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Correspondence to: Soo Il Shin, Ph.D., Department of Information Systems and Security, Kennesaw State University, 585 Cobb Avenue NW, Room 2306, MD 0405, Kennesaw, GA 30144, USA.
The demand for advanced practice nurses (APNs) has increased globally due to a shortage of physicians and an increased demand for high-quality healthcare. Research is needed on the enhancement of advanced practice nurses' organization commitment. Organization commitment (OC) directly impacts the retention of APNs. This study aims to identify the key factors affecting the OC of advanced practice nurses.
Method
A cross-sectional survey was conducted at the largest hospital in South Korea. A total of 189 APNs answered survey questions. A partial least squares-structural equation modeling method was employed to analyze the survey responses.
Results
A pay scale of APNs is positively associated with person-organization fit (POF). However, the effect of job location and computer self-efficacy on POF is not significant. Job satisfaction plays a salient direct role in supervision and POF. Job satisfaction is also a significant moderator in the relationship between supervision and POF. POF is significantly associated with both OC and supervision. Supervision has a positive effect on organization commitment.
Conclusions
Pay scale, job satisfaction, supervision, and POF are significant factors affecting organization commitment. Establishing an intra-organization entity, such as APN steering committee, to ensure mutual consensus and transparent communication between administrators and APNs would enhance POF, the rating of supervision, and organization commitment.
Advanced practice nurses (APNs) are registered nurses working as “nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives” [
American Nurses Association (ANA). Advanced practice registered nurses (APRN) [Internet]: American Nurses Association, American Nurses Credentialing Center, American Nurses Foundation [cited 2022 December 31]. Available from: https://www.nursingworld.org/practice-policy/aprn/.
]. They are “registered nurses who have acquired the expert knowledge base, complex decision-making skills, and clinical competencies needed for expanded practice, the characteristics of which are shaped by the context and/or country in which she/he is credentialed to practice” [
]. There are two major reasons. One is a shortage of physicians. The other is the need to deliver quality healthcare at lower medical costs. In many countries, APNs perform primary physician duties and/or work alongside physicians as full team members. As a strong force contributing to increased access to quality healthcare at lower costs [
APNs, however, encounter barriers in many countries. Barriers include lack of autonomy, professional under-recognition, lack of understanding of their unique role, and lack of support from administrations and from other clinicians [
]. These barriers can prevent APNs from fulfilling their responsibilities and fully integrating themselves within the healthcare system. There is much work to be done to utilize APNs to the fullest extent possible, but there has been little research on the improvement of the work conditions for APNs and the efficient management and retention of APNs. The relatively recent emergence of APNs in healthcare systems and the relatively small number of APNs in the general nurse population contribute to the scant research on them. Given the crisis in healthcare, however, the demand for APNs has increased and will continue to increase. The retention of APNs and the enhancement of their commitment to their profession and organization have thus become crucial global topics in healthcare management.
The current study focuses on the organization commitment (OC) of APNs. OC is defined as “an individual's loyalty or bond to his or her employing organization” [
]. It is an established finding that a high level of OC plays an important role in determining employee retention, low overall turnover in a profession, and the sustainability of the organization itself [
Researchers have identified a number of factors impacting OC. They include motivation, job satisfaction, job environment, inter-relationships within the workplace, person-organization fit (POF), and turnover intentions [
Among various factors affecting organization commitment, our study employs job environment (pay scale, supervision, and job location), job satisfaction, computer self-efficacy (CSE), and POF as variables. Job location and pay scale are, respectively, measures that reflect the adjustment to the working environment and monetary magnitude of a person's job performance [
, p. 192]. POF is defined as “the compatibility between people and organizations that occurs when: (a) at least one entity provides what the other needs, or (b) they share similar fundamental characteristics, or (c) both” [
, pp. 4–5]. Job satisfaction is defined as a positive feeling that one holds toward one's job, resulting from the appraisement and various experiences one has at a workplace [
Given these definitions, we posit direct and moderating effects among variables. For example, pay scale and job location are posited as positively associated with POF as direct effects. Job satisfaction is posited as moderating the relationship between POF and supervision. The Theoretical Background and Research Model section discusses detailed associations among these perceptional constructs.
The goal of our study is to examine direct and moderating effects on APNs' OC using partial least squares - structural equation modeling (PLS-SEM). This is done to (1) explore precursory job environmental factors affecting APNs' perception of POF, (2) identify moderating factors affecting POF and supervision, and (3) understand the direct effects of POF and supervision on APNs' OC. The Partial Least Squares (PLS) is a unique assessment method that can identify the direct effects of variables and moderating effects on a dependent variable (e.g., commitment).
The current study was conducted on APNs in the largest hospital in South Korea (‘Korea’ hereafter). This hospital has employed the largest number of APNs (n = 378) and has the longest-running (20 years) APN program in Korea. The Korean healthcare system exceeds global standards for excellent medical care, and APNs play a pivotal role in it. However, the Korean healthcare system is experiencing the same problems that healthcare systems over the world are: physician shortages in residency programs and an urgent need to deliver optimal care at low costs. In Korea, as in many other countries, APNs perform some of the functions that physicians do or work as full team members with physicians. They are experiencing the same barriers experienced the world over by APNs. The findings of this study are likely to have relevant implications for APNs in general.
Literature review and theoretical background
Some research on various factors affecting OC has been previously conducted. A brief review of the research on the six factors under consideration in our study-- pay scale, job location, supervision, job satisfaction, CSE, and POF follows.
Job environment – pay scale, job location, and supervision
Our study considers three aspects of the job environment and personal fit: pay scale, supervision [
]. A prior study suggested that these factors play an important role in determining the personal expectations of a job position and in building a strong connection between employees and organizations [
]. According to Porter & Steers (1973), immediate work environment, job satisfaction, and pay scale are three essential elements influencing employee turnover rate and absenteeism. In our study, supervision is taken to be a part of the immediate work environment, while pay scale counts as an organization-wide factor.
Pay scale measures an employee's emotional satisfaction at a pay level and reflects the organization's judgment of employee work performance. Pay scale is considered a salient factor, along with promotion, affecting an employee's compensation for her job performance and the potential possibility of withdrawal from her duties [
]. Studies on supervision have focused on well-fitted dyadic relationships between a supervisor and a subordinate. For instance, similar personalities, similar values, and goal congruity among supervisors and subordinates are considered important factors in achieving a strong supervisor-employee relationship [
]. Our study focuses on the relation of APNs' pay scale and job location to her OC, and on supervisors' support for APNs' performance, recognition of successful job performance, and assistance to APNs in resolving conflicts in the medical setting.
Job satisfaction
In general, satisfaction is defined as “the summary psychological state resulting when emotion surrounding disconfirmed expectation is coupled with the consumer's prior feelings about the consumption experience” [
]. Specifically, job satisfaction is referred to as a positive feeling that one holds toward one's job, resulting from the appraisement and various experiences one has at a workplace [
]. Our study focuses specifically on the satisfaction that an APN experiences in 1) providing medical interventions to clients/patients, 2) being recognized by the supervisor because of successful performance of duties, and 3) interacting with patients/clients. A study of APNs' job satisfaction reveals that it is an integral part of healthcare performance, retention, and the delivery of quality work [
Prior studies also emphasized that job satisfaction can be salient in playing a direct role but also in becoming a moderator among various employee perceptions. Accordingly, we consider all of the above theoretical characteristics of job satisfaction as a direct indicator and a moderator between constructs within our research framework in the APNs' OC context.
Based on the theoretical characteristics of job satisfaction as a direct indicator and a moderator between constructs, we employed job satisfaction to examine its both direct and moderating effects on other variables to APNs' path to OC within our research frameworks.
Computer self-efficacy
CSE is rooted in the original concept of self-efficacy, which can be defined as the judgment of one's own capability to organize and execute courses of action required to attain designated types of performances [
]. Thus, an individual's degree of self-efficacy affects the selection of behavioral activities and their eventual performance, given their current state of motivation [
] to organize and execute computer-related courses of action. Since self-efficacy affects our behaviors and performances, it is likely that CSE does the same.
In today's work environment, CSE can be essential to the performance of an APNs' daily duties. CSE is not simply measuring an APN's computing proficiency in hardware and software management for the assigned daily duties. Rather, an APN's CSE reflects his or her judgment of capability to organize and execute computer-related medical duties assigned to him/her. Recent studies note a positive relation among CSE, work performance, and job satisfaction in a variety of work contexts [
]. In all likelihood, an APN with a higher level of CSE is capable of successfully mastering a more comprehensive array of duties in a computing environment than an APN with lower CSE. Almost by definition, a higher level of CSE indicates a greater ability to work in a clinical environment with diverse software or hardware. Belief in one's mastery of computer-related daily duties would produce higher job satisfaction for an APN. In our study, we did not measure “internet self-efficacy” which can be essential to the performance of APNs' daily duties and to job satisfaction.
Person-organization fit (POF)
POF indicates the congruence of values between an individual and an organization. In detail, unlike person-job fit, which concerns aspects of people's job-related qualifications (e.g., skill, knowledge, and capability), POF concerns an individual's and an organization's congruence of beliefs, values, and norms [
]. For instance, a good POF implies a close alignment of an individual's values with an organization's aims. If people perceive themselves as fitting well within an organization, they tend to regard themselves as a part of the organization and are more likely to join a “psychological group” within an organization [
Does person-organization fit matter in the public -sector? Testing the mediating effect of person-organization fit in the relationship between public service motivation and work attitudes.
]. Needs – supplies fit occurs when an organization fulfills an individual's needs and desires in response to or in return for an individual's service [
]. A demands – abilities fit between an organization and an individual occurs when an individual is capable of satisfying the organization's demands, resulting in high job performance [
Another significant aspect of POF is the distinction between actual and perceived POF. While actual POF refers to “the actual similarity of an employee and an organization on fundamental characteristics,” perceived POF refers to “the extent to which individuals believe they fit the organization” [
]. In our research, we focus on perceived POF, since our research is based on the perception of APNs.
Little work has been done on APNs' POF and its significance. Organizations have simply assumed that APNs have or will adopt their beliefs, values, and norms; mutual congruence has not been a question that organizations have had in mind [
The effect of person-environment fit (person-job fit, person-organization fit, person-supervisor fit) and job embeddedness on turnover intention in clinical nurses.
Based on a comprehensive literature review and the theoretical background stated above, we constructed a theoretical conceptual framework that organizational commitment is explained by Person-Job Environment, POF, CSE, and Job Satisfaction (see Figure S1 in the Supplementary Tables and Figures).
We developed the following six hypotheses on the direct and indirect associations of the variables affecting APNs' OC and a research model to test those hypotheses (see Figure 1).
]. An organization that provides a better job environment will positively affect employees' POF. The literature indicates that job location and pay scale, as aspects of the job environment, influence APNs' POF. In particular, fewer environmental barriers in pay scale and job location tend to result in the perception of higher compatibility with an organization.
The concept of CSE records a computer user's self-judgment about his or her capability to use a computer to successfully complete a specific task, as well as his or her perception of what can be done in the future [
]. In today's work environment, CSE is essential to the performance of an APN's daily duties. In all likelihood, an APN with a higher level of CSE is capable of successfully mastering a more comprehensive array of skills in a computing environment than an APN with lower CSE. A study found that an individual's anxiety about computer capability is a barrier to successful performance and liable to result in a lower perception of POF [
]. We claim that APNs who have successfully adapted to a work environment and attained high CSE tend to share their organization's values and beliefs and positively perceive their fit to the organization (H3). Thus, we posit:
H1-3: An APN's job location (H1), pay scale (H2), and CSE (H3) are positively associated with his or her POF.
The role of job satisfaction, POF, and supervision
An APN's job satisfaction is an integral factor affecting retention and the delivery of quality work [
Higher job satisfaction is derived from active and positive interactions with other organization members. Prior studies show that APNs' job satisfaction is positively associated with supervision. Thus, we argue that job satisfaction increases when APNs are acknowledged by their supervisors or other nurses [
]. A supervisor is an active member of an organization who represents the organization's values and who interacts directly with APNs. Job satisfaction is derived from interactions with other organization members. Accordingly, APNs with higher job satisfaction tend to perceive supervision more positively if a little conflict occurs, and harmonious job performance is achieved through smooth interaction with a supervisor. Job satisfaction is also significantly associated with POF [
Job satisfaction and hospital performance rated by physicians in China: a moderated mediation analysis on the role of income and person-organization fit.
]. The degree of APNs' job satisfaction is likely to affect the perceived value of the employer organization, the hospital.
Based on the review of the literature, we posit that job satisfaction positively affects both POF and supervision. Since APNs with high perception POF are likely to rate supervision more positively if they are satisfied with their jobs, we claim that APNs' job satisfaction moderates the relationship between POF and supervision. That is, we posit
H4: An APN's job satisfaction is positively associated with his or her POF (H4a) and supervision (H4b).
H4c: An APN's job satisfaction positively moderates the relationship between POF and supervision.
The role of person-organization fit (POF)
POF concerns an individual's and an organization's congruence of beliefs, values, and norms [
]. High POF indicates a close alignment of an individual's beliefs, values, and norms with those of an organization. Multiple studies show that POF has a significant effect on job satisfaction, commitment, and intention to leave a position [
]. In addition, positive POF provides an employee with a sense of meaningfulness and psychological attachment to an organization. That leads to a higher employee engagement level and consequently a lower turnover rate [
Organizations have simply assumed that APNs have or will adopt the beliefs, values, and norms of their organizations; mutual adjustment has not been a question for organizations [
The effect of person-environment fit (person-job fit, person-organization fit, person-supervisor fit) and job embeddedness on turnover intention in clinical nurses.
]. A study of RNs employed in a Midwestern hospital system, however, shows that highly positive POF, conceptualized in terms of supplementary adjustment and congruence, produces positive work outcomes [
Does person-organization fit matter in the public -sector? Testing the mediating effect of person-organization fit in the relationship between public service motivation and work attitudes.
]. Given these findings, we claim 1) that an individual's willingness to remain in an organization tends to be stronger if he/she perceives high congruence of his/her beliefs, values, and norms with those of the employing health care organization.
Research has also found that employees' POF plays a vital role in supervisor ratings and career success [
]. A supervisor's role in supporting APNs is particularly significant as far as the POF perspective is concerned. APNs' supervision ratings are positive when they believe that their values and beliefs coincide with those of supervisors. Supervisors represent and promulgate a healthcare organization's culture when they support and assist APNs. The higher the perceived POF, the more positive the supervision rating [
]. Thus, we claim 2) that POF influences APNs' rating of supervision. On the basis of 1) and 2), we posit:
H5: An APN's POF is positively associated with his/her OC (H5a) and supervision performed within the healthcare organization (H5b).
The role of supervision
Supervision is referred to as a supervisor's managing style toward his or her subordinate, interaction with a working unit and peers, providing feedback based on his or her working experience, and the receipt of recognition as an important immediate job environment factor within an organization [
Supervisors can significantly influence workers' wellbeing, personal growth, and development. Workers who receive guidance and support from their supervisors exhibit higher OC levels [
Organizational commitment and supervisor support, perception of procedural fairness, tenure in the hospital: the mediating effect of work-life balance - study in nurses.
]. In addition, a positive relationship between supervisors and employees is strongly associated with lower employee turnover rates, a more positive job attitude, and a higher satisfaction level [
]. When APNs perceive that their supervisors “are on their side” as far as their professional work and growth are concerned, their emotional bonds with them deepen and a strong OC results [
]. Given these findings, we claim that a higher APN rating of supervision leads to a stronger commitment to a healthcare organization.
H6: Supervision is positively associated with OC. The research model from the literature review and the hypotheses we posit is shown in Figure 1.
Research method
Study design
Our study identifies inter-relationships among the key factors affecting APNs' OC: job environment, job satisfaction, POF, and supervision. To this end, a cross-sectional research design employing a survey was used. Hypotheses were tested using the PLS method. The PLS method is one of the two analysis methods of the structural equation model (SEM). One method is covariance-based, the other is variance-based. The PLS method offers benefits that include: identifying the possible existence of nonlinear relationships among measured constructs, being well-suited for a small sample size, and recognizing mediating or moderating effects among constructs [
]. In addition, the PLS is well known for its capability to explore significant associations among latent variables. That is a welcomed benefit: our research model recognizes the possibility of just such significant associations among latent variables.
Ethical considerations
The current study (Proposal #2018-1400) was approved by the IRB in the Asan Medical Center in which the research was conducted.
Selection of measurement items
To measure the core dependent variable of organization commitment, five measurement items were adopted from a prior study [
]. Selected survey items correspond to organization commitment, defined as “the strength of an individual's identification with and involvement in a particular organization” [
]. The items represent employees' perception of organization fitting, with organization fit conceptualized in terms of congruence of personal values with an organization's culture [
] The items measure APNs' emotional responses to their daily duties, current working environment, and position compensation. Five items to measure CSE were adopted from Compeau and Higgins [
]. The theory is constructed to explain “people's judgments of their capabilities to organize and execute courses of action to attain designated types of performance”. Finally, two items measure APNs' perceptions of job location as an environmental factor affecting POF. Nine additional items concern demographics for control variables (gender, years of working, law compliance, education, affiliated department, age, motive, marital status, and paid leave).
All survey items were assessed using a 7-point Likert scale ranging from “1 (strongly disagree)” to “7 (strongly agree)”, except for the construct of CSE. The CSE items were measured using a bipolar continuum of 10 scales. Survey questions were translated into Korean by the authors. Four bilingual nursing professionals with a master's or higher degree validated the translation. One author later reverse-translated the survey questions into English and confirmed the validity of the Korean translations.
With PLS-SEM/variance-based SEM models as guides, three or four items were selected for each construct on the basis of cross-loadings. It indicated the best reflective latent variable and qualified the uni-dimensionality and the maximum of latent variable identification of each construct [
The survey was conducted at the largest hospital in South Korea. The hospital is located in Southeast Seoul. It has 2705 beds and serves, on average, 11,885 outpatients and 2540 inpatients per day. The survey was limited to APNs. APNs are divided into two groups: clinical nurse specialists (CNSs) and physician assistants. The hospital employs approximately 120 CNSs. Nurses are certified as CNSs through a CNS exam. CNSs have been engaged in nursing research, have acquired professional knowledge in clinical nursing, and have served patients in practice areas designated by the APN executive council. The hospital also employs 258 physician assistants. Among them, 86 are members of the Department of Medical Specialty, while 172 are members of the Department of Nursing.
Paper survey materials were sent to 200 APNs in the hospital. One hundred and eighty-nine participants (95.5%) answered and returned the survey. In determining the minimum sample size, a prior study suggested calculating the statistical power and effect sizes a priori [
]. Assessing a priori by power analysis in PLS-SEM benefits minimizing Type II errors (false negative – not declining a false hypothesis). Therefore, we set the standard values of effect size (a value of .1), error probability (a value of .05), and power (1-α) (a value of .8) using G∗Power 3.1 [
]. The number of predictors is set for two reasons. First, the maximum number of paths directed to a single construct in a valid research model is four; and second, on the research model, POF is influenced by job satisfaction, job location, pay scale, and CSE [
]. The minimum required sample size for securing valid results was determined to be 125. Detailed demographic information about the participants is shown in Table 1.
Table 1Characteristics of Participants.
Characteristics
N (%)
Gender
Men
2 (1.1)
Women
184 (98.4)
No response
1 (0.5)
Age
21–30
12 (6.4)
31–40
113 (60.4)
41–50
59 (31.6)
51–60
2 (1.1)
No response
1 (0.5)
Marital status
Married
141 (75.4)
Single
45 (24.1)
Divorced
1 (0.5)
Education
AND
3 (1.6)
BSN
54 (28.9)
Master
124 (66.3)
Ph.D.
6 (3.2)
Affiliated department
Nursing
183 (97.9)
Medical
1 (0.5)
Others
2 (1.1)
No response
1 (0.5)
Paid leave
Yes
34 (18.2)
No
152 (81.3)
No response
1 (0.5)
Years of working
3–5 years
2 (1.1)
6–10 years
32 (17.1)
11–15 years
48 (25.7)
16–20 years
68 (36.4)
21–25 years
29 (15.5)
26 years or more
7 (3.7)
No response
1 (0.5)
Law compliance
Yes
159 (85.0)
No
28 (15.0)
Motive
Being assigned/transferred
17 (9.1)
Being interested in
18 (9.6)
Working in a more professional position
119 (63.6)
To avoid a work shift (e.g., 8-hours or night shift)
10 (5.3)
To pursue a self-development
22 (11.8)
Others
1 (0.5)
Note. ADN = Associate Degree in Nursing; BSN = Bachelor of Science in Nursing.
Ninety-eight percent (n = 184) of ANPs surveyed were female. The age range was 21 to 60 and was divided into four groups. Ninety-two percent of the participants (n = 172) fell into two age groups. The range of the two age groups was 31 to 50. Seventy-five percent of participants were married at the time of the survey. More than 60.0% of the participants had earned a master's degree, and more than 90.0% at least a bachelor's degree. Almost all participants (98.0%) were working in the nursing department. 152 participants (81.3%) answered that they did not have paid leave.
Data collection process
After the IRB approval, a briefing on the research was conducted at a meeting of APNs at the hospital. Names of volunteering APNs were collected by the Department of Nursing and sent to the research team. The research team then sent emails to volunteering APNs to confirm their willingness to participate in the study. APNs who confirmed their willingness to participate received a package in which the paper survey, a consent form, and a self-addressed and stamped envelope were included. Participating APNs completed the survey, signed the consent form, and mailed them to the research team. After remaining sealed for two weeks, the surveys were opened for analysis.
Data analysis
WarpPLS 7.0 software was used to test the hypotheses and analyze the research model [
]. Two model assessments of the data were conducted. A measurement assessment confirmed the validity and reliability of the data, measured by convergent validity and discriminant validity. A structural model assessment identified path coefficients, effect sizes, and p-values. Details can be found below.
Results
Measurement model assessment
We assessed a measurement model using internal consistency, convergent validity, and discriminant validity per PLS-SEM reporting standard [
]. Internal consistency is examined by composite reliability and Cronbach's α. Convergent validity is examined by indicator reliability. Our analysis shows that the composite reliabilities ranged from .96 to .84 and Cronbach's α ranged from .62 to .93 (see Table 2). All indicator reliabilities are higher than the minimum of 0.6 (see Table 2). Thus, measures of internal consistency and convergent validity met or surpassed the recommended minimum thresholds [
Discriminant validity is identified by the heterotrait-monotrait ratio of correlations and examined by the cross-loadings of each construct. All heterotrait-monotrait ratio values in our measurement model are smaller than the conservative threshold of 0.85 [
]. Thus, all constructs are conceptually distinct (see Table 2). The rotated cross-loadings of each construct are much less than the indicator's outer loadings (see Table S1 in the Supplementary Tables and Figures). Thus, all results support discriminant validity.
Structural model assessment and hypothesis testing
In testing the hypotheses, our results show that APNs' pay scale is positively associated with POF (β = 0.21, p < .001), indicating that H2 is supported (see Figure 2).
Figure 2Testing Hypotheses. Note: Control variables – only statistically significant variables are included in the figure.
However, job location and CSE are not associated significantly with POF (respectively: β = 0.11, p = .061; β = −0.8, p = .138). H1 and H3 are thus not supported. As for H4, job satisfaction has a significant effect on both POF and supervision (respectively: β = 0.48, p < .001; β = 0.27, p < .001). H4a and H4b are thus supported. The results also show that job satisfaction positively and significantly moderates the relationship between a supervisor and person-organization fit (β = 0.14, p = .024). H4c is thus supported. In particular, supervision is influenced by APNs' low and high job satisfaction levels as the degree of POF increases (that is, as toward the right side of the POF axis. See Figure S2 in the Supplementary Tables and Figures). Given a low job satisfaction level, the effect of supervision gets suddenly weaker when the POF becomes positive on the POF axis. However, given a high job satisfaction level, the supervision effect is greater when the POF increases. Note that the WarpPLS application assumes nonlinear relationships among people's perceptions and behaviors. This is because such nonlinear relationships are common and well-established in social studies [
Regarding H5, POF is positively and significantly associated with both an APN's commitment to healthcare organization and supervision (respectively: β = 0.41, p < .001; β = 0.27, p < .001). H5 is thus supported. Supervision has a positive effect on OC (β = 0.14, p = .028). H6 is thus also supported. Among control variables, only age, motive, and marital status are statistically significant (respectively: β = 0.13, p = .032; β = 0.13, p = .031; β = −0.19, p < .004).
Total indirect effects and specific indirect effects in this model are listed in Table 3. In examining indirect effects, the path of job satisfaction → POF → OC indicates both the highest total and specific indirect effects.
The study investigated the key factors affecting APNs' OC in their healthcare organization. The results provide a number of insights.
The aspects of the work environment (i.e., job location – H1 and pay scale – H2) show mixed relations, resulting in mixed outcomes. Pay scale for APNs is a significant factor for POF, but job location is not. In the case of job location, 93.0% of the survey participants reported that they had worked in the hospital for more than 8 years. We infer that their place of residence is within a readily commutable distance; thus, job location does not significantly affect POF. Participants considered pay scale an important factor impacting POF. This finding aligns with the findings from prior studies [
]. Well-paid APNs tend to perceive high congruence with their organizations.
CSE was examined in relation to APNs' years of working experience, in conjunction with the length of electronic health records (EHR) and EHRs use in the hospital. Our finding is that CSE is not a significant factor affecting APNs' perceived POF. Some APNs, however, expressed a desire for hospital assistance with new EHRs systems. This indicates a need for future research concerning APNs' perception of CSE in updated computing environments and the impact of such perception on POF.
The study also shows that job satisfaction is a salient factor underlying precursory factors (e.g., supervision and POF) affecting OC. Job satisfaction thus plays a dual role: 1) it is a direct antecedent factor influencing both supervision and POF and 2) it is a simultaneous moderator between POF and supervision. In particular, in the examination of the moderating effects between POF and supervison, the level of job satisfaction plays a crucial role in explaining the relationship between POF and supervision; given a high job satisfaction level, POF and supervision are positively associated with each other; given a low job satisfaction level, POF and supervision are negatively associated with each other at a certain point.
Another salient aspect of job satisfaction is found in the path of JS → POF → OC in Table 3. This path shows the strongest indirect effect (.20) among other specific indirect effects. The total indirect effect between JS and OC is the greatest (.26) among all total indirect effects. Our findings indicate that APNs' job satisfaction cannot sufficiently explain his or her OC if the APNs' perception of POF is not considered in the relationship between JS and OC.
The findings point to an effective potential resource for the retention of APNs and for the improvement of overall quality healthcare: the enhancement of APNs' job satisfaction. APNs' job satisfaction can be enhanced effectively when patients and supervisors recognize the contribution and value of APNs' performances. Well-crafted institutional programs can promote such recognition and thus enhance APNs' job satisfaction.
Concerning POF, the findings indicate the important role of POF on supervision and OC. Both our research and earlier studies support POF's association with OC. Survey participants are strongly committed to their organizations when their perceived organization values fit well with their own personal values. Another significant finding is an association of POF with supervision rating. This finding deserves the attention of healthcare organizations because personal value congruence with an organization's value is strongly associated with the interaction between an individual and his or her supervisor at their duty stations.
The congruence of APNs' aims and values with those of their organization is not easy to achieve. Values tend to diverge in an institutional setting, but one-sided assimilation of APNs' values to those of a health organization is neither desirable nor possible. Neither is the converse assimilation. Necessary is a mutual effort by both parties through transparent communication and negotiation of values, led by the healthcare organization [
]. Such congruence requires that the organization strive to establish ethical and socially acceptable mission/value statements and policies on promotion, reward, and the resolution of conflicts and to secure the acceptance of such statements and policies from organization stakeholders, including APNs. Efforts need to be made to know and reflect on APNs' values and goals and to include APNs in the decision-making process. The decision-making process must be inclusive, transparent, and equitable for APNs and all stakeholders. APNs' POF would be best promoted with committed organizational support for the mutual congruence between APNs and their organizations. Committees or programs constructed to serve that purpose are indirect routes to improved POF.
The construct of supervision influences OC directly. Our finding is in keeping with other studies: a more supportive and helpful supervisor enhances APNs' commitment to a healthcare organization [
]. Our findings suggest that supervisors of APNs should develop positive relationships with them and be supportive in guiding, evaluating, and assisting them. Positive supervision results from a committed organizational effort to initiate and support clear and transparent communication and the professionalism of supervisors. Committed organizational support for effective supervision of supervisors for APNs is much needed.
Implications
Our discussion has indicated the need for committed organizational support to enhance job satisfaction, POF, and supervision for the OC of APNs. At the hospital where the research was conducted, there is an APN steering committee which manages APN job duties. The committee consists of top-ranking officers and APN supervisor representatives in the hospital. Among its powers and duties are setting pay rates, promoting APNs, evaluation and recognition of job performance of APNs, and communication with supervisors regarding organization policies and activities. This steering committee has been recognized as an effective instrument in managing the APN system. APNs are managed by supervisors who communicate with administrators and convey organizational values and norms to APNs. The APN steering committee has been instrumental in enhancing the positive ratings of supervision, POF, and OC. Our results thus have important practical implications for reducing the APN turnover rate. They suggest that establishing an APN steering committee or establishing a procedure that ensures direct and transparent communication among the healthcare organization, supervisors, and APNs may help achieve high POF and high ratings of supervision, as well as secure higher OC levels.
Limitations
Our research has limitations as follows; first, studies of the OC of APNs are relatively rare. Our findings are based only on data collected at a single hospital in Korea. Even though it is the largest hospital in Korea, the findings need to be further validated. To increase confidence in the results, more research in different social and cultural settings is needed. Additional research will help clinical policymakers devise effective strategies to improve APNs' OC.
Second, given that our data are cross-sectional, causal relationships cannot be inferred from our findings. For example, (1) job satisfaction can play a role as both an antecedent condition and as a target variable, and (2) POF may be, given only our data, an outcome variable influenced by supervision. Cross-sectional data alone are not sufficient to confirm the causal relationships that our results may suggest. Confirmation requires not just the collection and analysis of similar data over periods of time but a more rigorous test to draw inferences about causal relationships among constructs.
Last, our study offers useful insights into APNs' OC level at a specific place and point in time, but OC is always at least partly a function of place and time. We thus suggest that culturally disparate and in-depth longitudinal studies of APNs' OC be conducted. This is of some importance. Shortages of APNs already exist, and duties, positions, status, staffing, institutional arrangements, and other variables are ever changing. Identifying factors which significantly impact OC can provide a deeper managerial insight and thereby help to improve APN loyalty and enhance APN retention.
Conclusions
Our conclusions are: 1) Job satisfaction significantly impacts APNs' POF and supervision. 2) POF significantly impacts APNs' OC. 3) Supervision has a high impact on APNs' OC. These findings suggest that healthcare organizations strive to retain APNs primarily by enhancing their job satisfaction, their POF, and supervision. If our study suggests one practical implication for nursing management, it is to establish an entity such as the APN steering committee or an official procedure to establish and enhance mutual consensus and transparent communication between administrators and APNs.
Authors' contributions
Project administration: MHJ. Funding acquisition: YHK. Research Conceptualization: SIS, MHJ, YHK. Overall Introduction: YHK, MHJ. Hypotheses and research model development: SIS, MHJ, HKK. Data curation: YHK, MHJ. Formal analysis: SIS. Methodology: SIS, MHJ. Writing – original draft: SIS, HKK, MHJ. Writing – review & editing: MHJ, HKK, YHK, WM.
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Acknowledgment
The 2020 Research Fund of the University of Ulsan.
Appendix 1. Measurement Items
Organization Commitment
OC1. I talk up my healthcare organization to my friends as a great place to work.
OC2. I am proud to tell others that I am part of my healthcare organization.
OC3. I am extremely glad that I chose this healthcare organization to work for over others I was considering at the time I joined.
OC4. For me, this is the best of all possible healthcare organizations to work.
OC5. Deciding to work for my healthcare organization was a definite mistake on my part (RC).
Supervision
SUP1. My Clinic Manager is helpful in resolving issues of conflict.
SUP2. My Clinic Manager is supportive when I need to increase or decrease my scope of practice for the needs of my patients.
SUP3. Good performance is acknowledged.
Job Satisfaction
JS1. Patients and my Clinic Manager value my intervention.
JS2. Work is rewarding.
JS3. My intervention makes a difference to patients and my Clinic Manager.
Pay Scale
PAY1. I am content with my level of compensation.
PAY2. My compensation is an adequate reflection of my performance.
Job Location
JL1. My clinic location fits my interests.
JL2. My community matches my interests for outside of work activities.
Person-Organization Fit
POF1. The things that I value in life are very similar to the things that my healthcare organization values.
POF2. My personal values match my healthcare organization's values and culture.
POF3. My healthcare organization's values and culture provide a good fit with the things that I value in life.
Computer Self-Efficacy
I could complete the job using the software package…..
CSE1 …. If I could call someone for help if I got stuck:
CSE2 …. If someone else had helped me get started:
CSE3 …. If I had a lot of time to complete the job for which the software was provided:
CSE4 …. If I had just the built-in help facility for assistance:
CSE5 …. If someone showed me how to do it first:
Demographic Information
(Gender) What is your gender?
1.
Male
2.
Female
(Age) What is your age? ( )
(Affiliated Department) Please select your current working department
1.
Nursing office
2.
Medical office
3.
Others
(Marital Status) Please select your marital status
1.
Married
2.
Single
3.
Divorced
(Motive) Please select your motivation to become an NP or ANP
1.
Being assigned/transferred
2.
Being interested in
3.
Working in a more professional position
4.
To avoid a work shift (e.g., 8-hours or night shift)
5.
To pursue self-development
6.
Others
(Years of working) Please indicate years of working in the current hospital ( )
(Paid leave) I can use all my available vacation or leave days whenever I wish.
1.
Yes
2.
No
(Law compliance) I am worried about working in the current position of NP or ANP because of a lack of relevant protective laws and compliance.
1.
Yes
2.
No
(Education) Please indicate your terminal degree.
1.
AND
2.
NSN
3.
Master
4.
Ph.D.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
American Nurses Association (ANA). Advanced practice registered nurses (APRN) [Internet]: American Nurses Association, American Nurses Credentialing Center, American Nurses Foundation [cited 2022 December 31]. Available from: https://www.nursingworld.org/practice-policy/aprn/.
Does person-organization fit matter in the public -sector? Testing the mediating effect of person-organization fit in the relationship between public service motivation and work attitudes.
The effect of person-environment fit (person-job fit, person-organization fit, person-supervisor fit) and job embeddedness on turnover intention in clinical nurses.
Job satisfaction and hospital performance rated by physicians in China: a moderated mediation analysis on the role of income and person-organization fit.
Organizational commitment and supervisor support, perception of procedural fairness, tenure in the hospital: the mediating effect of work-life balance - study in nurses.
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