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A study of relationship between job stress, quality of working life and

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

A study of the relationship between job

satisfaction, organizational commitment
and turnover intention among hospital
employees

Ali Mohammad Mosadeghrad*†, Ewan Ferlie† and Duska Rosenberg†

*Health Policy and Management, School of Health, Tehran University of Medical Sciences, Iran;
†
School of Management, Royal Holloway University of London, UK

The purpose of this descriptive, co-relational and cross-sectional study was to gain a
better understanding of the relationships between job satisfaction and organizational
commitment of employees, and their impact on turnover intention at Isfahan Hospitals,
Isfahan, Iran, in 2005. Data were collected by the distribution of two questionnaires
among 629 employees of these hospitals through a stratified random sampling method.
The results of the paper indicate that hospital employees are moderately satisfied with
their jobs and committed to their organization. Employees’ job satisfaction and
organizational commitment were closely inter-related and correlated with turnover
intention (P , 0.001). The positive correlation between the two was expected, but there
was also unexpected correlation with turnover intention. This may be due to external
factors, such as job market conditions, which may influence perceived opportunities for
career advancement elsewhere. The impact of such external factors is outside the scope
of this study, but will have to be investigated in further research. As job satisfaction and
organizational commitment have strong correlation with turnover, it is very important
to reinforce them by applying the right human resource policies.

Introduction effectiveness and efficiency. Organizations

cannot succeed without their employees’
Organizations are social systems where human efforts and commitment. Employees’ satisfac-
resources are the most important factors for tion with their jobs and commitment to their
organizations has been viewed as major deter-
Ali Mohammad Mosadeghrad BSc MSc, Lecturer, Health minants of organizational effectiveness.1
Policy and Management, School of Health, Tehran
University of Medical Sciences, Iran and Doctoral
Job satisfaction and commitment are critical
Researcher, School of Management; Ewan Ferlie MA PhD, to retaining and attracting well-qualified per-
Professor (Management), School of Management; Duska sonnel. Concerns about employees’ job satisfac-
Rosenberg MA PhD, Professor (Information and tion and organizational commitment are just as,
Communications Management), School of Management, or even more, critical in the knowledge-based
Royal Holloway University of London, Egham, Surrey
TW20 0QS, UK
sectors, such as the health-care industry as they
Correspondence to: Ali Mohammad Mosadeghrad are in other business sectors. These factors are
Email: m.mosadeghrad@rhul.ac.uk especially important in professionalized and

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Health Services Management Research

service-based organizations, such as hospitals their intention to leave the organization.

where long-term specialist training and reten- There are no known studies related to the
tion issues are highly important. links between these subjects in the health-care
Employees who experience job satisfaction organizations of Iran.
are more likely to be productive and stay on the The results of this research will allow a better
job.2 Job dissatisfaction has been found to be a understanding of the relationship between
strong and consistent predictor of intention to employees’ job satisfaction and their organiz-
leave as well as turnover.3 – 6 Employees’ job ational commitment, and their impact on turn-
satisfaction is also found to be positively over intention. The results will also enhance our
related to patient satisfaction in health-care set- understanding of the determinants of these two
tings.7 Employees’ commitment is a valuable important employee attitudes. It is anticipated
asset in an organization. Research has shown that a better understanding of these issues and
that increased commitment improves employ- their relationships can aid further research, pin-
ees’ job satisfaction, motivation, performance point better strategies for recruiting, promotion
and creativeness, and reduces absenteeism and and training of future hospital employees, par-
turnover.8 – 10 ticularly in Iran but probably in other societies
Justification for the need to investigate as well.
employees’ job satisfaction and organizational
commitment is exemplified in the seemingly
observed relationship between the lower levels Literature review
of job satisfaction and commitment, and nega- Organizational commitment
tive symptoms of absenteeism, grievance
expression, tardiness, low morale and high Organizational commitment reflects a multi-
turnover. Job satisfaction and organizational dimensional psychological attachment of an
commitment are important indicators to man- individual to the organization,11 which plays a
agers because of the desire to retain a stable positive role in retention of members in the
and committed workforce. Researchers are organization. Meyer and Allen12 defined
keenly interested in understanding the factors organizational commitment as:
that influence an individual’s decision to stay
A psychological state that characterizes the
or leave an organization. employee’s relationships with the organization
Iran’s health system is passing though a and has implications for the decision to continue
period of transformation. Since early 2000 the membership in the organization.
Ministry of Health has been working on a
comprehensive health-care reform programme, Meyer and Allen12 differentiated organiz-
especially in hospitals. One of the aims of this ational commitment into three components:
reform programme is to strengthen health-care affective, continuance and normative commit-
management. However, human resource mana- ment. Affective commitment refers to employ-
gement is still not what it should be and the ees’ perceptions of their emotional attachment
human aspects relating to employee satisfac- to their organization and its goals.13
tion and organizational commitment, which Employees with high affective attachment to
affect productivity, are neglected. organization have strong motivation to con-
There are a small number of research tribute to the organization goals because they
studies in the literature that have examined see them as theirs.14 According to Kate and
the associations between job satisfaction, Masako,11 individual and organizational
organizational commitment and turnover factors may influence the level of affective
intention. Most of these studies have been commitment. Individual factors include, for
based on data collected in Western countries example, factors such as personality, values
and, also, limited to health-care employees. orientation, education or age, while organiz-
However, where job satisfaction has been ational factors include believing that employ-
found to be a direct predictor of turnover, ee’s roles and job goals are clearly defined and
organizational commitment has not been ana- receive management support.
lysed. This study aims to overcome this by Continuance commitment represents cognitive
focusing on issues such as employee attitudes, attachment between employees and their organ-
like satisfaction and commitment, and the izations because of the costs associated with
extent to which these factors contribute to leaving the organization.13,11 It is based on the

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 Relationship between job satisfaction, organizational commitment and turnover intention

assumption that individuals do not leave an consistently reported by studies.19 – 22 The links
organization if they would lose their benefits, between organizational commitment and job
take a pay cut, incur job search expenses and risk satisfaction are complex and it is not clear
of being unemployed.15 The level of investment whether satisfaction is a precursor to commit-
employees have accumulated in an organization ment or whether commitment influences one’s
and lack of alternative jobs outside the organiz- level of satisfaction. The dominant view in the
ation are the most important factors that may literature supports the causal precedence of
lead to continuance commitment. If employees satisfaction over commitment.23 – 25 There is
believe that fewer work opportunities exist also evidence indicating that high levels of
outside their organizations, the perceived costs commitment to the organization cause job
of leaving current organizations will be higher, satisfaction.26,27 Several other studies have
and they will develop a stronger sense of con- concluded that a reciprocal effect exists
tinuance commitment to their organizations.16 between satisfaction and commitment.28,29
Finally, normative commitment refers to A fourth group of studies finds no evidence of
typical feelings of obligation to remain with an causal relationship in either direction.30
organization.13 Normative commitment is based Numerous studies have reported that job
on an ideology or a sense of obligation; satisfaction31,32 and organizational commit-
employee feels obligated to stay with the organ- ment33 – 35 are negatively related to turnover
ization because it is the moral and right thing to intention. According to Tett and Meyer,8 organ-
do. Factors that may influence the level of nor- izational commitment and job satisfaction are
mative commitment are education, age and different, and each contributed uniquely to
related factors.11 Normative commitment could turnover intentions. Job satisfaction correlated
be based on organization investment in an more strongly with turnover intention, whereas
employee who then feels a ‘moral’ obligation to organizational commitment had the strongest
stay with the organization, based on employee’s correlation with actual turnover.
social or cultural norms and believes that one
should be loyal to one’s organization.
The theoretical framework of the study
Job satisfaction There are a variety of individual, social, cultural,
Job satisfaction is an attitude that people have organizational and environmental factors that
about their jobs and the organizations in which can influence a person’s level of job satisfaction
they perform these jobs. Job satisfaction is and organizational commitment. Individual
defined as ‘the extent to which people like or factors include age, gender, marital status, per-
dislike their jobs’.17 It is an employee’s affective sonality, education, intelligence and abilities.
reaction to a job, based on a comparison Social factors include relationships with co-
between actual outcomes and desired outcomes. workers, group working and norms, and oppor-
Job satisfaction is generally recognized as a tunities for interaction. Cultural factors include
multifaceted construct that includes employees’ underlying attitudes, beliefs and values.
feelings about a variety of both intrinsic and Organizational factors include organization
extrinsic job elements. Intrinsic elements of job structure, policies and procedures, supervision
satisfaction, derived from internally mediated and styles of leadership, management systems,
rewards, such as the job itself and opportunities and working conditions. Finally, environmental
for personal growth and accomplishment; and factors include economic, social, technical, poli-
extrinsic elements of job satisfaction, resulting tical and governmental influences.
from externally mediated rewards such as satis- This study aims to investigate the role of
faction with pay and benefits, company policies individual, social, and organizational factors,
and support, supervision, co-workers, job secur- and employees’ level of job satisfaction, organi-
ity and chances for promotion.18 zational commitment and turnover intention
with a sample of Iranian hospital employees.
Job satisfaction, organizational commitment It was not possible to examine all aspects of
this hypothesized model within the confines
and intention to leave of the present study. Thus, the study is con-
A positive association between job satisfaction fined to testing hypothesized relationships
and organizational commitment has been between job satisfaction, organizational

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Health Services Management Research

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

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

214
 Relationship between job satisfaction, organizational commitment and turnover intention

hundred and forty employees were selected in the questionnaire. These included: sal-
for this research after a pilot study using the aries and benefits, recognition and pro-
following formula (N ¼ 2411, d ¼ 0.03, motion, management and supervision,
z ¼ 1.96 and s ¼ 0.50). Employees who had co-workers, task requirement, organization
less than six months of work experience were policies, working conditions, nature of the
excluded from this study. job and job security (Table 1). This ques-
tionnaire had 36 items (4 items in each
NZ2 S2 domain). A further four items were also
n¼
Nd2 þ Z2 S2 included in the questionnaire: employees
asked about their overall job satisfaction,
ability to do their job well, intention to
leave the organization if they received a
Instruments good offer from other health-care organiz-
A survey instrument was designed to measure ations and if they would recommend the
and identify demographic characteristics, hospital to others for work. The question-
levels of job satisfaction and commitment naire utilizes a Likert-type scale with six
among employees of hospitals and their inten- response alternatives ranging from
tion to leave the organization. A cover letter ‘Strongly disagree’ (weighted 1) to
briefly explained the purpose of the study and ‘Strongly agree’ (weighted 6) for each of
the mechanisms to maintain confidentiality. the 40 items. In part II of the question-
Further explanations were given when naire, employees were asked to specify the
requested. The respondents received and importance of those nine dimensions of
answered the questionnaires at their work job satisfaction according to their personal
place. Participation was voluntary. The ques- interests on a six-point scale from ‘less
tionnaire consisted of three sections as follows: important’ (weighted 1) to ‘very import-
ant’ (weighted 6).
† Section 1 – Demographics: As hospital † Section 3 – Organizational Commitment Scale.
employees deal with very specific tasks on This variable was measured using Meyer
a daily basis, there may be a link between and Allen’s12 Organizational Commitment
individuals’ demographic characteristics Scale, which contains three six-item com-
and their job satisfaction to a particular ponents: affective, continuance and norma-
type of work. Therefore, demographic tive commitment (Table 2). Ratings were
data on employees were also gathered. completed on a six-point scale from
The questionnaire gathered data relative to
participants’: (a) gender; (b) marital status;
(c) age; (d) years working in the hospital; Table 1 Definition of job satisfaction dimensions
(e) education level; (f) employment status; Salaries and benefits: remuneration, pay and fringe
(g) department they work in; and (h) benefits for the work done
monthly salaries received. We chose these Recognition and promotion: the opportunity to
characteristics based upon a review of advance; achievements
related literature. Management and supervision: competence of
† Section 2 – Job Satisfaction Scale: A self- supervisor and way the boss handles employees
developed questionnaire was used to Co-workers: relationships with co-workers; quality
assess the level of job satisfaction among of interactions
hospital employees according to nine sub- Task requirement: what employees need to do their
scales. First, the domains of job satisfaction job well, such as education, resources and some
were defined. To accomplish this, a litera- degree of autonomy
ture review was conducted to identify the Organization policies: satisfaction with organization
dimensions of job satisfaction.17,37,38 From policies and rules
each study, a list of dimensions was Working conditions: all facets of the work environ-
created. Using a Delphi technique, the ment, safety
organizational behaviour and management Nature of the job: job identity, meaningful work;
experts’ opinions were used in completing level of responsibility and authority and
this list. The nine most common job satis- Job security: steady employment of the job
faction domains were chosen for inclusion

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Health Services Management Research

Table 2 Definition of organizational commitment capabilities and understanding of hospital

dimensions employees in Iran. The panel was also asked
to eliminate items or questions they found to
Affective commitment: psychological attachment to be irrelevant to the Iranian culture and make
organization; suggestions on how to simplify the items that
Continuance commitment: costs associated with were not relevant. After some modifications
leaving the organization; and were made, the instruments were resubmitted
Normative commitment: perceived obligation to to the experts. The experts unanimously re-
remain with the organization commended the use of the modified instru-
ments for this study.

‘strongly disagree’ (weighted 1) to ‘strongly

agree’ (weighted 6). The translation fol- Reliability of research instruments
lowed an established forward–backward Internal consistency reliability was measured
translation procedure, with independent by Cronbach’s coefficient a as 0.9210 for job
translations and counter-translation. satisfaction questionnaire and 0.8383 for
organizational commitment questionnaire. The
results in Table 3 show that the values of
Access and ethical approval Cronbach’s a derived for the constructs
Ethical approval of the study was gained from ranged between 0.70 and 0.89, indicating a
the Isfahan Medical University’s Research high reliability of the scales.
Ethics Committee. The main ethical issues
involved in this study were respondents’ Acceptability of research instruments
rights to self-determination, anonymity and
confidentiality. For this reason, respondents Acceptability was assessed in terms of refusal
were given full information on the nature of rates and rates of missing responses. A total of
the study through a letter, which was distribu- 629 (85%) hospital employees filled in the ques-
ted with the questionnaire. The questionnaire tionnaires. Organization-specific response rates
data were kept confidential and respondents
were assured of their right to withdraw at any
time. The names of the respondents were not Table 3 Internal consistency analysis
recorded and so all the data were rendered Constructs Number of Cronbach’s
anonymous. items a
Salaries and fringe 4 0.81
Pilot study benefits
A pilot study was undertaken to test the rele- Recognition and 4 0.80
vance and clarity of the questions, and to promotion
refine them as needed to avoid misunder- Management and 4 0.73
standing. A small sample of 40 randomly supervision
selected hospital employees, who were not Co-workers 4 0.78
included in the sample, received the question- Task requirement 4 0.70
naires. The questionnaires were found to be Working conditions 4 0.72
understandable, acceptable and could be com- Nature of work 4 0.74
pleted in about 15 min. Organization policies 4 0.72
Job security 4 0.70
Overall job satisfaction 40 0.92
Validation of research instruments Affective commitment 6 0.86
Continuance 6 0.71
Content and face validity were established by
commitment
a panel of experts consisting of management
Normative 6 0.89
and organizational behaviour experts. The
commitment
panel was asked to review the content of the
Overall organizational 18 0.83
items in each of the instruments and deter-
commitment
mine if the items were within the linguistic

216
 Relationship between job satisfaction, organizational commitment and turnover intention

varied from 87% to 94%. Missing data analysis Most (63.8%) had at least a college degree. Just
showed that 90.3% respondents had no missing over half (56.9%) had a monthly income
values for the entire set of 58 items. ,2,000,000 Rials (poverty line in Iran in 2005;
equivalent to 250 US$). A total of 51.4% of
Data collection employees had permanent employment. In
public, semi-public and private hospitals,
Stratified random sampling method was used. 52.2%, 89% and 19.5% of employees, respect-
Data collection was undertaken in the last ively, had permanent job contracts. The age of
two weeks of October 2005. Informed consent these hospital employees ranged from 18 to
was obtained from all subjects following 73, with an average age of 35.29 + 8.58
receipt of information on the purpose of (mean + SD). Nearly three-fourth of respon-
the study, assurances of anonymity and dents (71.9%) were ,40 years old. The
confidentiality. average age of the employees’ in public, semi-
public and private hospitals was 37, 34 and 33
Data analysis years, respectively. On an average, employees
had 12.2 years of work experience,
All data were analysed using the statistical respectively.
package for the Social Sciences (SPSS 11, SPSS
for Windows, ‘V’11 [SPSS, Inc]). Appropriate
statistical procedures were used for descrip-
tion and inference. The missing values were Job satisfaction
checked prior to further statistical analysis. In Total job satisfaction of the respondents was
order to normalize the Likert 1– 6 scales for measured on a six-point scale, where 6 stood
each domain of job satisfaction and organiz- for highly satisfied and 1 for highly dissatis-
ational commitment questionnaires, the sum fied. Overall, hospital employees were satis-
of raw scores of items in each domain was fied with their job showing a mean score of
divided by the number of items in each 3.51 + 0.74 (moderate satisfaction) compared
domain and for overall job satisfaction and with the possible range of 1.20 – 5.61.
commitment, sum of raw scores of items were Approximately, 1.6, 23, 45, 28.8 and 1.6% of
divided by 40 and 18, respectively. The possi- hospital employees had, respectively, very low,
ble justified scores varied between 1 and low, medium, high and very high satisfaction
6. Scores of 2 or lower on the total scale indi- with their job.
cate very low, scores between 2 and 2.99 indi- Within the nine items of the Job Satisfaction
cate low, scores between 3 and 3.99 indicate Scale, the three dimensions of the job with
moderate, scores between 4 and 4.99 indicate which respondents were most satisfied were:
high and scores of 5 or higher indicate very co-workers, nature of the job and task require-
high job satisfaction or commitment. ment. Respondents were least satisfied with
The differences between groups were tested the salaries and benefits, working conditions,
with the chi-square, independent t-test, recognition and promotion and job security
Mann-Whitney and Kruskal-Wallis tests. The (Table 5).
correlation coefficients were calculated to As indicated in Table 5, co-workers, salaries
evaluate the relationship between variables. and benefits, management and supervision,
Forward conditional logistic regression analy- nature of job and job security were the most
sis was used to identify the most important important facets of job satisfaction from the
predictor domains in global satisfaction and points of view of the employees. The differences
commitment. Data were presented as the in the gap scores (perception minus expectation,
mean + standard deviation (SD) and percen- P 2 E ¼ gap) for all the nine dimensions of job
tage (P , 0.05 were considered as significant). satisfaction were studied. This gap was more in
salaries and fringe benefits, working conditions,
Results and recognition and promotion, and less in
nature of work, task requirement and co-
Characteristics of the respondents workers dimensions of job satisfaction.
As described in Table 4, over half of The differences between values of employ-
the respondents were women (54.3%) and ees’ job satisfaction in different hospitals
over three-fourths (78.8%) were married. were statistically significant (P , 0.05).

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Health Services Management Research

Table 4 Percentage of participants and the mean score of their job satisfaction and commitment
Demographic Percent of Job satisfaction Organizational
parameters sample commitment

Mean SD Mean SD
Gender
Male 45.7 3.59 0.68 4.03 0.66
Female 54.3 3.44 0.78 3.93 0.70
Marital status
Single 21.2 3.38 0.70 3.77 0.64
Married 78.8 3.54 0.72 4.03 0.69
Education
Illiterate 0.5 4.17 0.70 4.21 0.49
Under diploma 8.5 3.67 0.74 4.36 0.77
Diploma 27.2 3.50 0.68 3.97 0.68
Post-diploma 16.9 3.66 0.69 4.15 0.59
Bachelor’s degree 40.6 3.41 0.79 3.81 0.69
Master’s degree or GP 4.7 3.56 0.67 3.84 0.50
Doctoral degree 1.6 3.54 0.81 4.34 0.49
Area of work
Managerial and clerical 19.1 3.73 0.75 4.15 0.59
Ancillary or logistic 17.1 3.75 0.74 4.13 0.72
Therapeutic 51.2 3.31 0.66 3.86 0.71
Diagnostic 12.6 3.69 0.72 3.99 0.57
Age (years)
, 20 0.7 4.48 0.78 3.91 1.13
20–30 34.9 3.40 0.72 3.81 0.66
31–40 36.3 3.56 0.75 4.01 0.70
41–50 24.4 3.53 0.73 4.10 0.65
. 50 3.7 3.86 0.64 4.27 0.66
Tenure (years)
, 1 (6 months –1 year) 6.4 3.28 0.78 3.83 0.67
1–5 23.1 3.35 0.74 3.77 0.71
6–10 21.4 3.59 0.75 3.94 0.59
11–15 16.2 3.48 0.69 4.02 0.71
16–20 11.4 3.78 0.61 4.29 0.65
21–25 14.6 3.44 0.78 4.00 0.64
26–30 6.4 3.64 0.63 4.13 0.69
. 30 0.5 4.45 0.08 4.84 0.38
Received wages (in Rials)
, 2,000,000 56.9 3.48 0.76 3.93 0.69
. 2,000,000 43.1 3.57 0.71 4.04 0.66

Employees’ job satisfaction in private hospitals their colleagues in public and private hospi-
was higher than public and semi-public hospi- tals, but they are less satisfied with working
tals. The differences between values of conditions (Table 6). SSO provides more
employees’ job satisfaction in these hospitals benefits to employees. Health-care services in
were statistically significant (P , 0.01). In SSO hospitals are free of charge for people
private hospitals, employees have more satis- under SSO insurance programme. Therefore,
faction with co-workers, and less satisfaction these hospitals are always overcrowded.
with wages and benefits. Employees in social Furthermore, customers in these hospitals
security hospital are more satisfied with sal- have a kind of ownership sense and are more
aries, benefits, recognition and promotion than demanding than patients in other hospitals.

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 Relationship between job satisfaction, organizational commitment and turnover intention

Table 5 The mean score of employees’ expectation and and computer centre (4.01) were high and in
perception about job satisfying factors (on a 6-scale) cardiology ward (2.89), pathology department
(2.97), psychiatry ward (2.99), obstetrics ward
Job satisfying factors P E P –E (3.04), urology ward (3.20), medical records
Salaries and fringe benefits 2.57 5.01 22.44 department (3.27) and paediatrics ward (3.30)
Recognition and promotion 2.88 4.85 21.97 were low.
Management and supervision 3.84 4.96 21.12 There was a strong correlation between the
Co-workers 4.54 5.15 20.61 job satisfaction of employees’ and their
Task requirement 4.17 4.76 20.59 gender, marital status, age, years of work
Working conditions 2.59 4.86 22.27 experience, organizational position, type of
Nature of work 4.37 4.94 20.57 employment (permanent or contract employ-
Organization policies 3.24 4.80 21.56 ment) and salaries received (P , 0.05).
Job security 3.11 4.89 21.78 As regards differences according to age and
Overall job satisfaction 3.51 4.91 21.40 seniority, we observed a curvilinear relation-
ship: scores were higher for the lowest and
highest ages and seniority ranges. There was
statistically significant correlation (reverse)
When the participants were stratified by the between job satisfaction of employees’ and
type of hospitals, teaching or non-teaching their graduation levels (P , 0.05). Supervisors
hospital, there were significant differences in or managers represented 15.7% of our sample.
the total job satisfaction scores (P , 0.05). Supervisors’ job satisfaction was found to be
It was 3.43 + 0.68 in the teaching hospitals significantly higher (m ¼ 3.64) compared with
and 3.57 + 0.78 in the non-teaching hospitals. their staff (m ¼ 3.48). Job satisfaction appeared
The differences were because of working con- to increase with the level of hierarchy.
ditions and management and supervision In order to determine the main factors that
dimensions of job satisfaction (Table 7). cause satisfaction and/or dissatisfaction with
The employees’ job satisfaction in thera- work, the relationship between total job satis-
peutic and diagnostic departments was lower faction and job satisfying factors was analysed.
than administrative and ancillary departments. Calculations of Spearman’s ratios revealed the
A statistical significant association was seen strongest correlation between total job satisfac-
between employees’ job satisfaction and their tion and such characteristics as management
area of work or specialty (P , 0.001). The and supervision, recognition and promotion,
mean score of employees’ job satisfaction in job security and task requirement. On the
the cash office (4.46), medical equipment office other hand, working conditions and co-
(4.35), administrative office (4.34), secretarial workers had less significant effect on employ-
unit (4.10), material supply department (4.08) ees’ job satisfaction, respectively. As Table 8

Table 6 The mean score of employees’ job satisfaction in public, semi-public and private hospitals (on a 6-scale)
Job satisfying factors Public hospital Social security Private hospital
hospital

P E P–E P E P–E P E P –E
Salary and fringe benefits 2.35 4.94 22.59 3.24 4.99 21.75 2.53 5.20 22.67
Recognition and promotion 2.84 4.99 22.15 3.05 4.72 21.67 2.95 4.72 21.77
Management and supervision 3.77 4.88 21.11 3.88 5.07 21.19 4.05 5.04 20.99
Co-workers 4.55 5.21 20.66 4.41 5.14 20.73 4.64 4.99 20.35
Task requirement 4.08 4.57 20.49 4.18 4.80 20.62 4.49 5.22 20.73
Working conditions 2.59 4.74 22.15 2.49 4.67 22.18 2.67 5.36 22.69
Nature of work 4.39 4.91 20.52 4.16 4.87 20.71 4.50 5.11 20.61
Organization policies 3.20 4.76 21.56 3.23 4.64 21.41 3.30 5.05 21.75
Job security 3.11 4.87 21.76 3.07 4.71 21.64 3.14 5.13 21.99
Overall job satisfaction 3.45 4.87 21.42 3.56 4.84 21.28 3.63 5.09 21.46

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Health Services Management Research

Table 7 The mean score of employees’ job satisfaction in teaching and non-teaching hospitals (on a 6-scale)
Job satisfying factors Educational hospitals Non-educational hospitals

P E P–E P E P –E
Salary and fringe benefits 2.39 4.85 22.46 2.68 5.11 22.43
Recognition and promotion 2.77 4.95 22.18 2.94 4.81 21.87
Management and supervision 3.67 5.01 21.34 3.99 4.93 20.94
Co-workers 4.47 5.21 20.74 4.60 5.11 20.51
Task requirement 4.01 4.69 20.68 4.32 4.81 20.49
Working conditions 2.66 4.68 22.02 2.55 4.98 22.43
Nature of work 4.42 4.94 20.52 4.35 4.94 20.59
Organization policies 3.20 4.85 21.65 3.25 4.76 21.51
Job security 3.10 4.76 21.66 3.12 4.97 21.85
Overall job satisfaction 3.43 4.88 21.45 3.57 4.93 21.36

shows, this relationship was statistically sig- different among the six hospitals (P ¼ 0.54).
nificant in all the cases (P , 0.001). Some demographic variables were related to
The mean score of employees’ satisfaction of one or more of the three commitment mea-
job factors, organizational factors and social sures. Significant differences were obtained
factors were 4.37, 3.20 and 4.54 credit from 6, between employees’ organizational commit-
respectively. The results of the simultaneous ment and their marital status, age and years of
multiple regression model indicate that organ- work experiences, type of employment and
izational, social, job and individual factors salaries received (P , 0.03). Married (as
overall explained 98.8% of the variance in opposed to single) employees have shown
employees’ job satisfaction. Organizational more affective, continuance and normative
factors explained the largest amount of the commitment. Age and tenure were related to
variance (94.3%), followed by job, social and affective and normative commitment. A nega-
individual factors. With regards to organi- tive association was seen between employees’
zational factors, management and supervision organizational commitment and their edu-
explained the largest amount of the variance, cational levels (r ¼ 20.156, P , 0.001), such
followed by promotion, task requirement, that those with fewer years of education
security, and salaries and benefits. revealed more continuance commitment. This
could be explained by external factors, if there
are fewer opportunities for finding suitable or
better jobs outside the organization.
Organizational commitment In correlation analysis between organiz-
Employees were moderately committed to ational commitment and its three dimensions,
their organizations, with a mean global score affective, continuance and normative commit-
of 3.98 + 0.68 on a six-scale. The overall ment, respectively, had positive and the
scores ranged from 2.05 to 5.67 (possible range highest effect on employees’ organizational
1 – 6). Organizational commitment was low, commitment in that order.
medium, high and very high in 9.1, 41.7, 43.7 The results of the simultaneous multiple
and 5.5% of hospital employees. The mean regression model indicate that organizational,
score of affective, continuance and normative social, job and individual factors overall
commitment were 3.86 + 1.12, 3.97 + 0.73 explained 44.7% of the variance in employees’
and 4.13 + 0.64, respectively. organizational commitment. Organizational
The employees’ organizational commitment factors explained the largest amount of the
in therapeutic and diagnostic departments variance (33.3%), followed by job, individual
was less than administrative and ancillary and social factors. With regards to organi-
departments. The differences between values zational factors, management and supervision
were statistically significant (P , 0.001). Total explained the largest amount of the variance,
organizational commitment scores were not followed by organization policies and job

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

221
Relationship between job satisfaction, organizational commitment and turnover intention
Health Services Management Research

security. Employees’ characteristics explain a

lower degree of variation in commitment. This
is primarily the result of the effect of the
employee’s age and education.

Relationships between job satisfaction,

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

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 Relationship between job satisfaction, organizational commitment and turnover intention

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

223
Health Services Management Research

employees. These findings suggest that types Conclusions

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

224
 Relationship between job satisfaction, organizational commitment and turnover intention

satisfaction and organizational commitment Nevertheless, managers spend a minimal

have strong correlation with job performances, amount of time learning more about human
it is very important to reinforce them by behaviour, communication, and how their atti-
applying the right human resource policies. tudes and behaviours impact employee’s per-
If employees are highly satisfied with their formance. Management requires a keen
work, supervision, co-workers, policies and understanding of human nature, the basic
pay, and derive high level of overall job satis- needs, wants and abilities of people. Managers
faction with their jobs they are more likely to at any level cannot motivate an employee;
be committed to the organization than if they they must create the environment for individ-
are not satisfied. uals to motivate themselves. It is in the interest
The results of this study revealed that of an organization to retain employees and
management and supervision are important minimize turnover. However, many hospital
predictors of job satisfaction, organizational managers have little understanding of how to
commitment and turnover intention among satisfy their employees and how these employ-
hospital employees. A supportive manage- ees’ satisfaction levels influence their intent to
ment style, demonstrated through open com- leave their positions. In fact, because of this
munication, respect and recognition can limited understanding, managers’ efforts
greatly improve the satisfaction of employees towards employees’ satisfaction can some-
on the job. Management might be able to times create more dissonance than cohesion
increase the level of commitment in the organ- between employees and management, leading
ization by increasing satisfaction with policies, to excessive employee turnover. Possessing
work conditions, equal compensation and knowledge and information about employee
equal promotion. Changes in organizational motivation helps managers understand how
variables, such as benefit scales, employee employees can be involved to achieve process
input in policy development and work improvement. More understanding of the
environment, could then be made in an effort needs and wants of their employees, as well as
to increase employees’ job satisfaction, organi- a better understanding of the impact of their
zational commitment and decrease subsequent own managerial behaviour on others would
turnover. help them in terms of improving performance
This study revealed that hospital employees’ in the workplace.
commitment is more because of normative
commitment. The employees commit to and
remain with the organization because of feel- Limitations and implications for
ings of obligation. In other words, employees
think that they ought to remain with an organ- future research
ization because they think it is morally right to In this study, employees’ participation was
do so. It could be because of investigation of voluntary and was conducted at six hospitals
this concept in an Islamic country where in Isfahan city, Iran an Islamic country. So, the
working in a hospital is a holy job. Nursing findings should be interpreted with caution as
and providing services for patients is strongly the participants were hospital employees from
recommended in Islam. So, management a particular province of Iran and do not rep-
should implement policies that will increase resent all hospital employees in this country.
employees’ affective commitment. Policies More studies of Iranian health-care employees
such as treating the employee with respect are needed with samples, which are large
and consideration, improving their quality of enough to detect statistically significant
work, defining the job and responsibilities of associations between the variables under
employees, designing, stimulating and chal- investigation.
lenging jobs, providing high-quality infor- Another potential limitation of this study
mation to employees about organization’s includes cross-sectional nature of the design,
plans and activities, providing appropriate which does not allow for an assessment of
working environment, fair assessment and impact or cause and effect. Perhaps, most
promotion, compensation and benefits can be valuable would be prospective cohort of hos-
helpful. pital employees, which are able to detect
In summary, employees are the most changes in employees’ job satisfaction and
important resource of an organization. commitment. If these studies also incorporated

225
Health Services Management Research

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