The mediating effects of nurses’ professional values on the relationship between work environment and organizational commitment among long-term care hospital nurses

Abstract

Background

Organizational commitment is emphasized as an essential element for improving nurses’ work performance and organizational productivity. There is a lack of research investigating both the direct and indirect factors influencing organizational commitment among long-term care (LTC) hospital nurses.

Purpose

This study explored the mediating effects of nurses’ professional values on the relationship between the nursing work environment and organizational commitment among LTC hospital nurses.

Methods

Participants included 154 nurses from nine LTC hospitals in South Korea. Data were collected using Korean versions of the Practice Environment Scale of the Nursing Work Index, Nursing Professional Values Scale-Revised, and Organizational Commitment Questionnaire. Subsequent analyses were conducted using Baron and Kenny’s three-step regression method and the Sobel test.

Results

The analyses showed that nursing professional values partially mediated the relationship between the nursing work environment and organizational commitment (Z = 3.43, p = .001).

Conclusion

LTC hospital managers need to make efforts to improve the nursing work environment and to promote nursing professional values for increasing nurses’ organizational commitment.

Introduction

Elderly populations are rapidly increasing throughout the world [1]. Such a rapid increase has placed intense demands on long-term care (LTC) services, increasing the number of LTC hospitals in South Korea grew from 690 in 2008 to 1,382 in 2024 [2].

Nurses comprise the largest proportion of the LTC workforce. They are responsible for many medical and nursing duties in areas of personal care, social services, and medical/rehabilitative care while also being tasked with integrated services, including those aimed at daily life performance for patients [3]. These heavy workloads may create burnout, which reduces care quality and negatively affects patient outcomes [4]; meanwhile, poor work life increases turnover intention [5]. In Korea, reports show a 20.4% turnover rate among LTC hospital nurses, which is substantially higher than the 11.6% found at tertiary general hospitals [6]. This further increases workloads and stress levels among the remaining nurses while negatively impacting the quality of patient care and overall organizational effectiveness [4].

The nursing literature clearly shows that organizational commitment can reduce burnout and turnover intention [7, 8]. It is a useful concept for predicting the behaviors of organizational members, and has been found to encourage vigorous and devoted work in the nursing environment, with significant impacts on work performance, organizational productivity, and efficiency [9, 10]. Therefore, increasing the organizational commitment of LTC hospital nurses is an important aspect of efficient human resource management and organizational performance, so it is important to assess their organizational commitment and identify related factors.

Medical organizations should establish nursing work environments that help nurses provide patients with quality professional care; this includes the physical environment, colleague interactions, and organizational/policy aspects [11]. A good nursing work environment increases organizational commitment by enhancing job satisfaction and supporting the best nursing work [12]. By contrast, poor work environments and associated stresses have been found to reduce job satisfaction for hospital nurses, thereby diminishing organizational commitment [12]. This is further affected by the trust relationship between nurses and head nurses, which is a subfactor of the nursing work environment [10, 13]. As LTC hospitals have fewer personnel and less material support than general hospitals [14], it is especially important to understand and improve the relationship between organizational commitment among LTC nurses and their nursing work environment.

While the nursing work environment may directly impact organizational commitment, this can partially be adjusted through personal factors (e.g., resilience) [12]. In other words, there may be a limited range of improvement potentials depending on the institutional characteristics. This highlights the need to identify personal factors that buffer the effects of the nursing work environment on organizational commitment. In addition to working efficiently, confidently, and with pride, nurses with strong nursing professional values improve job involution via positive attitudes and satisfaction [15]. Research has shown that higher nursing professional values can positively affect organizational commitment [16]. Meanwhile, nursing professional values are facilitated through good nursing work environments, which entail positive professional relations, professional autonomy, and opportunities for professional advancement [17]. As both the nursing work environment and nursing professional values can affect organizational commitment, it can reasonably be predicted that nursing professional values directly and indirectly buffers the impacts of the nursing work environment on organizational commitment.

Studies on nursing work environment, nursing professional values, and nurses’ organizational commitment have focused primarily on general hospital nurses [5, 9, 16, 18]. In addition, studies of LTC hospital nurses have focused on the fragmentary relationships among these variables [12]. Many studies have confirmed the effectiveness of organizational commitment at predicting turnover intention [5, 7], and to only investigate direct and indirect factors affecting organizational commitment among LTC hospital nurses is insufficient [8]. Therefore, this study is intended to identify the mediating effects of nursing professional values on the relationship between the nursing work environment and organizational commitment among LTC hospital nurses. Investigating both the direct and indirect factors influencing organizational commitment among LTC hospital nurses can provide important managerial implications for establishing interventional strategies to promote their organizational commitment.

Aims

The current study aimed to (1) examine the differences in organizational commitment scores by type of demographic characteristics among LTC hospital nurses; (2) explore the associations among nursing work environment, nursing professional values, and organizational commitment among LTC hospital nurses; (3) evaluate the mediating effects of nursing professional values on the relationship between nursing work environment and organizational commitment among LTC hospital nurses.

Methods

Study design

A cross-sectional and correlational study design was employed to confirm the mediating effects of nursing professional values on the relationship between the nursing work environment and organizational commitment among LTC nurses.

Sample

Participants were a convenience sample of 154 nurses across nine LTC hospitals in Daegu Metropolitan City and Gyeongbuk Province in South Korea. All were required to understand the study purpose/contents and provide their written agreement to participate. Using the G-power 3.1.9.2 software (significance level of 0.05, 80% power, and medium effect size of 0.15), a linear multiple regression analysis conducted with 12 predictors (10 demographic characteristics, nursing work environment, and nursing professional values) showed a minimum required sample size of n = 127 for statistical analysis.

Ethical consideration

This study was approved by the Institutional Review Board of the Keimyung university (approval number: 40525-202308-HR-035-03) on December 18, 2023. Permission was obtained from authorities at all hospitals. All participants provided written informed consent prior to participation.

Measurements

Nursing work environment

The nursing work environment was measured using the Korean version of the Practice Environment Scale of the Nursing Work Index (K-PES-NWI) [19] translated into Korean and verified for reliability and validity for Korean clinical nurses [20], which contains 29 items across five dimensions, including the participation of nurses in hospital operations (nine items), foundation for quality nursing (nine items), ability of nursing managers, leadership, support for nurses (four items), sufficient manpower and material support (four items), and doctor’s cooperative relationship (three items). Responses are given on a 4-point Likert-type scale ranging from 1 (not at all) to 4 (highly likely), with higher scores indicating more positive perceptions of the work environment. Cho et al. [20] produced a Cronbach’s alpha value of 0.93 for the entire scale, with dimensional coefficients ranging from 0.80 to.84. This study produced a Cronbach’s alpha value of 0.89 for the entire scale, with dimensional coefficients ranging from 0.70 to 0.80.

Nursing professional values

Nursing professional values were measured using the Nursing Professional Values Scale-Revised (NPVS-R) [21] translated into Korean and verified for reliability and validity for Korean clinical nurses [22], which contains 26 items that are rated using a 5-point Likert scale, with higher scores indicating stronger professional values. Moon et al. [22] produced a Cronbach’s alpha value of 0.93, while in this study it was 0.90.

Organizational commitment

Organizational commitment was measured using the Organizational Commitment Questionnaire (OCQ) [23] translated into Korean and verified for reliability and validity for Korean clinical nurses [24], which contains 15 items across three dimensions, including identification (five items), organizational attachment (five items), and continuance (five items). Responses are given on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating higher organizational commitment. Park [24] produced a Cronbach’s alpha value of 0.91, while this study produced a 0.86.

Data collection

Data were collected from December 22, 2023 to March 20, 2024. The researcher visited the hospitals and explained the study purpose to the nursing department heads. After obtaining permission, the researcher explained the study to participants, who were given questionnaires upon providing written consent. All were informed that the study was voluntary, that anonymity would be maintained, that there was no correct answer to the question, and the purpose of the study was to identify general trends, not individual evaluation, and that they could decline participation and/or withdraw at any time without disadvantage. The questionnaires took approximately 30 min to complete and were immediately collected. A total of 160 questionnaires were distributed, and 158 were recovered. Of these, 154 were analyzed (four excluded for insincere responses).

Data analysis

Data were analyzed using IBM SPSS (version 25.0; IBM Corp., Armonk, NY, USA). The means and standard deviations of the degree of nursing work environment, nursing professional values, and organizational commitment were identified. According to general participant characteristics, differences in organizational commitment were analyzed using t-tests and analyses of variance. The Scheffé test was used for post-hoc analyses. Pearson’s correlations were used to determine correlations between variables.

In the relationship between nursing work environment and organizational commitment, the mediating effect of nursing professional values was verified using a three-step mediated regression analysis proposed by Baron and Kenny [25]. Fulfillment of all the following three step conditions was required to establish a mediating effect: the independent variable must be a significant predictor of the mediating variable in Step 1; the independent variable must be a significant predictor of the dependent variable in Step 2; and the mediating variable must be a significant predictor of the dependent variable in Step 3, although the effect of the independent variable on the dependent variable must be greater in Step 2 than it is in Step 3. If there is a significant relationship between the independent and dependent variables in Step 3, the mediating variable was considered to exert a partial mediating effect on this relationship. The Sobel test was used to determine the significance of the mediation effect.

Results

Participant demographics

Nearly all participants were women (98.7%, n = 152). Most were in their 30s (42.9%, n = 66), the majority were married (76.0%, n = 117), over half were religious (64.3%, n = 99), and most were vocational college graduates (85.7%, n = 132). Further, most had less than three years of clinical experience (60.4%, n = 93), held staff nurse positions (92.2%, n = 142), worked in three shifts (84.4%, n = 130), and had incomes of USD $2,000 or more (81.2%, n = 125); more than half (n = 89, 57.8%) were dissatisfied with their salaries (Table 1).

Table 1 Participants’ demographics (N = 154)

Mean variable scores

Mean scores were as follows: nursing work environment = 2.46 (SD = 0.30, range: 1–4), nursing professional values = 3.40 (SD = 0.36, range: 1–5), organizational commitment = 3.12 (SD = 0.41, range: 1–5) (Table 2).

Table 2 Mean variable scores and correlations (N = 154)

Organizational commitment by general characteristics

Organizational commitment scores differed significantly by age (F = 2.95, p = .035), position (t = -4.68, p < .001), and duty type (t = 2.40, p = .018). Scores were higher for participants with charge nurse positions and who worked day duty. However, the Scheffé test for post-hoc analysis showed no significant differences in organizational commitment scores between the four nominal age scales (Table 3).

Table 3 Organizational commitment by demographic characteristics (N = 154)

Variable correlations

The nursing work environment was positively correlated with nursing professional values (r = .60, p < .001) and organizational commitment (r = .64, p < .001). Nursing professional values was positively correlated with organizational commitment (r = .56, p < .001) (Table 2).

Mediating effects of nursing professional values on the relationship between the nursing work environment and organizational commitment

Prior to the regression analysis, the assumption was checked to confirm the mediating effects of nursing professional values on the relationship between the nursing work environment and organizational commitment. The Durbin-Watson value was 1.80, indicating no autocorrelation. The tolerance of the independent variables was 0.55–0.89 (> 0.1), while the variance inflation factor (VIF) was 1.11–1.89 (< 10), thus confirming no problems with multicollinearity. The model was therefore suitable for the regression analysis.

Following Baron and Kenny [25], a three-step regression analysis was conducted to verify the mediating effects of nursing professional values on the relationship between the nursing work environment and organizational commitment. In the first step, the nursing work environment was set as the independent variable, and found to have a significant effect on nursing professional values (B = 0.71, p < .001). In the second step, the nursing work environment (independent variable) was found to have a statistically significant effect on organizational commitment (dependent variable) (B = 0.65, p < .001). Finally, nursing professional values had a statistically significant effect on organizational commitment when controlling for the nursing work environment (independent variable) (B = 0.32, p < .001). In the second stage, it should specifically be noted that the nursing work environment (independent variable) had an effect on organizational commitment of 0.65, which was less than the value of B at 0.88 (statistically significant at p < .001); this indicates that nursing professional values had a partial mediating effect in the relationship between the nursing work environment and organizational commitment. The Sobel test (see Data analysis section) confirmed that nursing professional values was a significant mediating variable in the relationship between the nursing work environment and organizational commitment (Z = 3.43, p = .001) (Table 4; Fig. 1).

Table 4 Mediating effects of nursing professional values on the relationship between the nursing work environment and organizational commitment (N = 154)

Fig. 1

Mediating effects of nursing professional values on the relationship between the nursing work environment and organizational commitment. *p < .001

Discussion

This study’s results constitute basic data for improving organizational commitment among nurses working in LTC hospitals. In particular, nursing professional values was found to partially mediate the relationship between the nursing work environment and organizational commitment. In this study, participants rated the nursing work environment as 2.46 out of 4, which is similar to the 2.50 that Hwang and Cho [26] found among LTC nurses using same measurement tool. Both numbers are lower than the 2.62 found among nurses working at general hospitals [12] and the 3.10 found among hospital nurses in the United States [27]. Regarding care quality, research has shown that LTC facilities with better nursing work environments report fewer pressure ulcers and hospitalizations [14]. Meanwhile, nurses in facilities with positive work environments are significantly less likely to exhibit burnout and job dissatisfaction. In other words, a proper nursing work environment is critical for improving care quality and retaining nurses in LTC facilities [14]. As such, LTC hospital managers must actively target this factor.

This study returned a nursing professional values score of 3.40 out of 5, which is similar to the 3.48 reported by a previous study among LTC nurses [28]. However, a study in Iran reported a score of 3.95 using the same tool among university hospital nurses [29]. This difference is understandable, as nursing professional values may differ depending on the institutional type and/or national culture [30].

This study returned an organizational commitment score of 3.12 out of 5. In Turkey, a study among clinical nurses found a substantially higher score of 3.91 [31]. In previous study, nurses had the lowest level of organizational commitment compared to other healthcare workers [32]. Given that a committed nursing workforce fosters work engagement, job satisfaction, and quality of care [9, 31], nursing managers in LTC hospital need to be interested in the organizational commitment of nurses and actively strive to improve it.

Participants with full-time work had higher organizational commitment than those with three-shift work. Akgerman and Sönmez [33] also found that full-time workers had higher organizational commitment than shift workers. Shift work exacerbates fatigue and may result in chronic sleep problems, which makes it difficult to concentrate on nursing tasks. These factors may induce negative organizational perceptions, thereby decreasing organizational commitment [34]. Meanwhile, full-time nurses tend to have more experience and higher positions [18] while playing key organizational roles and do not want to leave the organization with a strong sense of responsibility and actively participate in work, which positively influences organizational commitment [35]. This highlights the need for strategies aimed at maintaining positive organizational commitment by identifying attitudes toward the nursing organization.

This study confirmed that nursing professional values partially mediated the relationship between the nursing work environment and organizational commitment. Notably, nursing professional values can buffer the effects of the nursing working environment on organizational commitment. LTC hospital nursing managers need to actively target these factors and strive to improve them. This is consistent with previous studies among nurses in which organizational commitment increased with increasingly positive perceptions of the nursing work environment and nursing professional values [8]. White et al. [14] found that only 22% of LTC nurses perceived good nursing work environments. This underscores the need to actively improve the nursing work environment for LTC hospital nurses. In other words, LTC hospital nursing managers need to create a good nursing work environment by providing nurses with opportunities to participate in decision-making related to hospital operations and offering various rewards in respect of their opinions. For example, idea contests can help solicit information to improve hospital operations while offering nurses a way to participate in decisions related to hospital problems and operations [36]. In addition, institutional and administrative efforts of LTC hospital nursing managers such as securing appropriate nurse manpower, establishing work-related incentives, and holding workshops to improve communication skills among professionals will be necessary to improve the nursing work environment [36]. Furthermore, in order to firmly establish nursing professional values among LTC hospital nurses, it is necessary to redesign jobs that can reduce the ambiguity of work divisions and roles and promote nurses’ responsibility and autonomy, and to offer systematic practical education and training on this basis [37].

Across both Eastern and Western contexts, the issue of nurse turnover in long-term care hospitals is a critical concern [6, 37, 38]. This study holds practical significance in nursing practice as it identifies key factors influencing organizational commitment, which is a crucial determinant of nurse turnover. By providing empirical evidence to enhance nurses’ organizational commitment, this research ultimately contributes to turnover prevention. A previous study conducted on LTC hospital nurses in the United States highlighted the significance of the nursing work environment in increasing their intent to stay [38]. Similarly, a study focusing on LTC hospital nurses in China emphasized the importance of recognizing and developing nurses’ professional competencies [37]. In this context, sustained attention to the nursing work environment and nursing professional values of LTC hospital nurses is essential.

Synthetically, this study confirmed that nursing professional values can buffer the effects of the nursing work environment on organizational commitment among LTC hospital nurses. Therefore, LTC hospital managers should strive to enhance the nursing work environment and foster professional nursing values to strengthen nurses’ organizational commitment.

Limitations

Since the participants were identified using convenience sampling from nine LTC hospitals in one Metropolitan City and one Province, the study results cannot be generalized to all LTC hospitals nurses. Therefore, a more extensive study including a representative sample is recommended to provide general implications for LTC hospitals nurses. Cross-sectional study design also prevented the establishment of causal relationships. Longitudinal studies are thus needed to clarify any relationships. The use of self-reported questionnaire with Likert scale may have led to common method bias as participants might have systematically under- or overestimated their responses. Future studies should therefore adopt objective measurement methods (e.g., observations). Finally, this study did not establish a theoretical framework to explain the relationship between the research variables. Although the Sobel test in this study was used to validate the mediating effect, future research should more clearly investigate the causal relationship between variables using structural equation modeling analysis based on the theoretical framework.

Conclusions

This study confirmed that nursing professional values can buffer the effects of the nursing work environment on organizational commitment among LTC hospital nurses. Uniquely, it identified personal factors that can help these nurses immerse themselves in their organizations despite poor nursing work environments while also highlighting the importance of strengthening nursing professional values. Efforts to improve the nursing work environment while strengthening nursing professional values may constitute an effective strategy for increasing organizational commitment among LTC hospital nurses.