a study of the relationship between job satisfaction, organizational commitment and turnover...

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DOI: 10.1258/hsmr.2007.007015

2008 21: 211Health Serv Manage ResAli Mohammad Mosadeghrad, Ewan Ferlie and Duska Rosenberg

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

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A study of the relationship between jobsatisfaction, organizational commitmentand turnover intention among hospitalemployees

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 abetter understanding of the relationships between job satisfaction and organizationalcommitment of employees, and their impact on turnover intention at Isfahan Hospitals,Isfahan, Iran, in 2005. Data were collected by the distribution of two questionnairesamong 629 employees of these hospitals through a stratified random sampling method.The results of the paper indicate that hospital employees are moderately satisfied withtheir jobs and committed to their organization. Employees’ job satisfaction andorganizational commitment were closely inter-related and correlated with turnoverintention (P , 0.001). The positive correlation between the two was expected, but therewas also unexpected correlation with turnover intention. This may be due to externalfactors, such as job market conditions, which may influence perceived opportunities forcareer advancement elsewhere. The impact of such external factors is outside the scopeof this study, but will have to be investigated in further research. As job satisfaction andorganizational commitment have strong correlation with turnover, it is very importantto reinforce them by applying the right human resource policies.

Introduction

Organizations are social systems where humanresources are the most important factors for

effectiveness and efficiency. Organizationscannot succeed without their employees’efforts and commitment. Employees’ satisfac-tion with their jobs and commitment to theirorganizations has been viewed as major deter-minants of organizational effectiveness.1

Job satisfaction and commitment are criticalto retaining and attracting well-qualified per-sonnel. Concerns about employees’ job satisfac-tion and organizational commitment are just as,or even more, critical in the knowledge-basedsectors, such as the health-care industry as theyare in other business sectors. These factors areespecially important in professionalized and

Ali Mohammad Mosadeghrad BSc MSc, Lecturer, HealthPolicy and Management, School of Health, TehranUniversity of Medical Sciences, Iran and DoctoralResearcher, School of Management; Ewan Ferlie MA PhD,Professor (Management), School of Management; DuskaRosenberg MA PhD, Professor (Information andCommunications Management), School of Management,Royal Holloway University of London, Egham, SurreyTW20 0QS, UKCorrespondence to: Ali Mohammad MosadeghradEmail: [email protected]

Health Services Management Research 21: 211–227. DOI: 10.1258/hsmr.2007.007015# 2008 Royal Society of Medicine Press

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at Abant Izzet Baysal University on May 6, 2014hsm.sagepub.comDownloaded from


service-based organizations, such as hospitalswhere long-term specialist training and reten-tion issues are highly important.

Employees who experience job satisfactionare more likely to be productive and stay on thejob.2 Job dissatisfaction has been found to be astrong and consistent predictor of intention toleave as well as turnover.3 – 6 Employees’ jobsatisfaction is also found to be positivelyrelated to patient satisfaction in health-care set-tings.7 Employees’ commitment is a valuableasset in an organization. Research has shownthat increased commitment improves employ-ees’ job satisfaction, motivation, performanceand creativeness, and reduces absenteeism andturnover.8 – 10

Justification for the need to investigateemployees’ job satisfaction and organizationalcommitment is exemplified in the seeminglyobserved relationship between the lower levelsof job satisfaction and commitment, and nega-tive symptoms of absenteeism, grievanceexpression, tardiness, low morale and highturnover. Job satisfaction and organizationalcommitment are important indicators to man-agers because of the desire to retain a stableand committed workforce. Researchers arekeenly interested in understanding the factorsthat influence an individual’s decision to stayor leave an organization.

Iran’s health system is passing though aperiod of transformation. Since early 2000 theMinistry of Health has been working on acomprehensive health-care reform programme,especially in hospitals. One of the aims of thisreform programme is to strengthen health-caremanagement. However, human resource mana-gement is still not what it should be and thehuman aspects relating to employee satisfac-tion and organizational commitment, whichaffect productivity, are neglected.

There are a small number of researchstudies in the literature that have examinedthe associations between job satisfaction,organizational commitment and turnoverintention. Most of these studies have beenbased on data collected in Western countriesand, also, limited to health-care employees.However, where job satisfaction has beenfound to be a direct predictor of turnover,organizational commitment has not been ana-lysed. This study aims to overcome this byfocusing on issues such as employee attitudes,like satisfaction and commitment, and theextent to which these factors contribute to

their intention to leave the organization.There are no known studies related to thelinks between these subjects in the health-careorganizations of Iran.

The results of this research will allow a betterunderstanding of the relationship betweenemployees’ job satisfaction and their organiz-ational commitment, and their impact on turn-over intention. The results will also enhance ourunderstanding of the determinants of these twoimportant employee attitudes. It is anticipatedthat a better understanding of these issues andtheir relationships can aid further research, pin-point better strategies for recruiting, promotionand training of future hospital employees, par-ticularly in Iran but probably in other societiesas well.

Literature review

Organizational commitment

Organizational commitment reflects a multi-dimensional psychological attachment of anindividual to the organization,11 which plays apositive role in retention of members in theorganization. Meyer and Allen12 definedorganizational commitment as:

A psychological state that characterizes theemployee’s relationships with the organizationand has implications for the decision to continuemembership in the organization.

Meyer and Allen12 differentiated organiz-ational commitment into three components:affective, continuance and normative commit-ment. Affective commitment refers to employ-ees’ perceptions of their emotional attachmentto their organization and its goals.13

Employees with high affective attachment toorganization have strong motivation to con-tribute to the organization goals because theysee them as theirs.14 According to Kate andMasako,11 individual and organizationalfactors may influence the level of affectivecommitment. Individual factors include, forexample, factors such as personality, valuesorientation, education or age, while organiz-ational factors include believing that employ-ee’s roles and job goals are clearly defined andreceive management support.

Continuance commitment represents cognitiveattachment between employees and their organ-izations because of the costs associated withleaving the organization.13,11 It is based on the

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assumption that individuals do not leave anorganization if they would lose their benefits,take a pay cut, incur job search expenses and riskof being unemployed.15 The level of investmentemployees have accumulated in an organizationand lack of alternative jobs outside the organiz-ation are the most important factors that maylead to continuance commitment. If employeesbelieve that fewer work opportunities existoutside their organizations, the perceived costsof leaving current organizations will be higher,and they will develop a stronger sense of con-tinuance commitment to their organizations.16

Finally, normative commitment refers totypical feelings of obligation to remain with anorganization.13 Normative commitment is basedon an ideology or a sense of obligation;employee feels obligated to stay with the organ-ization because it is the moral and right thing todo. Factors that may influence the level of nor-mative commitment are education, age andrelated factors.11 Normative commitment couldbe based on organization investment in anemployee who then feels a ‘moral’ obligation tostay with the organization, based on employee’ssocial or cultural norms and believes that oneshould be loyal to one’s organization.

Job satisfaction

Job satisfaction is an attitude that people haveabout their jobs and the organizations in whichthey perform these jobs. Job satisfaction isdefined as ‘the extent to which people like ordislike their jobs’.17 It is an employee’s affectivereaction to a job, based on a comparisonbetween actual outcomes and desired outcomes.Job satisfaction is generally recognized as amultifaceted construct that includes employees’feelings about a variety of both intrinsic andextrinsic job elements. Intrinsic elements of jobsatisfaction, derived from internally mediatedrewards, such as the job itself and opportunitiesfor personal growth and accomplishment; andextrinsic elements of job satisfaction, resultingfrom externally mediated rewards such as satis-faction with pay and benefits, company policiesand support, supervision, co-workers, job secur-ity and chances for promotion.18

Job satisfaction, organizational commitmentand intention to leave

A positive association between job satisfactionand organizational commitment has been

consistently reported by studies.19 – 22 The linksbetween organizational commitment and jobsatisfaction are complex and it is not clearwhether satisfaction is a precursor to commit-ment or whether commitment influences one’slevel of satisfaction. The dominant view in theliterature supports the causal precedence ofsatisfaction over commitment.23 – 25 There isalso evidence indicating that high levels ofcommitment to the organization cause jobsatisfaction.26,27 Several other studies haveconcluded that a reciprocal effect existsbetween satisfaction and commitment.28,29

A fourth group of studies finds no evidence ofcausal relationship in either direction.30

Numerous studies have reported that jobsatisfaction31,32 and organizational commit-ment33– 35 are negatively related to turnoverintention. According to Tett and Meyer,8 organ-izational commitment and job satisfaction aredifferent, and each contributed uniquely toturnover intentions. Job satisfaction correlatedmore strongly with turnover intention, whereasorganizational commitment had the strongestcorrelation with actual turnover.

The theoretical framework of the study

There are a variety of individual, social, cultural,organizational and environmental factors thatcan influence a person’s level of job satisfactionand organizational commitment. Individualfactors include age, gender, marital status, per-sonality, education, intelligence and abilities.Social factors include relationships with co-workers, group working and norms, and oppor-tunities for interaction. Cultural factors includeunderlying attitudes, beliefs and values.Organizational factors include organizationstructure, policies and procedures, supervisionand styles of leadership, management systems,and working conditions. Finally, environmentalfactors include economic, social, technical, poli-tical and governmental influences.

This study aims to investigate the role ofindividual, social, and organizational factors,and employees’ level of job satisfaction, organi-zational commitment and turnover intentionwith a sample of Iranian hospital employees.It was not possible to examine all aspects ofthis hypothesized model within the confinesof the present study. Thus, the study is con-fined to testing hypothesized relationshipsbetween job satisfaction, organizational

Relationship between job satisfaction, organizational commitment and turnover intention

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commitment and turnover intention, and theother relevant variables, which relate to jobsatisfaction and commitment.

As shown in Figure 1, the relationshipbetween job satisfiers and employees’ out-comes is moderated by individual and culturalfactors. The initial hypothesis is that job satis-faction is positively related to organizationalcommitment, which is negatively related toturnover intention. Therefore:

Hypothesis 1: The greater the employees’job satisfaction, the greater their organizationalcommitment or vice versa.

Hypothesis 2: The greater the employees’job satisfaction and commitment, the lowertheir turnover intention.

Methodology

The study utilized descriptive correlationdesign and cross-sectional survey methodology.

Purpose and objectives

The purpose of this paper is to examine therelationships between job satisfaction, organi-zational commitment and turnover intentionamong hospital employees in Isfahan, Iran.

This survey investigates possible causes forlow levels of job satisfaction and commitmentas precedents for turnover and decision toleave the workforce. This study also focuseson revealing homogeneous demographiccharacteristics these employees exhibit, whichaffect their satisfaction and commitment leveland turnover intention.

Setting

Hospital care in Iran is provided by a networkof regional hospitals located in the main cities.This includes government-financed Ministryof Health hospitals (MOH), the Social Securityorganization-affiliated hospitals (SSO) andprivate hospitals.36 The study was carried outin six hospitals: three public MOH (two teach-ing and one non-teaching), one SSO (semi-public hospital) and two private hospitals.The six hospitals of the study were selected torepresent the three dominant hospital-caresystems in Iran.

Participation

At the time of the study (2005), these hospitalsemployed 2411 full-time employees. Seven

Figure 1 Hypothesized relationship between job satisfaction, organizational commitment and turnover intention


214



hundred and forty employees were selectedfor this research after a pilot study using thefollowing formula (N ¼ 2411, d ¼ 0.03,z ¼ 1.96 and s ¼ 0.50). Employees who hadless than six months of work experience wereexcluded from this study.

n ¼ NZ2S2

Nd2 þ Z2S2

Instruments

A survey instrument was designed to measureand identify demographic characteristics,levels of job satisfaction and commitmentamong employees of hospitals and their inten-tion to leave the organization. A cover letterbriefly explained the purpose of the study andthe mechanisms to maintain confidentiality.Further explanations were given whenrequested. The respondents received andanswered the questionnaires at their workplace. Participation was voluntary. The ques-tionnaire consisted of three sections as follows:

† Section 1 – Demographics: As hospitalemployees deal with very specific tasks ona daily basis, there may be a link betweenindividuals’ demographic characteristicsand their job satisfaction to a particulartype of work. Therefore, demographicdata on employees were also gathered.The questionnaire gathered data relative toparticipants’: (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 thesecharacteristics based upon a review ofrelated literature.

† Section 2 – Job Satisfaction Scale: A self-developed questionnaire was used toassess the level of job satisfaction amonghospital employees according to nine sub-scales. First, the domains of job satisfactionwere defined. To accomplish this, a litera-ture review was conducted to identify thedimensions of job satisfaction.17,37,38 Fromeach study, a list of dimensions wascreated. Using a Delphi technique, theorganizational behaviour and managementexperts’ opinions were used in completingthis list. The nine most common job satis-faction domains were chosen for inclusion

in the questionnaire. These included: sal-aries and benefits, recognition and pro-motion, management and supervision,co-workers, task requirement, organizationpolicies, working conditions, nature of thejob and job security (Table 1). This ques-tionnaire had 36 items (4 items in eachdomain). A further four items were alsoincluded in the questionnaire: employeesasked about their overall job satisfaction,ability to do their job well, intention toleave the organization if they received agood offer from other health-care organiz-ations and if they would recommend thehospital to others for work. The question-naire utilizes a Likert-type scale with sixresponse alternatives ranging from‘Strongly disagree’ (weighted 1) to‘Strongly agree’ (weighted 6) for each ofthe 40 items. In part II of the question-naire, employees were asked to specify theimportance of those nine dimensions ofjob satisfaction according to their personalinterests on a six-point scale from ‘lessimportant’ (weighted 1) to ‘very import-ant’ (weighted 6).

† Section 3 – Organizational Commitment Scale.This variable was measured using Meyerand Allen’s12 Organizational CommitmentScale, which contains three six-item com-ponents: affective, continuance and norma-tive commitment (Table 2). Ratings werecompleted on a six-point scale from

Table 1 Definition of job satisfaction dimensions

Salaries and benefits: remuneration, pay and fringebenefits for the work done

Recognition and promotion: the opportunity toadvance; achievements

Management and supervision: competence ofsupervisor and way the boss handles employees

Co-workers: relationships with co-workers; qualityof interactions

Task requirement: what employees need to do theirjob well, such as education, resources and somedegree of autonomy

Organization policies: satisfaction with organizationpolicies and rules

Working conditions: all facets of the work environ-ment, safety

Nature of the job: job identity, meaningful work;level of responsibility and authority and

Job security: steady employment of the job


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‘strongly disagree’ (weighted 1) to ‘stronglyagree’ (weighted 6). The translation fol-lowed an established forward–backwardtranslation procedure, with independenttranslations and counter-translation.

Access and ethical approval

Ethical approval of the study was gained fromthe Isfahan Medical University’s ResearchEthics Committee. The main ethical issuesinvolved in this study were respondents’rights to self-determination, anonymity andconfidentiality. For this reason, respondentswere given full information on the nature ofthe study through a letter, which was distribu-ted with the questionnaire. The questionnairedata were kept confidential and respondentswere assured of their right to withdraw at anytime. The names of the respondents were notrecorded and so all the data were renderedanonymous.

Pilot study

A pilot study was undertaken to test the rele-vance and clarity of the questions, and torefine them as needed to avoid misunder-standing. A small sample of 40 randomlyselected hospital employees, who were notincluded in the sample, received the question-naires. The questionnaires were found to beunderstandable, acceptable and could be com-pleted in about 15 min.

Validation of research instruments

Content and face validity were established bya panel of experts consisting of managementand organizational behaviour experts. Thepanel was asked to review the content of theitems in each of the instruments and deter-mine if the items were within the linguistic

capabilities and understanding of hospitalemployees in Iran. The panel was also askedto eliminate items or questions they found tobe irrelevant to the Iranian culture and makesuggestions on how to simplify the items thatwere not relevant. After some modificationswere made, the instruments were resubmittedto the experts. The experts unanimously re-commended the use of the modified instru-ments for this study.

Reliability of research instruments

Internal consistency reliability was measuredby Cronbach’s coefficient a as 0.9210 for jobsatisfaction questionnaire and 0.8383 fororganizational commitment questionnaire. Theresults in Table 3 show that the values ofCronbach’s a derived for the constructsranged between 0.70 and 0.89, indicating ahigh reliability of the scales.

Acceptability of research instruments

Acceptability was assessed in terms of refusalrates and rates of missing responses. A total of629 (85%) hospital employees filled in the ques-tionnaires. Organization-specific response rates

Table 2 Definition of organizational commitmentdimensions

Affective commitment: psychological attachment toorganization;

Continuance commitment: costs associated withleaving the organization; and

Normative commitment: perceived obligation toremain with the organization

Table 3 Internal consistency analysis

Constructs Number ofitems

Cronbach’sa

Salaries and fringebenefits

4 0.81

Recognition andpromotion

4 0.80

Management andsupervision

4 0.73

Co-workers 4 0.78Task requirement 4 0.70Working conditions 4 0.72Nature of work 4 0.74Organization policies 4 0.72Job security 4 0.70Overall job satisfaction 40 0.92Affective commitment 6 0.86Continuance

commitment6 0.71

Normativecommitment

6 0.89

Overall organizationalcommitment

18 0.83


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varied from 87% to 94%. Missing data analysisshowed that 90.3% respondents had no missingvalues for the entire set of 58 items.

Data collection

Stratified random sampling method was used.Data collection was undertaken in the lasttwo weeks of October 2005. Informed consentwas obtained from all subjects followingreceipt of information on the purpose ofthe study, assurances of anonymity andconfidentiality.

Data analysis

All data were analysed using the statisticalpackage for the Social Sciences (SPSS 11, SPSSfor Windows, ‘V’11 [SPSS, Inc]). Appropriatestatistical procedures were used for descrip-tion and inference. The missing values werechecked prior to further statistical analysis. Inorder to normalize the Likert 1–6 scales foreach domain of job satisfaction and organiz-ational commitment questionnaires, the sumof raw scores of items in each domain wasdivided by the number of items in eachdomain and for overall job satisfaction andcommitment, sum of raw scores of items weredivided by 40 and 18, respectively. The possi-ble justified scores varied between 1 and6. Scores of 2 or lower on the total scale indi-cate very low, scores between 2 and 2.99 indi-cate low, scores between 3 and 3.99 indicatemoderate, scores between 4 and 4.99 indicatehigh and scores of 5 or higher indicate veryhigh job satisfaction or commitment.

The differences between groups were testedwith the chi-square, independent t-test,Mann-Whitney and Kruskal-Wallis tests. Thecorrelation coefficients were calculated toevaluate the relationship between variables.Forward conditional logistic regression analy-sis was used to identify the most importantpredictor domains in global satisfaction andcommitment. Data were presented as themean + standard deviation (SD) and percen-tage (P , 0.05 were considered as significant).

Results

Characteristics of the respondents

As described in Table 4, over half ofthe respondents were women (54.3%) andover three-fourths (78.8%) were married.

Most (63.8%) had at least a college degree. Justover 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% ofemployees had permanent employment. Inpublic, semi-public and private hospitals,52.2%, 89% and 19.5% of employees, respect-ively, had permanent job contracts. The age ofthese hospital employees ranged from 18 to73, with an average age of 35.29 + 8.58(mean + SD). Nearly three-fourth of respon-dents (71.9%) were ,40 years old. Theaverage age of the employees’ in public, semi-public and private hospitals was 37, 34 and 33years, respectively. On an average, employeeshad 12.2 years of work experience,respectively.

Job satisfaction

Total job satisfaction of the respondents wasmeasured on a six-point scale, where 6 stoodfor highly satisfied and 1 for highly dissatis-fied. Overall, hospital employees were satis-fied with their job showing a mean score of3.51 + 0.74 (moderate satisfaction) comparedwith the possible range of 1.20–5.61.Approximately, 1.6, 23, 45, 28.8 and 1.6% ofhospital employees had, respectively, very low,low, medium, high and very high satisfactionwith their job.

Within the nine items of the Job SatisfactionScale, the three dimensions of the job withwhich respondents were most satisfied were:co-workers, nature of the job and task require-ment. Respondents were least satisfied withthe salaries and benefits, working conditions,recognition and promotion and job security(Table 5).

As indicated in Table 5, co-workers, salariesand benefits, management and supervision,nature of job and job security were the mostimportant facets of job satisfaction from thepoints of view of the employees. The differencesin the gap scores (perception minus expectation,P 2 E ¼ gap) for all the nine dimensions of jobsatisfaction were studied. This gap was more insalaries and fringe benefits, working conditions,and recognition and promotion, and less innature of work, task requirement and co-workers dimensions of job satisfaction.

The differences between values of employ-ees’ job satisfaction in different hospitalswere statistically significant (P , 0.05).


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Employees’ job satisfaction in private hospitalswas higher than public and semi-public hospi-tals. The differences between values ofemployees’ job satisfaction in these hospitalswere statistically significant (P , 0.01). Inprivate hospitals, employees have more satis-faction with co-workers, and less satisfactionwith wages and benefits. Employees in socialsecurity hospital are more satisfied with sal-aries, benefits, recognition and promotion than

their colleagues in public and private hospi-tals, but they are less satisfied with workingconditions (Table 6). SSO provides morebenefits to employees. Health-care services inSSO hospitals are free of charge for peopleunder SSO insurance programme. Therefore,these hospitals are always overcrowded.Furthermore, customers in these hospitalshave a kind of ownership sense and are moredemanding than patients in other hospitals.

Table 4 Percentage of participants and the mean score of their job satisfaction and commitment

Demographicparameters

Percent ofsample

Job satisfaction Organizationalcommitment

Mean SD Mean SD

GenderMale 45.7 3.59 0.68 4.03 0.66Female 54.3 3.44 0.78 3.93 0.70

Marital statusSingle 21.2 3.38 0.70 3.77 0.64Married 78.8 3.54 0.72 4.03 0.69

EducationIlliterate 0.5 4.17 0.70 4.21 0.49Under diploma 8.5 3.67 0.74 4.36 0.77Diploma 27.2 3.50 0.68 3.97 0.68Post-diploma 16.9 3.66 0.69 4.15 0.59Bachelor’s degree 40.6 3.41 0.79 3.81 0.69Master’s degree or GP 4.7 3.56 0.67 3.84 0.50Doctoral degree 1.6 3.54 0.81 4.34 0.49

Area of workManagerial and clerical 19.1 3.73 0.75 4.15 0.59Ancillary or logistic 17.1 3.75 0.74 4.13 0.72Therapeutic 51.2 3.31 0.66 3.86 0.71Diagnostic 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 0.6631–40 36.3 3.56 0.75 4.01 0.7041–50 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 0.716–10 21.4 3.59 0.75 3.94 0.5911–15 16.2 3.48 0.69 4.02 0.7116–20 11.4 3.78 0.61 4.29 0.6521–25 14.6 3.44 0.78 4.00 0.6426–30 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


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When the participants were stratified by thetype of hospitals, teaching or non-teachinghospital, there were significant differences inthe total job satisfaction scores (P , 0.05).It was 3.43 + 0.68 in the teaching hospitalsand 3.57 + 0.78 in the non-teaching hospitals.The differences were because of working con-ditions and management and supervisiondimensions of job satisfaction (Table 7).

The employees’ job satisfaction in thera-peutic and diagnostic departments was lowerthan administrative and ancillary departments.A statistical significant association was seenbetween employees’ job satisfaction and theirarea of work or specialty (P , 0.001). Themean score of employees’ job satisfaction inthe cash office (4.46), medical equipment office(4.35), administrative office (4.34), secretarialunit (4.10), material supply department (4.08)

and computer centre (4.01) were high and incardiology ward (2.89), pathology department(2.97), psychiatry ward (2.99), obstetrics ward(3.04), urology ward (3.20), medical recordsdepartment (3.27) and paediatrics ward (3.30)were low.

There was a strong correlation between thejob satisfaction of employees’ and theirgender, marital status, age, years of workexperience, organizational position, type ofemployment (permanent or contract employ-ment) and salaries received (P , 0.05).As regards differences according to age andseniority, we observed a curvilinear relation-ship: scores were higher for the lowest andhighest ages and seniority ranges. There wasstatistically significant correlation (reverse)between job satisfaction of employees’ andtheir graduation levels (P , 0.05). Supervisorsor managers represented 15.7% of our sample.Supervisors’ job satisfaction was found to besignificantly higher (m ¼ 3.64) compared withtheir staff (m ¼ 3.48). Job satisfaction appearedto increase with the level of hierarchy.

In order to determine the main factors thatcause satisfaction and/or dissatisfaction withwork, the relationship between total job satis-faction and job satisfying factors was analysed.Calculations of Spearman’s ratios revealed thestrongest correlation between total job satisfac-tion and such characteristics as managementand supervision, recognition and promotion,job security and task requirement. On theother hand, working conditions and co-workers had less significant effect on employ-ees’ job satisfaction, respectively. As Table 8

Table 5 The mean score of employees’ expectation andperception about job satisfying factors (on a 6-scale)

Job satisfying factors P E P–E

Salaries and fringe benefits 2.57 5.01 22.44Recognition and promotion 2.88 4.85 21.97Management and supervision 3.84 4.96 21.12Co-workers 4.54 5.15 20.61Task requirement 4.17 4.76 20.59Working conditions 2.59 4.86 22.27Nature of work 4.37 4.94 20.57Organization policies 3.24 4.80 21.56Job security 3.11 4.89 21.78Overall job satisfaction 3.51 4.91 21.40

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 securityhospital

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 22.67Recognition and promotion 2.84 4.99 22.15 3.05 4.72 21.67 2.95 4.72 21.77Management and supervision 3.77 4.88 21.11 3.88 5.07 21.19 4.05 5.04 20.99Co-workers 4.55 5.21 20.66 4.41 5.14 20.73 4.64 4.99 20.35Task requirement 4.08 4.57 20.49 4.18 4.80 20.62 4.49 5.22 20.73Working conditions 2.59 4.74 22.15 2.49 4.67 22.18 2.67 5.36 22.69Nature of work 4.39 4.91 20.52 4.16 4.87 20.71 4.50 5.11 20.61Organization policies 3.20 4.76 21.56 3.23 4.64 21.41 3.30 5.05 21.75Job security 3.11 4.87 21.76 3.07 4.71 21.64 3.14 5.13 21.99Overall job satisfaction 3.45 4.87 21.42 3.56 4.84 21.28 3.63 5.09 21.46


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shows, this relationship was statistically sig-nificant in all the cases (P , 0.001).

The mean score of employees’ satisfaction ofjob factors, organizational factors and socialfactors were 4.37, 3.20 and 4.54 credit from 6,respectively. The results of the simultaneousmultiple regression model indicate that organ-izational, social, job and individual factorsoverall explained 98.8% of the variance inemployees’ job satisfaction. Organizationalfactors explained the largest amount of thevariance (94.3%), followed by job, social andindividual factors. With regards to organi-zational factors, management and supervisionexplained the largest amount of the variance,followed by promotion, task requirement,security, and salaries and benefits.

Organizational commitment

Employees were moderately committed totheir organizations, with a mean global scoreof 3.98 + 0.68 on a six-scale. The overallscores ranged from 2.05 to 5.67 (possible range1–6). Organizational commitment was low,medium, high and very high in 9.1, 41.7, 43.7and 5.5% of hospital employees. The meanscore of affective, continuance and normativecommitment were 3.86 + 1.12, 3.97 + 0.73and 4.13 + 0.64, respectively.

The employees’ organizational commitmentin therapeutic and diagnostic departmentswas less than administrative and ancillarydepartments. The differences between valueswere statistically significant (P , 0.001). Totalorganizational commitment scores were not

different among the six hospitals (P ¼ 0.54).Some demographic variables were related toone or more of the three commitment mea-sures. Significant differences were obtainedbetween employees’ organizational commit-ment and their marital status, age and years ofwork experiences, type of employment andsalaries received (P , 0.03). Married (asopposed to single) employees have shownmore affective, continuance and normativecommitment. Age and tenure were related toaffective and normative commitment. A nega-tive association was seen between employees’organizational commitment and their edu-cational levels (r ¼ 20.156, P , 0.001), suchthat those with fewer years of educationrevealed more continuance commitment. Thiscould be explained by external factors, if thereare fewer opportunities for finding suitable orbetter jobs outside the organization.

In correlation analysis between organiz-ational commitment and its three dimensions,affective, continuance and normative commit-ment, respectively, had positive and thehighest effect on employees’ organizationalcommitment in that order.

The results of the simultaneous multipleregression model indicate that organizational,social, job and individual factors overallexplained 44.7% of the variance in employees’organizational commitment. Organizationalfactors explained the largest amount of thevariance (33.3%), followed by job, individualand social factors. With regards to organi-zational factors, management and supervisionexplained the largest amount of the variance,followed by organization policies and job

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 22.43Recognition and promotion 2.77 4.95 22.18 2.94 4.81 21.87Management and supervision 3.67 5.01 21.34 3.99 4.93 20.94Co-workers 4.47 5.21 20.74 4.60 5.11 20.51Task requirement 4.01 4.69 20.68 4.32 4.81 20.49Working conditions 2.66 4.68 22.02 2.55 4.98 22.43Nature of work 4.42 4.94 20.52 4.35 4.94 20.59Organization policies 3.20 4.85 21.65 3.25 4.76 21.51Job security 3.10 4.76 21.66 3.12 4.97 21.85Overall job satisfaction 3.43 4.88 21.45 3.57 4.93 21.36


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221



security. Employees’ characteristics explain alower degree of variation in commitment. Thisis primarily the result of the effect of theemployee’s age and education.

Relationships between job satisfaction,organizational commitment andintention to leave

Table 8 shows the correlations between thesethree variables. As can be seen, there is apositive correlation between job satisfactionand organizational commitment (rs ¼ 0.637,P , 0.001) indicating that those employeeswho are more satisfied with their job are alsomore committed to the health-care service.This study observed an asymmetric relation-ship where satisfaction had a stronger effecton commitment than the reverse. The relation-ship running from satisfaction to commitmentis much stronger than the relationship runningin the other direction.

The positive correlation between intentionto leave and organizational commitment(rs ¼ 0.436, P , 0.001) and job satisfaction(rs ¼ 0.452, P , 0.001) indicates that those whoare less satisfied with their job are less com-mitted to their organization. The influence ofexternal factors needs to be investigatedfurther, particularly with respect to normativeand continuance commitment.

Furthermore, correlation analysis revealedthat job satisfaction dimensions such as natureof the job, management and supervision, taskrequirement, co-workers, job security, andrecognition and promotion had more effecton employees’ organizational commitment.Nature of the work, co-workers, and manage-ment and supervision had the most effect onaffective commitment. Management andsupervision, nature of work and job securityhad the most effect on continuance commit-ment. Finally, nature of the job and co-workershad the most effect on normative commitment.On the other hand, affective commitment hadmore effect on employees’ job satisfaction.

Employees’ job satisfaction and commitmentare significant predictors of turnover intention.The results of the simultaneous multipleregression model indicate that together, thesetwo variables explain 22.5% of the variancein employees’ turnover intention. Job satisfac-tion explained the largest amount of thevariance (19.2%) followed by commitment.

Organizational factors explained 14% of thevariance in employees’ turnover intention(Figure 2).

Factors that have a significant impact onintention to leave are affective commitment,job satisfaction, organizational policies, jobsecurity, management and supervision, recog-nition, amount of salaries received and thedepartment in which the employees work.Factors that have a significant impact onrecommending the hospital to others byemployees as a good place for work are jobsatisfaction, affective commitment, recognitionand promotion, management and supervision,amount of salaries and task requirement.

Discussion

This study set out to assess the degree of jobsatisfaction and organizational commitmentamong Iranian hospital employees andexamine the relationships between those vari-ables and employees’ turnover intention. Fromthe results of this study, the job satisfactionlevel of hospital employees’ can be seen to bein a medium scale, mainly because of salariesand benefits, working conditions, recognitionand job security. It is recommended that par-ticular attention be given to improve employ-ees’ job satisfaction by addressing these issuesat the managerial level.

This study confirmed a positive relationshipexisting between job satisfaction and organi-zational commitment. Findings revealed thatemployees who were more satisfied with theirjob had higher levels of organizational commit-ment. The result supported Hypothesis 1 thatjob satisfaction is positively related to organi-zational commitment. This finding is consistentwith the findings of other previous studiesin health-care settings.20 – 22 Furthermore, jobsatisfaction and commitment were significantly

Figure 2 Relationship between job satisfaction, organiz-ational commitment and turnover intention


222



associated with employees’ intention to leave.The results do not support Hypothesis 2 thatthere is a negative relationship between turn-over intention and employees’ job satisfactionand commitment. This may be due to externalfactors, such as job market conditions andworkforce mobility, which may influence per-ceived opportunities for career advancementelsewhere.

Several researchers have concluded thatemployees’ job satisfaction generally and inhealth-care organizations is shown to be corre-lated with age, gender, marital status, numberof children, educational level and work experi-ence (years).37 – 44 In this current study, vari-ables such as employees’ age, gender, maritalstatus, work experience years, organizationalposition, education level, type of employmentand salaries received, and benefits were seenas having significant effects on their jobsatisfaction.

A higher level of job satisfaction in illiterateemployees may be due to the fact that most ofthese individuals are old and have beenworking in the hospitals for many years.Therefore, they are receiving higher paybecause of their length of service and the pri-vileges that this brings. Also, they do not dodifficult jobs in hospitals. However, theiryounger colleagues who do not have highereducation, have to do the hard and non-professional jobs in hospitals, such as workingin the laundry, cleaning patients’ rooms andso on.

The U-formed relationship between age andseniority and job satisfaction requires twokinds of explanation. Among younger employ-ees, a higher level of satisfaction may be dueto the fact that inexperienced employees havefewer duties and responsibilities, less pressureand fewer demands from colleagues. Theymay also be less exposed to work-to-familyconflicts. Among older employees, highersatisfaction could be explained by a betterknowledge of hospital working, by benefitslinked to seniority and by fewer externaldemands. It is also possible that older employ-ees refocus their priorities to factors outsidethe work setting, such as family and/or plan-ning for retirement.

The current study showed that promotionopportunities were another significant predic-tor of job satisfaction and organizational com-mitment among study participants. Thegreater the chances are for advancement

within the organization, the higher it is likelyto be the level of organizational commitmentand job satisfaction expressed by theemployee. This finding is consistent withother studies that have shown that the oppor-tunity for personal and professional growthand achievement is one of the best predictorsof job satisfaction and organizational commit-ment.40,43,45 Unfair promotion policies per-ceived by employees may negatively impacttheir organizational commitment. It is there-fore, recommended that managers provideequal promotion opportunities for employees.Management should put in place localizationprogrammes and initiatives that wouldpromote employees’ to key positions andincrease their involvement in decision-making.Such steps will help to increase the level of jobsatisfaction and commitment.

Tenure was significantly related to affectiveand normative commitment. When the experi-ence increases, commitment will rise as well;but there is an exception in employees withone to five years of work experience.Employees in the first year of their job careerare highly committed to their organization,especially because of continuance and affec-tive commitments. The employees enter theirorganizations with great expectations, butwhen they realize that they may have overesti-mated what they might be able to achieve,their commitment may decrease.

Marital status was related to commitment,especially affective commitment, as marriedemployees demonstrated more emotionalattachment than single employees. This couldagain reflect a tendency for married employ-ees’ to be more family-oriented and see theorganization as a kind of ‘family provider’,as opposed to single employees who, beingmore self-oriented, may view the employingorganization only as a source of income andtherefore feel less emotionally attached to it.Education also showed a significant negativecorrelation, such that those with fewer years ofeducation revealed more normative commit-ment. These findings are also consistent withseveral studies in which education wasfound to have an inverse relationship withorganizational commitment.34,46 Amount ofsalaries was correlated with continuancecommitment.

Employees with permanent contracts noti-fied higher levels of job satisfaction andorganizational commitment than temporary


223



employees. These findings suggest that typesof employment may have an independenteffect on employees’ job satisfaction. Furtherresearch is necessary to overcome variousshortcomings of this study, and to assess therole either job security or level of income andsocial protection.

This study also demonstrates that thoseemployees who work with patients had less jobsatisfaction and as a result less commitment.Employees working in cardiology, psychiatry,pathology, obstetric, urology and paediatricwards had less satisfaction. Job rotation couldpossibly be a good strategy for improving jobsatisfaction of these employees. Lower levels ofjob satisfaction in employees working in themedical record department is likely due to thespecific nature of the jobs they perform.Automation is not used in these hospitals andthese employees have to perform their tasksmanually. Documentation, repetition of dutiesand low salaries are the most importantsources of dissatisfaction of employees in thisdepartment. It is recommended that manage-ment use job enrichment as a motivationalstrategy to satisfy these employees.

Another major finding as the cause ofemployee job dissatisfaction is the lack ofrespect and recognition they receive from hos-pital management. Recognition and respectare highly important, especially for employeeswho are in direct contact with patients,families, peers and other health-care teammembers. Respect and recognition from man-agers for good performance is vital in increas-ing job satisfaction and is central to boostingcommitment.

It is interesting to mention that employees’expectations about their jobs in private hospi-tals are greater than in public and semi-publichospitals. Type of organization shapes theemployees’ expectation. Employees in publichospitals know about the limitations and diffi-culties in their organization, so will modifytheir expectations and demands.

The strongest direct predictors of intentionto leave, based on this study, are low organiz-ational commitment (particularly affectivecommitment), lack of job satisfaction and itsdimensions (especially organizational pol-icies), lack of job security, and managementand supervision. Thus, managers should try toimprove employees’ commitment by increas-ing their job satisfaction and thus reduce theirintention of leaving the organization.

Conclusions

In a cross-sectional study, the relationshipbetween employees’ job satisfaction andorganizational commitment, and their turn-over intention in Isfahan Hospitals, Isfahan,Iran were explored. This study revealed a posi-tive relationship between employees’ job satis-faction and organizational commitment, and arelationship between job satisfaction, commit-ment and intention to leave the organization.This research has found that job satisfactionand organizational commitment appear to bepredictors of turnover intention but moderat-ing factors, such as individual and culturalcharacteristics, play a significant role in bothturnover intention and actual turnover.

The findings show that hospital employeesare moderately satisfied with their jobs.Factors that may influence the level of employ-ees’ job satisfaction are demographic variablesof gender, age, marital status, education, yearsof work experience, organizational position,monthly salary, type of employment, type ofhospital, employees’ organizational commit-ment (and its three dimensions) and the ninesubscales of job satisfying factors, as indictedin Table 5. Management and supervision, rec-ognition and promotion, job security and taskrequirement are the best predictors of job satis-faction among hospital employees. Specific jobsatisfaction dimensions indicate that highestdissatisfaction level occurs in the area ofworking conditions, salaries and benefits, rec-ognition and job security. Thus, areas of dissa-tisfaction can be interpreted as signals thatchange is needed.

The findings also revealed that hospitalemployees are moderately committed to theirorganization. Factors that may influence thelevel of employees’ organizational commit-ment are demographic variables of gender,age, marital status, education, years of workexperience, monthly salary, type of employ-ment, employees’ job satisfaction (and its ninedimensions) and the three subscales of organi-zational commitment dimensions. Affective,continuance and normative commitment arethe best predictors of organizational commit-ment among hospitals employees.

Implications for management

There are several practical implications thatcan be derived from our findings. As job


224



satisfaction and organizational commitmenthave strong correlation with job performances,it is very important to reinforce them byapplying the right human resource policies.If employees are highly satisfied with theirwork, supervision, co-workers, policies andpay, and derive high level of overall job satis-faction with their jobs they are more likely tobe committed to the organization than if theyare not satisfied.

The results of this study revealed thatmanagement and supervision are importantpredictors of job satisfaction, organizationalcommitment and turnover intention amonghospital employees. A supportive manage-ment style, demonstrated through open com-munication, respect and recognition cangreatly improve the satisfaction of employeeson the job. Management might be able toincrease the level of commitment in the organ-ization by increasing satisfaction with policies,work conditions, equal compensation andequal promotion. Changes in organizationalvariables, such as benefit scales, employeeinput in policy development and workenvironment, could then be made in an effortto increase employees’ job satisfaction, organi-zational commitment and decrease subsequentturnover.

This study revealed that hospital employees’commitment is more because of normativecommitment. The employees commit to andremain with the organization because of feel-ings of obligation. In other words, employeesthink that they ought to remain with an organ-ization because they think it is morally right todo so. It could be because of investigation ofthis concept in an Islamic country whereworking in a hospital is a holy job. Nursingand providing services for patients is stronglyrecommended in Islam. So, managementshould implement policies that will increaseemployees’ affective commitment. Policiessuch as treating the employee with respectand consideration, improving their quality ofwork, defining the job and responsibilities ofemployees, designing, stimulating and chal-lenging jobs, providing high-quality infor-mation to employees about organization’splans and activities, providing appropriateworking environment, fair assessment andpromotion, compensation and benefits can behelpful.

In summary, employees are the mostimportant resource of an organization.

Nevertheless, managers spend a minimalamount of time learning more about humanbehaviour, communication, and how their atti-tudes and behaviours impact employee’s per-formance. Management requires a keenunderstanding of human nature, the basicneeds, wants and abilities of people. Managersat any level cannot motivate an employee;they must create the environment for individ-uals to motivate themselves. It is in the interestof an organization to retain employees andminimize turnover. However, many hospitalmanagers have little understanding of how tosatisfy their employees and how these employ-ees’ satisfaction levels influence their intent toleave their positions. In fact, because of thislimited understanding, managers’ effortstowards employees’ satisfaction can some-times create more dissonance than cohesionbetween employees and management, leadingto excessive employee turnover. Possessingknowledge and information about employeemotivation helps managers understand howemployees can be involved to achieve processimprovement. More understanding of theneeds and wants of their employees, as well asa better understanding of the impact of theirown managerial behaviour on others wouldhelp them in terms of improving performancein the workplace.

Limitations and implications forfuture research

In this study, employees’ participation wasvoluntary and was conducted at six hospitalsin Isfahan city, Iran an Islamic country. So, thefindings should be interpreted with caution asthe participants were hospital employees froma particular province of Iran and do not rep-resent all hospital employees in this country.More studies of Iranian health-care employeesare needed with samples, which are largeenough to detect statistically significantassociations between the variables underinvestigation.

Another potential limitation of this studyincludes cross-sectional nature of the design,which does not allow for an assessment ofimpact or cause and effect. Perhaps, mostvaluable would be prospective cohort of hos-pital employees, which are able to detectchanges in employees’ job satisfaction andcommitment. If these studies also incorporated


225



interviews with subjects, this would increaseour understanding of the factors within hospi-tal services as a job which influences job satis-faction and commitment. Future research alsoneeds to explore the effects of variables thatwere not measured in the current study, whichcan also directly or indirectly influence feel-ings of job satisfaction and commitment, suchas the organization’s structure and culture.

From a methodology perspective, thereliance on the Delphi method that involvesconsulting the domain experts in the instru-ments design may present additional limit-ations. It would be beneficial if future studieswere to enhance the reliability of the methodby other means, for example, relying moreheavily on the model illustrated in Figure 1.As more results become available from thesurveys, their findings can further define therelationships between job satisfiers, moderat-ing factors and employees’ outcomes in differ-ent real-life contexts. Such an enhancementmay also serve to articulate important aspectsof expert knowledge, thus providing a moreexplicit formulation of the cause-effect andcorrelation types of relationship.

Furthermore, this study may serve as afoundation for future studies in differentcountries, on a larger scale. More studies,which involve hospital employees from othercountries, would enrich the literature on hos-pital employees’ job satisfaction and commit-ment, which in turn could generate strategiesto improve the global retention of new hospi-tal managers and employees.

AcknowledgementsThis study was the result of a phase of aresearch funded by Ministry of Health, Iran.The authors gratefully acknowledge the hospi-tal managers and employees for their assis-tance in performing this research.

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Further reading

Meyer JP, Allen NJ. A three component conceptualizationof organizational commitment. Hum Resour Manage Rev1991;1:61–89


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a study of the relationship between job satisfaction, organizational commitment and turnover...

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