Abstract
Introduction
Commitment is defined etymologically as a pledge or promise. This concept embodies a profound dedication to fulfilling tasks, adhering to promises, and responding to obligations (Stevenson, 2020). In legal contexts, commitment entails a legal or contractual undertaking wherein individuals commit to performing specific actions or refraining from certain behaviors toward others. These commitments, formed originally and following the legal statutes and regulations, may manifest in written or oral formats. In a broad sense, commitment represents a promise or obligation made by an individual to oneself or others, extending across various domains such as legal, social, professional, and familial realms (Doucette et al., 2019).
Professional commitment in nursing is characterized by a set of obligations, responsibilities, and ethical standards. This commitment is of paramount importance as nurses navigate a profession intertwined with social service, directly impacting lives and earning public trust. Contrary to the misconception that professional commitment in nursing solely involves spending hours with patients and giving physical care, it encompasses a profound sense of responsibility, empathy, compassion, and dedication in delivering care. This commitment, in conjunction with the distinctive attributes of nursing, has positioned the field at the forefront of professions that garner public trust, as evidenced by a Gallup survey (Lestari et al., 2021). As an esteemed profession, nursing demands from its practitioners not only technical proficiency and medical knowledge but also a steadfast commitment to dedicating their lives to the care and betterment of others (Herrera & De Las Heras-Rosas, 2021; Wang et al., 2021).
However, despite the prevailing professional commitment in nursing, recent years have witnessed a concerning decline. Influenced by global conditions, the impact of the COVID-19 pandemic, economic circumstances, and various cultural and social factors, the healthcare industry is struggling with a substantial reduction in professional commitment among nurses. This decline may stem from factors such as increased workload, job fatigue, emotional exhaustion, compassion fatigue, economic pressure, lack of autonomy, population aging, generational shifts, reduced social connections, industrialization, and the dominance of capitalist systems over nations (Nabi Foodani et al., 2023; Tatoy et al., 2023).
Theoretical Framework
Nurses’ professional commitment is a complex concept influenced by various individual, organizational, and systemic factors. This commitment is essential for ensuring high-quality patient care, promoting job satisfaction, and sustaining a stable workforce (Ö zkan Şat et al., 2021). The scoping review is based on key frameworks that explore the intricacies of professional commitment in nursing. Occupational stress theory is a fundamental perspective, showing how ongoing exposure to stressors like heavy workloads, understaffing, and emotional demands can result in burnout and reduced commitment. Furthermore, theories of organizational behavior offer insights into how organizational culture, leadership styles, and structural elements such as job design and role clarity impact nurses’ engagement and dedication to their profession (Bell & Sheridan, 2020).
Self-determination theory (SDT) provides a detailed understanding of how both intrinsic and extrinsic motivators can impact the professional commitment of nurses. According to SDT, meeting the basic psychological needs of autonomy, competence, and relatedness is crucial for fostering intrinsic motivation and maintaining commitment. In the nursing field, this implies that environments that respect nurses’ autonomy, offer opportunities for growth, and promote a sense of belonging and teamwork are likely to enhance commitment. On the other hand, environments that fail to address these needs may result in decreased motivation and higher turnover rates (Onyishi et al., 2019). Additionally, social exchange theory (SET) offers insights into the reciprocal relationships between nurses and their organizations. SET suggests that the perceived balance between contributions and rewards in the workplace can significantly influence levels of commitment. Nurses who feel appreciated and fairly rewarded for their work are more likely to demonstrate strong professional commitment (Khan & Iqbal, 2020).
This study aims to elucidate the nuanced dynamics of diminishing professional commitment among nurses by delving into seminal studies by Ten Hoeve et al. (2020), Hara et al. (2020), and Chang et al. (2014). In this respect, Ten Hoeve et al. (2020) revealed a direct negative correlation between the lack of colleague support, negative patient experiences, and professional commitment among novice nurses. These authors identified an indirect negative relationship between these factors and the complexity of nursing care, lack of autonomy, and work–life imbalance (Ten Hoeve et al., 2020). Hara et al. (2020) identified diminished independence and autonomy as key contributors to reduced job commitment among nurses. Also, they showed the effect of these factors on decreased professional commitment and an increased propensity to leave the profession (Hara et al., 2020). Chang et al. (2014) investigated the significance of autonomy and job attractiveness in nurses’ decline in professional commitment (Chang et al., 2014).
The repercussions of reduced professional commitment in nursing are profound and extend across all stakeholders in the healthcare system, including patients, healthcare staff, and investors. Negative effects on patients may include decreased satisfaction, strained therapeutic relationships, prolonged hospital stays, increased readmission rates, financial burdens, and compromised wellbeing. Simultaneously, the nursing profession experiences detrimental consequences such as diminished societal trust, erosion of professional status, decreased job satisfaction, loss of opportunities, and the erosion of high ethical values (Lin et al., 2023). Additional adverse effects encompass reduced interdisciplinary collaboration, financial losses in the healthcare industry, breakdown of interprofessional interactions, weakening of the scientific standing of nursing, and the emergence of sociopolitical movements against the nursing profession (Azemian et al., 2021).
Given the far-reaching impact of reduced professional commitment on the multifaceted aspects of nursing, understanding the root causes of this decline is of great importance. This study aims to identify these reasons and propose actionable solutions to mitigate the challenges posed by diminishing professional commitment in nursing.
Methods
The present study employs the scoping review methodology for an extensive exploration of evidence breadth rather than depth. This method is particularly advantageous in cases where there exists a disparity in study findings (Prihodova et al., 2015). The study protocol is constructed based on the framework originally proposed by Arksey and O'Malley (2005) for conducting scoping reviews, later refined by the Joanna Briggs Institute (Peters et al., 2015). Following this framework, the study progresses through five key stages: (1) formulating the research question; (2) identifying pertinent studies; (3) selecting studies; (4) charting data; and (5) collecting, summarizing, and reporting the findings.
Identification of Research Questions
The main research question for this study is: “What factors are causing the decrease in professional commitment among nurses, and how do these factors interact in various healthcare settings?” This question seeks to explore the complex reasons for reduced commitment, taking into account individual, organizational, and systemic factors.
The secondary research question is: “What evidence-based strategies and interventions can be implemented to effectively address these factors and improve professional commitment among nurses?” This question aims to discover practical solutions and proven methods that can be utilized in different healthcare settings to strengthen nurses’ passion and involvement in their field.
Identification of Relevant Studies
To obtain pertinent studies, two researchers independently conducted searches on Scopus, Medline (via Pubmed), Proquest, SID, Magiran, and Web of Science databases. Table 1 presents the search strategies used in the present study. The search strategy was not restricted by study design or publication date (search period: 1945 to September 7, 2023). Besides, the search scope was broadened by manually reviewing the reference lists of selected studies.
Search Strategies.
Study Selection
To select studies, two researchers independently performed the study selection process based on predefined inclusion criteria. Initially, they examined the abstracts of the reviewed articles, and if deemed appropriate, they retrieved the full text of the articles for further evaluation. Any discrepancies were resolved through discussion. In cases where a consensus could not be reached, the opinion of a third researcher was sought (Figure 1).
PRISMA flowchart for choosing the relevant studies.
Inclusion and Exclusion Criteria
The inclusion criteria were as follows: the study (a) articles written in English or Persian due to researchers proficiency in these languages, (b) was published in peer review journal to maintain the quality and credibility of the studies, (c) both quantitative and qualitative studies, and (d) focused on the topic of interest. The reason for including these sources was to ensure that the research captured all existing knowledge about factors effective in Lowering Professional Commitment in Nursing and Strategies to Address Them. Exclusion criteria incorporated: (a) content unrelated to the topic, (b) those without full access to their content, and (c) text not written in English or persian.
Methodological Quality Appraisal
All 19 identified studies were evaluated for methodological quality using the Crombie Model for critiquing qualitative or quantitative research (Glasper & Carpenter, 2021). Although critical appraisal is not mandatory in a scoping study (Colquhoun et al., 2014; Dijkers, 2015), we used a set of questions as a framework to assess the studies’ trustworthiness, value, and relevance in a specific context. This process included a critique of each study's objectives, methods, results, and conclusions. No study was excluded due to lack of trustworthiness.
Charting Data
In this stage, the data extracted from the primary studies were organized into a table, including author names, publication year, study population, study objectives, study methodology, and key findings.
Data Collection, Summarization, and Reporting
The data were analyzed using thematic analysis in two stages with the aim of (1) identifying the reasons for the decline in professional commitment among nurses and (2) finding solutions to overcome this challenge.
Results
In the present study, 1,570 articles were identified from various databases, and all were imported into the EndNote software. After removing duplicate articles (n = 398), title, and abstract screening was conducted on the remaining 1,172 studies, and the full text of 281 studies was evaluated. Ultimately, 17 articles were included in the research. Two additional studies were included in the second stage of the search, which involved reviewing the references of the selected studies. In total, 19 studies were selected, which spanned the period from 2007 to 2023. Of these articles, 16 had a cross-sectional design (Alzoubi et al., 2021; Bakirhan & Tan, 2023; Caricati et al., 2014; Chang et al., 2019, 2020; Duran et al., 2021, 2022; Goldfarb et al., 2021; Guerrero et al., 2017; Hsu et al., 2015; Kanten & Ulker, 2014; Mersin et al., 2020; Özkan Şat et al., 2021; Sadeghnezhad et al., 2020; Teng et al., 2007; Yu et al., 2021), one was a content analysis study (Jafaraghaee et al., 2014), one was a phenomenological study (Momeni & Khatooni, 2023), and one had a cohort design (Ten Hoeve et al., 2020). The characteristics of the selected articles are presented in Table 2.
Specifications of the Selected Articles.
In response to the primary research question and after examining and categorizing the data, the reasons for the decline in professional commitment in nursing were grouped into seven main themes. These seven themes include (1) professional and organizational challenges, (2) human relations, (3) personal wellbeing and coping, (4) work–life balance and success, (5) organizational culture, (6) the nature of the nursing profession and beliefs, and (7) human emotions, values, and ethics.
Professional and Organizational Challenges
The existence of various organizational and professional challenges in the nursing profession is among the factors that can lead to a decrease in professional commitment to nursing. Many studies have identified obstacles related to professional career development (e.g., difficulties in advancement, low occupational rankings, and job-related discrimination) as effective factors in reducing professional commitment (Chang et al., 2019; Jafaraghaee et al., 2014; Momeni & Khatooni, 2023; Sadeghnezhad et al., 2020; Yu et al., 2021).
Issues related to professional recognition are also among the factors that contribute to a decline in professional commitment to nursing. Some of these issues include perceived discrimination toward the nursing profession and the lack of societal respect for nursing as a profession (Chang et al., 2019; Jafaraghaee et al., 2014; Momeni & Khatooni, 2023). Previous studies have reported increased workload and job demands as another cause of reduced professional commitment (Goldfarb et al., 2021; Jafaraghaee et al., 2014; Teng et al., 2007). Rising expectations of nurses, largely driven by media pressure and conflicts arising among nurses, organizations, patients, and their families, are also among the factors lowering the professional commitment (Guerrero et al., 2017; Mersin et al., 2020).
Work-related violence (including physical, verbal, and sexual violence) and violence from colleagues are another set of factors within the realm of professional and organizational challenges that lower professional commitment in nursing (Chang et al., 2020; Duran et al., 2021; Özkan Şat et al., 2021; Ten Hoeve et al., 2020). Caricati et al. (2014) mentioned a negative work atmosphere and a punitive work environment as factors leading to the reduction of professional commitment in nursing.
Human Relations
Humans are social beings, and their relationships affect all aspects of their lives, including their professional lives. Challenges with colleagues, patients, and managers were identified as factors influencing professional commitment in nursing (Duru et al., 2022). Lack of support from the family, nursing leaders, and managerial support is also considered a significant factor in reducing professional commitment to nursing (Chang et al., 2020; Jafaraghaee et al., 2014; Yu et al., 2021).
Individual Wellbeing and Coping
Research has shown that physical and mental health problems in nurses lower their professional commitment (Duran et al., 2021; Kanten & Ulker, 2014). Ineffective coping mechanisms and a lack of resilience in nurses can also have an unfavorable impact on their professional commitment (Goldfarb et al., 2021; Teng et al., 2007).
Balance Between Personal and Work Life and Success
Conflicts between family and work, lack of family support, and the nonacceptance of nursing work by the family can lead to mental struggles for nurses, thereby lowering their professional commitment (Duran et al., 2021; Momeni & Khatooni, 2023). Difficulty in achieving career success and advancement is another influential factor in reducing professional commitment to nursing (Chang et al., 2019).
Organizational Culture
The prevailing organizational culture in which a nurse works can, directly and indirectly, affect their professional commitment. Factors such as colleagues’ solidarity and collaboration, attention to nurses’ financial issues, financial and moral support from the organization, and addressing gender equality and organizational roles can enhance nurses’ professional commitment. Neglecting these issues may significantly decline nurses’ professional commitment (Alzoubi et al., 2021; Duru et al., 2022; Jafaraghaee et al., 2014).
Nature of Nursing Profession
Some issues that negatively impact professional commitment are inherent to the nursing profession (e.g., a stressful work environment), dealing with existential events like death and patient suffering, and working in an environment where the risk of contracting various diseases exists (Bakirhan & Tan, 2023; Teng et al., 2007).
Beliefs, Values, Attitudes, and Ethics
According to the literature, having spiritual and religious beliefs, attention to spirituality and ethics, and lacking proper goals can influence nurses’ professional commitment (Momeni & Khatooni, 2023; Yu et al., 2021). Working in units contrary to one's intrinsic preferences is another factor that may lower professional commitment among nurses (Duru et al., 2022).
The secondary question of the research was about the strategies to cope with the challenge of reduced professional commitment in nursing. In this respect, we identified four main themes: (1) empowering nurses, (2) nursing leadership and support, (3) safety concerns and interactions with patients, and (4) welfare facilities.
Empowering Nurses
Various aspects of this empowerment have been addressed while discussing the issue of empowering nurses. Some of these include educational empowerment, which can involve providing advanced nursing courses and international courses for nurses. Besides, paying attention to continuous and in-service training for nurses was another factor that could mitigate a reduction in professional commitment to nursing (Chang et al., 2019; Goldfarb et al., 2021).
Other aspects in this area included focusing on involving nurses in decision making related to their profession, creating a sense of value and respect for nurses, and implementing advanced nursing care plans. Providing financial and moral rewards, facilitating career advancement, ensuring the safety of the work environment, offering relaxation time, and addressing issues such as work hours reduction and compensating nursing staff shortages were also among the strategies suggested to prevent professional commitment reduction among nurses (Jafaraghaee et al., 2014; Momeni & Khatooni, 2023; Sadeghnezhad et al., 2020).
Nursing Leadership and Support
Another factor that could prevent a decrease in professional commitment was strong support from nursing leaders and managers. This support could be psychological, moral, and legal. Nursing managers could enhance the autonomy and independence of nurses, develop professional development policies, share experiences with new nurses, and provide financial and moral resources. These actions by nursing leaders and managers could contribute to preventing a decrease in professional commitment among nurses (Chang et al., 2019; Duran et al., 2021; Jafaraghaee et al., 2014; Momeni & Khatooni, 2023).
Safety Concerns and Interactions With Patients
Addressing safety concerns by providing a safe environment, developing policies to prevent violence against nurses, transferring the burden of care efforts to the families of patients, and acknowledging the efforts of nurses were identified as strategies to prevent professional commitment reduction in nurses. Positive feedback from the families of patients to nurses was also mentioned as a factor that could contribute to maintaining professional commitment (Chang et al., 2019; Duran et al., 2021; Özkan Şat et al., 2021).
Welfare Facilities
Providing welfare facilities for nurses and their families such as offering recreational trips, arranging loans and financial incentives, creating environments for the care of nurses’ families (including children, disabled individuals, or the elderly), and providing comfortable and equipped pavilions for nurses to rest were mentioned as measures to mitigate professional commitment reduction among nurses (Alzoubi et al., 2021; Duran et al., 2021; Momeni & Khatooni, 2023).
Discussion
Based on the results of the present study, the reasons for professional commitment reduction in nursing include professional and organizational challenges, human relationships, individual wellbeing and coping, work–life balance and success, organizational culture, the nature of the nursing profession, and beliefs, emotions, values, and human ethics. The strategies to cope with this decrease in professional commitment include empowering nurses, nursing leadership and support, safety concerns and interactions with patients, and welfare facilities.
Miedaner et al. (2018) recognized organizational characteristics as a significant factor in demonstrating professional commitment among employees. Moreover, leadership support in nursing was reported as another major factor in demonstrating professional commitment. These authors also highlighted autonomy as an effective factor in professional commitment. Overall, these findings are consistent with those of the present study.
El-aal and Hassan (2014) examined and confirmed the positive relationship between the ability to establish human relationships and professional commitment among supervisors and nurses. Furthermore, two studies explored the impact of personal wellbeing and coping abilities on the professional commitment level in nursing, suggesting the significant role of coping abilities (Bell & Sheridan, 2020). Another factor affecting professional commitment in nursing is the dominant organizational culture, as confirmed by Kim et al. (2017). These results collectively support the findings of the present study.
The nature of the nursing profession, considered a challenging profession, was identified as a factor influencing nurses’ professional commitment. While some studies represent nursing as a human-friendly and gentle profession, the challenges such as job-related injuries, long working hours, high workload, and existential events can affect their professional commitment (Teng et al., 2007). In this regard, studying the impact of nurses’ beliefs and values on their professional commitment reveals that individual beliefs, attitudes, and values affect their level of professional commitment (Hendel & Kagan, 2014; Noor et al., 2021).
The implementation of nurse empowerment programs is one key solution highlighted in various studies to overcome the challenges of reduced professional commitment in nursing (Fragkos et al., 2020; Yang et al., 2013). The support of nursing leaders for nurses can also contribute to enhancing professional commitment, a finding supported by the present study (Lorber & Skela-Savič, 2014).
Another insight from the current scoping review was the influence of interactions with patients and safety considerations on the level of professional commitment among nurses. Establishing proper professional relationships with patients was identified as a factor that could promote professional commitment among nurses (Parnikh et al., 2022). Furthermore, providing personal safety facilities for nurses and reducing their concerns about contracting diseases were recognized as factors that could enhance professional commitment (Ates & Erdogan, 2022).
Limitations
Among the primary limitations of this study is the lack of access to the full text of all articles and databases worldwide. Future studies, building on the findings of the present scoping review, are recommended to conduct more systematic review studies. Moreover, based on the results of the current study, further research can be conducted to design and develop interventions aimed at improving professional commitment.
Conclusion
The present study revealed numerous challenges and reasons for professional commitment reduction in nursing. These challenges may degrade the quality of patient care and jeopardize patient safety. The study also highlighted certain strategies to overcome the challenge of reduced professional commitment in nursing. Decision-makers in nursing, nursing leaders, and policymakers in the healthcare sector can consider these actions in their decision-making processes to promote the development and excellence of nursing.
Footnotes
Acknowledgments
Authors’ Contributions
Declaration of Conflicting Interests
Funding
ORCID iDs
