Journal of Nursing Research Vol. 15, No.

4, 2007

Effects of Internal Marketing on Nurse Job Satisfaction and Organizational Commitment: Example of Medical Centers in Southern Taiwan
Ching-Sheng Chang Hsin-Hsin Chang*
ABSTRACT: As nurses typically represent the largest percentage of employees at medical centers, their role in

medical care is exceptionally important and becoming more so over time. The quality and functions of nurses impact greatly on medical care quality. The concept of internal marketing, with origins in the field of market research, argues that enterprises should value and respect their employees by treating them as internal customers. Such a marketing concept challenges traditional marketing methods, which focus on serving external customers only. The main objective of internal marketing is to help internal customers (employees) gain greater job satisfaction, which should promote job performance and facilitate the organization accomplishing its ultimate business objectives. A question in the medical service industry is whether internal marketing can similarly increase the job satisfaction of nurses and enhance their commitment to the organization. This study aimed to explore the relational model of nurse perceptions related to internal marketing, job satisfaction, and organizational commitment by choosing nurses from two medical centers in Southern Taiwan as research subjects. Of 450 questionnaire distributed, 300 valid questionnaires were returned, giving a response rate of 66.7%. After conducting statistical analysis and estimation using structural equation modeling, findings included: (1) job satisfaction has positive effects on organizational commitment; (2) nurse perceptions of internal marketing have positive effects on job satisfaction; and (3) nurse perceptions of internal marketing have positive effects on organizational commitment. Key Words: internal marketing, job satisfaction, organizational commitment, structural equation modeling (SEM).

Introduction
The concept of internal marketing originated in the field of marketing research in the service industry (Berry, 1981; Gronroos, 1981), emphasizing that enterprises should value and respect their employees and regard them as internal customers (Longbottom, Osseo-Asare, Chourides, & Murphy, 2006). Viewing employees as an organizations internal customers, Berry (1981) treated employees with marketing-like methods, which allowed the employees to obtain satisfactory products, or jobs. Berry and Parasuraman (1991) pointed out that internal marketing

refers to the development of products that meet employees needs in order to attract, develop, inspire, and retain qualified employees. Internal marketing is the management philosophy of treating employees as customers, as well as a development strategy of offering the products (or jobs) that meet employees demands in order to win employee loyalty and organizational commitment (Longbottom et al., 2006). Employee job satisfaction represents the subjective attitudes and evaluations of employees toward their overall work environment and reflects the success of an enterprise in providing a workplace environment that fully meets employees demands for skill utilization, social value, and

MBA, Instructor, Department of International Trade & Business Administration, Wenzao Ursuline College of Languages & Doctoral Student, Graduate School of Business Management, National Cheng Kung University; *PhD, Associate Professor, Department of Business Administration, National Cheng Kung University. Received: May 9, 2007 Revised: August 6, 2007 Accepted: September 13, 2007 Address correspondence to: Ching-Sheng Chang, 19F, No. 25, Fu-Kuo Rd., Kaohsiung 81357, Taiwan, ROC. Tel: 886(7)558-4262; E-mail: arthur0660@yahoo.com.tw

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achievement, and serves as the judgment indicator for fairness and appropriateness of an organizations regulations (Shimizu, Eto, et al., 2005). Therefore, internal marketing has a powerful influence on employees sense of belonging, isolation, and work motivation (Kudo et al., 2006). The concept that organizational commitment is regarded as the identification with an organization was first proposed by Whyte in 1956, followed by cause-effect models of organizational commitment with organizational commitment as the intervening variable, as successively suggested by Mowday, Porter, and Steers (1982) and Trimble (2006). Through the research of these scholars, it was found that employees with strong organizational commitment show three types of tendencies toward an organization, including a strong belief in and acceptance of organizational objectives and values; willingness to dedicate more effort to the organization; and the desire to remain a part of the organization. Employee job satisfaction gives a precise prediction of organizational commitment (Lambert, Pasupuleti, Cluse-Tolar, Jennings, & Baker, 2006). Nurses working at hospitals not only implement independent and professional nursing activities in accordance with doctors advice, but also take responsibility for any immediate threat to patient lives. Thus, the importance of nurse is undeniable, and the influence of nurse qualities and capabilities on medical care quality cannot be ignored (Bernstein, 2005). From a management viewpoint, hospitals can be seen as enterprises engaged in activities involving the entire medical system where everything, from the simplest tasks to systemic planning and management, relies on human input and control. Therefore, a primary concern of medical care is to effectively utilize internal marketing to enhance and develop the job satisfaction and organizational commitment of nurses in order to promote competitive advantage (Bernstein, 2005; Longbottom et al., 2006). In summary of the aforementioned research background and motives, this study aims to discuss the correlation between nurse job satisfaction and organizational commitment from the perspective of internal marketing. The discussion in this research can be generalized into three parts, as follows: 1. Discussion of the correlation between nurse job satisfaction and organizational commitment. 2. Discussion of the correlation between nurse perceptions of internal marketing and job satisfaction. 3. Discussion of the correlation between nurse perceptions of internal marketing and organizational commitment.

Because this study aims to discuss correlations among nurses internal marketing, job satisfaction, and organizational commitment, the following research objectiverelated hypotheses are proposed: (1) Hypothesis 1: Nurse job satisfaction has a positive influence on organizational commitment. (2) Hypothesis 2: Nurse perceptions of internal marketing have a positive influence on job satisfaction. (3) Hypothesis 3: Nurse perceptions of internal marketing have a positive influence on organizational commitment.

Literature Review
1. Internal marketing
Gronroos (1981), the scholar who first introduced the term internal marketing, defined the term as the behavior of selling a corporation to its internal customers (employees) under the principle that highly satisfied employees will help create a market-oriented and customer-centered corporation and, consequently, encourage employees with customer-oriented awareness (Bernstein, 2005; Longbottom et al., 2006). Greene, Walls, and Schrest (1994) assumed that internal marketing refers to the application of marketing philosophy and methods to employees who serve customers in order to utilize and maintain employees and ensure they strive to finish work. Hence, the concept of internal marketing sees employees as internal customers and their work as internal products, and, therefore, dedicates efforts to the design of products that better satisfy employee needs (Longbottom et al., 2006). Zeithaml and Bitner (2000) indicated that in the service triangle, the objective of external marketing is to establish commitment, interactive marketing to fulfill commitment, and internal marketing to improve the ability to fulfill commitment. In other words, the three types of marketing in the service triangle are critical to successful service and higher corporate profits. Internal marketing is a communication process, and the purpose is to create the customer-oriented organizational culture (Bernstein, 2005). Employees are regarded as corporate partners who cooperate with corporations to provide products and services for external customers. Conduit and Mavondo (2001) divided internal marketing activities into five constructs based on the seven categories proposed by Gronroos (2000), with the five constructs related to one another as revealed in the results of a sample survey (Suzuki et al.,

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2006). These five constructs are: (1) market training and education; (2) management support; (3) internal communication; (4) personnel management; and (5) employee involvement in external communication. The constructs suggested by Conduit and Mavondo (2001) were adopted by this study.

3. Organizational commitment
The concept of organizational commitment has become an important research topic in the field of organizational behaviors ever since it was first proposed by Whyte (1956). Porter, Steers, Mowday, and Boulian (1974) suggested that organizational commitment is the degree of an individuals identification with, and devotion to, a specific organization, and includes: (1) value commitment: strong belief in, and acceptance of, organizational objectives and values; (2) effort commitment: willingness to dedicate greater effort to benefit the organization; (3) retention commitment: willingness to remain as a member of an organization (Lambert et al., 2006; Moss, McFarland, Ngu, & Kijowska, 2007). Buchanan (1974) believed that organizational commitment means an individual is attached emotionally to an organization, including identification with, and acceptance of, organizational objectives and values; mental devotion to, and concentration on, a job role; and loyalty to, and affection for, the organization (Dee, Henkin, & Singleton, 2006). Therefore, the concept of organizational commitment embraces the following employee factors: (1) desire to strive to the fullest in order to represent an organization; (2) desire to remain with an organization; (3) feelings of belonging and loyalty to an organization; (4) acceptance of major organizational goals and values; (5) positive evaluation of an organization. Organizational commitment refers to a sense of emotional identification with organizational objectives and values, relevant professional roles, and an organization and group, with the characteristics of identification, devotion, and loyalty. According to Meyer, Allen, and Smith (1993), organizational commitment should contain the following three constructs: (1) affective commitment: members of an organization are emotionally attached to, identify themselves with, and feel devoted to, an organization; (2) continuance commitment: the existence of commitment is based on the consideration of costs occurring when members leave an organization; (3) normative commitment: employees are firmly convinced that loyalty to an organization is an essential and absolutely obligatory value (Erdheim, Wang, & Zickar, 2006). After a comprehensive survey of scholarly research from the viewpoint of organizational commitment, the perspective of Porter et al. (1974) and Trimble (2006) that organizational commitment can be evaluated as the degree of individual identification with, and devotion to, a specific organization, including strong belief in, and acceptance of, organizational objectives and values, willing-

2. Job satisfaction
Robbins (1996) assumed that job satisfaction stands for the general attitudes that a worker has toward his or her job, with a high level of job satisfaction indicating a positive attitude. Job satisfaction refers to a joyful or positive emotional state regarding work or the work experience (Shimizu, Eto, et al., 2005; Suzuki et al., 2006). Porter and Lawlers (1968) definition of job satisfaction includes both internal and external satisfaction. Internal satisfaction refers to the causes that create job satisfaction, and are closely related to the job itself. In other words, it is the level of satisfaction achieved through the job itself, through facets such as sense of achievement, growth, self-esteem, independence, and sense of control (Shimizu, Feng, & Nagata, 2005; Shimizu, Eto, et al., 2005). External satisfaction, on the other hand, is indirectly related to the job itself, and includes such facets as good working environment, welfare, high salary, promotion, etc. By combining the factors that affect job satisfaction proposed by domestic and foreign scholars, we can conclude the following: Job satisfaction refers to a workers feelings of, or emotional response to, his or her job and relevant elements (Takeda, Ibaraki, Yokoyama, Miyake, & Ohida, 2005). Degree of satisfaction depends on the difference between actual gains and expected gains, and can be divided into two constructs: internal satisfaction and external satisfaction. Internal satisfaction refers to the degree of an individuals feelings toward, and satisfaction with, current job activities, independence, creativity, variation, and opportunities to utilize skills, job duty importance, job achievements and responsibilities, job stability and security, contribution to society and social status of the job, as well as work ethic and values. External satisfaction refers to the degree of an individuals satisfaction with all aspects of the current job not related to job content. Such includes possibility of promotion, rewards and praise earned, organizational policies and executive approaches, technical guidance, and interpersonal relationships (Castle, Engberg, & Anderson, 2007; Shimizu, Feng, et al., 2005).

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ness to dedicate more efforts for organizational benefits, and willingness to remain a member of an organization, was adopted in this study. The three constructs of value commitment, effort commitment, and retention commitment were chosen as research variables.

4. Relationships among internal marketing, job satisfaction, and organizational commitment

The most widely accepted viewpoint is that job satisfaction influences employees commitment to an organization (Mowday et al., 1982; Trimble, 2006). As pointed out by scholars who side with this perspective, the concept of job satisfaction tends to be created from a micro viewpoint, while organizational commitment is created from a macro viewpoint (Lambert et al., 2006). As such, job satisfaction is just a determinant of organizational commitment. In their studies on the correlation between internal marketing perceptions and job satisfaction, Berry and Parasuraman (1991) pointed out that enterprises must promote services to internal employees first and allow them to find pleasure in work before employees will be capable of providing effective service to external customers of the enterprise. Internal marketing refers to the application of marketing concepts to an organizations internal management (Longbottom et al., 2006). Thus, the theoretical rela-

tionship and development of internal marketing and organizational commitment have been generally elaborated by marketing scholars. Kohli and Jaworski (1990) pointed out that the employees of an organization with the concept of internal marketing as its enterprise philosophy have generally higher job satisfaction and organizational commitment (Trimble, 2006). Combining all of the above, we can conclude the following: (1) job satisfaction has positive effects on organizational commitment; (2) nurse perceptions of internal marketing have positive effects on job satisfaction; and (3) nurse perceptions of internal marketing have positive effects on organizational commitment. Therefore, based on the literature review conducted for this study. The overall research framework is shown in Figure 1.

Methods
A research framework and research hypotheses were established at the outset of this study based on research motives, objectives, and literature review. Afterward, a questionnaire was designed and sample survey taken. The development of each construct and methods used for data analysis will be explained. The limitations on this study are stated at the end of this paper.

Internal Marketing
1. Management support 2. Human resources management 3. External communication 4. Internal communication 5. Education training

Job Satisfaction
1. Internal satisfaction 2. External satisfaction

H2 H1

H3

Organizational Commitment
1. Value commitment 2. Effort commitment 3. Retention commitment

Figure 1. Conceptual framework of the relationship among internal marketing, job satisfaction, and organizational commitment. Notes. H1 shows the nurse job satisfaction has a positive influence on organizational commitment. H2 shows nurse perceptions of internal marketing have a positive influence on job satisfaction. H3 shows nurse perceptions of internal marketing have a positive influence on organizational commitment.

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Data Collection and Sampling

The questionnaire used in this study was drafted after reviewing a wide range of relevant literature and then amended through multiple discussion sessions with three professors and two physicians and experts in order to ensure questionnaire content validity of the. Afterward, a pre-test was conducted on nurses to remove invalid items and ensure questionnaire content completeness and significance so that it would measure effectively correlations among nurse perceptions of internal marketing, job satisfaction and organizational commitment. With the nurse of two medical centers in southern Taiwan as study subjects, a total of 450 questionnaire were distributed. Of the 318 copies returned, 18 were excluded due to incomplete answers, which gave a total 300 effective copies were retrieved and a valid response rate of 66.7%.

Data Analysis Methods

After questionnaires were collected, they were inspected and processed in order to exclude copies with incomplete answers. Valid copies were then assigned numbers and filed. Analysis software, including SPSS 11.0 and LISREL 8.50 (Linear Structural Relationship), was applied in data analysis and processing, with tests including reliability analysis, descriptive statistics analysis, and structural equation modeling (SEM).

Structural Equation Modeling (SEM)

The Linear Structural Relationship Model was employed to examine relationships among internal marketing, job satisfaction, and organizational commitment. To test the research hypotheses, this study primarily used LISREL 8.50 to do the structural equation modeling (SEM) in order to assess relationships across various dimensions. According to Joreskog and Sorbom (1989), structural equation modeling allows not only the determination of relationship extent between variables, but also the examination of chain of cause and effect. This means that results do not merely show empirical relationships between variables when defining the practical situation. For this reason, this study chose structural equation modeling to test hypotheses. This study also used several indices, such as the ratio of Chi-square, goodness of fit index (GFI), adjusted goodness of fix index (AGFI), normal fix index (NFI), and root mean square residual (RMSR) to evaluate overall model fitness.

Instrument
This questionnaire was constructed as a self-designed, structured questionnaire after consulting numerous related articles and repeated discussion with experts. It encompassed three dimensions, including internal marketing, job satisfaction and organizational commitment. General factor analysis was concurrently adopted to verify factor names and reliability analysis (See Table 1). A 7-point Likert scale was adopted for scales. As shown in Table 1, Cronbachs a values for all dimensions measured higher than .6, indicating adequate questionnaire reliability (Chang, Weng, Chang, & Hsu, 2006; Onwuegbuzie & Leech, 2005).

Table 1. Names and Reliability Analyses of the Factors of Each Construct Construct/Factor Name Internal Marketing Management support Human resources management External communication Internal communication Education training Job Satisfaction Internal satisfaction External satisfaction Organizational Commitment Value commitment Effort commitment Retention commitment Factor loading .832 .912 .856 .808 .872 .891 .886 .891 .861 .816 .883 .848 .887 .910 Cronbachs a .906 KMO .915

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Results
Demographic Characteristics
All of the nurse in this study were female. Roughly half were aged 30 years or less (49%) and most were not married (57.7%). In terms of educational level, most held college degrees or less (60.7%). In terms of seniority, most had worked for their employer between 3~6 years (30%). Most worked in a ward (51%) (see Table 2).

Table 2. Descriptive Statistics of Sample (N = 300) Variable Gender Female Age 30 or under 31-40 41-50 Marital Status Married Not married Education College or under Bachelor Master or above Seniority Less than 3 years 3-6 years 6-10 years 10 years or above Department Ward Intensive care unit Others Job Title Nurse Head nurse n 300 147 113 040 127 173 182 101 017 053 090 079 078 153 076 071 279 021 % 100 49.0 37.7 13.3 42.3 57.7 60.7 33.7 05.6 17.7 30.0 26.3 26.0 51.0 25.3 23.7 93.0 07.0

Relationships Among Internal Marketing, Job Satisfaction, and Organizational Commitment

The Linear Structural Relationship Model was applied to examine relationships among nurse perceptions of internal marketing, job satisfaction, and organizational commitment, with results described below. (1) Relationship between job satisfaction and organizational commitment As shown in Figure 2, parameter estimates of the correlation between job satisfaction and organizational commitment reveal a path coefficient from job satisfaction to organizational commitment of .56 (t = 17.62), which reaches significance (p < .05), reflects a positive relationship and indicates that job satisfaction has an evidently

Value Commitment e1 .74 Internal Satisfaction l1 l2 e2 .63 External Satisfaction .61 .52 .51 h1 Job Satisfaction g11 .56 b21 g21 h2 Organizational Commitment l3 .47 Effort Commitment

e3 .78

.69 l4 l5 .49 Retention Commitment e5 .76 e4 .52

.46

Internal Marketing l6 l7 .72 l8 Management Support d1 .69

x1 l10 .46

.55

.58

l9

.62

External Internal x1 Human Resources x2 x3 x4 Communication Communication Management d2 .48 d3 .66 d4 .79

Education Training d5 .62

x5

Figure 2. Structural equation modeling with internal marketing as the moderator variable between job satisfaction and organizational commitment. Note. all parameters reach the significance level of p < .05.

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positive influence on organizational commitment. Hypothesis 1 is, therefore, accepted. (2) Relationships among perceptions of internal marketing and job satisfaction As illustrated in Figure 2, parameter estimates of the path coefficient among internal marketing and job satisfaction reveal a path coefficient from internal marketing to job satisfaction of .52 (t = 12.75), which reaches significance (p < .05), reflects a positive relationship, indicating that internal marketing has an evidently positive influence on job satisfaction. Hypothesis 2 is, therefore, accepted. (3) Relationships among perceptions of internal marketing and organizational commitment As illustrated in Figure 2, parameter estimates of the path coefficient among internal marketing and organizational commitment reveal a path coefficient from internal marketing to organizational commitment of .46 (t = 8.63), which reaches significance (p < .05). This reflects a positive relationship, supporting the premise that internal marketing has an evidently positive influence on organizational commitment. Hypothesis 3 is, therefore, accepted. (4) Table 3 shows the model fit goodness of the LISREL model, in which the ratio of Chi-square 2.12 is smaller than the recommended ratio of 3; the GFI exceeds the recommended value of .9; the AGFI exceeds the recommended value of .8; the NFI exceeds the recommended value of .9; and the RMSR is lower than the recommended value of .08 (Bagozzi & Yi, 1988; Joreskog & Sorbom, 1989).
Table 3. The Model Fit Goodness of the LISREL Model Fitness Statistics Standard Value Conceptual Model c2/df. <3 2.12 GFI > .9 .92 AGFI > .8 .91 NFI > .9 .92 RMSR < .08 .036

Note. GFI = Goodness of Fit Index; AGFI = Adjusted GFI; NFI = Normal Fix Index; RMSR = Root Mean Square Residual.

Discussion
The two major results of this study are (1) job satisfaction has positive effects on organizational commitment; (2) nurse perceptions of internal marketing have positive effects on job satisfaction; and (3) nurse perceptions

of internal marketing have positive effects on organizational commitment. The three results are discussed below. Job satisfaction has an obviously positive influence on organizational commitment. When nurse job satisfaction increases, organizational commitment is enhanced correspondingly. In other words, a higher level of job satisfaction indicates that a nurse is more likely to recognize organizational values and goals, remain with the organization, and dedicate more effort toward accomplishing organizational objectives in order to assist the organization develop and succeed. This corresponds with the assertions of relevant studies in the past. For example, Trimble (2006) believed that a high level job satisfaction represents employees strong identification with, and loyalty to, an organization, willingness to accept hardships and overcome predicaments as a team, higher interest in job responsibilities. Our findings support the statement that internal marketing has a clearly positive influence on job satisfaction and organizational commitment and that differences in nurse perceptions with regard to internal marketing positively influence their job satisfaction. This agrees with assertions made in previous studies, such as that by Heskett, Thomas, Lovemen, Sasser, and Schlesinger (1990) proposing a causal model of service profit chain internal service quality that drives employee satisfaction and that of Longbottom et al. (2006), which pointed out that internal marketing aims to provide services to internal employees, promote employee job satisfaction and facilitate organizational growth and development. Study findings also support that internal marketing has a clearly positive influence on organizational commitment. Differences in nurse perceptions of internal marketing positively influence organizational commitment. This also agrees with assertions made in previous relevant studies. For instance, Trimble (2006) indicated that employees have a higher level of job satisfaction and organizational commitment when organizations adopt marketing concepts as their enterprise philosophy both internally and externally. Gronroos (2000) suggested that organization utilization of the concept of internal marketing contributes to enhanced employee organizational commitment. Deserving of special attention is that, as internal marketing has a positive influence on job satisfaction and organizational commitment, differences in nurse perceptions of internal marketing affect their organizational commitment in two ways: (A) Internal marketing directly affects organizational commitment, which represents a direct effect;

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(B) Job satisfaction is used as an intervening variable to affect organizational commitment, which represents an indirect effect. According to the above findings, we learn that nurse perceptions of internal marketing also positively influence organizational commitment, with the requirement of job satisfaction as the intervening variable. This finding varies from the previous assumption that job satisfaction alone can positively influence organizational commitment. In conclusion, hospital operations rely on the active participation and assistance of nurses. As significant time and costs are involved in training and cultivating nursing talent, a way to retain outstanding nurses and reduce turnover costs and problems is for employers to pay greater attention to the needs and expectations of their nursing staff. Therefore, with regard to human resource management and utilization, increasing nurse job satisfaction represents a practical and sound strategy targeting enhanced organizational commitment. Therefore, according to the findings of this study, we can infer that high satisfaction with job-related activities, independence and creativity; opportunities to utilize skills; achievements; responsibility; job stability; service to society; social status; possibility of promotion, rewards and praise; and organizational policies and executive measures will influence nurses commitment to an organization. This can be reflected in behavior such as a strong sense of belonging to an organization, willingness to dedicate efforts toward organization success, identification with current job, and a desire to remain in his or her position. Finally, three research limitations identified for this paper include: (1) This study only discussed relationships among nurse perceptions of internal marketing, job satisfaction, and organizational commitment. The factors affecting organizational commitment are quite complicated, and include other variables such as job characteristics, work environment, work experience, management style, and so on, which were not included in the scope of discussion in this study. (2) The scope of this study was limited to two medical centers in southern Taiwan. Thus, the applicability of study findings to the entire nurse population may be limited. (3) Because of time restrictions, this study was conducted at a single time point and, thus, was not able to assess relevant long-term factors of influence. Suggestions for future researchers are to adopt a time crossing

methodology for research design rather than a single time point. This will provide data at several time periods and allow the observation of long-term factors that exert mutual influence over all variables that will allow for more objective results.

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450 300 66.7%(1) (2)(3)

* 96 5 9 96 8 6 96 9 13 81357 25 19

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