical errors, jeopardized patient safety 3,5,13 , and increased length of hospital stay and re hospitalization 14,17 , diminished patient satisfaction with services, and fostered treatment costs, all predisposing to low quality of care 3,16 .The level of nurses' organizational commitment may affect the quality of nursing care, manner of care provision, and patients' satisfaction with care 18 .It has been shown that due to the undeniable effect of organizational commitment on care quality, an exploration of influential factors as a basis for fundamental decision-making by nursing managers is of utmost significance 13 .Nursing managers can take giant strides in promoting nursing care provision through recognizing the factors affecting organizational commitment 19 .It has been recommended that organizational, contextual, and individual factors on organizational commitment should be considered by nurses and nursing managers in their assessment 20,21 .Indeed, organizational commitment is an allinclusive concept in organizational efficiency, efficacy, and effectiveness of the organizational outcome and output forming the sine qua none of the organizational success 14,[20][21] .The level of organizational commitment may predispose to numerous consequences affecting positively the fulfillment of organizational goals and objectives 1,3,22 .Hence, the identification and categorization of these factors enjoy specific impetus.
The results of most studies conducted so far indicates that the level of organizational commitment is influenced by several factors requiring an understanding of nurses' attitudes and approaches; nonetheless, most of these studies have focused on the concept of organizational support, attitudes, the related behaviors, consequences.While a survey of these factors necessitates deeper studies with a greater emphasis on nurses' experiences, attitudes, and perceptions.Consequently, the aim of this study was to explore the factors affecting organizational commitment perceived by Iranian nurses.

Material and Methods
This qualitative study was carried out on the basis of conventional content analysis method using semistructured deep interviews to identify and describe the factors affecting organizational commitment.The study was conducted where the phenomenon occurred.Given the maximum possible diversity between the terms and conditions of work in hospitals, the study hospital was affiliated to Iranian Social Security Organization in Khorramabad, western Iran.This hospital is non-governmental non-teaching social security hospital which has been established to treat the patients covered by social security insurance as the greatest healthcare insurance company in Iran.Participants were selected from among all the nurses in the hospital at all levels (nurse managers, supervisors, headnurses, and nurses) via purposive sampling and maximum variability because informationrich samples can significantly facilitate an in-depth study to advance the core objectives.The inclusion criteria were consent to participate familiarity with organizational commitment, holding at least a BS in nursing, a one-year experience of hospital work, and willingness for participation in the study.At any point of the study, nurses who were unwilling or had the inability to continue their participation were excluded.At first, the general details of the research were approved by the Committee of Ethics in Research at Shahid Beheshti University of Medical Sciences in Tehran, Iran, under ethics code: SBMU2.REC.1394.103.Subsequently, the hospital's permission was obtained and the researcher was introduced to the wards.Informed written consent was obtained from each participant.After making contacts with the participants and introduction of the researcher to them, the details of interview methods were explained to them.The participants were ensured that all personal information and interviews would be kept confidential.Then, the researcher commenced the interview with one participant by asking one general question about their experiences with and perceptions of organizational commitment and the factors that affect it.The interview guide included: "What has made you remain in the system?", "What factors discourage you from working in the hospital?","what are the consequence of having commitment to hospital?".Then, probing questions were employed in order to deepen and enrich the data like: "Can you tell me more about that?"According to the result of the interview data, the probing questions for co-construction of the next interview were revised.
Interviews had more flexibility and were carried out in an informal or non structured style at any time required.All interviews were conducted faceto-face apart from ward in a private secluded area of the hospital office which was comfortable quiet and private for most nurses.All the interviews were recorded by a digital voice recorder.Immediately after each interview, the audio files of the interview were transcribed verbatim to maintain the integrity of data and reduce researcher bias.The duration of interviews varied from 30-65 min depending on the conditions and interest of the participants, experiences and perceptions.The average length of each interview was 47 min.Generally, data collection lasted 5 months from May 2015 to September 2015.Data saturation was achieved at the completion of the 14 th interview.However, for the greater rigor of the data, two additional interviews were performed to make sure that no new codes or classes would emerge.To ensure of the accuracy of the obtained data, two other nurses were interviewed again.Therefore in the final analysis, 18 interviews were conducted with 16 participants.No participant left the study till the end of the research process.

Data Analysis
After verbatim transcription of interviews data were analyzed utilizing content analysis with a conventional approach 23,24 recommended by Graneheim & Landman's 25 .Accordingly, data analysis began through the reading of all transcripts repeatedly to obtain a sense of the whole and achieve immersion.Thereafter, the data were read word by word, and the texts reflecting the participant's experiences of organizational commitment were obtained and brought together into on text, which created the unit of analysis.Then 'meaning units' were made which were then shortened.The 'meaning units' were abstracted, and notes of first thoughts, impressions, and initial analysis were made by the authors (open coding).Then by axial coding, different codes were sorted into subcategories, based on how they were linked and related.A process of discussion and reflection was developed to establish an agreement between authors on how to organize the codes in subcategories.Depending on the relationships between the emergent subcategories, fewer categories were created to group and organize subcategories into meaningful categories to form the manifest content.Finally, the concealed meaning or the latent content of these categories was formulated into one theme.The theme and categories from raw data were accurately investigated and revised via constant comparative method.To report the results, exemplars for each category were identified from the data.Lincoln and Guba's criteria were adopted to ensure the rigor and integrity of the data.(23, 24,  26).The following provisions were made by authors to promote credibility: prolonged engagement between the researcher and the participants, frequent report sessions between members of the research team, peer debriefing of the research project, and member checks.The data from interviews were reviewed after transcription and coding by the research team.Moreover, the full-text of transcribed interviews alongside in vivo codes (wordings use by patients in the interview) were made available to two participants in order to determine the appropriateness of transcripts of dialogues with the experiences of the participants.Then, three experts in the field of management nursing theories and qualitative studies were requested to examine the interviews, and observations, codes, subcategories, categories, and themes extracted, and if necessary, modifications were made based on suggestions and interpretation of data.Ethical Clearance: The study was approved by ethics Committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran; Nursing Manager of Iranian Social Security Organization, Khorramabad, Iran

Results
The participants included 3 males and 13 females with a mean age of 35.5 years.Most of them held a BS degree in nursing with a work experience of 1-20 years, had a rotating shift, and worked in general wards (Table 1).At first, 490 codes were extracted from the completed interviews.After merging, reduction, deletion, and integration of similar codes at diffident stages, the total number was reduced to 188 codes.Finally, there were 16 subcategories, 5 main categories, and 3 main themes including: "organizational factors", "occupational challenges", "and contributory management" (Table 2).Really, our job difficulty is not comparable to that of support staff "(p2).In nurses' perspective, performance evaluation and exercise of justice in it are very important."The evaluation system of personnel is very obsolete and impractical.Nurses could not be realistically evaluated by this method.Surely, the assessment is biased; it is not fair and even-handed"(p5).Another problem was the method of developing nurses' work schedule "Here, it is forbidden to be off for more than 3 shifts, to have integrated continuous shifts"(p8).

Occupational challenges
Occupational challenges refer to the problems experienced by nurses in their job as occupational burnout or the intention for leave."The nursing manpower is not really proportional to the ward activities and number of patients especially during the evening and night shifts.We do obligatory overwork, and we have little off time.All these exhaust the staff "(p4).Additionally, the participants believed that they spend much time to document the data."The writing of this amount of documents keeps us away from the patient's bedside.This is possible only if there is a standard patient-to-nurse ratio "(p11).The participants also believed that psychosomatic fatigue in nurses would finally lead them to "work leave" and early retirement requests."Considering this volume of workload, limited manpower, the obligation for observing the work standards, and great volume of documentations, all the staff thinks about escaping from the health system" (p1)."That is a pity that the experienced nurses who are skilled and efficient desire to leave the healthcare system "(p15).

Contributory Management
Another theme perceived by the participants was "contributory management".In their perspective, valuing the nurses, management style, contribution, and reciprocal interaction are important in team formation."Surely, I would not get interested in my work environment if my matron or head nurse did not appreciate me"(P2)."They should appreciate me.The manner makes no difference, that's enough to appreciate me and respect and value me"(P6).With respect to management style, explained: "The dictatorship method of management does not work well.The head nurse should be with nurses"(P10).Also, regarding managers' and nurses' contribution to the work environment, a nurse asserted: "The head nurses should benefit from the experience, knowledge, and science of the personnel in doing the ward affairs"(P13).Interaction between managers and nurses are necessary."Surely, the managers' ability to communicate and interact with nurses can greatly help us perform our duties"(p7).The participants further believed that a pleasant learning environment is one of the cornerstones of contributory and participatory management."We can perform our duties with greater awareness through theoretical and practical training.If so, we experience less stress and work with greater confidence"(p14)."The days of traditional management are gone the managers, too, should acquire the required managerial capabilities" (p14).

Discussion
The findings of the present study entail concepts that collectively demonstrate the nurses' real perceptions and experiences of factors affecting their organizational commitment.An analysis of the participants' experiences revealed that the nurses had perceived factors affecting their organizational commitment through organizational parameters, occupational challenges, and contributory/ participatory management.Regarding the domain of the present study, the participating nurses mentioned organizational factors as one of the most influential issues affecting their organizational commitment.They believed that among the organizational factors, the hospital setting including the physical space, welfare facilities and official rules and regulations can serve as a suitable factor for absorption, maintenance, and motivation of nurses, organize the work system, and reduce their fatigue and lack of confidence towards their work environment.While the inappropriacy of these conditions create many mental challenges for them; leading to their diminished work interest and dependence among the hospital personnel.Therefore, nursing managers are required to make their best efforts to create the most suitable organizational conditions and factors as far as possible establishing a strong and reliable rapport between the nurses and the related organization to promote their organizational commitment.The findings of several studies have suggested that the existence of hospitals with proper, attractive 4,26,27 , lawful organized 28 , and disciplined environment with acceptable satisfying welfare facilities functions as a leading factor in attracting and maintaining the professional personnel and their dependence on the profession and hospital [29][30][31] .Conversely, hospitals with unattractive milieu, low quality welfare facilities 28 , and/or stringent, tough, and inflexible rules and regulations may serve as a negative factor reducing the attraction of the hospital setting for the nurses and their maintenance 32,33 .Lack of justice and the exercise of discrimination in payments in the presence of hard nursing work, the effect of method of nurses' performance appraisal and work shift programming serve as three important influential factors in the nurses' remaining in the hospital.The correct implementation of these processes is mandatory for warranting the quality of care provision, reinforcement of positive performance, and improvement of the rapport between nurses and nursing mangers.Modifying the current methods of assessment and the use of innovative methods of performance appraisal and work planning are rendered as a necessity for all nursing managers.
The findings of different studies confirms the point that exercise of injustice in payments 34,35 , inappropriate methods of personnel appraisal 36,37 , and scheduling the work shifts for nurses can potentially lead to reduced attraction of hospital setting for nurses [38][39][40] .Anyhow, the issue has a certain je ne Sais pas quoi that has to be resolved.Another finding was nurses' occupational challenges as factors that reduce organizational commitment.The nurses suffer from many occupational workplace problems like work overload, imposed occupational responsibilities, unusually numerous work shifts, toleration of continuous chronic stress, extreme amounts of documentation, inappropriate patientto-nurse ratio, occupational fatigue and burnout, reduced quality of patient care, and patients' and nurses' diminished satisfaction with the present situation; All these ultimately result in organizational loss of the skilled and experienced nurses leading to reduced satisfaction of the clients and nurses who have remained in the system.Thus, the hospital and nurse mangers are rightly required to determine the nursing policies of each hospital, revise the nurses' duties, provide appropriate patient-to-nurse ratio, provide a sufficient number of work shifts, create suitable working conditions, and interact properly with nurses to reduce their occupational burnout and fatigue.Numerous evidence and studies indicated that overwork, fatigue, and intensive stress in the nursing profession and consequently, inclination for work leave and nursing leave may lead to reduced organizational commitment [38][39][40][41] .Another perceived theme indicated that nurses render contributory management as an important factor in promoting organizational commitment.The type of nurse management' style serves as one of the most important factors in promotion of nursing care quality and its efficacy and is also the most powerful organizational predictor.The managers' ability in allowing nurses' participation in administrative affairs and important decision-makings along with their empowerment indicate that nurse mangers value the nurses and their beliefs leading to their feeling of being valued, their improved interaction with managers and colleagues, increased sympathy and dependence, and creation of an integrated team in the wards and hospital.All these would result in decreased occupational stress and anxiety, reduced inclination for work leave, fostered motivation for work, and improved job satisfaction.The findings of different studies suggest that respecting and valuing the nurses 42 , allowing nurses' contribution in selecting the manner of care provision as an integrated treatment team 43 , establishing proper nurse-manager interactions [44][45] , and cooperation in performing nursing affairs 46 would end in a great revolution in nurses' attitude towards the hospital setting.Although our findings can reflect nurses' opinions in one hospital, they cannot be generalized to other settings due to small sample volume.Moreover, the perceptions of other influential parties like physicians and other personnel can affect determination of the factors that affect organizational commitment influencing the generalizability of the findings.Hence, it is advised that future studies elucidate the perceptions of other parties in other healthcare centers.

Conclusion
The results of the present study revealed that factors related to work environment, nurses' professional problems in hospital, and management style affect nurses' organizational commitment greatly.Hence, the identification of these factors is highly important to enable mangers to optimize, adjust, and promote these cases.Our findings can also be used to increase knowledge and awareness of nurse mangers and direct them to increase nurses' organizational commitment.