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An integrative review of literature on determinants of nurses′ organizational commitment

Background: This integrative review was aimed to examine in literature and integrate the determinants of nurses′ organizational commitment in hospital settings. Materials and Methods: In this study, an integrative review of the literature was used. The search strategy began with six electronic databases (e.g. CINAHL and Medline). Considering the inclusion criteria, published studies that examined the factors influencing nurses′ organizational commitment in the timeframe of 2000 through 2013 were chosen. Data extraction and analysis were completed on all included studies. The final sample for this integrative review comprised 33 studies. Results: Based on common meanings and central issues, 63 different factors contributing to nurses′ organizational commitment were integrated and grouped into four main categories: Personal characteristics and traits of nurses, leadership and management style and behavior, perception of organizational context, and characteristics of job and work environment. Conclusions: In general, categories emerged in this study could be useful for formulating initiatives to stimulate nurses′ OC. However, little is known about the relative significance of each identified factor among nurses working in different countries. Qualitative research is recommended for narrowing this gap. Future research should be directed to examine the psychometric properties of the organizational scales for nurses in different cultures.

According to Zangaro, the most widely accepted definition of OC is that suggested by Mowday et al. [5] They define it as "the relative strength of an individual's linkage to the organization"; this is further characterized by three factors which are strong belief in and acceptance of the organization's goals and values, willingness to exert considerable effort on behalf of the organization, and strong desire to maintain membership in the organization. [8] It can be assumed that factors influencing OC may change over time. That is because nurses continue to experience changes in role and function in the workplace. Carver and Candela emphasize on each generation's unique perspective of OC. [9] It is extremely important for nurse managers to understand the influencing factors on the OC of the current nursing workforce. Thus, the current review was aimed to assess in literature and integrate the determinants of nurses' OC in hospital settings.

IntroductIon
I t is widely agreed that organizational commitment (OC) is an important determinant of nurse turnover. [1,2] Previous research has suggested a significant positive association between work outcomes such as performance and productivity, and OC. [3,4] In general, OC is variously defined and conceptualized in the literature; however, there are two perspectives on this concept in general: Attitudinal and behavioral. [5] The attitudinal perspective focuses on employee's identifying with the organization and his/her desire to maintain the relationship with the organization, [6] whereas OC, from a behavioral perspective, describes a person's preoccupation with the organization as evidenced by personal time devoted to organizational activities. [7] Vagharseyyedin: Nurses' organizational commitment

Study design
In this integrative review, the methodology proposed by Whittemore and Knafl was followed. Since the integrative review method has been critiqued for lack of rigor and its potential for bias, Whittemore and Knafl have provided a five-step process to enhance the rigor of this method in nursing. According to them, the process of an integrative review includes articulation of the problem to be studied, completion of a well-defined literature search, evaluation of the quality of data, analysis of the data, and presentation of conclusions. The first step is a clear identification of the problem that the review is addressing and the purpose of the review. Literature search should clearly address issues such as search terms, the databases used, additional search strategies, and the inclusion and exclusion criteria for determining relevant primary sources. For evaluating and interpreting the quality of included studies, no gold standard exists. [10] The American Association of Critical Care Nurses' (AACN) Evidence-Leveling Hierarchy [11] has been effectively used for grading in the integrative review method, where diverse primary sources (such as quantitative and qualitative studies) are included. [12,13] In the data analysis process, data from primary sources are ordered, coded, categorized, and summarized into a unified and integrated conclusion. Finally, conclusions of reviews can be reported in a table or diagram. [10] A systematic search was conducted using six online databases: CINAHL, Medline, ERIC, PROQUEST, and two Iranian databases: Iran Medex, and Scientific Information Database. Keywords used for this review were "organisational commitment" or "organizational commitment" with limitation to studies conducted in nursing. The inclusion criteria were: (a) Works written in English or Persian in the timeframe of 2000 through March 2013, (b) the inclusion of the search term in the title or the keywords, (c) scholarly works published in a peer-reviewed journals, and (d) studies including nurses who worked only in hospitals. Studies that used a mixed sample of nurses along with other healthcare workers were included if only the studies consistently analyzed and reported nurses' information separately from other participants. The studies that were excluded included those described in one-page reviews, letters, and those published in other than the selected languages. Furthermore, additional papers from reference lists of the studies reviewed were identified. The purpose of this study was to identify the determinants of nurses' OC; therefore, those studies that applied experimental design were excluded with the goal of improved understanding of factors influencing OC in the absence of variable manipulation. The search was completed in April 2013.
The initial search resulted in a sample of 594 articles (464 English and 130 Persian articles). In light of the inclusion and exclusion criteria, 33 studies remained in our review [ Table 1].

Measures
In the current review, studies were evaluated for quality using the AACN revised evidence-leveling system. The new AACN structure consists of six rating levels. Meta-analyses and meta-syntheses are placed as the highest levels of evidence (Level A). Level B includes both randomized and non-randomized well-designed controlled studies. Level C encompasses qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. Level D indicates peer-reviewed professional organizational standards. Level E signifies theory-based evidence from multiple-case reports and expert opinion, and Level M is used to identify manufacturer recommendations. [11] In the current review, 32 out of the 33 included studies (96.9%) used a quantitative cross-sectional design. McNeese-Smith used a qualitative method, however. [40] Therefore, as presented in Table 1, almost all the included studies were descriptive in nature with most receiving a level C rating.

Analytic strategy
The data were analyzed with consideration of purpose, methods, and findings of the reviewed studies. Taking into consideration the main findings, descriptions of determinants of OC were first extracted and the way these factors affected OC was identified and summarized. Then, based on common meanings and central issues of these findings, they were organized and integrated as categories and themes. A summary of four main categories and their themes was emerged and are presented in Table 2.

Measurement of OC and methodological aspects of the studies reviewed
The three scales developed by Allen and Meyer (1990), Meyer et al. (1993), and Meyer and Allen (1997) were used in 17 out of 33 included studies. [14,[16][17][18][22][23][24][25]29,[31][32][33][34][35]41,42,44] According to Meyer and Allen, OC contains the following three dimensions: (1) Affective commitment that refers to the members of an organization who are emotionally attached to, identify themselves with, and feel devoted to an organization; (2) continuance commitment that describes the employees who are committed because they believe the costs associated with leaving the organization are too high and, hence, they remain; and (3) normative commitment that refers to the group of employees who feel like they should stay with the organization beyond Vagharseyyedin: Nurses' organizational commitment  [14] To examine the relationships between nurses' empowerment, job satisfaction, and OC in culturally and developmentally different societies Quantitative cross-sectional study Random sample of nurses in two teaching hospitals in Malaysia and England (N=556) Meyer and Allen's (1991) OC scale C Bahrami et al., 2010 [15] To investigate the relationship between staff's personality traits (introversion/ extraversion) and OC Quantitative cross-sectional study Random sample of nurses working at two hospitals in Iran (N=175) 15-item scale developed by Mowday et al. (1979) C Bakhshi Soreshjani, 2010 [16] To investigate the relationship between emotional intelligence, mental health, and employees' OC Quantitative cross-sectional study Random sample of teachers, nurses, and a water and power plant personnel in Iran (N=400) Scale developed by Allen and Meyer (1990) C Brunetto et al., 2013 [17] To assess the impact of workplace relationships (perceived organizational support, supervisor-nurse relationships, and teamwork) on the engagement, wellbeing, OC, and turnover intentions Quantitative cross-sectional study Random sample of nurses from Australian hospitals (n=510) and nurses from US hospitals (n=718) Eight-item scale developed by Allen and Meyer (1990) C Camerino et al., 2008 [18] To assess the relationships between relevant individual, organizational, and psychosocial factors, and the frequency of several types of workplace violence To examine the direct as well as the interactive impact of violence and psychosocial factors Quantitative cross-sectional study and a questionnairebased longitudinal survey design Two designs: Random sample of institutions from eight EU countries concerning the cross-sectional design. For the longitudinal design, 12 months after the baseline assessment, all nursing staff employed at the institutions which took part in the first assessment were invited to fill in a second questionnaire on OC and perceived health Four-item scale adapted from Allen and Meyer (1990) C Chang and Chang, 2007 [19] To explore the relational model of nurse perceptions related to internal marketing, job satisfaction, and OC  [21] To determine the effect of leadership behaviors on nurses' job satisfaction, productivity, and OC in an acute-care tertiary hospital in Singapore  [25] To examine the influence of fairness perceptions of management practices and underlying employee cynicism on nurses' OC Quantitative cross-sectional study Random sample of nurses in Western Australia (N=1104; 29.6% response rate) Six items selected from the scale developed by Meyer and Allen (1997) C Contd...  [29] To measure the relationship between job satisfaction and three components of OC   [43] To explore the structural relationships among internal marketing, OC, and service quality Quantitative cross-sectional study Nursing staff from three regional teaching hospitals in Taiwan  C a sense of obligation. [47] It is noteworthy that 11 studies used the affective OC subscale of each of the above scales. [18,[22][23][24][25][26][27][28][29][30][31][32][33][34][35]41,42,44,46] The 15-item scale by Mowday et al. (1979) was used to measure OC in 7 of the 33 included studies. [15,26,27,[37][38][39]43,45] Yang and Chang (2008) used the scale developed by Mowday et al. (1982) which contained three dimensions:

Vagharseyyedin: Nurses' organizational commitment
(1) A strong belief in, and acceptance of, the organization's goals and values (value commitment); (2) a willingness to exert a considerable effort on behalf of the organization (effort commitment); and (3) a strong intent or desire to remain with the organization (retention commitment). [45] Chang and Chang [19] and Ho et al. [28] evaluated OC through a researcher-made questionnaire. Leach [36] assessed OC using a 15-item commitment scale developed by Penley and Gould (1988). This scale contains three subscales: Moral commitment (a normative, internalized identification with organization), calculative commitment (a remunerative or compliance involvement in organization), and alienative commitment (a negative resistance). [36] The 15-item OC scale developed by Porter et al. (1974) was used in Chiok Foong Loke's study. [21] Jalonen et al. used a single question to inquire about OC. [30] Finally, in the study of Chang et al., [20] OC was measured by Blauetal's (1993) tool, which comprised six items.
In the majority of studies reviewed, nurses' OC was measured using similar tools. Thus, it should be said that the authors had a similar view of the empirical referents of OC. On the one hand, it can be considered as a potential strength because the results of such studies enable researchers to make international comparisons.

Personal characteristics and traits of nurses
Biopsychosocial parameters (+) Age; exception: One study found age to be negatively correlated with OC (+) Job tenure; exception: One study found a negative association between OC and job tenure and one study did not find a significant association between OC and job tenure (+) Personality trait of extroversion (+) Well-being/mental health

Vagharseyyedin: Nurses' organizational commitment
In light of the statistical analysis, all the reviewed studies except three [24,27,36] used multiple regression analysis. Moreover, a considerable number of researchers used the Structural Equation Modeling (SEM). [17,22,26,28,35,43,45] It is obvious that applying such statistical technique can be helpful to test the proposed models of OC in nursing field and, consequently, to develop the body of knowledge in nursing. Some included studies were guided by a theoretical framework [22,32,35,36,41,45] which enhances the validity of the studies.

Determinants of nurses' OC Personal characteristics and traits of nurses
The category of personal characteristics and traits of nurses encompasses two themes including a) biopsychosocial parameters and b) personal and family life.
Regarding the biopsychosocial parameters theme, age was positively correlated with OC in three studies. [20,30,36] Also, age was found to be negatively associated with calculative commitment in one study. [36] In Tsai and Wu's study, OC was not related to age. [43] These findings indicate a need for more exploration of impact of age on OC.
Four studies reported that as job tenure increased, OC increased too. [15,20,29,36] However, in Liou and Cheng's (2010) study, job tenure was negatively related to OC. [37] Personality trait of extroversion, as a third psychological factor in this theme, positively influenced OC. [15] Furthermore, mental health, emotional intelligence, [16] and well-being [17] were found to be associated with increased levels of OC. The other factors included psychological distress, [30] individual levels of negative affectivity, [18] and burnout [22,35] that were found to negatively impact OC. Negative affectivity was considered as the extent to which certain negative emotions were experienced by nurses. As opposed to these latter factors, psychological empowerment (the psychological state that employees must experience for managerial empowerment interventions to be successful) positively influenced OC in two studies. [34,41] Within this theme, factors such as employee engagement, [17] job satisfaction, [14,19,21,26,28,29,38] social rewards, [42] and professional commitment [39] were also identified as positive determinants of nurses' OC. In addition, McNeese-Smith showed that preferring stability to change positively affected OC. [40] The final factor in this theme was "surface acting" which negatively impacted OC. In surface acting, persons modify and control their emotional expressions. Inauthentic surface acting may result over time in a feeling of detachment from one's true feelings. [45] Five factors formed the theme of personal and family life. Life satisfaction was found to be positively correlated with OC. [44] The remaining four factors included meeting the family's needs, creating a better life for self and family, and having a plan to retire from the organization, all of which were reported as positive determinants of OC. [40]

Leadership and management style and behavior
Both nature of relationships and leadership style were themes of influence within the leadership and management style and behavior category. Nature of relationships included factors such as psychological rewards from the head nurse and supervisor incivility which were effective in shaping the interpersonal relationships between managers and nurses. First, perception of nurses of managers' practice was cited as an important determinant of OC. For example, in English and Chalon's study, fairness perception of change management was associated with higher levels of affective commitment. [25] Also, a positive correlation was reported between OC and relational justice. Relational justice refers to the extent to which employees perceive the supervisor as treating them with politeness and consideration. [30] Finally, the researchers found that both psychological rewards received from the head nurse [23] and trust in management [33] were positive predictors of OC. In contrast to the four factors described, the remaining two factors within nature of relationships theme, i.e., supervisor in civility [35,41] and employee cynicism, were negatively related to OC. [25] According to English and Chalon who studied the relationship between employee cynicism and OC, employee cynicism is targeted toward senior management and stems from perceptions of unfair management practices. [25] Organizational context Two themes were identified within this category: Organization's norms and performance and organizational policies and procedures.
Organization's norms and performance theme focused on findings about the perception held by nurses concerning

Category Theme Findings
Mutual respect (+) Participative safety (−) Workplace bullying (−) Workplace violence/internal emotional abuse (−) Coworker incivility (+) Good relations with coworkers (+) Psychological rewards from the physician Vagharseyyedin: Nurses' organizational commitment organizational climate and practice. As presented in Table 2, this theme included eight factors. First, positive perceptions of the fairness of personnel practices (procedural justice and interactional justice) were positively related to OC. [25] Conversely, lack of fairness from organization was related to lack of OC in the study of McNeese-Smith. [40] As the next factor, favorable perception of internal marketing was noted as a positive predictor of OC. [43] The concept of internal marketing argues that enterprises should value and respect their employees by treating them as internal customers. Another factor identified was perceived organizational support, which was found to be associated with increased levels of OC. [17] In one study, perception of organizational culture (emotional climate, practice issues, and collaborative relations) was a strong positive predictor of nurses' OC. [26] Within this theme, organizational trust was also a positive predictor of commitment among nurses. [31] The relationship between OC and psychological contracts, as another factor, was found to be positive in the study of Kafashpour et al. [31] These authors defined psychological contract as the individual's idea about mutual obligations in the context of the relationship between the employer and the employee. Finally, factors related to organizational climate such as warmth, conflicts, and standards were shown to be positively correlated with higher levels of OC. [37] The organizational policies and procedures theme encompasses two factors: Permanent job status/job security and monetary benefits. Change from temporary job status to a permanent one predicted sustained OC of the staff nurses in two studies. [27,30] Consistent with this finding, job security was one of the emerged factors in the study conducted by McNeese-Smith. [40] Also, in the above-mentioned study, nurses cited monetary benefits as one of the factors shaping high-level commitment.

Characteristics of job and work environment
This category included three themes: Growth and development, content and organization of tasks, and mutual respect.
Growth and development theme consisted of seven studies that examined the influence of appropriate role performance and career development on OC. Chang et al. [20] found that the gap between career needs and career development programs made negative contributions to OC. In five studies, having access to conditions that enabled optimal role performance of the nurses (structural empowerment) positively influenced affective OC. [22,[33][34][35][36][37][38][39]41] A negative correlation between uncertainty of patients' treatment and affective OC was also reported. [18] Finally, being in a learning environment, modern technology, the opportunity for acquiring new skills, and continuing education were found to be associated with higher levels of OC. [40] Several factors related to the nature of nurses' tasks and work environment conditions were integrated into the content and organization of tasks theme. A favorable perception of work environment conditions, such as interpersonal relationships, managerial support, and regular routines, was found to be positively associated with higher levels of affective commitment in two studies. [42,44] Job control [30] and job rotation [28] were cited as significant determinants of OC. In two of the included studies, the perception of role conflict and ambiguity were negatively related to nurses' OC. [18,39] Also, significant positive relationships between OC, professional privilege, [42] workplace spirituality, [32] and clinical challenges [42] were reported. In McNeese-Smith's study, [40] difficult or repetitive patient care negatively influenced OC. In addition, time pressure, [18] job stress, [39,35] and overload [40] were found to be negative determinants of OC.
Focus of mutual respect theme covered interpersonal relationships existing in the work environment. One of the factors within this theme was participative safety, [42] which was found to be a positive determinant of nurses' OC. Generally, participative safety was conceptualized as the extent to which the interpersonal atmosphere was non-threatening in the study of Jalonen et al. [30] Workplace violence, [18,24] bullying, and internal emotional abuse [24] were identified as negative determinants of OC. According to Demir and Rodwell, [24] internal emotional abuse points out to types of workplace violence exerted by coworkers or supervisors. Consistent with these findings, McNeese-Smith [40] reported that having good relations with coworkers was associated with higher levels of OC. Finally, nurses' satisfaction with psychological rewards received from physicians was identified to positively impact their affective OC. [23] dIscussIon The purpose of this integrative review was to examine in literature and integrate the determinants of nurses' OC in hospital settings. Different factors from 33 included studies were integrated into nine themes. Afterward, based on the common meanings and the relationships between the themes, this rather large number of themes was combined into four main categories. The categories included: Personal characteristics and traits of nurses, leadership and management style and behavior, perception of organizational context, and characteristics of job and work environment. Factors within each theme were found to positively or negatively influence the OC of nurses working in hospitals. The current review also showed that research was inconsistent with respect to the correlation between some personal factors such as age and OC. A possible argument is that these findings may be context-specific and should be taken into account when managers want to Vagharseyyedin: Nurses' organizational commitment design initiatives to stimulate nurses' OC. In other words, issues important for a specific age group of nurses in one country may not be as much important for nurses of the same age group in another country.
A review of literature indicates that many factors influencing OC identified in this study can be improved by specific interventions designed to this end. Job stress, coworker incivility, burnout, work environment conditions, empowerment, and management style are among these factors. [48][49][50][51][52][53] In addition, as noted previously, researchers believed that different generations of nurses have unique perspectives of OC. Employees born into a generational cohort of peers have similar life experiences. These experiences have strong effects on their work values and needs as well as their expectations of employers, which in turn impact the influential parameters of employees' OC. As an example, Carver and Candela [9] believed that nurses born during 1961-1981 prefer working independently, while younger ones enjoy working in groups. [9] So, it can be expected the integrated findings in the current review provide a foundation for comparison of factors that contribute to OC of different generations of nurses. Further, these findings have potential for developing the body of knowledge related to OC in nursing context and clarifying theoretical basis of this concept.
As another finding in this study, it became evident that all the tools applied for measuring nurses' OC were developed in western countries. It has been suggested that the concept of OC is culturally specific. [5] Since work culture varies in different countries, the conceptual framework and operationalization of commitment may be understood differently across various countries. [54] It is not meant that tools developed in western countries are not valid in other countries such as Iran; it simply means that these tools need to be tested more in other cultures before their validity can be fully established. On the other hand, healthcare organizations in different countries face different challenges, which in turn impact the OC of employees. Qualitative research has the potential to offer some insights into nurses' experiences of OC in different countries and cultures and, hence, to provide valuable context-based data.
Most of the included studies used a cross-sectional design, and hence, the potential reciprocal relationships between revealed determinants and nurses' OC cannot be fully interpreted causally. Therefore, as far as possible, future research could be conducted using longitudinal designs to further consider the impact of the specific determinants of OC.
Also, only three studies addressed anonymity of respondents. [23,32,43] This limitation may have influenced the responses to some extent if nurses felt worried about loss of their job position in hospital. Also, all the studies reviewed relied upon self-report of OC levels when assessing determinants. In the future studies, researchers may need to examine the OC among nurses using data triangulation that refers to the use of multiple methods of data sources to validate conclusions. For example, the nurses' performance and questions regarding their performance appraisal should be included in the assessment of OC. In addition, measurement of the level of OC, along with the related outcomes such as nurse turnover, [55] may contribute to a broader understanding of nurses' feelings toward their organizations. Moreover, positive results bias should not be ignored when interpreting the results of the current review.
Positive results bias means that the researchers who obtain positive findings are more likely to submit their papers to a journal. Nevertheless, the included studies had considerable strengths. Notably, all but four studies drew their samples from more than one site, which in turn might have increased the generalizability of studies included. [21,24,31,45] We acknowledge that this review has some limitations. In the present review, only those studies published in English and Persian were included. This may have resulted in the omission of several valuable studies. Also, it is evident that OC is an important construct in turnover research.
Considering the selected inclusion criteria in this review, we may have possibly missed research studies that have looked at the antecedents and consequences of OC in the context of turnover.

conclusIon
Nurses' OC is influenced by various factors related to personal characteristics, leadership and management, organizational context, and characteristics of job and work environment. Given the different work cultures across the world, nevertheless, little is known about the relative significance of each factor among nurses working in different countries. These issues should be taken into account in planning the evidence-based strategies to improve nurses' OC. For this end, qualitative research will be an invaluable tool. These studies will capture the real perception of nurses about OC and specific factors impacting it. The findings of the present study could be useful for formulating initiatives to stimulate nurses' OC. In future researches, reviewing this construct, specifically in the context of turnover, can be considered. As the next step, researchers are recommended to plan research studies that will reveal the causes of high OC on which organizations can influence directly. Future research can also be designed to compare the influential Vagharseyyedin: Nurses' organizational commitment factors on OC in different generations of nurses in countries such as Iran with its specific social and economical context. Finally, regarding the used scales for measuring the OC, future research can be directed to test the psychometric properties of the OC scales for nurses in the different societies or cultures.