Organizational support and perceived environment impact on quality of care and job satisfaction: a study with Pakistani nurses

The healthcare industry plays a significant role in delivering quality healthcare services (Shabbir et al., 2016), and more and more contributions indicate that the latter seems highly dependent on the quality of care and job satisfaction among nursing staff (Hamid et al., 2014). Some literature indications (e.g. Busse et al., 2019; Mosadeghrad, 2014) highlighted that healthcare consumers place extreme importance on service quality and care standards, and for that reason, in almost all healthcare organizations, quality of care is given great importance. Al-Mailam (2005) and Tzeng et al. (2002) highlighted three factors considered as key contributors to nursing care quality: (1) satisfaction of patients, (2) well-being of patients and (3) the healthcare organization's performance. Furthermore, it is necessary to consider that healthcare workers well-being and turnover intention seems directly associated with how they perceive their workplace environment, both in terms of internal environmental factors and the functioning of the offered services (Choi et al., 2004; Mulugeta et al., 2019). Furthermore, job satisfaction is also related to the level of stress experienced by the nurses, while job stress has a direct relationship with the working environment (Guo et al., 2019; Ramaci et al., 2020).

There are a plethora of studies that empirically show the relationship between the practice environment of nurses and nurses' quality of care and job satisfaction (e.g. López-Ibort et al., 2021; Pahlevan Sharif et al., 2018). Despite that, there is still a need to explore the mechanism underlying the organizational support perception and nurse's outcome effects, especially as regards the contribution and role of motivational aspects such as commitment (Dinc et al., 2018; Ridwan et al., 2020).

According to Labrague et al. (2018a), organizational commitment can be determined by the following three factors: (1) employees' emotional connection with the organization (Affective Commitment), (2) the cost that they perceive they will receive in the event of organizational exit (Continuance) and (3) their moral duty toward organizational stay (Normative Commitment). Previous studies have elaborated on the relationship between Organizational Commitment and nurses' outcomes, and Job Engagement and Work Effectiveness seem to be directly linked with the Organizational Commitment of nurses (Diana et al., 2022; Labrague et al., 2018b, 2021).

Pakistan, as an emerging economy, has seen tremendous growth in the healthcare sector in recent years; however, there has been limited work in the area of nurse job satisfaction and quality of care mechanisms and determinants. With demanding work schedules always attentive to change, especially in countries with high development and growth, nurse's satisfaction and turnover are particularly under pressure, pointing to companies and research that there are some controllable organizational factors (e.g. organizational support and environmental perceptions) that need to be investigated to better know how they have an effect on outcomes, also through the possible action of motivational processes (Afsar et al., 2018; Bahalkani et al., 2011).

Social exchange theory argues that when nurses receive adequate support from their organization, in the form of good and cooperative staff, and from managers, and if there are healthy relationships between nurses and physicians, combined with many other contributing factors, they will be internally motivated to give their best, increasing their level of commitment toward their organization and therefore, their level of productivity will increase (Atefi et al., 2014; Khomeiran et al., 2006; Javadi and Jafari, 2013); consequently, it seems clear that a strong employee–employer relationship will result in the form of greater quality of care and job satisfaction.

Recent literature on nursing shows that the morale and work-related outcomes of nurses are influenced by various work environment-related factors (Alsufyani et al., 2021; Ho et al., 2021; Huyghebaert et al., 2019). The significant impact of the work environment on the organizational commitment of nurses was also studied using the Job Demand Resources (JD-R) model (e.g. Orgambídez et al., 2019; Van der Heijden et al., 2019). Moreover, Tanskanen et al. (2019) claimed that although various mechanisms have been proposed by scholars to study the workplace environment in relation to different work-related outcomes, the need to study workplace environment in relation to various individual/group and organizational level outcomes still exists.

Rochefort and Clarke (2010) defined work environment as “a set of concrete or abstract features of an organization, related to its structures and processes that are perceived by nurses as either facilitating or constraining their professional practice” (p. 2214); according to Khan et al. (2012), work environment factors influence the job satisfaction and organizational commitment of employees, whereas Huyghebaert et al. (2019) claimed career advancement options were the most significant factor in nurse satisfaction.

Van Bogaert et al. (2014) studied a sample of nursing unit managers and found that nurses' well-being is predicted by role conflict and role meaningfulness; moreover, staff well-being is positively influenced by supervisor support, whereas role conflict and role ambiguity negatively affect job satisfaction. At the same time, the availability of support in an organization decreases the negative impact of work overload and role conflict (Kang et al., 2011; Rodwell and Ellershaw, 2016). Therefore, perceived organizational support is considered to be an important predictor of organizational commitment (Kurtessis et al., 2017; Pattnaik et al., 2020; Rhoades and Eisenberger, 2002; Wang and Sun, 2011; Wang et al., 2017). Following these indications, we hypothesized as follow:

Nurses' quality of care has been fairly studied, as well as its relationship with job satisfaction, organizational constraints, unit type, procedural justice, better nurse–physician relations (Stimpfel et al., 2019), nurse turnover (Antwi and Bowblis, 2018), positive work environment and burnout (Liu et al., 2019). However, studies looking at the relationship between quality of care and organizational commitment, while showing a positive relationship between the two variables, are very limited (Diana et al., 2022; López-Ibort et al., 2021; McNeese-Smith, 2001; Naghneh et al., 2017). Basing on these considerations, the following hypothesis has been formulated:

Job satisfaction has been an extensively studied topic for decades, due to its significant role in employee performance and overall organizational productivity. It has been studied with work engagement and burnout (Havens et al., 2018), ethical climate, and organizational commitment (Paliwal and Dhanshetti, 2020; Serafin et al., 2019). Li et al. (2018) reviewed 1,572 articles on psychological empowerment and job satisfaction and concluded there was a significant correlation between motivational aspects and job satisfaction. Overall, many studies confirmed the positive relationship between organizational commitment and nurses' job satisfaction (Jehangir et al., 2011; Margharei et al., 2021; Mulugeta et al., 2019; Moustafa et al., 2019; Vanaki and Vagharseyyedin, 2009). Consequentially, the following hypothesis has been developed:

Conducted a study in which the respondents were 459 nurses from 22 ICUs in China. Liu et al. (2019) highlighted that positive work environment results in higher job satisfaction and higher quality of care in 459 Chinese nurses. Another study (Serafin et al., 2019) on Swedish and Polish nurses revealed that possibilities of achievement, professional skills development and promotion were strong work environment factors that contributed toward job satisfaction and quality of care. Khowaja et al. (2005) reported that various work environmental factors, including excessive workload, lack of respect, lack of recognition and lack of support, are the major contributors to declined job satisfaction in Pakistani nurses. Escribà-Agüir and Tenías-Burillo (2004) suggested that employee health and well-being are significantly predicted by work environment perception (Lake et al., 2019; Oshodi et al., 2019; Wei et al., 2018). A fair number of researches have provided indications for the positive relationship between the practice environment of nurses and nurses' quality of care (e.g. Brešan et al., 2021; Martins and Lucas, 2021; Pahlevan Sharif et al., 2018; Weldetsadik et al., 2019).

Therefore, the following hypotheses have been formulated:

The concept of organizational commitment was studied by Meyer and Allen (1997) and several definitions, theories and related themes were formulated and refined. The concept of organizational commitment has gained the attention of researchers in various fields such as psychology (Gutierrez et al., 2012), business management (Coyle-Shapiro and Shore, 2007; Goulet and Frank, 2002) and education (Buck and Watson, 2002; Cummings et al., 2020). This is because organizations are now trying to improve the commitment of their workers and staff, having realized how important this is in achieving organizational goals that lead the organization toward long-term stability (Timalsina et al., 2018). Previously, organizational commitment has been studied with various predictors, antecedents and other organizational characteristics, or work-related factors that could have direct or indirect relationships with this variable (Diana et al., 2022; Klein et al., 2009; Gutierrez et al., 2012; Rodwell and Ellershaw, 2016).

Conflicting results were gathered regarding the relationship between organizational support, commitment and satisfaction in nurses (Labrague et al., 2018b; Li et al., 2021; Timalsina et al., 2018), calling for further investigation to explore the underlying mechanisms of the possible effect of one factor on the other. Li et al. (2018) reviewed 1,572 articles on psychological empowerment and job satisfaction and concluded that perceived organizational support does not influence job outcomes such as organizational commitment, work performance, job autonomy and job satisfaction.

However, theoretical support and empirical evidence for organizational commitment being a mediator between the many aspects of perceived organizational support and nurse satisfaction are available (Cao et al., 2019; Kim et al., 2017; Li et al., 2021). The organizational commitment was found to play a mediating role between, for example, authentic leadership and job outcomes of experienced registered nurses (Guerrero et al., 2017). To the best of the author's knowledge, there is no study looking at the mediating role of organizational commitment in organizational support and job outcomes for nurses (Park, 2020; Sharma and Dhar, 2016). Therefore, the study tries to fill the existing gap in the literature, and the following hypotheses have been developed for testing:

Figure 1 shows the research model for current research.

Based on the above descripted rationale and integrating the contributions of both the organizational empowerment theory (Kanter, 1993) and the social exchange theory (Cropanzano and Mitchell, 2005), a theoretical model was developed taking into account both organizational determinants (organizational support and perceived environment) and outcomes (quality of care and job satisfaction), and a correlational study was designed to test it and to respond to the different gaps in the literature: firstly, to pick out the work environment organizational characteristics and nursing practice support relationship with nurses' quality of care and job satisfaction as the outcomes. Secondly, to identify the possible mediating role of organizational commitment in the above-stated relationship. Thirdly, to investigate the effect of perceived environment in achieving nurse's quality of care and job satisfaction. Moreover, the study will also contribute toward a better understanding of determinants of job outcomes and will provide policy implications for the healthcare sector. The correlational study was designed with nurses from the public and private sectors. The proposed relationships between variables (Figure 1) were tested through structural equation modeling (SEM).

Data was collected from three districts (Attock, Rawalpindi and Islamabad) of Pakistan, from September to November 2020. Nurses received a copy of the questionnaire through hospital administration. The researchers explained the research scope and important terminology in the questionnaire to nursing staff and requested that they complete and return the questionnaires within 5 days. The study was approved by an ethical committee and complied with ethical standards. Participation was voluntary and nurses could cease participation at any time. Participants were provided with information about the questionnaire and the purposes of the survey and were asked to sign informed consent.

We selected three districts (Attock, Rawalpindi and Islamabad) of Pakistan because patients from resource-poor areas were always referred/transferred to these districts, which increase the workload of nurses in hospitals. According to the World Bank report (2019), for one thousand people, the number of nurses' availability is 0.4832, which indicates the shortage of nursing staff in-country. Approximately, the number of nurses in our selected districts is 10,000. Following the literature guidelines (Hayat, 2013), questionnaires were distributed using convenience sampling among 370 registered nurses in seven private and public hospitals of selected districts. Responses collected from Civil Hospitals of District Attock constituted 38.1% of the total percentage. 11.4% of responses were collected from PAC Hospital Kamra, 10.2% from Khalid Saeed Hospital, 10.2% were from POF Hospital Wah, 8% were from CMH and PIMS Hospital Islamabad each, whereas 6.8% were collected from Quaid-e-Azam International Hospital Rawalpindi. 7.4% of responses were gathered from Maryam Memorial Hospital Rawalpindi. The total number of useable questionnaires was 352, which were further employed from data analysis.

Data was collected using a self-designed questionnaire, including six sections: (1) Demographics, (2) Quality of Care, (3) Organizational Support, (4) Job Satisfaction, (5) Organizational Commitment and (6) Perceived Environment.

Quality of care: 24 items Caring Behavior Inventory (CBI-24) was used to measure the quality of care (Pahlevan Sharif et al., 2018; Wu et al., 2006). The dimensions of this scale are (1) eight items of assurance, (2) five items of knowledge and skills, (3) six items of respectfulness and (4) five items of connectedness; a five-points Likert scale was used, ranging from 1 (“never”) to 5 (“always”).

Organizational support: The scale used is a 9-item subscale for Organizational Support for Nursing Practices (Aiken et al., 2002). Flynn et al. (2018) defined it as “a set of core attributes of a supportive work environment that are modifiable through managerial decision making”. The subscale items include (1) resource adequacy, (2) nurse autonomy, (3) practice environment nurse control and (4) relationship between nurse–physician. A five-point Likert scale was used for responses, ranging from 0 (“strongly disagree”) to 4 (“strongly agree”).

Job satisfaction: a five-point Likert scale (Aiken et al., 2002) was used to measure the job satisfaction level, ranging from 1 (“strongly disagree”) to 5 (“strongly agree”).

Organizational commitment: 24 items based on the three-component organizational commitment scale developed by Mayer and Allen was used (1997). It is a seven-point Likert scale from 1 (“strongly disagree”) to 7 (“strongly agree”). The scale consists of three subscales named (1) affective commitment (8-items), (2) continuance commitment (8-items) and (3) normative commitment (8-items).

Perceived environment: The Nursing Working Index (NWI) was specifically designed to measure nurses' job satisfaction and quality of care (Aiken and Patrician, 2000); The original index is based on 65 items (Choi et al., 2004), while the scale used is the Perceived Nursing Working Environment (PNWE) having 42 items and 7 subscales. The subscales include (1) professional practice (13 items), (2) staffing and resource adequacy (5 items), (3) nursing management (5 items), (4) nursing process (6 items), (5) nurse/physician collaboration (4 items), (6) nursing competence (6 items) and (7) positive scheduling climate (3 items). A four-point Likert scale ranging from 1 (strongly agree) to 4 (strongly disagree) was used for measurement.

Table 1 shows the demographic details of the sample. Most of the respondents were females between 25 and 30 years old, following the same working hours of 8 h/week. Most of the nurses (60.8%) were married, whereas 64.8% reported that experience level is less than 3 years, which represents new induction. Moreover, there were various job titles, such as nursing instructor, head nurse, nursing assistant, ICU (Intensive Care Unit) nurse, CCU (Critical Care Unit) nurse and OT (Occupational Therapy) sister.

The structural equation modeling technique was used to test the research model, and partial least squares (PLS) was used as the statistical tool to examine the measurement and structural model as it can accommodate smaller sample sizes without normality assumption and survey research is normally not normally distributed (Chin et al., 2003). We followed the suggestions of Hair et al. (2019) and Ramayah et al. (2018) by testing the model in two stages: (1) Measurement model (to assess validity and reliability of the measures) and then (2) structural model (to test the hypotheses developed).

Common method variance issues related to the use of a single questionnaire were controlled through methods suggested in the literature (Jordan and Troth, 2020; Podsakoff et al., 2003): the questionnaire had different scale formats and endpoints for each scale (to lower commonalities and anchoring effects), scales were visually separated, and items were randomly inserted into the questionnaire.

To assess the measurement items and constructs, we tested for convergent validity. The test for reliability and convergent validity is presented in Table 2. In step 1, we used composite reliability to assess reliability, and values more than 0.7 are considered sufficient (Hair et al., 2019). Convergent validity assesses the degree to which the items are related to the construct as theoretically conceptualized and can be checked by looking at the item loadings and the average variance extracted (AVE) for each construct (Hair et al., 2019). We first tested the validity and reliability of the first-order measurement model before proceeding to check the second-order measurement validity and reliability. All the item loadings exceeded 0.7 (since we have a great number of indictors the loadings are not reported in Table 2), and the AVE exceeded 0.5 for all constructs thus indicating adequate convergent validity of the measurement model.

Then in step 2, we assessed the discriminant validity using the HTMT criterion suggested by Henseler et al. (2015) and updated by Franke and Sarstedt (2019). The HTMT values should be ≤0.85 the stricter criterion and the mode lenient criterion is it should be ≤0.90. As shown in Table 3, the values of HTMT were all lower than the stricter criterion of ≤0.85 as such we can conclude that the respondents understood that the five constructs are distinct. Taken together both these validity test has shown that the measurement items are both valid and reliable.

We tested the hypothesis by running a bootstrapping procedure with 5,000 resamples (Hair et al., 2019; Ramayah et al., 2018). The bootstrapping produces the beta values, std errors, t-values, p-values and also the effect sizes.

As shown in Table 4, there was a positive relationship between organization support (β = 0.413, p ≤ 0.01) and organization commitment explaining 17% of the variance in organizational commitment, and organizational commitment (β = 0.127, p ≤ 0.05) and perceived environment (β = 0.204, p ≤ 0.01) were also both positively related to the quality of care explaining 5.9% of the variance. Thus, H1, H2 and H4 were supported. We then tested the effect of organizational commitment and perceived environment on job satisfaction. Organization commitment (β = 0.652, p ≤ 0.01) was positively related to job satisfaction but the perceived environment (β = −0.086, p ≥ 0.05) was not a significant predictor of job satisfaction explaining about 43% of the variance in job satisfaction. Thus, H3 was supported while H5 was not supported.

Next, we tested two mediating effects of organizational commitment on quality care and job satisfaction. The Organizational Support → Organizational Commitment → Quality Care (β = 0.052, p ≤ 0.05) was significant with the bias corrected confidence interval not straddling a 0, thus H6 was supported. Next, the Organizational Support → Organizational Commitment → Job Satisfaction (β = 0.269, p ≤ 0.01) was significant with the bias corrected confidence interval not straddling a 0, thus H7 was also supported.

This study investigates the impact of organizational support and perceived environment on quality of care and job satisfaction with the mediating role of organizational commitment in the nursing sector. This study filled the theoretical gap identified by various researchers, which is (1) what is the impact of organizational support on quality of care and (2) the lesser focus on the mediating role of organizational commitment between organizational support and quality of care and satisfaction.

Organizational support has a significant and positive relationship with organizational commitment, which supports H1. These findings are in line with Pattnaik et al. (2020) and Wang et al. (2017), however contradict the findings of Labrague et al. (2018b). According to social exchange theory, employees with a stronger sense of belonging support their organizations and are more committed to their organizations (Gutierrez et al., 2012).

The relationship of organizational commitment with quality of care and job satisfaction is also significant, which supports hypotheses H2 and H3. Our findings are in line with the previous findings (Hogh et al., 2018; Li et al., 2018; Naghneh et al., 2017; Orgambidez et al., 2019). Furthermore, Yasin et al. (2020) conducted a systematic literature review on factors affecting nursing job satisfaction and found that organizational commitment is positively related to job satisfaction. Similarly, Naghneh et al. (2017) also highlighted that increased organizational commitment among nurses leads to more caring behavior by nursing staff. According to social exchange theory, an individual's performance is associated with the risk and reward they get from the organization where they work, where exchange factors are considered to be all the individual's efforts that are exchanged for what they receive from their organization (Hamrin et al., 2010; Yan et al., 2016).

Previous studies support the fact that nurses' quality of care and job satisfaction are closely related to organizational support (Aiken et al., 2002; Pahlevan Sharif et al., 2018; Rochefort and Clarke, 2010; Van Bogaert et al., 2014); moreover, distributed leadership styles also positively impact nurses' satisfaction, commitment and trust (Barattucci et al., 2020).

In line with previous findings (Liu et al., 2019; Martins and Lucas, 2021; Oshodi et al., 2019), hypothesis 4 (H4) was supported, indicating that perceived environment is positively related to the quality of care: a better perceived and empowered practice environment makes them more active with patients and results in a greater quality of care (Wei et al., 2018). Moreover, an empowered practice environment provided to nurses helps them to adopt empowering leadership styles and ultimately enhance their workplace innovativeness (Jønsson et al., 2021); furthermore, an improved practice environment provides a commitment by the nursing workforce to contribute to a better quality of care (Coetzee et al., 2013; Dorigan and Guirardello, 2018; Liu et al., 2019).

Our findings show that perceived environment has a positive relationship with job satisfaction, which does not support our proposed hypothesis that there is a relationship between perceived environment and job satisfaction (H5). This result also contradicts the findings of Yasin et al. (2020) and Al-Hamdan et al. (2017). The rejection of hypothesis could be explained by many factors that can influence job satisfaction in different environments; employees can be satisfied based on pay packages, promotion possibilities, fair policies and practices within the organization, the level of caring within the organization, appreciation, health, and safety and relationships with supervisors, but these factors may vary from individual to individual (Kol et al., 2017).

Organizational commitment mediates the relationship between organizational support and quality of care, which provide support to our hypothesis H6. Similarly, organizational commitment also mediates the relationship between organizational support and job satisfaction, which provides support to our hypothesis H7. These findings are consistent with Sharma and Dhar (2016) and Cao et al. (2019).

Unlike previous research (e.g. Yasin et al., 2020), the influence of all possible factors affecting nurses' quality of care and job satisfaction was assessed. The proposed relationships also strengthen the robustness of the proposed conceptual model and yield an important theoretical contribution. Considering social exchange theory, the findings highlighted that organizational commitment is just as important as high organizational support (Kutney-Lee et al., 2017). Thus, its effect on organizational commitment can be evaluated by its effect on job satisfaction. This outcome corroborates the study's claim that organizational support is essential to support an organization's competence for individual satisfaction (Gutierrez et al., 2012; Maan et al., 2020).

This study adds to the existing literature available on the nursing sector and provides a basis for further studies. Moreover, it suggests policymakers and HR managers in healthcare organizations formulate strategies and take measures at three levels (organizational, workgroup and the individual level) to ensure favorable working conditions which can help improve organizational commitment and nurse job satisfaction, so they can work with maximum effort, fully dedicated and motivated to improving quality of care.

Moreover, issues like lack of managerial support, lack of peer support, salary inequities, unfair working conditions, lack of job autonomy, high workload and lack of opportunities for career growth should be addressed by the management promptly and impartially (Horan et al., 2018). Management practitioners can possibly implement the six conditions from Kanter's theory on structural empowerment, in both letter and spirit, to ensure job satisfaction, organizational commitment and quality of care among the nursing staff at Pakistani healthcare organizations.

Furthermore, the Pakistan Nursing Council needs to review the curriculum of education for nurses and other related staff to include some courses to build self-efficacy among nurses; regular but flexible training should be designed for nurses to generate a high level of work engagement and improve their personal skills in addition to their professional skills; nurses should be trained in emotional strength and workload handling to reduce the negative effects of work-related factors that reduce nurse job satisfaction. The administrators of healthcare organizations should conduct regular surveys to get feedback from nursing staff regarding current working conditions and environment, and suggestions for its improvement: a working environment where employees have mutual trust, work collaboration, a sense of accountability for the safety of their patients and quality of care needs to be promoted. The building of such a positive work environment would definitely lead to enhanced organizational commitment of nursing staff. Finally, the perks and benefits designed for the nursing sector need to be redesigned after a thorough study and review of workload, input effort and availability of resources to address the grievances of the nursing sector.

The results of this study must be considered in the light of the different limitations: first of all, the low sample size does not allow for broad generalizations, as well as the use of convenience sampling techniques, and data being collected from a single district as a result of COVID and other financial constraints. Future research should consider a more heterogeneous sample of nurses based on their seniority and focus on other job-related outcomes such as turnover intention, as well as different research designs.

Overall, results show strategies to improve organizational support and perceived environment are critical in increasing nurses' job satisfaction, which finally leads to the improved quality of care which is crucial for healthcare organizations to achieve their goals effectively and efficiently. The presence of a significant relationship between organizational support, organizational commitment, perceived environment, quality of care and job satisfaction in the nursing sector of Pakistan was confirmed, which to the best of the author's knowledge had never been studied before.

Additionally, results seem to illustrate that the business value of organizational commitment extends beyond its use as a tool to assist in devising human resource strategies, also functioning as a component of the business for a number of business skills.