Examining the Relationship between Job Satisfaction, Organization Commitment, and Turnover Intention Among Nurses in Malaysia

Purpose: Shortages of the nursing workforce in the healthcare industries have been a persistent global phenomenon and worse during the recent COVID-19 pandemic. This study explores the relationship between job satisfaction, organizational commitment, and turnover intention among nurses in Malaysia. As a result, affective, continuance, and normative commitment depicted a significant positive effect, while job satisfaction shows no negative effect on turnover intention. In addition, low wages, excessive non-nursing tasks workload, non-conducive work conditions, and managers’ inefficiency in governing the nursing staff also moderated the nurses’ turnover intention. The study’s outcomes serve to inform hospital managers and policymakers to employ effective measures for nurses’ retention strategies to combat the unending shortage of nursing workforce in Malaysia and across the globe. Limitations and future research are discussed. Design/methodology/approach: This quantitative study adopted an analytical cross-sectional research design to gather data from 284 registered nurses using a Google eForm. The collected data were analyzed using Jeffreys’s Amazing Statistics Program, version 0.17.1 (JASP 0.17.1). Findings: The results indicated that turnover intention, affective commitment, continuance commitment, and normative commitment have a positive relationship with the nurses’ turnover intention in Malaysia. On a positive note, this study also shed new light compared to the traditional finding in the relation between job satisfaction and turnover intention, because it was noted that instead of depicting a negative relationship between these two variables as reported in the previous studies, it was rather the opposite result. This signifies that, based on the findings, the nurses in Malaysia manifested a high rate of job satisfaction. Originality/value: This study focuses on variables and factors that could enhance the nursing retention strategy for the nursing workforce in Malaysia. The data was collected from registered nurses working in the country and studying at the Open University of Malaysia.


Introduction Background of the study
The healthcare system is characterized by its dynamic and intricate nature, attributed to technological advancements and the rapid evolution of healthcare practices.Despite its complexity, the healthcare industry remains sustainable, given its indispensable role in our lives.The emergence of new diseases, exemplified by the recent global pandemic of the Coronavirus Disease , has added to the challenges faced by hospitals worldwide.During such crises, hospitals grapple with an influx of patients exhibiting a spectrum of symptoms, ranging from severe manifestations to mild flu-like conditions.Beyond pandemics, the day-to-day operations of healthcare facilities witness a continual rise in patient admission, encompassing acute cases like appendicitis, chronic conditions such as heart problems or cancer treatments, preventive measures like health screenings, emergencies like road traffic accidents (RTA), natural childbirth, and outpatient cases like hemodialysis for patients with renal impairment.In the contemporary era, a hospital has become analogous to a second home for patients enduring prolonged hospitalizations due to chronic illnesses.Within the healthcare workforce, where the workplace is often regarded as a second home, nursing services stand out as the predominant service providers.
The profession of nursing has undergone significant evolution, spanning from its roots in Islamic history to the modern era.This positive progression is marked by substantial advancements in education and training for nursing professionals.The historical reliance on on-the-job training, a practice adopted by British doctors and unit supervisors, has transformed into a structured educational system.Today, nurses undergo a minimum of three years of training leading to a diploma, followed by options for advanced diplomas, bachelor's degrees, master's degrees, and even doctoral-level education.Despite these measures, the persistent global challenge of nursing shortages persists, and Malaysia is no exception to this phenomenon.Various factors contribute to this shortage, with nurse turnover being identified as a significant contributor (Hayes et al., 2012).Gurkova et al. (2013) note that nurses who resign or leave their home countries often opt to work in another hospital or country, while others may leave the profession due to divergent career pathways (Gök & Kocaman, 2011).In the Malaysian context, the turnover rate has become a cause for concern, reaching over 50% within a span of five years (Choong et al., 2012).
The nurse turnover issue in Malaysia has been exacerbated, particularly during the period between 2005 and 2010, witnessing a surge from 400 to 1049 nurses (Choong et al., 2012).Notably, Lee et al. (2015) reported a substantial exodus of approximately 25,000 Malaysian nurses migrating to work abroad, predominantly in Middle Eastern countries such as the Kingdom of Saudi Arabia (KSA) or the United Arab Emirates (UAE), including Dubai.This trend of nurses leaving Malaysia for overseas employment is reiterated by a recent report by CodeBlue (2022), which highlighted a critical shortage of nurses in the state of Johor, ranging from 15,000 to 18,000.Further evidence from SamaSamaJaga.com (2022) underlines the challenges faced by the Malaysian healthcare system.Approximately 2,000 Malaysian nurses were reported to be working in KSA.However, due to the imposition of taxes on their income by the government of Saudi Arabia, many nurses chose to return home.

Literature Review
Nurses' turnover according to Prince and Mueller (1981) is the act of employees who had made up their minds to leave or quit their jobs.It was frequently defined as the voluntary action of employees either moving out of the organization or from their jobs (Coomber & Barriball, 2007;Prince & Mueller 1981).However, Prince and Mueller (1981) explained that dismissal, retirement, and death are not categorized as turnover, as they are categorized as involuntary leaving.In addition to these, intra-organizational movement such as when the employees were promoted or transferred to another department was not considered as voluntary turnover (Prince & Mueller, 1981).According to Currie & Hill (2012), turnover is calculated according to the employee gain and loss ratio, which means turnover is commonly determined in terms of the length of the employees remain in their employment position.For a clearer view, Bae et al. (2010) explained that the turnover rate can be calculated by comparing the sum of the nurses who had resigned during a stipulated duration and the mean number of nurses during a similar stipulated duration.As for Hayes et al. (2012), they stated that the turnover rate reflected the ability of the organization to retain its existing staff.However, in the nursing realm, a different definition was brought forward by Morrell (2005).He stated that turnover is a withdrawal process that starts from the unit level being the first stage followed by the organization level and lastly the profession level.
Turnover Intention.Turnover intention and turnover, while sharing linguistic similarities, represent distinct concepts within the realm of organizational psychology.Empirical studies have consistently affirmed turnover intention as a significant predictor of actual turnover.Prince and Mueller (1981) define turnover intention as individuals' perceptions regarding the contemplation of leaving or quitting their current employment.It serves as a mediating factor in the complex interplay of attitudes influencing the intent to quit and the subsequent act of leaving an organization (Glissmeyer, Bishop, & Fass, 2008).Mobley's intermediate linkages model further elucidates that turnover intention is a pivotal stage in the decision-making process, acting as a precursor to the ultimate decision to leave or quit an organization (Mobley, 1982).Other studies posit turnover intention as a multi-stage withdrawal process rooted in psychological components.Negative workplace experiences can trigger adverse psychological and cognitive responses, culminating in an actual turnover (Takase, 2010).In the context of nurses, turnover intention manifests at various levels, encompassing intraorganizational, inter-organizational, country, and profession-related considerations.Existing literature, as highlighted by Tang (2018), predominantly focuses on inter-organizational and professional turnover intention, with limited exploration of intra-organizational and countryspecific turnover intention.Intra-organizational turnover intention involves leaving a specific unit within the same organization, while inter-organizational turnover intention pertains to departing from the current organization to join another within the same country (Tang, 2018).The profession turnover intention extends to nurses contemplating an exit from the nursing profession altogether to pursue an alternative career.Lastly, country turnover intention involves nurses relocating to another country, often driven by factors such as higher remuneration and improved career prospects.In the current study, turnover intention specifically denotes the inclination of Malaysian nurses to seek employment abroad, particularly in the Middle East or Singapore.

Job Satisfaction
Job satisfaction, as defined by Locke (1993), is characterized as a pleasurable or positive emotional state resulting from the evaluation of one's job or job experiences.This emotional state becomes particularly significant when examined in conjunction with organizational commitment and turnover intention, as highlighted by Ferguson (2005).Prince (2001) contributes to this understanding by framing job satisfaction as the affective orientation of employees towards their work.This effective orientation encompasses various aspects, including employee relations, appreciation, communication, co-workers, fringe benefits, job conditions, the nature of the work, organizational characteristics, policies and procedures, compensation, personal growth, promotion opportunities, recognition, security, and supervision (Spector, 1997).Judge, Thorensen, Bono, and Patton's (2001) study further underscores the pivotal role of job satisfaction, indicating its significant impact on both the organization and employees.The study suggests that satisfied employees, tend to perform their duties more effectively and are less likely to engage in counterproductive behaviors (Chen & Spector, 1991).Conversely, research, such as that conducted by Estryn-Behar, van der Heijden, Fry, and Hasselhorn (2010), highlights the negative influence of work-related factors-such as time pressure, quality of care, lack of autonomy, work schedule difficulties, and dissatisfaction with pay-on nurses, leading to heightened turnover intentions.Therefore, interventions aimed at increasing job satisfaction have the potential to mitigate turnover intentions among employees in professions like nursing (Cavanagh & Coffin, 1992).The interconnectedness of job satisfaction, employee performance, and retention underscores its significance as a critical determinant of organizational success and employee well-being.

Organization Commitment
Organizational commitment has been conceptualized in diverse ways, capturing the depth of an individual's connection to their workplace.Mowday, Steers, and Porter (1979) define organizational commitment as an affective attachment to an organization stemming from an individual's belief in shared values with the organization.This attachment reflects a genuine desire to stay loyal and continue working for the same organization.Porter et al. (1974) further elaborates on organization commitment, characterizing it as an active form of loyalty where employees willingly contribute to the organization's welfare.This active loyalty serves as a strong predictor of employees' likelihood to stay within the organization, establishing a psychological bond between the individual and the organization (Meyer, Allen, & Gellatly, 1990).This positive psychological state fosters a continuous desire among employees to remain integral members of the organization (Meyer & Allen, 1991).Meyer and Allen's (1991) comprehensive model of commitment, as cited by the International Journal of Business and Management (2012), introduces three distinct components: affective commitment, continuance commitment, and normative commitment.Affective commitment reflects an emotional attachment, indicating genuine affection and identification with the organization.Continuance commitment is characterized by an awareness of the costs associated with leaving the organization, such as the investment of time and energy, making employees feel compelled to stay.Normative commitment, on the other hand, arises from a sense of obligation or moral duty to remain with the organization.Together, these three components provide a nuanced understanding of organizational commitment, emphasizing emotional ties, perceived costs of leaving, and a sense of duty as integral factors in shaping employees' commitment levels.

i. Affective Commitment
Affective commitment refers to the state of the employees' emotional attachment to the organization, they identify themselves to the value of the organization and are H2 Affective Commitment (AC) very much involved with the well-being of the organization.The employees who have strong affective commitment will continue to work with the organization because they want to (Meyer and Allen, 1991).

ii. Continuance Commitment
Continuance commitment refers to the state of the employees' feeling the need to stay in the same organization based on various reasons such as the potential loss of benefits if they resign, or perhaps due to lack of employment alternative, or because they know it will cost them some other great values if they choose to leave.The employees that are associated with the organization in continuance commitment will remain in the same organization because they feel they have to (Meyer and Allen, 1991).

iii. Normative Commitment
Normative commitment refers to the state of the employees' feeling of obligation to remain in the same organization.During their years of service, they have been taught to be loyal to the organization they are working with, and this made the employees feel obligated to stay.This feeling is perhaps because they have to repay the organization their tuition fees, or their skills training which they have received from the organization.Employees with a high level of normative commitment feel that they ought to remain working with the same organization (Meyer and Allen, 1991).Figure 1 below is the conceptual framework for this study.H4: There is a positive and significant relationship between Normative Commitment and Turnover Intention among nurses in Malaysia.

Research Methodology
The study employs a quantitative research method with a focus on descriptive and explanatory aspects, aiming to utilize specific, measurable, and evaluative numerical data or statistics.This approach is characterized by its objectivity and lack of bias, often involving a substantial number of respondents.A survey research design, as advocated by Auster (2000), has been chosen for its suitability in providing a comprehensive overview of the subject under investigation and facilitating the generalization of findings to a larger population.To execute this research design, a carefully crafted self-administered questionnaire was utilized.This questionnaire is structured to capture relevant information on JS, AC, CC, and NC.Targeting registered nurses at all levels currently enrolled in the Open University of Malaysia, the questionnaire was distributed using Google eForms via email and various social media platforms.The overarching goal of this research is to delve into turnover intention among nurses in Malaysia, placing specific emphasis on influential factors such as job satisfaction and organizational commitment.The latter is scrutinized across its three dimensions, namely affective commitment, continuance commitment, and normative commitment.By adopting a quantitative approach, the study seeks to contribute valuable insights that can inform the development of effective nursing retention strategies.These strategies are crucial for addressing the challenges posed by high turnover rates in Malaysia and fostering a more sustainable healthcare workforce.In pursuit of rigor and reliability, the survey was extensively distributed to ensure a diverse and representative sample of respondents.The use of Google eForms facilitated efficient data collection, enabling respondents to access and complete the questionnaire through email and various social media platforms.The advantage of quantitative methods lies in their ability to generate numerical data, facilitating statistical analysis.This analytical approach supports the exploration of patterns, correlations, and trends within the data, providing a robust foundation for drawing conclusions and making informed recommendations

Instrument Development
The questionnaire set was developed based on the constructs of several studies as shown in Table 1 below

Data Analysis
In the dataset consisting of 284 responses, it is noteworthy that 50.4% of the participants are employed in the government sector, whereas 49.6% belong to the private sector.When considering their tenure in the health industry, a majority, constituting 50.4%, have accumulated more than 11 years of experience.Meanwhile, 40.5% have a work history ranging from 6 to 10 years, and the remaining 9.1% have dedicated 5 years or less to the nursing field.The demographic information also encompasses the diverse regions in Malaysia where these respondents are currently engaged in their professional roles.

Assessment of Measurement Model
A reliability assessment, employing Cronbach's Alpha (α), was conducted on each of the five variables in this study.The purpose was to ascertain the reliability of the collected data, ensuring consistency and accuracy in the results.Introduced by Nunally in 1967, Cronbach's Alpha is utilized to gauge internal consistency and reliability, with the generally accepted threshold being above 0.70.In a similar vein, Hair et al. (2017) have indicated that values falling between 0.60 and 0.70 are also considered sufficient for composite reliability.Furthermore, Hair et al. (2017) proposed a threshold of 0.80 for Composite Reliability, emphasizing the importance of the Average Variance Extracted metric in measuring convergent validity, which should exceed 0.60.This comprehensive evaluation ensures a robust foundation for the study's findings.
Table 2 reveals that Turnover Intention exhibits the highest Cronbach's α value at 0.868, encompassing three items, followed by Normative Commitment at 0.814, which includes four items.These values indicate good reliability, as the alpha coefficient range surpasses 0.8.Affective and Continuance Commitment also demonstrate adequate and reliable associations, recording values of 0.789 (four items) and 0.742 (four items), respectively.Job Satisfaction, consisting of five items, exhibits a reliable mean of 0.726.It's noteworthy that for two negatively framed questions, "I consider my job rather unpleasant" and "Each day of work seems like it will never end," reverse scoring was applied.Conversely, the other three items, "I feel fairly satisfied with my present job," "most days I am enthusiastic about my work," and "I find real enjoyment in my work," were scored normally.In conclusion, the data in the table confirms that all variables, along with their respective items, meet the reliability measurement criterion (0.70 and above), making them suitable for analysis in this study.The results presented in Table 3 highlight the correlation coefficients for Pearson's correlation analysis.AC exhibits a moderate negative correlation with TI, reflected by a coefficient of -0.495 and a highly significant p-value of less than 0.001.Similarly, NC demonstrates a moderate positive correlation with TI, as evidenced by a correlation coefficient of 0.425, also accompanied by a highly significant p-value of less than 0.001.Conversely, JS and CC exhibit weak correlations with TI, with correlation coefficients of -0.103 (JS) and -0.173 CC.The significance level for CC is noted to be less than 0.01.Consequently, these correlations are classified as weak to moderate, falling within the range of ±0.10 to ±0.50, as outlined in Table 3.To summarize, only two independent variables, AC, and CC, demonstrate a moderate positive correlation with the dependent variable, Turnover Intention.Importantly, Table 3 indicates the absence of multicollinearity among the independent variables, as all coefficient values are below 0.80.This suggests a diverse and non-repetitive construct, contributing to favorable research outcomes.The simple linear regression results presented in Tables 4 and 5 indicate a remarkably strong correlation between JS and TI, evidenced by a substantial R-value of 0.936, with a highly significant p-value of less than 0.001.This robust correlation analysis establishes a significant positive relationship between JS and TI, leading to the rejection of Hypothesis 1 (H1), as the observed very high positive JS levels are associated with a corresponding high positive level of nursing TI.Similarly, the data in Tables 4 and 5 reveal a high level of correlation between AC and TI, with significant R-values reaching 0.868 and a p-value of less than 0.001.Consequently, the correlation analysis supports the existence of a significant positive relationship between AC and TI, leading to the acceptance of Hypothesis 2 (H2).The high level of AC is associated with a correspondingly high level of nursing TI.Source: Constructed for this study Moreover, the correlation analysis in Tables 4 and 5 demonstrates a very strong correlation between CC and TI, reflected by substantial R-values of 0.906 and a highly significant p-value of less than 0.001.This supports the acceptance of Hypothesis 3 (H3), as the observed very high CC levels are related to a corresponding very high level of nursing TI.Finally, the data in Tables 4 and 5 reveal a high level of correlation between NC and TI, with a significant R-value of 0.874 and a p-value of less than 0.001.The correlation analysis supports the acceptance of Hypothesis 4 (H4), as the high level of NC is associated with a correspondingly high level of nursing Turnover Intention.

Discussion & Conclution
The examination of the data revealed a notable correlation between JS and TI among nurses in Malaysia.Contrary to conventional expectations, the findings demonstrated that high JS did not correspond to a lower intention to leave.This unexpected result prompts a deeper exploration into the dynamics influencing nurses' decisions, potentially tied to external factors like economic conditions and job market trends, as evidenced by the high turnover rates despite reported JS.AC emerged as a key factor, showcasing a significant positive correlation with turnover intention.This implies that nurses who exhibit a deep emotional attachment to their organization are still expressing an intention to leave.This departure from traditional assumptions regarding organizational commitment prompts a re-evaluation of existing theories.The influence of external offers or opportunities on this positive relationship should be explored to better understand the complex interplay between emotional connection and the intention to quit.The study uncovered a strong positive correlation between CC and TI.This suggests that nurses, despite perceiving costs associated with leaving the organization, are still inclined to consider external opportunities.Meyer and Allen's Continuance Commitment theory comes into play, indicating that attractive external offers may trigger the intention to quit.This highlights the delicate balance between the perceived costs of leaving and the allure of external opportunities.The findings regarding NC revealed a positive correlation with TI, signaling a sense of obligation to stay due to factors like tuition repayment.Aligning with Testa's and Meyer's perspectives, this loyalty and obligation, while influencing turnover intentions positively, may be subject to the duration of commitments, such as repaying tuition fees.The delicate balance between loyalty and the perceived moral obligation to remain in the organization merits further examination.
A comprehensive comparison with existing literature on job satisfaction, organizational commitment, and turnover intention sheds light on departures from traditional expectations and the confirmation of established theories.The cultural and contextual In conclusion, this study aimed to explore the relationship among job satisfaction, organizational commitment (affective, continuance, and normative commitment), and turnover intention among nurses in Malaysia.The variables of job satisfaction, affective commitment, continuance commitment, and normative commitment were considered independent variables (IVs), while turnover intention served as the dependent variable (DV).The findings revealed significant relationships between all independent variables and turnover intention.However, a noteworthy discovery was the rejection of the hypothesis related to job satisfaction, challenging the conventional belief that higher job satisfaction leads to lower turnover intention.The study sheds light on the complex dynamics influencing nurses in Malaysia, particularly in a developing country where the cost of living is increasing, and nurses perceive themselves as underpaid.Addressing this issue by revising salary scales is identified as a crucial aspect that requires special attention to mitigate the high turnover rates among nurses.Contrary to traditional expectations that job satisfaction negatively influences turnover intention, this study uncovered that, despite high job satisfaction rates, nurses in Malaysia still consider leaving their positions.Consequently, the study emphasizes the significance of organizational commitment, including affective, continuance, and normative commitment, in nursing retention strategies.The implication is that efforts and resources should be directed toward fostering a strong sense of commitment among nurses to promote retention.

Research limitations
The distribution of the survey forms was restricted to registered nurses who are studying at the Open University of Malaysia, which means only those who have internet access were included in the survey.This also leads to the limitation of the data set, because the data was collected in Malaysia as a whole, and not specified to a specific geographical location for example between Peninsular Malaysia and East Malaysia.It is also limited in generality because the respondence demographic was not specified between the married and nonmarried respondents, which might affect their turnover intention due to differences in financial commitment.In addition, the research framework was based on a study that was done 11 years ago and was done in other countries with different sets of populations.A recent framework in the context and setting of Malaysia is required for more updated and current information.

Practical implications
The findings of the study verify the positive effect of organizational commitment in the context of affective commitment, continuance commitment, and normative commitment on turnover intention among nurses in Malaysia.These findings could be useful for hospital management and human resources to consider the effect of organizational commitments and not merely consider the nurses' job satisfaction alone, and to incorporate them in their nursing retention strategies.In addition, other factors such as adjustment of salary scale, conducive work environment especially in the public sectors and reducing the non-nursing related tasks, and assigning them to the right personnel as well as developing the management soft skills among nursing managers to help them govern effectively the nursing workforce as a whole.

Contribution of this Study
This research makes substantial contributions both theoretically and contextually to the existing knowledge in the field of nursing turnover intention.The theoretical significance lies in its extension of current understanding by empirically examining the relationships between job satisfaction, affective commitment, continuance commitment, normative commitment, and turnover intention among nurses in Malaysia.By applying established theoretical frameworks such as organizational commitment models, this study provides nuanced insights into the specific factors influencing turnover intention in the nursing profession.Moreover, in the context of Malaysia's healthcare system, where the shortage of nurses has been a persistent challenge, the findings of this research offer practical implications.By identifying the key determinants of turnover intention, healthcare administrators and policymakers can develop targeted strategies for nurse retention.This research, therefore, not only enriches theoretical frameworks but also offers actionable insights that can positively impact nursing management practices in Malaysia.

Table 4
Simple Linear Regression -Overall Model Summary, Turnover Intention (TI)

Table 5
Simple Linear Regression -Overall Summary of Coefficients of the Independent variablesVariablesModel Un Malaysia may contribute to unique findings, emphasizing the need for a nuanced understanding of the local work environment.The practical implications of these findings for healthcare organizations in Malaysia are substantial.It underscores the importance of competitive salary structures, ongoing training, and effective managerial practices in retaining nursing staff.The recommendations include the development of organizational strategies that prioritize affective and continuance commitment, addressing the nuanced factors contributing to turnover intentions.While the study provides valuable insights, it is crucial to acknowledge its limitations, such as sample size or potential biases.Proposing areas for future research, particularly examining the factors influencing turnover intentions in more depth, is imperative.Expanding the study to different contexts or conducting longitudinal research could provide additional insights and contribute to the ongoing discourse on nursing retention.