Background: According to the 2007 Taiwan Labor Front Human Resources Report, as much as 47.6% of nurses at some public hospitals were contracted rather than full time. Furthermore, turnover rates for contract nurses were found to be as high as five to eight times of those for full-time nurses. Because high turnover rates are likely to induce negative impacts on the stability of care provided in the absence of staffing continuity, the association between nursing employment arrangement and nursing care quality is attracting greater attention.
Purpose: This study was designed to investigate the work status of contract versus full-time nurses at a public hospital in Taiwan and to examine the impact of such on work-related attitudes, organizational citizenship behavior, and job performance.
Methods: Samples were recruited from a public hospital in Taiwan. In addition to self-rated items, researchers used supervisor-rated structured questionnaires for job performance to attenuate the possible effect of common method bias. The study investigated the impact of hospital nurse employment status on work-related attitudes, organizational citizenship behavior, and job performance using a regression model that included the critical work-related attitudes variables of job satisfaction and organizational commitment.
Results: Study findings included the following: (a) organizational commitment, job satisfaction, organizational citizenship behavior, and job performance correlate positively with one another. (b) No significant difference between contract and full-time nurses was found in terms of organizational commitment, job satisfaction, organizational citizenship behavior, and self-rated job performance. However, when rated by supervisors, reported job performance levels for full-time nurses were significantly higher than those of contract nurses. (c) Organizational citizenship behavior exhibited a mediating effect between job satisfaction, organizational commitment, and job performance.
Conclusions: In this study, supervisors gave higher job performance ratings to full-time nurses than to contract nurses. This result deserves further investigation.
1PhD, Associate Professor, Institute of Public Health, Tzu Chi University;
2MS, Senior Specialist, Codman Healthcare Consulting Co. LTD.
Received: August 25, 2010 Revised: November 19, 2010 Accepted: December 7, 2010
*Address correspondence to: Cheng-I Chu, No. 701, Chung-Yang Rd. Sec. 3, Hualien City 97004, Taiwan, ROC. Tel: +886 (3) 856-5301 ext. 2277; Fax: +886 (3) 856-4041; E-mail: firstname.lastname@example.org
Ever since the implementation of the national health insurance system in 1995, hospitals in Taiwan have faced strict cost containment policies, such as global budgeting and DRGs. Financial pressures became more severe when hospitals were required in 1998 to abide by the Labor Law, which regulated a maximum number of hours (ceiling) that hospital employees may work per week and forced hospitals to allocate funds equal to at least 6% of employee salaries into pension funds for full-time employees. The new Labor Law regulations have affected public hospitals the most because the government has concurrently reduced its financial aid to public hospitals and required them to maintain financial solvency. As a consequence, public hospitals have abandoned full-time employment arrangements and copied the practice of private hospitals in using short-term "contract nurses" in their wards. Contract nurses typically are hired on annual contracts and while working the same numbers of shifts and average hours as full-time nurses receive no pension and only trivial benefits. According to the 2007 Taiwan Labor Front Human Resources Report, as much as 47.6% of the nursing roster at some public hospitals comprises contract nurses, with turnover rates in this group five to eight times those of full-time nurses. Because high turnover rates are likely to induce negative impacts on the stability of care provided in the absence of staffing continuity (Duffield, Roche, O'Brien-Pallas, & Catling-Paull, 2009; Hueston, 2006), the association between nursing employment arrangement and nursing care quality is attracting increasing attention. This study intends to investigate the impact of nurses' contract or full-time employment status on job attitudes, organizational citizenship behavior (OCB), and job performance.
Consistency in nurse-provided care is essential in guaranteeing continuity in care delivery and health quality (Gunn, Vasquez-Villagram, & Bird, 2006; Jones, 2004). When nurse turnover rates are low, the experience and competence of nurses can accumulate and expand, leading to the provision of better and more professional care. On the other hand, a lack of continuity or stability, which diminishes the quality of care provided to patients, is very likely to happen when turnover rates are high. Furthermore, the hazards presented to medical professionals during the 2003 severe acute respiratory syndrome (SARS) epidemic in Taiwan has encouraged academics and medical professionals to rethink the appropriateness of care for patients and fairness to medical staff with regard to the use of contract nurses. When higher risk-taking and quality tasks are expected, nurses deserve to have more security via full-time employment relationships and retirement pension funds. The impact of hiring increasing numbers of contract nurses quality of patient care and nurse organizational commitment and job satisfaction has yet to be thoroughly examined.
This research examines the effects of contract or full-time employment status on organizational commitment, job satisfaction, OCBs, and job performance of nurses working at a public hospital. There is not much literature on the subject of non-full-time employees in the medical profession, and our literature review found only a few articles that had investigated some general differences between full-time and part-time employees. For example, Burke and Greenglass (2000), Han, Moon, and Yun (2009), and Morrow and McElroy (1994) found full-time employees exhibited higher levels of organizational commitment. Stamper and Dyne (2001) also found full-time employees exhibited higher levels of OCB. Hall and Doran (2004) further confirmed that, in comparison with part-time nurses, full-time nurses demonstrated better job performance. Because the definition and conditions of full-time and part-time nurses may not duplicate those of contract employees in Taiwan, it is necessary to investigate the impact of this specific employment status within the medical field.
Organizational commitment and job satisfaction are well-known work attitudes examined in the employment-related literature. Meyer and Allen (1997) defined that organizational commitment is a psychological state that characterizes the employee's relationships with the organization and has implications for the decision to continue membership in the organization. Job satisfaction is defined as the extent to which people like (satisfaction) or dislike (dissatisfaction) their jobs (Spector, 1997). This definition implies job satisfaction is a general affective reaction that employees hold toward their jobs. Nurses who have higher job satisfaction levels have been reported to provide quality, safe, cost-effective patient care (Perry, 2008). Although the causal sequence of organizational commitment and job satisfaction is still in question, literature found them to be associated variables (Gregory, Way, LeFort, Barrett, & Parfrey, 2007, Yang & Chang, 2008) that affect organizational outcomes such as turnover (Price, 2001), OCB (Bateman & Organ, 1983; Chang & Chang, 2010; Organ,1988; Puffer,1987; Smith, Organ, & Near, 1983; Tsai & Wu, 2010), and job performance (Shore & Martin, 1989).
In the last 20 years, OCB has generated a prominent stream of research. OCBs represent a special type of discretionary work behavior that are beneficial to the organization but not directly or explicitly recognized by the formal job description or reward system. Scholars hold differing views regarding OCB dimensionality (e.g., five dimensions of altruism, courtesy, civic virtue, conscientiousness, and sportsmanship by Organ, 1988). However, Hoffman, Blair, Meriac, and Woehr (2007) have suggested that measurement of OCB is best viewed as a global factor because not much is to be gained through the use of separate dimensional measures over using an overall composite indicator. Many studies have demonstrated job satisfaction and organizational commitment as two major robust antecedents of OCBs (Bateman & Organ, 1983; Organ, 1988; Puffer, 1987; Smith et al., 1983). Consequently, it is believed that OCBs can improve work group and organizational performance by enhancing coworker and/or managerial productivity (Posdakoff & Mackenzie, 1994; Smith et al., 1983).
Job performance is strongly associated with discretionary work behaviors. Orr, Sackett, and Mercer (1989) found that supervisors job performance ratings tend to incorporate citizenship behaviors in addition to actual job performance with their ratings. The current study also included citizenship behaviors and job performance because of the importance of these two variables to overall hospital performance. Furthermore, little research has investigated differences in OCBs and job performance between contract nurses and full-time nurses. The results of this study are hoped to provide essential references for hospital employment policymakers.
A coded questionnaire was delivered on March 1, 2005, for distribution to all 145 nurses employed by the target public hospital. The target sample comprised 106 (73.1%) full-time nurses and 39 (26.9%) contract nurses. In addition to personal characteristics questions (e.g., age and marital status), the questionnaire included measures of organizational commitment, job satisfaction, OCBs, and self-rated job performance. Respondents were asked to return their completed questionnaire to the researchers in a provided business-reply envelope. The questionnaire was coded to maintain respondent confidentiality and anonymity while still enabling matching to the supervisor-rated job performance score of each respondent. A one-item supervisor-rated job performance form for each respondent was also sent to the supervisor and retrieved by the researcher when completed.
A total of 109 completed questionnaires were returned (75.2% response rate). Supervisor-rated job performance forms collected from nine supervisors were then matched to 103 (94.5%) of the 109 coded and anonymous respondents. Each job performance form was matched to the relevant respondent. The response rate achieved in this study is comparatively good in comparison with other studies on nurses.
Numerous variables were included in this study to investigate differences among full-time and contract nurses working at Taiwan public hospitals. These variables were categorized into five groups, including personal characteristics, organizational commitment, job satisfaction, OCBs, and job performance. Other than personal characteristics and supervisor-rated job performance, respondents indicated their agreement with each item on a 5-point Likert scale (from 1 = strongly disagree or dissatisfied to 5 = strongly agree or satisfied).
Researchers included a number of single item measures of personal characteristics. Age was measured by year of birth; seniority by years employed at the current hospital; employment status by indication of full-time or contract status; marital status by indicating married (includes separated), single (includes divorced and widowed), and other (includes cohabitation); and education by indicating high school, college, or university nursing degree.
Organizational commitment and job satisfaction
Organizational commitment was measured by a nine-item scale developed by Mowday and Steers (1979). The original Mowday and Steers Organizational Commitment Questionnaire used 15 items, 6 of which were negatively phrased and reverse coded. Our research followed recommendations by using only the nine positively worded items because the Organizational Commitment Questionnaire consistently splits into two factors along the positive or negative axis (Price, 1997). Previous studies exhibited a Cronbach's α of .83 to .93 for these items (Price, 1997).
Job satisfaction was measured using a six-item scale designed by Price (2001). A global approach toward job satisfaction has been adopted by Price. The six-item scale's Cronbach's α was measured at .86 by Chen, Chu, Wang, and Lin (2008).
Organizational citizenship behaviors
OCBs were measured using a 20-item Chinese OCB scale developed by Farh, Earley, and Lin (1997). The five dimensions extracted included (a) identification with the company, (b) altruism toward colleagues, (c) interpersonal harmony, (d) conscientiousness, and (e) protecting company resources. Because literature had supported combining multiple OCB dimensions into an overall measure of general OCB (Netemeyer, Boles, Mckee, & McMurrian, 1997; Organ & Ryan, 1995) and because the research did not focus on the relationships of each separate OCB dimension, this study used the combined score to represent the measured level of citizenship behaviors for each respondent. A previous study (Chu, Lee, & Hsu, 2006) found a satisfactory Cronbach's α for the instrument of .87.
Job performance was measured from two sources. One source was a seven-item self-evaluated in-role behavior performance scale developed by Williams and Anderson (1991). These seven items included questions such as "adequately completes assigned duties" and "meets formal job performance requirements of the job" and were developed on the basis of the definition of in-role behaviors recognized by the formal reward system of the hospital. The Cronbach's α of this measure was .91 in Williams and Anderson.
Another source of job performance measurement was a one-item question, which required the direct supervisor to evaluate each respondent with a 0 to 100 job performance grading, with 100 being the highest. The purpose of this second source of job performance evaluation was to compare the difference between self-evaluated and supervisor-evaluated job performance levels.
Table 1 shows some of the demographic characteristics of the sample. This study sample included 78 (71.6%) full-time and 31 (28.4%) contract nurses. The average age of respondents was 34.46 years, and respondents had been employed in their current hospital for an average 6.45 years. Full-time nurses had a significantly longer average seniority (7.70 years). Respondents were mainly women (107; 98.2%), with approximately 64.2% unmarried and 66.1% holding college degrees.
Table 2 illustrates appropriate Cronbach's α values for the study (.93 for organizational commitment, .74 for job satisfaction, .83 for OCB, and .89 for self-rated job performance). As expected, positive correlations were found among organizational commitment, job satisfaction, OCB, and self-rated job performance. Table 3 revealed no significant difference between contract nurses and full-time nurses in terms of organizational commitment (t = −1.595, p = .114), job satisfaction (t = 0.429, p = .669), OCB (t = 0.839, p = .404), or self-rated job performance (t = 1.685, p = .095). This illustrates that both nursing statuses produced similar working attitudes and self-rated job performance scores. However, supervisor-rated job performances for contract nurses and full-time nurses were significantly different (t = 3.187, p = .002), with full-time nurses tending to receive higher job performance ratings.
This study also probed relationships among work attitudes, OCB, and job performance using multiple regression analysis. Regression Model 1 in Table 4 demonstrates that, after controlling for demographic variables, the predictor coefficient of organizational commitment on OCB was .346 (p < .01), which explained 28.9% of variance in OCB. Regression Model 2 showed that after controlling for demographic variables, the predictor coefficient of job satisfaction on job performance was .242 (p < .05), which could explain 21.7% of variance in job performance. Regression Model 3 demonstrated that after controlling for demographic variables, the predictor coefficient of OCB on job performance was .575 (p < .01), which explained 45.2% of performance.
To serve as a mediating variable affecting the influence of organizational commitment and job satisfaction on job performance, OCB should meet three conditions: (a) significant correlation between OCB and organizational commitment and job satisfaction, (b) significant correlation between job performance and organizational commitment and job satisfaction, and (c) when predicting job performance using OCB, organizational commitment, and job satisfaction, the regression coefficients of organizational commitment and job satisfaction should be reduced (Baron & Kenny, 1986). Because the correlation and regression analysis results in this study validated the said conditions, we demonstrated the mediating effect of OCB on job satisfaction and organizational commitment on job performance.
Although employing contract nurses to replace full-time nurses is an increasingly used strategy by healthcare organizations in Taiwan, few empirical studies have yet examined the effects of such various critical job-related variables. Although there may be several explanations for why no differences between public hospital contract nurses and full-time nurses were found in our study's measurements of organizational commitment, job satisfaction, and OCBs, we should interpret the results with care seeing because of the relatively low number of contract nurses in the samples and the homogeneity in responses from both employment status groups.
Another viable rationale exists for attributing these results to the fact that nurses are cultivated within a professional culture that places a high priority upon patient care and nursing quality. Because of this aspect of their profession, contract nurses may be relatively less likely to reflect unconstructive attitudes and behaviors simply because of employment status inequities.
Noticeably, the job performance evaluation by the supervisors differs significantly for the two employment status groups, with supervisors giving on average significantly higher job performance ratings to full-time staff as compared with contract staff. Because this study focuses only on the situation in one public hospital, the significance and reason for such a finding requires further research. Factors contributing to higher ratings for full-time nurses may include inherent supervisor prejudices and the relatively longer time and experience in the hospital of full-time nurses (in this study, an average 7.70 years seniority for full-time nurse participants vs. 3.70 years seniority for contract nurses; Table 1).
Confirming the findings of past studies (Motowidlo & Scotter, 1994), this study showed nurse organizational commitment, job satisfaction, OCB, and job performance to correlate positively with one another. With regard to the validation of the relationship among work attitudes, OCB, and job performance, according to theory of Baron and Kenny (1986), this study validates the mediating effect of OCB between working attitudes and job performance on the basis of the predictors, as explained through multiple regression analysis.
Three limitations of this study should be noted. First, the cross-sectional approach of our data collection provides only limited support for causal inference. Second, respondents' self-reports of commitment, satisfaction, OCB, and job performance may have been affected by a social desirability effect. Third, the small sample size advises the expansion of research work to include a larger sample covering multiple public hospitals to better justify the generalizability of results.
Finally, on the basis of the process and results of this study, the suggestions for hospital management and future studies include the following:
Suggestions for Hospital Management
1. Careful employment arrangement for contract nurses: At present, many hospitals in Taiwan choose to hire contract nurses to reduce costs. However, this study revealed that contract nurse job performance, as evaluated by supervisors, to be inferior to that of full-time nurses. Although the validity of the one-item supervisor-rated scale is questionable, there may be an implicit quality gap and deficits that require further research and study.
2. Nurse organizational commitment and job satisfaction should be reinforced and the workplace atmosphere of the employees' OCB should be appropriately constructed. According to the findings of this study, OCB was shown to have a mediating effect on the influence of job satisfaction and organizational commitment on job performance. Thus, hospital management should invest greater effort in upgrading nurse commitment and satisfaction (Porter, Kolcaba, McNulty, & Fitzpatrick, 2010; Tsai & Wu, 2010). Examples of such include monitoring consistency between hospital's and nurses' goals and values, focusing on longevity and long-term retentions efforts, and developing work site-specific recruitment and retention plans (Ingersoll, Olsan, Drew-Cates, DeVinney, & Davis, 2002) to indirectly boost overall job performance via the effect of OCBs exhibited by committed and satisfied nurses.
Suggestions for Future Studies
1. Objective evaluation: Because of time and resources, with the exception of job performance, all research variables relied on respondent self-evaluation. Thus, answers tend to be affected by the impact of social desirability and do not reveal significant differences, suggesting that future studies can search for a more objective peer-reviewed evaluation of nurse organizational commitment, job satisfaction, OCB, and job performance. Colleague evaluations may offer another means to effectively distinguish differences between full-time and contract employees.
2. Further study of employment motivation: Previous literature has indicated that employment status influences nurse job performance. Future studies can further probe into the influence of employment motivation on working attitudes, OCB, and job performance.
3. Validation and extension of the research framework: This study is a cross-sectional study and cannot validate the causal relationship among variables and their predication. Future studies can further demonstrate these aspects on the basis of this research framework.
This research was supported in part by the Taiwan Department of Health, and the Institutional Review Board was approved by the Department of Health of Hualien Hospital. The authors thank Mr. Orrin Hoopman for his instrumental editing work.
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Keywords:© 2011 Lippincott Williams & Wilkins, Inc.
contract nurse; organizational commitment; job satisfaction; organizational citizenship behavior; job performance