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Effects of Job Satisfaction, Affective Commitment, and Organizational

Support on Job Performance and Turnover Intention in Healthcare Workers

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Arch Health Sci Res. 2021;8(2): 89-95
DOI: 10.5152/ArcHealthSciRes.2021.21044 Original Article

Effects of Job Satisfaction, Affective Commitment,

and Organizational Support on Job Performance and
Turnover Intention in Healthcare Workers
Sağlık Çalışanlarında İş Tatmini, Duygusal Bağlılık ve
Örgütsel Desteğin İş Performansı ve İşten Ayrılma Niyeti
Üzerine Etkisi
İbrahim GÜN , Selma SÖYÜK , Salih Haluk ÖZSARI
Department of Health Management, İstanbul University-Cerrahpaşa, Faculty of Health Sciences, İstanbul, Turkey

Cite this article as: Gün İ, Söyük S, Özsarı SH. Effects of Job Satisfaction, Affective Commitment, and Organizational Support on Job Performance
and Turnover Intention in Healthcare Workers. Arch Health Sci Res. 2021;8(2):89-95.
89
ABSTRACT
Objective: In this study, we investigated the effects of job satisfaction, affective commitment, and organizational support on job performance and
turnover intention in healthcare workers.
Material and Methods: This cross-sectional study was conducted in training and research hospitals in the Beyoğlu region of İstanbul. In this study,
we used the convenience sampling method. Structural equation modeling was used to analyze the relationships between variables. The validity
and reliability of the scales were performed by confirmatory factor analysis and Cronbach’s alpha coefficients.
Results: According to the results, the model fit the data well. The χ2/df value of the data was 2.84. The Goodness of Fit Index was 0.90, and the
normed fit index is 0.92. Tucker and Lewis Index was 0.94. Job satisfaction and affective commitment had an effect on job performance (P < .05);
and job satisfaction, emotional commitment, and job performance had an effect on turnover intention (P < .05).
Conclusion: Job satisfaction and affective commitment had a positive and significant effect on job performance and there was a negative and
significant effect on turnover intention (P < .05). In addition, job performance had a significant negative effect on turnover intention. Increase in
job performance and decrease in turnover intention could be possible with satisfaction, commitment, and support.
Keywords: Affective commitment, job performance, job satisfaction, organizational support, turnover intention

ÖZ
Amaç: Bu çalışma sağlık çalışanlarında iş tatmini, duygusal bağlılık ve örgütsel desteğin iş performansı ve işten ayrılma niyeti üzerine etkisini
araştırmaktadır.
Gereç ve Yöntem: Kesitsel olarak planlanan bu araştırma İstanbul Beyoğlu bölgesinde yer alan eğitim araştırma hastanelerinde gerçekleştir-
ilmiştir. Kolayda örnekleme yönteminin kullanıldığı bu araştırmada verilerin analizi yapısal eşitlik modeli ile (SEM) incelenmiştir. Geçerlilik ve
güvenilirlik analizleri doğrulayıcı faktör analizi ve Cronbach's Alpha katsayısı ile incelenmiştir.
Bulgular: Araştırma bulguları incelendiğinde verilerin modelle uyumunun oldukça iyi düzeyde olduğu tespit edilmiştir. Modelin, χ2/df değeri 2.84.
İyilik Uyum İndeksi (Goodness of Fit Index, GFI) 0.90. Normlaştırılmış Uyum İndeksi (Normed Fit Index, NFI): 0.92. Tucker & Lewis İndeksi 0.94
olarak bulunmuştur. İş tatmini ve duygusal bağlılık iş performansı üzerinde olumlu bir etkiye sahiptir (P < ,05). Ayrıca iş tatmini, duygusal bağlılık
ve iş performansı da işten ayrılma niyeti üzerinde anlamlı bir etkiye sahiptir (P < ,05).
Sonuç: İş tatmini ve duygusal bağlılık, iş performansı üzerinde olumlu ve anlamlı bir etkiye sahipken işten ayrılma niyeti üzerindeki etkisi anlamlı
ve negative yönlüdür. İş tatmini ve duygusal bağlılık arttıkça iş performansı artmakta ve işten ayrılma niyeti azalmaktadır.
Anahtar Kelimeler: Duygusal bağlılık, iş performansı, iş tatmini, örgütsel destek, işten ayrılma niyeti

Address for Correspondence: Selma SÖYÜK, Department of Health Management, İstanbul University-
Cerrahpaşa, Faculty of Health Sciences, İstanbul, Turkey, selmasoyuk@hotmail.com
Received: April 5, 2021
This work is licensed under a Creative Commons Attribution 4.0 International License. Accepted: April 14, 2021
 Arch Health Sci Res. 2021;8(2): 89-95

Introduction satisfaction has been seen as a variable that affects organi-

zational outcomes. An employee with high job satisfaction
One of the most important difficulties in accessing health makes extra efforts to do the job more effectively and effi-
services are under supply and maldistribution of the health ciently, which can improve job productivity. It has been found
workforce.1 According to the World Health Organization (WHO) in many studies that job satisfaction affects job performance
(2013), the shortage of healthcare workers worldwide is 7.2 mil- and turnover intention.11,12 In terms of potential impact on
lion, and this number is expected to increase to 12.9 million by organizations, job satisfaction plays an important role in the
2035.2 Turkey emphasized the importance of human resources employee turnover process. If this issue is not addressed,
with the “Health Transformation Program” launched in 2003. A dissatisfaction can lead to turnover intention and eventually
highly motivated health workforce equipped with knowledge turnover.13
and skills has been accepted as the cornerstone of transforma-
tion.3 Turkey is in the last place among OECD countries in terms Organizational commitment is a structure with multiple com-
of health workforce statistics. The average number of doctors ponents that typically define an individual’s feelings of commit-
per 100,000 is 351 in OECD countries, but it is 186 in Turkey. ment, identification, and commitment to the organization.14
The OECD average number is 1025 for the number of nurses Meyer and Allen15 suggested three types of organizational com-
and midwives per 100,000 people. This number is only 172 in mitment in 1991 called affective commitment, continuance
Turkey. In countries where human resources are limited, the commitment, and normative commitment.15 Affective commit-
performance of existing human resources and keeping quali- ment, defined as emotional attachment, is often discussed in
90 fied human resources within the organization is very import- reference to one’s organization and is sometimes referred to as
ant.4 organizational commitment.16 Affective commitment is one of
the critical drivers of behavior, such as work performance or
Improving job performance and reducing turnover intentions turnover by individuals in the workplace.13 According to Fazio
are important to enhance organizational effectiveness. The et al.17, affective commitment is a powerful predictor of turn-
performance of their employees obviously matters a great over intention. Employees who are affectively committed to
deal to organizations.5 Employee performance is one of the the organization have a strong sense of belonging and connect
most important challenges in an environment where there is themselves closely with the goals of the organization. They,
a high level of tension, such as health services. Performance therefore, have a strong desire to remain with the organiza-
problems, particularly for doctors and nurses, are inextricably tion. Numerous studies demonstrate the strong relationship
linked to patient safety. The main reason for this is that perfor- between affective commitment, turnover intention, and job
mance is closely related to efficiency, knowledge management, performance.2,17,18
quality elements, financing, and development.6
Since the introduction of perceived organizational support in
Job satisfaction has an impact on healthcare and service qual- the literature, many studies have shown that positive organi-
ity owing to its negative effects on physical and mental health. zational structure is positively associated with many positive
Being successful and reaching goals is easier when a healthcare outcomes.19
organization consists of satisfied employees.7 Human resourc-
es in healthcare are considered as one of the basic building Liu et al.14 indicated that the perceived organizational support
blocks of any health institution. Moreover, the efficiency and structure was first developed by Eisenberger et al”14 Perceived
productivity of an organization depends largely on the efficient organizational support reflects employee beliefs about an or-
and productive performance of its staff. The quality of patient ganization’s support, commitment, and interest toward them
care in a healthcare facility, the outcome of care, and their and has been found to be associated with mutual employee
commitment to healthcare facilities are directly related to the engagement to the organization. According to the theory of so-
job satisfaction of healthcare personnel. High job satisfaction cial change, “Eisenberger et al” have developed the concept of
in healthcare personnel brings positive and beneficial results. perceived organizational support to explain the development
Job satisfaction not only helps them increase their confidence of affective support in 1986.14 They claim that employees fol-
and perform their duties more carefully, but also helps them low the principle of social change that emphasizes reciprocity
improve relationships with their colleagues and reduce their to adjust their emotional commitment to the perceived organi-
mental stress.8 zational support level.17

Job satisfaction could be defined as “how people feel about According to the organizational support theory, employees
their jobs and different aspects of their jobs. It is the extent form a general perception of the extent to which the organi-
to which people like or dislike their jobs.” Job satisfaction is zation values their contributions and cares about their well-be-
a subjective judgment, and it is about how work that will be ing. Hence, experiencing perceived organizational support
done responds to expectations, organizational characteristics, expresses employee belief that they are on their side of the
and working conditions.9 organization.20

High levels of stress, anxiety, and depression can be seen in The close relationship between job performance and job
healthcare workers, especially in doctors and nurses. They are satisfaction has been known for a long time. Furthermore,
also more exposed to the psychosocial and biological effects job satisfaction is a key issue for healthcare professionals
of stress than people in other professions.10 Therefore, job around the world.6 Job performance studies are frequently
 Gün et al. Performance and Turnover Intention in Healthcare

seen in the international literature. It is seen as an important

dimension in management, human resource management, Job Satisfaction
Affective Organizational
and organizational psychology as well as organizational be- Commitent Support
havior studies.21 Job performance can be described as in-role
performance and extra-role performance. “The in-role per-
formance is described as required or expected outcomes and
behaviors of employees directly related to the goals of the Job Turnover
organization, whereas extra-role is described as voluntary Performance Intention
behaviors directly related to an organization’s effective func-
tioning without a necessary and direct impact on an employ-
Figure 1. Research Model
ee’s productivity.”22

One of the major factors of healthcare worker shortage is turn- and was developed by Meyer et al.30 in 1993. The Perceived
over.23 Employee turnover, which is one of the main concerns Organizational Support Scale developed by Chiang and Hsieh31
for employers, is an organizational problem. Nurse turnover, in was used in this study. The Job Performance Scale also devel-
particular, causes staff shortages, adversely affecting the qual- oped by Chiang and Hsieh31 was used in our study. The Turn-
ity of nursing care, patient safety, and is a factor that increases over Intention Scale validated by Nadiri and Tanova32 was used
the training cost of new nurses.24,25 Therefore, it attracts the in our study.
attention of both the field and theoretically the researchers. 91
Statistical analysis
According to Perreira et al.,16 “turnover intention is defined as a
The validity and reliability of the scales used in the study were
conscious and deliberate willingness to leave the organization.”
analyzed by confirmatory factor analysis (CFA) and Cronbach’s
In another definition, it is defined as the probability of employ-
alpha coefficients. Structural equation modeling (SEM) was
ees leaving their current jobs.26
used to test the hypotheses. In the analysis phase, a 2-step path
The current balance between supply and demand of healthcare proposed in the literature.31 In the first step, CFA was used to
professionals highlights a global problem of continuous brain validate the scales, and then SEM was used to test the relation-
drain. Till 2013, the worldwide shortage of healthcare workers ships in the established hypotheses. At this stage, the appropri-
(including physicians, nurses, and midwives) was estimated at ateness of the research data to the normal distribution from
7.2 million and is expected to rise to 12.9 million by 2035.27 the assumptions of the structural equation model was tested.
Turnover studies show that employee turnover, especially of Skewness and kurtosis values of each substance were examined
nurses, doctors, hospital managers, etc., causes remarkable and found to be suitable for normal distribution. In the study,
costs to healthcare organizations.5 Employee turnover is expen- the effect of exogenous variables (job satisfaction, emotional
sive because it leads to high costs such as recruitment costs, commitment, and organizational support) on endogenous vari-
training costs, and separation costs.28 ables (job performance and turnover intention) was examined
with the structural equation model. In the last hypothesis of
Material and Methods the study, the effect of job performance on turnover intention
was investigated. The hypotheses examining effects between
In this study, we aimed to investigate the effects of job sat-
the variables are presented in Figure 1. The study hypotheses
isfaction, affective commitment, and organizational support
are as follows:
on job performance and turnover intention. Ethics committee
approval, number 191486 from İstanbul University Social Sci- H1: Job satisfaction has a positive effect on job performance.
ences and Humanities Research Ethics Committee in May 05, H2: Affective commitment has a positive effect on job perfor-
2017, was obtained. The study was planned as a cross-section- mance.
al study and was carried out in educational research hospitals H3: Organizational support has a positive effect on job perfor-
that have similar characteristics and units located in Beyoğlu, mance.
Istanbul. After the incomplete questionnaire forms were elim- H4: Job satisfaction has a negative effect on turnover intention
inated, responses from 442 healthcare workers were included H5: Emotional commitment has a negative effect on turnover
in the analysis. The convenience sampling method was used intention
in this study. H6: Organizational support has a negative effect on turnover
intention
Data collection
H7: Job performance has a negative effect on turnover inten-
A questionnaire form was used as the data collection tool.
tion
This form consisted of job satisfaction, affective commitment,
organizational support, job performance, and turnover inten- Results
tion scales and demographic variable sections. All scales were
5-point Likert type. After missing answers and outliers were Demographic data of the participants are given in Table 1. Ac-
eliminated, 442 questionnaire forms were analyzed. The Job cording to this, 33.8% of the participants were between 18 and
Satisfaction Scale developed by Luthans, F., Avolio, B. J., Avey, 30 years, 32.7% were between 31 and 38 years, and 33.5% were
J. B., and Norman, S. M.; and the short form created by Çınar29 between 39 and 60 years. Of the participants, 66.7% were wom-
was used. The Affective Commitment Scale consisted of 6 items en, and 33.8% had undergraduate and 17.6% had graduate
 Arch Health Sci Res. 2021;8(2): 89-95

education. Most of the participants were nurses in our study Factor loads of the Job Satisfaction Scale ranged from 0.55 to
(38.7%). Most of the participants were working only during the 0.82. Cronbach’s alpha coefficient was 0.75. Factor loads of
day (66.1%) and 32% were working in shifts. the Affective Commitment scale were between 0.73 and 0.81,
and Cronbach’s alpha coefficient was 0.86. Factor loads of Or-
Table 2 contains the names of the scales, scale expressions, ganizational Support were between 0.81–0.92, and reliability
Cronbach’s alpha values, factor loads, means, and standard coefficient was found to be 0.93. Factor loads of the Job Per-
deviations of the scales. According to CFA results, all variable formance and Turnover Intention scales were 0.71 to 0.82 and
loadings were found significant at P < .01. 0.71 to 0.97, respectively; and Cronbach’s alpha values were
0.88 for both (Table 2). All factor loadings were significant at P
Table 1. Demographic Characteristics of Sample (n=422) < .001 and ranged from 0.55 to 0.92, which indicates that each
Demographic characteristics Frequency Percent indicator reflected the constructs they intended to measure.
Age (n=379), years The Cronbach’s alpha reliability values for the three latent con-
18–30 128 33.8 structs range from 0.75 to 0.93, which exceed the acceptable
31–38 124 32.7 levels of 0.70 Therefore, the measures show acceptable reliabil-
39–60 127 33.5 ity. In addition, all indicator variable loadings were significant
Sex (n=396) at P < .001.
Female 264 66.7
According to the findings, c2/df value was 2.84. The Goodness
92 Male 132 33.3
of Fit Index was 0.90, and the normed fit index was 0.92. The
Education (n=391) Tucker and Lewis Index was 0.94. The comparative fit index is
Other 190 48.6 0.95, and the root mean square error of approximation was
Bachelor 132 33.8 0.06 (Table 3). These test results show that the model fits the
Graduate 69 17.6 data well.
Occupation (n=385)
Doctor 56 14.5 According to the SEM results, the hypothesis that job satis-
Nurse 149 38.7 faction has a positive effect on job performance is supported
Other 180 46.8 (β=0.27, P < .01). Job satisfaction has a positive effect on job
Manner of work (n=381) performance, and job performance increases as job satisfaction
Day 252 66.1 increases (hypothesis 1 supported).
Night 7 1.8 Hypothesis 2 test results showed that affective commitment
Shift 122 32.0 had a positive effect on job performance (β=0.18, P < .05).

Table 2. Cronbach’s Alpha Coefficients, Factor Loads, Means and Standard Deviations of Variables
Variables Items Cronbach’s alpha Factor loads Mean SD
Satisfaction Generally, I am very satisfied with my job. 0.750 0.827 3.55 1.09
Generally satisfied with the qualification and content of 0.796 3.43 1.09
the jobs my position requires.
Most of staff are satisfied with their job in my hospital. 0.555 2.94 1.11
Affective I would be very happy to spend the rest of my career in 0.865 0.765 3.24 1.25
commitment this hospital.
I really feel as if this hospital’s problems are my own. 0.818 3.30 1.24
I feel like a “part of my family” at this hospital. 0.733 3.37 1.19
This hospital has a great deal of personal meaning for me. 0.808 3.16 1.24
I feel a strong sense of belonging to this hospital. 0.767 3.43 1.20
Emotional My hospital cares about my opinion 0.932 0.858 3.09 1.16
support My hospital really cares about my well-being. 0.920 3.09 1.20
My hospital strongly considers my goals and values. 0.923 3.10 1.16
Help is available from my hospital when I have a problem. 0.819 3.27 1.14
Job I fulfill specific job responsibilities 0.888 0.756 4.36 0.74
performance I meet performance standards and expectations. 0.822 4.17 0.86
My performance level is satisfactory. 0.808 4.13 0.89
I am effective in my job. 0.821 4.24 0.81
I produce high-quality work. 0.719 4.25 0.79
Turnover Often thought of quitting. 0.881 0.719 2.65 1.25
intention Looking for a new job next year probably. 0.976 2.24 1.14
Leaving the job next year. 0.866 2.22 1.15
Abbreviations: SD, standard deviation
 Gün et al. Performance and Turnover Intention in Healthcare

Table 3. Model Fit

χ2/df P value GFI NFI TLI CFI RMSEA
2.84 .000 0.907 0.924 0.939 0.949 0.065
Abbreviations: CFI, Comparative Fit Index; df, degrees of freedom; GFI, Goodness of Fit Index; NFI, Normed Fit Index; RMSEA, root mean square error of
approximation; TLI, Tucker and Lewis Index

Table 4. Results of Hypothesis Tests

Direct effect
Hypothesis Independent variable Dependent variable β CR P value Information
H1 Job satisfaction Job performance 0.270 3.395 .00 Supported
H2 Affective commitment 0.185 2.227 .02 Supported
H3 Organizational support −0.109 −1.418 .15 Not supported
H4 Job satisfaction Turnover intention −0.207 −2.597 .00 Supported
H5 Affective commitment −0.179 −2.248 .02 Supported
H6 Organizational support 0.088 1.205 .22 Not supported
H7 Job performance Turnover intention −0.164 −3.072 .00 Supported
Abbreviations: CR, composite reliability
93
As affective commitment increases, there is also an increase their productivity and job performance. In a study conducted
in job performance (hypothesis 2 supported). The effect of or- on nurses by Tong33 in 2018, again it has been found that there
ganizational support on job performance was not statistically is a positive relationship between job satisfaction and job per-
significant and could not be accepted. When the effect of job formance. According to the results, turnover rate and absentee-
satisfaction on turnover intention was examined, it was con- ism are generally lower in cases where job satisfaction is high.
cluded that the effect was negative and significant; and hence,
hypothesis 4 was accepted (β=0.20, P < .01). As a result of our study, affective commitment has a positive
effect on job performance and a negative effect on turnover
Affective commitment also has a negative impact on turnover intention. Tran et al.34 (2018) have concluded that relationships
intention, and hypothesis 5 has been accepted (β=−0.17, P < with organizational members and organizational commitment
.05). The hypothesis that organizational support has a negative were effective on job performance. Wong and Laschinger35
effect on turnover intention was not supported by the study found that organizational commitment had a negative impact
findings (P > .05). Hypothesis 7 that was based on the litera- on turnover intention in hospital front desk workers and that
ture knowledge was supported and accepted by the research tension at work was effective on turnover intention.
data. Job performance has a negative effect on the turnover
intention (β=−0.16, P < .01). All hypothesis test results and Perreira et al.16 in 2018 have studied fair organizational cli-
regression coefficients are presented in Table 4. mate, affective commitment, and turnover intention among
nurses. They found that fair climate and affective commitment
Discussion had effects on turnover intention. In our study, there was no
significant effect of organizational support on turnover inten-
The satisfaction level, organizational commitment, and job tion; however, in other studies, organizational support and
performance in healthcare workers are very important. In this organizational commitment had an impact on turnover inten-
sector, the urgency of the works, rapid decision making, and tion.4,22 Dinc et al.2 (2018) have concluded that organizational
the direct reflection of the results to the patient increase the commitment affects job satisfaction in nurses, and job satis-
importance of the issue. Unsatisfied employees make more faction indirectly affects job performance. They stated that job
mistakes. Commitment decreases, and they leave work. Finding satisfaction played a critical role in job performance.
new employees and getting them trained for the job is quite
expensive. In addition, there is a huge workload on a relatively Conclusion
small number of healthcare workers and institutions in Turkey.
With high turnover, new workloads will be added to the exist- The results of this study have important results for health man-
ing workers, and there will be increase in dissatisfaction in the agers. Turnover intention in healthcare workers and low per-
existing personnel. formance of the job may turn into action after a while. When
employees leave their jobs, the organization could face many
In our study, a positive relationship was found between job financial and moral problems. Therefore, in this study, the ef-
performance and job satisfaction. Platis et al.6 have reached fects of independent variables such as job satisfaction, affective
the same results in their study on nurses in 2015. In the study commitment, and organizational support on job performance
conducted by Chao et al.11 (2015) for health workers, the same and turnover intention were investigated. As evident from the
results were obtained. As in our study, Chao et al.11 have found results of the study, managers who follow them regularly by
a relationship between job performance and turnover inten- paying attention to the behaviors, attitudes, and feelings of the
tion. If health workers are dissatisfied with their job, they will employees can prevent the turnover intention of the employ-
be more likely to discontinue, quit their jobs, and/or decrease ees and ensure their stable and high performance.
 Arch Health Sci Res. 2021;8(2): 89-95

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