International Journal of Public Health Science (IJPHS)

Vol. 11, No. 4, December 2022, pp. 1357~1366

ISSN: 2252-8806, DOI: 10.11591/ijphs.v11i4.22000  1357

Nurse's foci of commitment model to decrease turnover

intention

Nursalam Nursalam1, Nurul Hikmatul Qowi2, Tri Johan Agus Yuswanto3, Ferry Efendi1
1
Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
2
Department of Nursing, Faculty of Health Science, Universitas Muhammadiyah Lamongan, Lamongan, Indonesia
3
Department of Nursing, Health Polytechnic Ministry of Health Malang, Malang, Indonesia

Article Info ABSTRACT

Article history: The hospital is an organization in the service sector with nurses as the main
resource. Increasing the commitment of the nurses was one of the ways to
Received Apr 21, 2022 retain nurses. This cross-sectional study explained nurse’s foci of
Revised Aug 16, 2022 commitment model to decrease turnover intention. Variables in this study
Accepted Sep 5, 2022 included nurse characteristics, job characteristics, work experience,
organizational factors, nurse commitment, and turnover intention. The
population was nurses who have worked in islamic hospital in Surabaya,
Keywords: Indonesia. The 119 nurses selected as sample based on simple random
sampling. Data collected using questionnaires and analyzed using partial
Commitment model least squares (PLS). Nurse characteristics influenced nurse commitments
Job satisfaction (path coefficient=0.252; t=2.953) and turnover intention (path coefficient=-
Nurse commitment 0.239; t=2.458). Job characteristics influenced nurse commitments (path
Organizational factor coefficient=0.190; t=2.409) and turnover intention (path coefficient=-0.183;
Turnover intention t=2.107). Work experience influenced nurse commitments (path
Work experience coefficient=0.208; t=2.231) and turnover intention (path coefficient=-0.153;
t=1.964). organizational factors influenced nurse commitments (path
coefficient=0.218; t=2.170) and turnover intention (path coefficient=-0.174;
t=2.330). Nurse commitment influenced turnover intention (path
coefficient=-0.226; t=2.084). The nurse's commitment as moderate these
factors in reducing turnover intention. The influence of job satisfaction,
nurse commitment, and perceived organizational support to turnover
intention needs further research.
This is an open access article under the CC BY-SA license.

Corresponding Author:
Nurul Hikmatul Qowi
Department of Nursing, Faculty of Health Science, Universitas Muhammadiyah Lamongan
Raya Plalangan Plosowahyu Street KM3 62218, Lamongan, Indonesia
Email: nurul_hikmatul_qowi@umla.ac.id

1. INTRODUCTION
These days, hospitals are competing to provide high-quality, cost-effective, and accessible services
to give people needs [1]. The success of the hospital as an organization depends on how leaders utilize
human resources effectively [2]. Nursing is one of the important resources of the hospital [3]. Every hospital
has major problems related to how to retain nursing staff to keep working in the same hospital for a long
period of time [4] causing the turnover of nurses [5]. The nurse turnover rate is 10-20% in the United
States [4], [6] United Kingdom, Australia, and Japan [6]. Turnover nurses rate who work in the first year in
the United States is as high as 27.1% [6] while the rate turnover of nurses in Taiwan around 22.1% of the
4,602 new nurses with years of work under three months at a health center in 2009 [7].

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Mexican hospitals cost more than 5% of annual operating costs due to nurse turnover [8].
The largest costs are used for temporary reimbursement, orientation and training [9]. Turnover also causes
the loss of trained and skilled nurses, resulting in decreased hospital productivity [6]. High nurse-patient
ratios as a result of reduced nurses will lead to high nursing workload, decreased quality of nursing care [10].
Therefore, organizations should make efforts to strengthen human resources for health [11]. One of the ways
used to retain employees is by increasing the commitment of the employees themselves [12].
Based on the model of organizational commitment, commitment is influenced by three factors
include personal characteristics, job characteristics, and work experience [12]. Organizational factors are
important factors affecting organizational commitment [13], [14]. Organizational factors include workload,
stress, management style, empowerment, and role perception, career development and salary
development [5].
The latest trends in commitment research is using analytic strategy that centered on individual
homogeneous thinking about the different commitments [15]. The target commitment (foci of commitment)
is a commitment to the organization, supervisors, workgroup, and occupation [16], [17]. The development of
foci of commitment for nursing staff in healthcare setting include commitment to hospital, commitment to
nurse unit manager, nurse, and occupation. Foci of commitment can affect employees' turnover
intention [18]. According to published literatures, employees’ commitments that can predict turnover are
organizational commitment [19], commitment to workgroups [20], affective commitment to super-
visors [15], [21] and occupation commitment [16].
Nurses who come in and out quickly reflect high turnover. This kind of phenomenon is very
detrimental to the hospital. Efforts to increase commitment through the foci of commitment approach give
nurses the flexibility to commit to anyone who is considered to provide comfort during work. The comfort
formed will reduce the nurse's intent to leave the hospital. Increasing nurse commitment is the best strategy
for resource retention of nurses in improving the quality of hospital services. This study aimed to explain
nurse's foci of commitment models to decrease turnover intention in health care setting.

2. RESEARCH METHOD
This study was done from February–March 2018 at one of the islamic hospital in Surabaya, East
Java, Indonesia. This was cross-sectional study involved sample from seven units include critical care,
emergency, surgery, inpatient, outpatient, haemodialysis, and neonatal care. The sample used in the first
stage were 119 nurses using cluster sampling. The number of respondents by unit was as follows: i) Critical
care (n=8); ii) Emergency (n=15); iii) Surgery (n=12); iv) Inpatient (n=57); v) Outpatient (n=11); vi)
haemodialysis (n=10); and vii) Neonatal care unit (n=6) (total nurses=119).
Gender, age, education, employment status, tenure, and the work unit were assessed as a
demographic data. Need for achievement as nurse characteristics measured using the manifest needs
questionnaire (MNQ) [22]. MNQ consist of five item with a 7-point likert type scale (1 refers to never and 7
refers to always). Job descriptions questionnaires [23], [24] was used to measure the job characteristics. Job
descriptions questionnaires consist of six item with 7-point likert type scale (1 refers to never and 7 refers to
always) include the identity of the task, the optional interaction and feedback. Work experience was
measured using a questionnaire prepared by the researchers. Work experience questionnaire consist of 20
item with 5-point likert type scale (1 refers to very disagree and 5 refers to very agree) include: i) Nurse
attitude; ii) Organizational dependability; iii) Personal importance, and iv) Met expectations. Nurse stress
scale [25] was used to measure the stress of work and the workload of nurses. Nurse stress scale consist of 29
item with 4-point likert type scale (0 refers to never and 3 refers to always) include: i) death and dying;
ii) conflict with physicians; iii) Inadequate preparation; iv) Lack of support; v) Conflict with other nurses;
vi) workload; and vii) uncertainty concerning treatment. Practice environment scale of the nursing work
index (PES-NWI) [26] was used to measure the management style, empowerment, and the role perception.
PES-NWI consist of 24 item with 4-point likert type scale (1 refers to very disagree and 4 refers to very
agree) include nurse participation in hospital affairs, nurse foundations for quality care, nurse manager
ability, leadership, and support of nurses. Career development was measured using the scale for nurses
career [27]. The scale for nurses career consist of 13 item with 5-point likert type scale (1 refers to very
disagree and 5 refers to very agree) include career goal, career capacity, and career opportunity. Salary was
measured using nurse job satisfaction questionnaire [28]. Nurse job satisfaction consist of 4 item with 5-point
likert type scale (1 refers to very unsatisfy and 5 refers to very satisfy). Foci of commitment was measured
using organizational commitment questionnaire [29] that consist of 12 item 5-point likert type scale (1 refers
to very disagree and 5 refers to very agree). This questionnaire used to measure commitment to hospital,
commitment to nurse unit manager, commitment to workgroup, and commitment to occupation. Turnover
intention was measured using a questionnaire developed by the researchers. Turnover intention questionnaire

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consist of six item with 5-point likert type scale (1 refers to very disagree and 5 refers to very agree) include
thinking of quitting, intent to search, and intent to quit.
The statistical analysis was using partial least squares (PLS). Strategical issues were determined
based on PLS result and discussed in a focus group discussion (FGD) to give the solutions how to decrease
turnover intention. This study was approved by the ethical committee of the islamic hospital Surabaya with
certificate number 0002/KEPK-RSI JS/II/2018.

3. RESULTS AND DISCUSSION

3.1. Results
Smart PLS-2 program were used to analyse research data. Based on Table 1, it can be seen that
nurses were mostly female (73.1%), and between 21–40 years old (97%). The nurses were completed
undergraduate degrees 70.6 %. Nurses with married status were 66.4% and employment status as a
permanent employee were 69.7%. The majority of the nurses had worked one to five years of work
experience 72.3%.

Table 1. Distribution of general characteristics of the respondent (n=119)

Characteristics n %
Gender
Female 87 7.1
Male 32 26.9
Age (year)
40-60 1 0.8
21-40 116 97.5
<21 2 1.7
Latest education
D3 (3-year diploma) 84 70.6
S1 (undergraduate)/D4 (4-year diploma) 35 29.4
S2 (postgraduate) 0 0
Marital status
Married 79 66.4
Single 39 32.8
Widow/widower 1 0.8
Employment status
Permanent 83 69.7
Non permanent 10 8.4
Contract 26 21.8
Tenure (Year)
1-5 86 72.3
6-10 25 21.0
11-20 7 5.9
>20 1 0.8
Work unit
Out patient 11 9.2
In patient 57 47.9
Emergency 15 12.6
Intensive care 8 6.7
Operating room 12 10.1
Hemodialysis 10 8.4
Neonatal care 6 5.0

Table 2 (see in Appendix) can be seen in appendix which presents the variables of nurse
commitment and turnover intention. The majority of nurses were had high need for achievement (79.8%). In
job characteristics, optional interaction was the lowest in high category (63%). In work experience, the
lowest was nurse attitude, which was in the negative attitude category (47.1%). In organizational factors, the
lowest was salary, which was in unsatisfy category (45.4%). At the nurse commitment, the highest was
commitment to occupation, which was in high category (27.7%) and low category (14.3%). At the turnover
intention, the highest was intent to search, which was in yes category (68.1%).
The result of hypothesis test of development nurse commitment model to reduce turnover intention
shows that nurse commitment influenced by personal characteristics, job characteristics, work experience,
organizational factors. Turnover intention also influenced by these factors and nurse commitment
(commitment to hospital, nurse unit manager, workgroup/ nurse, and occupation).
Based on Figure 1, the nurse characteristics influence the nurse commitment had a path coefficient
of 0.252. The job characteristics influence the nurse commitment had a path coefficient of 0.190. The work

Nurse's foci of commitment model to decrease turnover intention (Nursalam)

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experience influence the nurse commitment had a path coefficient of 0.208. The organizational factors
influence nurse commitment had a path coefficient of 0.218. The nurse commitment influence the turnover
intention had a path coefficient of -0.226. The nurse characteristics influence the turnover intention had a
path coefficient of -0.239. The job characteristics influence the turnover intention had a path coefficient of
-0.183. The work experience influence the turnover intention had a path coefficient of -0.153.
The organizational factors influence the turnover intention had a path coefficient of -0.174. Nurse
commitment decreased turnover intention by 48.2%. The results of the analysis on PLS tests that have been
done, variables are arranged according to the priority of the most influential factors. The last model of nurse
commitment based on foci of commitment is described in Figure 2.

X1 Nurse characteristics X3 Work experience Y1 Nurse commitment

X1.1 Need for achievement X3.1 Personal importance Y1.1 Commitment to workgroup (nurse)
X1.2 Age X3.2 Met Expectations Y2.1 Commitment to occupation
X3.3 Organizational dependability Y2.3 Commitment to nurse unit manager
X3.4 Nurse attitude Y2.4 Commitment to hospital
X2 Job characteristics X4 Organizational factors Y2 Turnover intention
X2.1 Optional interaction X4.1 Career development Y2.1 Thinking of quitting
X2.2 Feedback X4.2 Management style Y2.2 Intent to search
X2.3 Task identity X4.3 Role perception Y2.3 Intent to quit
X4.4 Empowerment
X4.5 Salary

Figure 1. The nurse’s foci of commitment model based on PLS test

As shown in Figure 1, nurse characteristics, job characteristics, work experience, and organizational
factors influenced the turnover of intention directly or through nurse commitment. Sobel test conducted to
determine the effect of nurse commitment as a mediator in reducing turnover intention. The sobel test results
showed at Table 3 that nurse characteristics (3.385>1.96), job characteristics (4.059>1.96), work experience
(3.549>1.96), and organizational factors (3.534>1.96) significant to decrease turnover intention.

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Figure 2. The final nurse’s foci of commitment model

Table 3. Sobel test result of nurse’s foci of commitment model (n=119)

No Variable Sobel test SE P value
1 Nurse characteristics (X1) → nurse commitment (Y1) → turnover intention (Y2) 3.385 0.053 0.0007
2 Job characteristics (X2) → nurse commitment (Y1) → turnover intention (Y2) 4.059 0.04 0.00004
3 Work experience (X3) → nurse commitment (Y1) → turnover intention (Y2) 3.549 0.053 0.00038
4 Organizational factors (X4) → nurse commitment (Y1) → turnover intention (Y2) 3.534 0.053 0.00035

3.2. Discussion
The nurse characteristics, job characteristics, work experience, organizational factors can increase
the nurse commitment and reduce turnover intention. Two indicators that can describe the nurse
characteristics include need for achievement and age. Nurse who have high need for achievement will do
their best for their work, improve their skill, and spirit in facing challenges in working.
The most influential indicators on job characteristics are optional interaction with co-workers
(other nurses, doctors, and hospital staff). Interactions with colleagues that occur on an ongoing basis will
form friendships in the work environment. The benefits of this interaction are felt in the presence of
improved teamwork and effective system support in work.
Personal importance is the indicator of work experience. The nurse will feel that the work is very
valuable if the nursing work is rewarded by nurse unit manager or a higher leader, such as a nursing manager.
Rewards not only given as salary or incentives, thank-you is one of the most important appreciation for
nurses. Nurses who are given additional responsibility also feel that their work in the hospital can be relied.
Career development influences organizational factors. Career development is very important for
nurses who have high career achievement goals. Nurses who can enjoy the their career can trigger nurse job
satisfaction. Another indicator that also affects organizational factors is management style. How leaders
behave, interact with employees, and how to solve problems will be accepted or rejected by the nurse.
Non-compliance of nurse expectation with leader can lead nurses to disrespect to leader, absent at work, and
other rejection behavior. Stress and workload are not an indicator of organizational factors. Stress and
workload depend on the nurse's perception and nurse’s comfort in doing their job. Nurses who feel
comfortable with their work will feel happy doing their work even though the workload in the unit is very
high, and vice versa.
The low commitment to workgroup (nurse) can decrease nurse commitment. The nurse's discomfort
in working causes the nurse to laze around the workplace and become unproductive. Improving teamwork
among the nurses can be done to increase the commitment to the workgroup. Turnover intention can be
decreased by preventing nurses from thinking of quitting from the hospital. Nurses who feel satisfied and
fulfilled their needs will want to stay in the hospital.
Figure 1 shows that nurse characteristics, job characteristic, work experience, and organizational
factors positively influenced nurse commitment. Hence, it was negatively associated with turnover intention.
Nurse characteristics, job characteristic, work experience, and organizational factors can be directly
decreased turnover intention.

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Foci of commitment is a unity consisting of individuals, groups, to whom an employee is

bound [30]. Commitment is complex, diverse, and can be directed to focused commitments within and
outside the organization [31]. In health services, the concept of the target (focus) of this commitment can be
used to consider the behavior of employees. This behavior can be a withdrawal behavior from the
workplace [32]. The fact that employees tend to commit to a variety of work focuses that have consequences
(directly or indirectly) for their decision to leave, or live together, at the organization [31].
The results of this study explain that turnover intention can be decreased by increasing the
commitment of nurses, which consists of commitment with workgroup (nurses), occupation, nurse unit
manager, and hospital. This result is in line with study that the foci of commitment consisting of commitment
to the organization, supervisors, co-workers and occupation can predict the willingness of employees to leave
the organization and leave their jobs [16], [17]. Commitment to the workgroup is the nurse's attachment to a
nurse who works in one room. The attachment between group members will tend to be higher than the
attachments between different work groups within the same organization [20]. Nurses will have a lot of
support from work groups rather than organizations [20]. Interaction with workgroups is more common and
individuals are more active in the workplace than in organizations in everyday life [33]. Affective
commitment to work groups can be improved through enhancing perceived work group cohesiveness [21]
through teamwork development.
Work commitment is a measure of workers' loyalty to a particular field of work [34]. Affective work
commitment reflects professional attachment, identification, and involvement in work or profession [35].
The suitability between the nurse's perception and experience gained during the work may influence the
nurse's decision to continue working [36]. A person who is satisfied with the fulfillment of basic needs can
increase work commitment [37]. Affective commitment to work can be built through career development and
professional skill enhancement and followed by rewards [38]. Commitment to nurse unit manager is a
commitment to the supervisor. Commitment to supervisors shows employees' trust and openness to
supervisors [39]. Commitment to the supervisor is related to vertical relevance based on the principle of
reciprocity [40]. Professional employees will show more loyalty to the supervisor than to the
organization [40]. Employees who are committed to high supervisors have a low intention to quit [15].
Affective commitment to the supervisor is strongly influenced by the leader member exchange (LMX) [21].
Definition of organizational commitment as a psychological construct that characterizes the
relationship of members of an organization with its organization and has implications for the individual's
decision to continue his membership in organization [41]. Individuals who are committed to high
organization will have greater work efficiency and job satisfaction. [42]. High job satisfaction will decrease
employees' desire to leave the organization. Affective commitment to the organization can be built through
employee engagement in decision making, formulating the needs and expectations of employees according to
hospital goals, building leadership behaviors that are nurses and tasks oriented, and enhancing the clarity of
employee roles in the organization [43].
Foci of commitment is a commitment built based on commitment targets. The separation of nurse
commitment has one purpose that is for the advancement of organization (hospital). In this study,
commitment to the workgroup is the first commitment to be built. This commitment is enhanced by the
improvement of team work. Before building a team work, the nurse must know the benefits of teamwork
first. The role of nurse and nurse unit manager becomes very important in creating a good working
atmosphere between nurses. This good teamwork will improve the relationship between nurses and nurses
with the nurse unit manager.

4. CONCLUSION
This study revelaed that nurse characteristics with the indicators of need for achievement directly
influenced nurse commitment. Job characteristics using the indicators of optional interaction influenced nurse
commitment. Work experience directly influenced nurse commitment, especially in personal importance.
Organizational factors in career development and management style also increase nurse commitment. Nurse
commitment influenced turnover intention in commitment to workgroup (nurses). Personal characteristics,
job characteristics, work experience, and organizational factors directly influenced turnover intention. The
nurse commitment model can decrease turnover intention by increase commitment to workgroup (nurses),
commitment to occupation, commitment to nurse unit manager, and commitment to hospital.
The importance of nurses’ emotional attachment and comfortable environment in working to
maintain nurses working in hospitals. Hospitals should do an effort how to reduce nurse intention turnover
through increased emotional attachment of nurses. Nurses are homogeneous individuals with different
commitment targets. Nurses can increase commitment to their chosen commitment targets, including
commitment to workgroup (nurse), commitment to occupation, commitment to nurse unit manager, and

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commitment to hospital. This commitment is enhanced through increased need for achievement, improve
nurse relationships with colleagues, provide additional responsibilities and awards to nurses, and develop a
clear career of nurses.
Limitations in this study are research results that can not be generalized in all hospitals. In addition,
the number of instruments used by researchers is very much to be able to represent each variable studied,
so that respondents feel bored that can affect the dishonesty of respondents in filling the questionnaire.
The influence of job satisfaction, nurse commitment, and perceived organizational support to turnover
intention needs further research.

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BIOGRAPHIES OF AUTHORS

Nursalam is a Professor of Faculty of Nursing, Universitas Airlangga. His

research interests are mainly focused in Nursing Management, Basic and Medical Surgical
Nursing, Critical Nursing. Active member and Head of Association of Indonesian Nurses
Education Center (AINEC) and Persatuan Perawat Nasional Indonesia (PPNI) at east java
province. He has written the books nursing management, research methodology in nursing,
English for nursing, nursing care for HIV/AIDS. He can be contacted at email:
nursalam@fkp.unair.ac.id.

Nurul Hikmatul Qowi is a lecturer in Nursing Department of Universitas

Muhammadiyah Lamongan, Indonesia. Her research interests are mainly focused in nursing
education, nursing management, and nursing informatics. Active member of Himpunan
Perawat Manajer Indonesia (HPMI). She has written the books nursing management,
anatomy and physiology. She can be contacted at email: nurul_hikmatul_qowi@umla.ac.id.

Int J Public Health Sci, Vol. 11, No. 4, December 2022: 1357-1366
Int J Public Health Sci ISSN: 2252-8806  1365

Tri Johan Agus Yuswanto is a lecturer of Polytechnic of Health of Malang,

Ministry of Health, Malang, Indonesia. His research interests are mainly focused in the
nursing management and leadership, patient safety, and diabetes mellitus. He is an active
member and head of Himpunan Perawat Manajer Indonesia (HPMI) of East Java Province.
He can be contacted at email: denbagusjohan@yahoo.co.id.

Ferry Efendi is lecturer and researcher of Faculty of Nursing, Universitas

Airlangga. His research interest is mainly focused in migrant nursing. He is founder of Nurse
Labour Market (NLM), android based application. He is also an active member of The
External Affairs Committee, Council of Asian Science Editor, AuthorAid, Healthspace Asia,
Global Health Network. He is 500 Best Researchers in Indonesia based on SINTA. He is
author of several international peer reviewed publications about nursing, healthcare and
human resources. He can be contacted at email: ferry-e@fkp.unair.ac.id.

APPENDIX

Table 2. Variables distribution of nurse’s foci of commitment model (n=119)

Variable n (%) x Score
Need for achievement
High 95 (79,8) 29.8 20-35
Moderate 24 (20,2)
Low 0
Optional interaction
High 75 (63.0) 11.3 6-14
Moderate 37 (31.1)
Low 7 (5.9)
Feedback
High 84 (70.6) 11.7 7-14
Moderate 34 (28.6)
Low 1 (0.8)
Task Identity
Dependent 4 (3.4) 11.9 1-14
Partially dependent 20 (16.8)
Independent 95 (79.8)
Personal importance
High 72 (60.5) 19.0 11-25
Moderate 46 (38.7)
Low 1 (0.8)
Met Expectation
High 68 (57.1) 19.3 14-25
Moderate 51 (42.9)
Low 0 (0)
Organizational dependability
High 71 (59.7) 18.9 15-25
Moderate 48 (40.3)
Low 0 (0)
Nurse attitude
Positive 63 (52.9) 18.5 13-25
Negative 56 (47.1)
Career development
Good 57 (47.9) 47.8 29-67
Enough 61 (51.3)
Less 1 (0.8)
Management style
Effective 45 (37.8) 15.6 6-21
Effective enough 69 (57.9)
Less effectif 5 (4.4)

Nurse's foci of commitment model to decrease turnover intention (Nursalam)

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Variable n (%) x Score

Empowerment
High 41 (34.5) 27.6 12-36
Moderate 76 (63.9)
Low 2 (1.7)
Role perception
Good 50 (42.0) 31.4 20-40
Enough 65 (54.6)
Less 4 (3.4)
Salary
Satisfy 65 (54.6) 11.4 4-20
Unsatisfy 54 (45.4)
Commitment to workgroup
High 18 (15.1) 40.1 21-62
Moderate 81 (68.1)
Low 20 (16.8)
Commitment to occupation
High 33 (27.7) 41.2 22-60
Moderate 69 (58.0)
Low 17 (14.3)
Commitment to nurse unit manager
High 16 (13.4) 39.9 35-59
Moderate 82 (68.9)
Low 21 (17.6)
Commitment to hospital
High 17 (14.3) 39.6 23-59
Moderate 84 (70.6)
Low 18 (15.1)
Thinking of quitting
Yes 55 (46.2) 5.15 2-10
No 64 (53.8)
Intent to search
Yes 81 (68.1) 6.01 2-10
No 38 (31.9)
Intent to quit
Yes 49 (41.2) 4.86 1-10
No 70 (58.8)

Int J Public Health Sci, Vol. 11, No. 4, December 2022: 1357-1366