Work Engagement: The Key Driver in Transforming Organizational Commitment into Enhanced Work Performance among Midwives - A Structural Equation Modelling Approach

Work Engagement: The Key Driver in Transforming Organizational Commitment into Enhanced Work Performance among Midwives - A Structural Equation Modelling Approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Work Engagement: The Key Driver in Transforming Organizational Commitment into Enhanced Work Performance among Midwives - A Structural Equation Modelling Approach Iddrisu Sisala Mohammed, Abubakari Wuni, Brenda Abena Nyarko, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6037580/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Health Services Research → Version 1 posted 13 You are reading this latest preprint version Abstract Background Midwives are at the heart of maternal and child health. However, their performance is significantly influenced by their organizational commitment and work engagement. Aim This study investigated the mediating effect of work engagement in the relationship between organizational commitment and work performance among midwives. Method Using an analytical cross-sectional design, data were collected from 254 midwives using validated scales measuring organizational commitment, work engagement, and work performance. Data analysis was conducted using SPSS Statistics and AMOS. Results Most participants were female (96.9%) and aged 30–39 years (54.3%). Organizational commitment was positively correlated with work engagement ( r = 0.125, p < 0.05) and work performance ( r = 0.166, p < 0.05). Work engagement also showed a strong positive correlation with work performance ( r = 0.662, p < 0.05). Mediation analysis confirmed that work engagement fully mediates the relationship between organizational commitment and work performance (β = 0.078, SE = 0.061, p < 0.001). Conclusion The results of the study highlight the vital role of work engagement as a positive and significant mediator between organizational commitment and work performance among midwives. Investing in strategies that boost midwives’ commitment and engagement is essential for strengthening maternal healthcare quality and workforce sustainability. Organizational commitment work engagement work performance midwives Figures Figure 1 Figure 2 Introduction Healthcare systems around the world depend significantly on the competence, motivation, and performance of frontline healthcare professionals [ 1 ]. However, prolonged exposure to stress among these professionals has been shown to negatively impact their health, work performance, and the overall quality of patient care [ 2 ]. Midwives, in particular, often operate under challenging conditions characterized by limited resources, high patient loads, inadequate opportunities for professional development, and insufficient institutional support [ 3 ]. These stressors not only impair their ability to perform effectively but also compromise the quality of care delivered to mothers and newborns [ 4 ]. Midwifery is inherently an emotional and demanding profession. Supporting women and their families amidst complex social circumstances often exposes midwives to feelings of anxiety, pain, fear, and sadness [ 5 ]. These emotional burdens can make it increasingly difficult for midwives to function effectively in already challenging work environment [ 5 , 6 ]. Consequently, low morale and work-related stress have become prominent concerns within the profession [ 7 ]. Despite these challenges, many midwives continue to demonstrate resilience by remaining committed to their roles and delivering essential care to women and newborns a phenomenon referred to as work engagement [ 7 ]. Work engagement is a crucial concept in understanding midwives’ behavior and performance [ 8 ]. It is defined as a positive, fulfilling work-related state of mind characterized by vigor, dedication, and absorption [ 9 ]. A substantial body of research has shown that high levels of work engagement are associated with improved work performance [ 10 , 11 ]. Studies across Europe, Asia, and North America have consistently linked work engagement to better work performance [ 10 , 12 , 13 , 14 ]. Workers with high engagement levels tend to be more productive, motivated, and committed to their organizations [ 14 ]. Various organizational and personal factors influence work engagement, including leadership style, organizational culture, job resources, worker recognition, manageable workloads, and opportunities for both personal and professional growth [ 15 ]. Among these, organizational commitment defined as an worker’s psychological attachment to their organization has received significant attention in the literature. Numerous studies have explored how organizational commitment impacts work performance, particularly among nurses and physicians, in both developed and developing countries, including Ghana [ 16 , 17 , 18 ]. However, there is a paucity of studies that have investigated this relationship among midwives. This is especially important considering that midwives continue to face challenging conditions that not only affect their performance but also influence the quality of care provided to mothers and newborns [ 19 ]. The implications of midwives’ performance extend beyond the workplace and into the broader realm of public health. In Ghana, maternal and neonatal mortality rates remain alarmingly high, 310 deaths per 100,000 live births and 25 deaths per 1,000 births, respectively, despite increased access to skilled birth attendance in recent years [ 20 ]. These statistics underscore the urgency of strengthening midwifery services and addressing the human factors that impact care delivery. Understanding the mediating role of work engagement in the relationship between organizational commitment and work performance among midwives is crucial, as it can inform targeted interventions to enhance both their commitment and engagement. Enhancing midwives’ performance is essential not only for achieving Sustainable Development Goal 3 (Good Health and Well-being) but also for protecting the health and rights of mothers and newborns throughout the country. Therefore, this study was conducted to investigate the mediating effect of work engagement in the relationship between organizational commitment and work performance among midwives. Literature Review Organizational commitment and work engagement Organizational commitment and work engagement have garnered substantial scholarly attention due to their significant impact on individual and organizational outcomes [ 21 ]. The Social Exchange Theory (SET) proposed by Blau in 1964 underpins their relationship, positing that workers reciprocate favorable organizational treatment through positive attitudes and behaviors (work engagement) [ 22 ]. Howard Becker’s Side-Bet Theory in 1960 conceptualized commitment as a calculative decision where workers remain due to accumulated investments (e.g., seniority, pension plans, social relationships, or career prospects) that would be lost upon departure [ 23 , 24 ]. Meyer and Allen’s Three-Component Model in 1997 expanded this view, defining commitment as the psychological attachment of an worker to their organization [ 25 ], and comprises affective (Emotional attachment to, identification with, and involvement in the organization. Workers stay because they want to), continuance (Awareness of the costs associated with leaving the organization. Workers stay because they need to), and normative (A feeling of obligation to remain with the organization. Workers stay because they ought to) [ 26 , 27 ]. Work engagement’s theoretical foundations stem from Kahn’s model in 1990, which identifies three psychological conditions (meaningfulness, safety, and resource availability) necessary for workers to invest physical, cognitive, and emotional energy into their roles [ 28 ]. Schaufeli et al [ 29 ] later distinguished engagement as a distinct motivational state characterized by vigor (High energy and mental resilience), dedication (Strong involvement, pride, and significance in work), and absorption (Full concentration and immersion in tasks) [ 30 ]. The Conservation of Resources (COR) theory and Job Demands-Resources (JD-R) model further elucidate this relationship [ 31 , 32 ]. The Conservation of Resources (COR) theory argues that individuals strive to obtain, retain, and protect resources [ 33 ]. In this context, organizational commitment represents a key psychological resource that workers draw upon to sustain high engagement levels [ 11 ]. Saks [ 34 ] argued that commitment operates as a psychological condition necessary for work engagement, indicating that workers need to feel a sense of belonging and purpose within the organization to be fully engaged [ 29 , 35 ]. Thus, when workers are affectively committed, they perceive alignment between their values and organizational goals, which fosters intrinsic motivation and energy, thereby enhancing their work engagement [ 11 , 36 ]. Empirical studies consistently affirm this link. For instance, Khalid and Khalid [ 37 ], Cesário and Chambel [ 38 ], Arcadio et al [ 39 ], and Tang et al [ 40 ] showed that there is a significant relationship between organizational commitment and work engagement, highlighting that committed workers exhibit higher work engagement. In healthcare settings, committed midwives often report higher levels of job satisfaction, resilience, and patient-centered care, all of which are hallmarks of work engagement [ 41 ]. Based on this theoretical and empirical foundation, we hypothesize that: Hypothesis 1 Midwives’ organizational commitment would affect their work engagement. Work engagement and work performance The concept of work performance has its roots in Frederick Taylor’s Scientific Management Theory in 1911, which emphasized efficiency and productivity as core components of work performance [ 42 ]. Modern research extends this view, demonstrating that engagement enhances both task execution (in-role performance) and discretionary contributions (extra-role performance) through its motivational effects [ 43 ]. The Job Demands-Resources (JD-R) model offers a foundational framework for understanding this relationship. According to the model, work engagement emerges when job resources such as autonomy, feedback, and social support interact with job demands, leading to motivational outcomes, including improved work performance [ 44 ]. Engaged workers are typically more energetic, resilient, and proactive in handling job demands, thereby demonstrating superior performance [ 45 ]. From the perspective of the Conservation of Resources (COR) theory proposed by Hobfoll in 1989, engaged workers possess and accumulate more psychological and emotional resources, such as resilience and optimism, which in turn empower them to invest greater effort into their work roles [ 46 ]. As individuals strive to gain and protect valued resources, those in an engaged state are more willing to go above and beyond job requirements, thereby enhancing performance outcomes [ 47 ]. Further theoretical grounding is provided by Self-Determination Theory [ 48 ], which indicates that individuals are intrinsically motivated to perform well when their basic psychological needs for autonomy, competence, and relatedness are fulfilled [ 49 ]. Engaged workers typically experience greater satisfaction of these needs, which drives superior performance through intrinsic motivation and self-regulation [ 48 ]. Thus, work engagement functions as a psychological mechanism that connects job conditions and personal characteristics to optimal functioning and performance [ 50 ]. Empirical studies support these theoretical claims, demonstrating a strong positive correlation between work engagement and improved performance outcomes [ 13 ]. Kaltiainen and Hakanen [ 51 ] further emphasize that engagement promotes adaptive and proactive performance. Engaged individuals not only perform better during work hours but also recover more effectively, maintaining consistent performance over time [ 52 ]. In healthcare settings, the impact of work engagement is especially pronounced. It is positively associated with critical outcomes such as quality of care, patient satisfaction, and safety, particularly among frontline professionals [ 53 ]. Higher levels of engagement are associated with fewer medical errors, stronger adherence to safety protocols, and more compassionate interactions with patients. Collectively, these outcomes reflect improved work performance in clinical environments [ 54 ]. Consistent with this evidence, we hypothesize that: Hypothesis 2 Midwives’ work engagement would affect their work performance. Organizational commitment and work performance Organizational commitment is a vital concept due to its far-reaching implications for individual workers, organizations, and society as a whole [ 55 ]. For workers, commitment brings both intrinsic satisfaction and extrinsic rewards, including recognition, job security, and career advancement opportunities provided by the organization [ 56 ]. From an organizational standpoint, committed workers are more likely to demonstrate loyalty, higher productivity, and lower turnover, factors that contribute to overall institutional effectiveness [ 11 ]. To better understand the relationship between organizational commitment and work performance, several theoretical frameworks have been developed. One of the most influential is Meyer and Allen’s [ 57 ] Three-Component Model (TCM), which conceptualizes organizational commitment as comprising three dimensions: affective commitment (emotional attachment to the organization), continuance commitment (awareness of the costs associated with leaving the organization), and normative commitment (a sense of obligation to remain) [ 58 ]. Affective commitment is consistently identified as the strongest and most positive predictor of work performance [ 59 ]. Workers who are emotionally invested in their organization are more likely to align with its goals and values, exert extra effort, and persist through challenges. They often go beyond the minimum requirements of their roles, engaging in discretionary behaviors that enhance organizational success [ 56 ]. They see organizational success as personal success and are thus more likely to channel their energy toward achieving work goals [ 60 ]. Continuance commitment, by contrast, often yields mixed results. While it may keep workers in their roles, it does not necessarily translate into optimal performance since it is driven by necessity rather than enthusiasm [ 57 ]. Normative commitment, rooted in obligation, occupies a middle ground; it may encourage consistent performance, especially in cultures where loyalty and duty are emphasized, but may not inspire innovation or extra effort [ 61 ]. To further explain these dynamics, Social Exchange Theory (SET), originally proposed by Blau in 1964, provides a complementary perspective. SET posits that workplace relationships are grounded in reciprocal exchanges [ 22 ]. When workers perceive that their organization treats them fairly, values their contributions, and invests in their well-being, they are likely to reciprocate with increased loyalty, engagement, and performance [ 62 ]. From this standpoint, organizational commitment is not merely an internal state but a transactional currency in an ongoing exchange. When organizations fail to uphold their end of the exchange, workers may become disengaged, leading to a decline in work performance even if tenure remains unchanged [ 63 ]. Goal-Setting Theory also sheds light on the motivational mechanisms linking commitment and performance [ 64 ]. According to the theory, committed workers set higher personal goals, invest more effort, and persist longer in the face of challenges. They internalize the goals of the organization as their own, they experience greater goal clarity and direction, leading to stronger achievement orientation and improved work performance [ 65 , 66 ]. Empirical research consistently supports the theoretical assumptions underpinning the link between organizational commitment and work performance. Studies across various sectors have demonstrated that workers with strong organizational commitment are more likely to exhibit higher job performance [ 67 , 68 , 69 , 70 , 71 ]. In clinical settings where the quality of performance can directly affect health outcomes, committed professionals are more likely to adhere to safety protocols, collaborate effectively with colleagues, and demonstrate empathy toward patients, all of which contribute to better service delivery [ 72 ]. These behaviors are clear indicators of elevated work performance driven by a deep sense of professional purpose and organizational loyalty. Therefore, the hypothesis is proposed as follows: Hypothesis 3 Midwives’ organizational commitment would affect their work performance. Mediating effect of work engagement in the relationship between organizational commitment and work performance Work engagement is increasingly recognized as a crucial construct in understanding the link between organizational commitment and work performance [ 73 ]. The dynamic interplay among these variables has attracted growing scholarly attention, particularly with regard to how work engagement mediates this relationship [ 38 , 60 ]. Theoretically, work engagement serves as a motivational state through which committed workers channel their energy, identity, and focus into performance-enhancing behaviors [ 74 ]. Drawing from the Job Demands-Resources (JD-R) model, it is suggested that personal and job-related resources promote work engagement, which in turn leads to higher performance [ 44 , 61 ]. In this context, organizational commitment functions as a personal resource that motivates workers to invest themselves physically, emotionally, and cognitively into their work. This increased engagement then translates into improved work performance [ 11 ]. The mediating role of engagement thus helps explain why not all committed workers necessarily perform well, only those whose commitment activates meaningful psychological engagement are likely to transform that motivation into tangible outcomes. Christian et al [ 10 ] provide a foundational understanding of work engagement, positing that it serves as a crucial link between antecedents, including organizational commitment, and work performance outcomes. Agu [ 75 ] similarly notes that organizational commitment combined with engagement fosters a positive attitude within organizations. Committed workers often experience a stronger sense of purpose and belonging, which boosts their engagement and work performance [ 11 ]. Supporting this view, Yalabik et al [ 76 ] demonstrated that work engagement not only mediates the relationship between commitment and performance but also mitigates turnover intentions. Cesário and Chambel [ 38 ] further emphasized that organizational commitment reflects a willingness to contribute meaningfully and go beyond basic job expectations. Workers with strong organizational commitment tend to exhibit greater engagement, which drives superior performance [ 38 ]. In the health sector, Brooks Carthon et al [ 77 ] similarly highlighted that work engagement encompasses commitment and motivation to provide high-quality patient care. Without engagement, however, commitment may remain a passive attitudinal state insufficient for achieving high performance. Engagement, therefore, becomes the behavioral manifestation of the psychological state of commitment [ 9 ]. From the above discussions, the authors hypothesized that: Hypothesis 4 Midwives’ work engagement would mediate the relationship between their organizational commitment and work performance. Based on insights from the literature, the conceptual model depicted in Fig. 1 was developed for this study. Material and methods Study design This study adopted an analytical cross-sectional design to investigate the mediating effect of work engagement in the relationship between organizational commitment and work performance among midwives. Study setting and population The study was conducted in three hospitals in the Tamale Metropolis, Northern Ghana. These hospitals are equipped with functional wards, laboratories, essential units, and provide round-the-clock healthcare services to people in Tamale and beyond. The total number of midwives across the three hospitals was 552 (TTH = 305, NRH = 117, and TWH = 130). The study population included all midwives working in these hospitals, regardless of rank or work experience. Sample size and sampling method The sample size was determined using Yamane [ 78 ] formula for finite populations: $$\:n=\frac{N}{1+N{\left(e\right)}^{2}}$$ Where: n represents the required sample size, N is the total population, and e is the margin of error (0.05). Given the population of 552 midwives, the calculated sample size was 231. To account for potential attrition, a 10% increase was added, resulting in a final sample size of 254. A stratified random sampling method was employed, grouping hospitals based on the number of midwives. The sample was proportionally distributed as follows: Tamale Teaching Hospital (305 midwives): 140 participants, Tamale West Hospital (130 midwives): 60 participants, and Tamale Regional Hospital (117 midwives): 54 participants. Simple random sampling was used to select participants from each hospital. The list of midwives in each ward was obtained and entered into SAS JMP Professional Statistical Software, where the random sampling function was applied to randomly select participants. Measures Organizational commitment The Organizational Commitment Scale developed and validated by Allen and Meyer [ 79 ], consisting of 18 items, was used to assess midwives' organizational commitment across three dimensions: affective commitment, continuance commitment, and normative commitment. Each item was rated on a 5-point Likert scale (1 = "Strongly disagree" to 5 = "Strongly agree"), with reverse scoring applied to negatively worded items. The total score ranged from 1 to 5, with higher scores indicating greater organizational commitment. Work engagement The Utrecht Work Engagement Scale (UWES-9), developed by Schaufeli et al [ 29 ], was used to measure midwives' work engagement. This 9-item scale comprises three dimensions: vigor, dedication, and absorption. Responses were recorded on a 7-point frequency scale (0 = "Never" to 6 = "Always"). The total score was calculated as the average across all items, ranging from 0 to 6, with higher scores reflecting greater work engagement. Work performance Work performance was assessed using the 18-item Individual Work Performance Questionnaire (IWPQ) developed by Koopmans et al [ 80 ]. The questionnaire measures three dimensions: task performance, contextual performance, and counterproductive work behavior. Task and contextual performance items were rated on a 5-point scale (0 = "Seldom" to 4 = "Always"), while counterproductive work behavior items used a 5-point scale (0 = "Never" to 4 = "Often"). A mean score was computed for the overall scale, with higher scores indicating better work performance. Validity and reliability In this study, the work engagement, work performance, and organizational commitment scales were adapted and validated within the Ghanaian context to ensure cultural relevance and psychometric robustness. Prior to the main data collection, the adapted instruments were pilot-tested among a sample of 50 midwives to assess clarity, appropriateness, and preliminary reliability. The pilot testing revealed that all items were well understood and contextually appropriate; therefore, no revisions were necessary. Following the pilot, the validity and reliability of the scales were carefully evaluated using multiple statistical metrics. Convergent validity was assessed using the Average Variance Extracted (AVE), which reflects the amount of variance captured by a construct in relation to the variance due to measurement error. An AVE value of 0.50 or higher is generally considered acceptable, indicating that the construct explains at least 50% of the variance in its items [ 81 ]. In this study, all scales met this criterion: work engagement (AVE = 0.64), work performance (AVE = 0.67), and organizational commitment (AVE = 0.61), demonstrating adequate convergent validity. In addition, composite reliability (CR) was also examined to assess the internal consistency of the constructs, with a recommended threshold of 0.70 or above indicating good reliability [ 82 ]. The CR values in this study were satisfactory across all scales: 0.89 for work engagement, 0.87 for work performance, and 0.80 for organizational commitment, suggesting that the items reliably measure their underlying constructs. Together, these findings confirm that the adapted scales demonstrate satisfactory validity and reliability, making them appropriate for use in the Ghanaian context. Data collection The data collection process commenced after receiving formal approval from the management of the three participating hospitals. All participants provided both verbal and written informed consent following a comprehensive briefing about the study's purpose, confidentiality protections, and voluntary nature of participation. The researchers distributed the questionnaires to the participants and supervised their completion. Participants were allotted 10–15 minutes to complete the questionnaires, with researchers available to ensure accurate responses. Each completed questionnaire was checked for missing or incomplete responses. To ensure privacy, questionnaires were sealed in envelopes labeled with unique identification codes to prevent personal identification. These envelopes were securely stored throughout the study to maintain confidentiality. Statistical analysis Data entry and cleaning were performed using SPSS Statistics version 27. Descriptive statistics summarized sociodemographic characteristics and study variables. Pearson correlation analysis examined relationships between organizational commitment, work engagement, and work performance. Mediation analysis was conducted using SPSS AMOS version 24 with 5,000 bootstrap resamples to assess both direct and indirect effects of organizational commitment on work performance, with work engagement as the mediator. Bootstrapping is a non-parametric resampling method commonly used in mediation analysis to test the significance of indirect effects without assuming normality of the sampling distribution. It provides more accurate confidence intervals, particularly for smaller samples or non-normal data. A resample size of 5,000 is generally recommended to ensure stable estimates and sufficient power [ 83 ]. All statistical test assumptions were verified prior to analysis. A p-value < 0.05 was considered statistically significant. Ethical consideration Ethical approval was obtained from the Committee on Human Research, Publications, and Ethics at Kwame Nkrumah University of Science and Technology (CHRPE/AP/013/24). Administrative permission was secured from all three participating hospitals. Written and verbal informed consent was obtained from all participants prior to data collection, with only eligible, consenting individuals included in the study. Participants were reminded of their right to withdraw at any time without consequence. Confidentiality was strictly maintained, with no personal identifiers linked to study data. Results Common method bias assessment Common method bias (CMB) was assessed to ensure that variance attributable to the measurement method, rather than the constructs of interest, did not unduly influence the results. A widely used approach for this purpose is Harman’s single-factor test, which involves conducting an exploratory factor analysis (EFA) on all measurement items using unrotated principal component extraction. The rationale is that if a single factor emerges, or if one factor accounts for a majority of the variance (typically 50% or more), it may suggest the presence of common method variance [ 84 ]. In this study, all items from the work engagement, work performance, and organizational commitment scales were included in the analysis. The results revealed that the first factor accounted for only 22.3% of the total variance, well below the 50% cutoff. This indicates that common method bias is unlikely to pose a serious threat to the validity of the study's findings. Sociodemographic characteristics Table 1 displays participant sociodemographic characteristics. Most participants were aged 30–39 years (54.3%) and female (96.9%). The majority were married (72.0%), while 37.0% had 1–2 children. Over half held a bachelor's degree or higher (61.4%), and slightly more than half (50.4%) had less than five years of work experience. Table 1 Sociodemographic characteristics of the participants Variable Frequency Percentage Age (years) 20–29 72 28.3 30–39 138 54.3 40–49 44 17.3 Gender Male 8 3.1 Female 246 96.9 Marital status Single 71 28.0 Married 183 72.0 Number of children 0 75 29.5 1–2 94 37.0 >2 85 33.5 Education status Bachelor's degree and higher 156 61.4 Diploma 98 38.6 Hospital type Primary hospital 114 44.9 Tertiary hospital 140 55.1 Work experience (years) 10 17 6.7 Rank Staff midwife 118 46.5 Senior midwife 115 45.3 Principal midwife 21 8.3 Descriptive statistics Table 2 presents the descriptive statistics for the study variables. Organizational commitment showed a mean score of 3.05 (SD = 0.54) with a median of 3.06. Work engagement demonstrated a mean of 2.41 (SD = 0.96) and median of 2.56. Work performance recorded the lowest mean score at 2.01 (SD = 0.67), with a median of 2.06. Table 2 Descriptive statistics of study variables 95% CI Mean Lower Upper Median SD Minimum Maximum Organizational commitment 3.05 2.98 3.12 3.06 0.542 1.17 4.44 Work engagement 2.41 2.29 2.53 2.56 0.963 0 4 Work performance 2.01 1.93 2.09 2.06 0.672 0 4 Note: “CI” denotes confidence interval, “SD” denotes standard deviation Correlation analysis As presented in Table 3 , the correlation analysis results supported all three hypotheses. Hypothesis 1 , which posited that midwives’ organizational commitment would affect their work engagement, was accepted, as a significant positive correlation was observed (r = 0.125, p < 0.05). Hypothesis 2 , which suggested that midwives’ work engagement would affect their work performance, was supported by a strong, significant positive correlation (r = 0.662, p < 0.05). Hypothesis 3 , which proposed that midwives’ organizational commitment would affect their work performance, was also accepted, with a significant positive correlation (r = 0.166, p < 0.05). Table 3 Correlation between organizational commitment, work engagement, and work performance Organizational commitment Work engagement Work performance Organizational commitment — Work engagement 0.125* — Work performance 0.166* 0.662* — *Statistically significant at p < 0.05 Mediation analysis As shown in Table 4 , the simple mediation analysis examined work engagement's mediating effect between organizational commitment and work performance. Results revealed that organizational commitment significantly predicted work engagement (β = 0.124, SE = 0.111, p = 0.046), which in turn significantly predicted work performance (β = 0.651, SE = 0.033, p < 0.001). While the direct effect of organizational commitment on work performance was non-significant (β = 0.085, SE = 0.090, p = 0.072), the indirect effect through work engagement was significant (β = 0.078, SE = 0.061, p < 0.001), demonstrating full mediation (Fig. 2 ). These findings support Hypothesis 4 , confirming that midwives’ work engagement would mediate the relationship between their organizational commitment and work performance. Table 4 Direct and indirect effects of organizational commitment on work performance through work engagement among midwives Model pathway Unstandardized Coefficient Std. Error Critical Ratio Standardized Coefficient Sig. (B) (Beta) Direct Effect Work Engagement <--- Organizational Commitment 0.221 0.111 1.997 0.124 0.046* Work Performance <--- Work Engagement 0.454 0.033 13.788 0.651 < 0.001* Work Performance <--- Organizational Commitment 0.105 0.090 1.801 0.085 0.072 Indirect Effect Work Performance <--- Work Engagement <--- Organizational Commitment 0.101 0.061 0.055 0.078 < 0.001* *Statistically significant at p < 0.05 Discussion This study investigated the mediating effect of work engagement in the relationship between organizational commitment and work performance among midwives. The study’s outcomes contribute to the literature by confirming and extending existing theoretical frameworks on worker engagement and performance, particularly in healthcare settings within low- and middle-income countries. By linking these findings with previous research, this study offers new insights into the dynamics of work engagement, organizational commitment, and work performance in the context of maternal healthcare. The first hypothesis, which proposed that organizational commitment would affect work engagement levels among midwives, was supported by statistically significant results. This result is consistent with past studies by Khalid and Khalid [ 37 ], Cesário and Chambel [ 38 ], and Arcadio et al [ 39 ], which reported that organizational commitment influences work engagement. These studies support the notion that when workers feel loyalty and identification with their organization, they are more likely to engage enthusiastically in their work. However, this study extends the literature by confirming this relationship among midwives within the Ghanaian healthcare context, where systemic challenges, such as staffing shortages and resource limitations, often impact morale [ 7 ]. This study’s results underline that organizational commitment is not merely a contributing factor but a foundational determinant of work engagement among midwives. However, it is worth noting that not all research supports this association. For instance, Jackson [ 85 ] found no significant relationship between organizational commitment and work engagement in their study. This discrepancy suggests that although the link between commitment and engagement is generally strong, it may not be universal. There might be potential influence of contextual factors such as organizational culture, leadership style, and work environment. The second hypothesis, which proposed that work engagement would influence work performance, was also supported. This finding is consistent with earlier studies by Sekhar et al [ 13 ], Sittar [ 86 ], and Mundhra and Pramanik [ 87 ], who similarly reported that work engagement impacts worker performance. In the present study, high engagement translated into improved work performance, particularly in midwifery care, which is essential for achieving better patient outcomes. This study adds to existing literature by demonstrating that promoting work engagement among midwives could have broader public health implications, especially since midwives' performance directly impacts maternal and neonatal health [ 88 ]. While some studies have suggested that other variables, like creativity and job satisfaction, mediate the relationship between engagement and performance [ 89 , 90 ], this study challenges this view. It highlights that even in resource-constrained environments, intrinsic motivation derived from engagement can independently drive performance improvements. Therefore, fostering a sense of purpose and encouraging teamwork can further enhance work engagement and performance, especially in high-stakes professions like midwifery. The third hypothesis, which proposed that organizational commitment would influence work performance levels among midwives, was supported by the data. This result corroborates previous studies by Dinc [ 67 ], Suharto et al [ 68 ], Krishnanathan and Mangaleswaran [ 69 ], Beigi and Lajevardi [ 70 ], and Cobbinah et al [ 71 ], which have established that organizational commitment is a significant predictor of work performance. This study adds depth by confirming the role of organizational commitment in improving work performance specifically among midwives [ 41 ]. Nonetheless, it is important to acknowledge conflicting findings in other studies, such as Tawiah [ 91 ] and James [ 92 ], where organizational commitment did not affect work performance. These divergent results could be due to variations in organizational culture or work environment. Finally, the fourth hypothesis, which proposed that work engagement would mediate the relationship between organizational commitment and work performance, was confirmed through full serial mediation. This finding is aligned with Suharto and Suprapto [ 93 ], who indicated that organizational commitment does not directly affect worker performance but operates through work engagement. Similarly, studies by Yalabik et al [ 76 ] and Cesário and Chambel [ 38 ] demonstrated that workers with strong organizational commitment exhibit higher levels of work engagement, which in turn drives superior performance. Furthermore, research by Lo et al [ 11 ] revealed that workers with high organizational commitment experience a greater sense of purpose and belonging, which positively influences their engagement and work performance. Importantly, this study provides insights that challenge simplistic interpretations of the commitment-performance relationship. While some literature has suggested that commitment alone is sufficient for performance improvements [ 67 , 68 , 69 ], this study presents a deeper perspective, showing that engagement is a critical mediator that enables the commitment-performance link. These findings have significant implications for healthcare organizations aiming to improve maternal care outcomes. Policies and programs should target both organizational commitment and work engagement to achieve sustainable performance gains. By prioritizing strategies that foster both commitment and engagement, healthcare organizations can enhance the overall work performance and well-being of midwives, ultimately improving the quality of care they provide. Limitations Although this study offers valuable insights, several limitations should be considered. First, the sample was confined to midwives within a specific region, which may limit the generalizability of the findings to other healthcare professionals or settings. Second, the cross-sectional design of the study prevents us from making causal inferences, as the observed relationships could be influenced by unmeasured third variables. Third, the self-reported nature of the data may introduce response biases, such as social desirability or recall bias, which could impact the accuracy of the results. Conclusion This study provides valuable insights into the relationships among organizational commitment, work engagement, and work performance in midwives. Our findings demonstrate that enhancing midwives' organizational commitment significantly improves both their work engagement and performance. The results further reveal that increased work engagement leads to substantially better performance, with work engagement serving as a full mediator between organizational commitment and work performance. These results suggest that organizational commitment boosts work performance primarily through its positive effect on work engagement, highlighting the crucial role of engagement in translating commitment into improved performance. Practical implications The Ministry of Health (MoH) in Ghana should incorporate organizational commitment and work engagement strategies into national healthcare policies, particularly by developing frameworks that recognize work engagement's mediating role in performance enhancement. Healthcare institutions should cultivate supportive work environments that value midwives' contributions through incentive programs, open communication channels, and continuous professional development opportunities. These measures will help maintain high engagement levels and motivation among midwifery staff, ultimately improving healthcare service delivery. While this study clarifies work engagement's mediating role, future research should explore additional mediators and moderators in the commitment-performance relationship. Longitudinal studies would particularly strengthen our understanding of these causal relationships over time. We encourage continued investigation in this area to develop targeted interventions that enhance midwives' performance, recommending that stakeholders support such evidence-based research to improve Ghana's healthcare system. Declarations Acknowledgement The authors gratefully acknowledge all midwives who voluntarily participated in this study. We also extend our sincere appreciation to the three public health facilities for their support throughout the research process. Clinical trial number Not applicable. Authors’ contribution I.S.M., A.W., M.M.I., L.C., and B.A.N. contributed to the study design and manuscript development, including writing the background, methodology, and editing/proofreading. I.S.M., M.M.I., and L.C. collected the data. M.M.I. conducted formal analysis and data visualization. A.W. and B.A.N. validated the results. All authors reviewed and approved the final manuscript. Funding This research received no external funding. Data availability The data used and/or analyzed in this research are available from the corresponding author upon reasonable request, provided that participants’ confidentiality is maintained. Ethics approval and consent to participate Ethical approval was obtained from the Committee on Human Research, Publications, and Ethics at Kwame Nkrumah University of Science and Technology (CHRPE/AP/013/24). Written informed consent was obtained from all study participants. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Deussom R, Mwarey D, Bayu M, Abdullah SS, Marcus R. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6037580","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":444731771,"identity":"28b3f40b-2927-47a5-acdf-cc9732b677e4","order_by":0,"name":"Iddrisu Sisala Mohammed","email":"","orcid":"","institution":"Nurses’ and Midwives’ Training College","correspondingAuthor":false,"prefix":"","firstName":"Iddrisu","middleName":"Sisala","lastName":"Mohammed","suffix":""},{"id":444731772,"identity":"8e3f0f30-b647-46d2-bee9-797ea3a45079","order_by":1,"name":"Abubakari Wuni","email":"","orcid":"","institution":"University of Kentucky","correspondingAuthor":false,"prefix":"","firstName":"Abubakari","middleName":"","lastName":"Wuni","suffix":""},{"id":444731775,"identity":"1a4a9450-4f53-4638-b8f8-93398905e59a","order_by":2,"name":"Brenda Abena Nyarko","email":"","orcid":"","institution":"University of Massachusetts","correspondingAuthor":false,"prefix":"","firstName":"Brenda","middleName":"Abena","lastName":"Nyarko","suffix":""},{"id":444731776,"identity":"a5c73e33-f8c1-4859-b959-398352a210df","order_by":3,"name":"Mudasir Mohammed Ibrahim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIiWNgGAWjYHACAyCWYGCTYGBgBrLt2NgbQIIWxGtJ5uc5ABKUIKQFrAuohYGBceaMBCgXB9Cdkbzx448/Fvl80r0PPxcUbGM2uPn86oYfBRIM/O3dCdi0mN1IK5bmbZOwbJM5biw9w+A2n8HtnLKbPUCHSZw5uwG7lhwDacYGCQM2iTQGaR6D28xALWk3eIBaDCRycWkx/vnjD1gL82+gFsYNN8+k3fyDX4uZBA8bWAsbyBag99mP3cZry5lnZdZAvxiwyRxjswZqAQZyDtttGQMJHpx+OZ68+eaPP3UG8rPbmG/z/LkNjMrjz26++WMjx9/ei1ULNsADjikeYpWDAPsDUlSPglEwCkbB8AcAYixc+zsf6ScAAAAASUVORK5CYII=","orcid":"","institution":"Nurses’ and Midwives’ Training College","correspondingAuthor":true,"prefix":"","firstName":"Mudasir","middleName":"Mohammed","lastName":"Ibrahim","suffix":""},{"id":444731777,"identity":"ef31a5e8-4bb0-4bca-b368-a93acbbbc5e7","order_by":4,"name":"Letitia Chanayireh","email":"","orcid":"","institution":"University for Development Studies","correspondingAuthor":false,"prefix":"","firstName":"Letitia","middleName":"","lastName":"Chanayireh","suffix":""}],"badges":[],"createdAt":"2025-02-15 16:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6037580/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6037580/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13062-4","type":"published","date":"2025-07-01T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81689926,"identity":"5b050d75-a99e-4771-a804-d70532a37f8c","added_by":"auto","created_at":"2025-04-30 11:26:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44707,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual model\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6037580/v1/5941676fb158fb69cfef0005.png"},{"id":81689927,"identity":"f82f540e-3567-4df2-81c1-5a6f5ece4117","added_by":"auto","created_at":"2025-04-30 11:26:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":97717,"visible":true,"origin":"","legend":"\u003cp\u003eSimple mediation model of the study variables\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6037580/v1/3b310022e80c3c318a174ce5.png"},{"id":86180232,"identity":"a9cbb064-1d7a-4eb9-af53-725f3e77229c","added_by":"auto","created_at":"2025-07-07 16:21:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1398953,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6037580/v1/9a516005-706b-4796-8b5c-b00334bc09aa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Work Engagement: The Key Driver in Transforming Organizational Commitment into Enhanced Work Performance among Midwives - A Structural Equation Modelling Approach","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealthcare systems around the world depend significantly on the competence, motivation, and performance of frontline healthcare professionals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, prolonged exposure to stress among these professionals has been shown to negatively impact their health, work performance, and the overall quality of patient care [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Midwives, in particular, often operate under challenging conditions characterized by limited resources, high patient loads, inadequate opportunities for professional development, and insufficient institutional support [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These stressors not only impair their ability to perform effectively but also compromise the quality of care delivered to mothers and newborns [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMidwifery is inherently an emotional and demanding profession. Supporting women and their families amidst complex social circumstances often exposes midwives to feelings of anxiety, pain, fear, and sadness [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These emotional burdens can make it increasingly difficult for midwives to function effectively in already challenging work environment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Consequently, low morale and work-related stress have become prominent concerns within the profession [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Despite these challenges, many midwives continue to demonstrate resilience by remaining committed to their roles and delivering essential care to women and newborns a phenomenon referred to as work engagement [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWork engagement is a crucial concept in understanding midwives\u0026rsquo; behavior and performance [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It is defined as a positive, fulfilling work-related state of mind characterized by vigor, dedication, and absorption [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A substantial body of research has shown that high levels of work engagement are associated with improved work performance [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Studies across Europe, Asia, and North America have consistently linked work engagement to better work performance [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Workers with high engagement levels tend to be more productive, motivated, and committed to their organizations [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVarious organizational and personal factors influence work engagement, including leadership style, organizational culture, job resources, worker recognition, manageable workloads, and opportunities for both personal and professional growth [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Among these, organizational commitment defined as an worker\u0026rsquo;s psychological attachment to their organization has received significant attention in the literature. Numerous studies have explored how organizational commitment impacts work performance, particularly among nurses and physicians, in both developed and developing countries, including Ghana [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, there is a paucity of studies that have investigated this relationship among midwives. This is especially important considering that midwives continue to face challenging conditions that not only affect their performance but also influence the quality of care provided to mothers and newborns [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe implications of midwives\u0026rsquo; performance extend beyond the workplace and into the broader realm of public health. In Ghana, maternal and neonatal mortality rates remain alarmingly high, 310 deaths per 100,000 live births and 25 deaths per 1,000 births, respectively, despite increased access to skilled birth attendance in recent years [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These statistics underscore the urgency of strengthening midwifery services and addressing the human factors that impact care delivery. Understanding the mediating role of work engagement in the relationship between organizational commitment and work performance among midwives is crucial, as it can inform targeted interventions to enhance both their commitment and engagement. Enhancing midwives\u0026rsquo; performance is essential not only for achieving Sustainable Development Goal 3 (Good Health and Well-being) but also for protecting the health and rights of mothers and newborns throughout the country. Therefore, this study was conducted to investigate the mediating effect of work engagement in the relationship between organizational commitment and work performance among midwives.\u003c/p\u003e"},{"header":"Literature Review","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eOrganizational commitment and work engagement\u003c/h2\u003e \u003cp\u003eOrganizational commitment and work engagement have garnered substantial scholarly attention due to their significant impact on individual and organizational outcomes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The Social Exchange Theory (SET) proposed by Blau in 1964 underpins their relationship, positing that workers reciprocate favorable organizational treatment through positive attitudes and behaviors (work engagement) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Howard Becker\u0026rsquo;s Side-Bet Theory in 1960 conceptualized commitment as a calculative decision where workers remain due to accumulated investments (e.g., seniority, pension plans, social relationships, or career prospects) that would be lost upon departure [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMeyer and Allen\u0026rsquo;s Three-Component Model in 1997 expanded this view, defining commitment as the psychological attachment of an worker to their organization [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and comprises affective (Emotional attachment to, identification with, and involvement in the organization. Workers stay because they want to), continuance (Awareness of the costs associated with leaving the organization. Workers stay because they need to), and normative (A feeling of obligation to remain with the organization. Workers stay because they ought to) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWork engagement\u0026rsquo;s theoretical foundations stem from Kahn\u0026rsquo;s model in 1990, which identifies three psychological conditions (meaningfulness, safety, and resource availability) necessary for workers to invest physical, cognitive, and emotional energy into their roles [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Schaufeli et al [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] later distinguished engagement as a distinct motivational state characterized by vigor (High energy and mental resilience), dedication (Strong involvement, pride, and significance in work), and absorption (Full concentration and immersion in tasks) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Conservation of Resources (COR) theory and Job Demands-Resources (JD-R) model further elucidate this relationship [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The Conservation of Resources (COR) theory argues that individuals strive to obtain, retain, and protect resources [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In this context, organizational commitment represents a key psychological resource that workers draw upon to sustain high engagement levels [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Saks [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] argued that commitment operates as a psychological condition necessary for work engagement, indicating that workers need to feel a sense of belonging and purpose within the organization to be fully engaged [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Thus, when workers are affectively committed, they perceive alignment between their values and organizational goals, which fosters intrinsic motivation and energy, thereby enhancing their work engagement [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmpirical studies consistently affirm this link. For instance, Khalid and Khalid [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], Ces\u0026aacute;rio and Chambel [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], Arcadio et al [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], and Tang et al [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] showed that there is a significant relationship between organizational commitment and work engagement, highlighting that committed workers exhibit higher work engagement. In healthcare settings, committed midwives often report higher levels of job satisfaction, resilience, and patient-centered care, all of which are hallmarks of work engagement [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Based on this theoretical and empirical foundation, we hypothesize that:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHypothesis 1\u003c/strong\u003e \u003cp\u003e \u003cem\u003eMidwives\u0026rsquo; organizational commitment would affect their work engagement.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eWork engagement and work performance\u003c/h3\u003e\n\u003cp\u003eThe concept of work performance has its roots in Frederick Taylor\u0026rsquo;s Scientific Management Theory in 1911, which emphasized efficiency and productivity as core components of work performance [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Modern research extends this view, demonstrating that engagement enhances both task execution (in-role performance) and discretionary contributions (extra-role performance) through its motivational effects [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Job Demands-Resources (JD-R) model offers a foundational framework for understanding this relationship. According to the model, work engagement emerges when job resources such as autonomy, feedback, and social support interact with job demands, leading to motivational outcomes, including improved work performance [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Engaged workers are typically more energetic, resilient, and proactive in handling job demands, thereby demonstrating superior performance [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom the perspective of the Conservation of Resources (COR) theory proposed by Hobfoll in 1989, engaged workers possess and accumulate more psychological and emotional resources, such as resilience and optimism, which in turn empower them to invest greater effort into their work roles [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. As individuals strive to gain and protect valued resources, those in an engaged state are more willing to go above and beyond job requirements, thereby enhancing performance outcomes [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurther theoretical grounding is provided by Self-Determination Theory [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], which indicates that individuals are intrinsically motivated to perform well when their basic psychological needs for autonomy, competence, and relatedness are fulfilled [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Engaged workers typically experience greater satisfaction of these needs, which drives superior performance through intrinsic motivation and self-regulation [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Thus, work engagement functions as a psychological mechanism that connects job conditions and personal characteristics to optimal functioning and performance [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmpirical studies support these theoretical claims, demonstrating a strong positive correlation between work engagement and improved performance outcomes [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Kaltiainen and Hakanen [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] further emphasize that engagement promotes adaptive and proactive performance. Engaged individuals not only perform better during work hours but also recover more effectively, maintaining consistent performance over time [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn healthcare settings, the impact of work engagement is especially pronounced. It is positively associated with critical outcomes such as quality of care, patient satisfaction, and safety, particularly among frontline professionals [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Higher levels of engagement are associated with fewer medical errors, stronger adherence to safety protocols, and more compassionate interactions with patients. Collectively, these outcomes reflect improved work performance in clinical environments [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Consistent with this evidence, we hypothesize that:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHypothesis 2\u003c/strong\u003e \u003cp\u003e \u003cem\u003eMidwives\u0026rsquo; work engagement would affect their work performance.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eOrganizational commitment and work performance\u003c/h3\u003e\n\u003cp\u003eOrganizational commitment is a vital concept due to its far-reaching implications for individual workers, organizations, and society as a whole [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. For workers, commitment brings both intrinsic satisfaction and extrinsic rewards, including recognition, job security, and career advancement opportunities provided by the organization [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. From an organizational standpoint, committed workers are more likely to demonstrate loyalty, higher productivity, and lower turnover, factors that contribute to overall institutional effectiveness [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo better understand the relationship between organizational commitment and work performance, several theoretical frameworks have been developed. One of the most influential is Meyer and Allen\u0026rsquo;s [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] Three-Component Model (TCM), which conceptualizes organizational commitment as comprising three dimensions: affective commitment (emotional attachment to the organization), continuance commitment (awareness of the costs associated with leaving the organization), and normative commitment (a sense of obligation to remain) [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Affective commitment is consistently identified as the strongest and most positive predictor of work performance [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Workers who are emotionally invested in their organization are more likely to align with its goals and values, exert extra effort, and persist through challenges. They often go beyond the minimum requirements of their roles, engaging in discretionary behaviors that enhance organizational success [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. They see organizational success as personal success and are thus more likely to channel their energy toward achieving work goals [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Continuance commitment, by contrast, often yields mixed results. While it may keep workers in their roles, it does not necessarily translate into optimal performance since it is driven by necessity rather than enthusiasm [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Normative commitment, rooted in obligation, occupies a middle ground; it may encourage consistent performance, especially in cultures where loyalty and duty are emphasized, but may not inspire innovation or extra effort [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo further explain these dynamics, Social Exchange Theory (SET), originally proposed by Blau in 1964, provides a complementary perspective. SET posits that workplace relationships are grounded in reciprocal exchanges [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. When workers perceive that their organization treats them fairly, values their contributions, and invests in their well-being, they are likely to reciprocate with increased loyalty, engagement, and performance [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. From this standpoint, organizational commitment is not merely an internal state but a transactional currency in an ongoing exchange. When organizations fail to uphold their end of the exchange, workers may become disengaged, leading to a decline in work performance even if tenure remains unchanged [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGoal-Setting Theory also sheds light on the motivational mechanisms linking commitment and performance [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. According to the theory, committed workers set higher personal goals, invest more effort, and persist longer in the face of challenges. They internalize the goals of the organization as their own, they experience greater goal clarity and direction, leading to stronger achievement orientation and improved work performance [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmpirical research consistently supports the theoretical assumptions underpinning the link between organizational commitment and work performance. Studies across various sectors have demonstrated that workers with strong organizational commitment are more likely to exhibit higher job performance [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. In clinical settings where the quality of performance can directly affect health outcomes, committed professionals are more likely to adhere to safety protocols, collaborate effectively with colleagues, and demonstrate empathy toward patients, all of which contribute to better service delivery [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. These behaviors are clear indicators of elevated work performance driven by a deep sense of professional purpose and organizational loyalty. Therefore, the hypothesis is proposed as follows:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHypothesis 3\u003c/strong\u003e \u003cp\u003e \u003cem\u003eMidwives\u0026rsquo; organizational commitment would affect their work performance.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eMediating effect of work engagement in the relationship between organizational commitment and work performance\u003c/h3\u003e\n\u003cp\u003eWork engagement is increasingly recognized as a crucial construct in understanding the link between organizational commitment and work performance [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. The dynamic interplay among these variables has attracted growing scholarly attention, particularly with regard to how work engagement mediates this relationship [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTheoretically, work engagement serves as a motivational state through which committed workers channel their energy, identity, and focus into performance-enhancing behaviors [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Drawing from the Job Demands-Resources (JD-R) model, it is suggested that personal and job-related resources promote work engagement, which in turn leads to higher performance [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. In this context, organizational commitment functions as a personal resource that motivates workers to invest themselves physically, emotionally, and cognitively into their work. This increased engagement then translates into improved work performance [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The mediating role of engagement thus helps explain why not all committed workers necessarily perform well, only those whose commitment activates meaningful psychological engagement are likely to transform that motivation into tangible outcomes.\u003c/p\u003e \u003cp\u003eChristian et al [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] provide a foundational understanding of work engagement, positing that it serves as a crucial link between antecedents, including organizational commitment, and work performance outcomes. Agu [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e] similarly notes that organizational commitment combined with engagement fosters a positive attitude within organizations. Committed workers often experience a stronger sense of purpose and belonging, which boosts their engagement and work performance [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Supporting this view, Yalabik et al [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e] demonstrated that work engagement not only mediates the relationship between commitment and performance but also mitigates turnover intentions.\u003c/p\u003e \u003cp\u003eCes\u0026aacute;rio and Chambel [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] further emphasized that organizational commitment reflects a willingness to contribute meaningfully and go beyond basic job expectations. Workers with strong organizational commitment tend to exhibit greater engagement, which drives superior performance [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the health sector, Brooks Carthon et al [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e] similarly highlighted that work engagement encompasses commitment and motivation to provide high-quality patient care. Without engagement, however, commitment may remain a passive attitudinal state insufficient for achieving high performance. Engagement, therefore, becomes the behavioral manifestation of the psychological state of commitment [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. From the above discussions, the authors hypothesized that:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHypothesis 4\u003c/strong\u003e \u003cp\u003e \u003cem\u003eMidwives\u0026rsquo; work engagement would mediate the relationship between their organizational commitment and work performance.\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003eBased on insights from the literature, the conceptual model depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e was developed for this study.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eMaterial and methods\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study adopted an analytical cross-sectional design to investigate the mediating effect of work engagement in the relationship between organizational commitment and work performance among midwives.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy setting and population\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in three hospitals in the Tamale Metropolis, Northern Ghana. These hospitals are equipped with functional wards, laboratories, essential units, and provide round-the-clock healthcare services to people in Tamale and beyond. The total number of midwives across the three hospitals was 552 (TTH\u0026thinsp;=\u0026thinsp;305, NRH\u0026thinsp;=\u0026thinsp;117, and TWH\u0026thinsp;=\u0026thinsp;130). The study population included all midwives working in these hospitals, regardless of rank or work experience.\u003c/p\u003e\n\u003ch3\u003eSample size and sampling method\u003c/h3\u003e\n\u003cp\u003eThe sample size was determined using Yamane [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e] formula for finite populations:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:n=\\frac{N}{1+N{\\left(e\\right)}^{2}}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhere:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003en\u003c/em\u003e represents the required sample size,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eN\u003c/em\u003e is the total population, and\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003ee\u003c/em\u003e is the margin of error (0.05).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eGiven the population of 552 midwives, the calculated sample size was 231. To account for potential attrition, a 10% increase was added, resulting in a final sample size of 254. A stratified random sampling method was employed, grouping hospitals based on the number of midwives. The sample was proportionally distributed as follows: Tamale Teaching Hospital (305 midwives): 140 participants, Tamale West Hospital (130 midwives): 60 participants, and Tamale Regional Hospital (117 midwives): 54 participants. Simple random sampling was used to select participants from each hospital. The list of midwives in each ward was obtained and entered into SAS JMP Professional Statistical Software, where the random sampling function was applied to randomly select participants.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eOrganizational commitment\u003c/h2\u003e \u003cp\u003eThe Organizational Commitment Scale developed and validated by Allen and Meyer [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e], consisting of 18 items, was used to assess midwives' organizational commitment across three dimensions: affective commitment, continuance commitment, and normative commitment. Each item was rated on a 5-point Likert scale (1 = \"Strongly disagree\" to 5 = \"Strongly agree\"), with reverse scoring applied to negatively worded items. The total score ranged from 1 to 5, with higher scores indicating greater organizational commitment.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eWork engagement\u003c/h2\u003e \u003cp\u003eThe Utrecht Work Engagement Scale (UWES-9), developed by Schaufeli et al [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], was used to measure midwives' work engagement. This 9-item scale comprises three dimensions: vigor, dedication, and absorption. Responses were recorded on a 7-point frequency scale (0 = \"Never\" to 6 = \"Always\"). The total score was calculated as the average across all items, ranging from 0 to 6, with higher scores reflecting greater work engagement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eWork performance\u003c/h2\u003e \u003cp\u003eWork performance was assessed using the 18-item Individual Work Performance Questionnaire (IWPQ) developed by Koopmans et al [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. The questionnaire measures three dimensions: task performance, contextual performance, and counterproductive work behavior. Task and contextual performance items were rated on a 5-point scale (0 = \"Seldom\" to 4 = \"Always\"), while counterproductive work behavior items used a 5-point scale (0 = \"Never\" to 4 = \"Often\"). A mean score was computed for the overall scale, with higher scores indicating better work performance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eValidity and reliability\u003c/h2\u003e \u003cp\u003eIn this study, the work engagement, work performance, and organizational commitment scales were adapted and validated within the Ghanaian context to ensure cultural relevance and psychometric robustness. Prior to the main data collection, the adapted instruments were pilot-tested among a sample of 50 midwives to assess clarity, appropriateness, and preliminary reliability. The pilot testing revealed that all items were well understood and contextually appropriate; therefore, no revisions were necessary.\u003c/p\u003e \u003cp\u003eFollowing the pilot, the validity and reliability of the scales were carefully evaluated using multiple statistical metrics. Convergent validity was assessed using the Average Variance Extracted (AVE), which reflects the amount of variance captured by a construct in relation to the variance due to measurement error. An AVE value of 0.50 or higher is generally considered acceptable, indicating that the construct explains at least 50% of the variance in its items [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e]. In this study, all scales met this criterion: work engagement (AVE\u0026thinsp;=\u0026thinsp;0.64), work performance (AVE\u0026thinsp;=\u0026thinsp;0.67), and organizational commitment (AVE\u0026thinsp;=\u0026thinsp;0.61), demonstrating adequate convergent validity. In addition, composite reliability (CR) was also examined to assess the internal consistency of the constructs, with a recommended threshold of 0.70 or above indicating good reliability [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. The CR values in this study were satisfactory across all scales: 0.89 for work engagement, 0.87 for work performance, and 0.80 for organizational commitment, suggesting that the items reliably measure their underlying constructs. Together, these findings confirm that the adapted scales demonstrate satisfactory validity and reliability, making them appropriate for use in the Ghanaian context.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe data collection process commenced after receiving formal approval from the management of the three participating hospitals. All participants provided both verbal and written informed consent following a comprehensive briefing about the study's purpose, confidentiality protections, and voluntary nature of participation. The researchers distributed the questionnaires to the participants and supervised their completion. Participants were allotted 10\u0026ndash;15 minutes to complete the questionnaires, with researchers available to ensure accurate responses. Each completed questionnaire was checked for missing or incomplete responses. To ensure privacy, questionnaires were sealed in envelopes labeled with unique identification codes to prevent personal identification. These envelopes were securely stored throughout the study to maintain confidentiality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData entry and cleaning were performed using SPSS Statistics version 27. Descriptive statistics summarized sociodemographic characteristics and study variables. Pearson correlation analysis examined relationships between organizational commitment, work engagement, and work performance. Mediation analysis was conducted using SPSS AMOS version 24 with 5,000 bootstrap resamples to assess both direct and indirect effects of organizational commitment on work performance, with work engagement as the mediator. Bootstrapping is a non-parametric resampling method commonly used in mediation analysis to test the significance of indirect effects without assuming normality of the sampling distribution. It provides more accurate confidence intervals, particularly for smaller samples or non-normal data. A resample size of 5,000 is generally recommended to ensure stable estimates and sufficient power [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. All statistical test assumptions were verified prior to analysis. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eEthical consideration\u003c/h2\u003e \u003cp\u003e Ethical approval was obtained from the Committee on Human Research, Publications, and Ethics at Kwame Nkrumah University of Science and Technology (CHRPE/AP/013/24). Administrative permission was secured from all three participating hospitals. Written and verbal informed consent was obtained from all participants prior to data collection, with only eligible, consenting individuals included in the study. Participants were reminded of their right to withdraw at any time without consequence. Confidentiality was strictly maintained, with no personal identifiers linked to study data.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eCommon method bias assessment\u003c/h2\u003e \u003cp\u003eCommon method bias (CMB) was assessed to ensure that variance attributable to the measurement method, rather than the constructs of interest, did not unduly influence the results. A widely used approach for this purpose is Harman\u0026rsquo;s single-factor test, which involves conducting an exploratory factor analysis (EFA) on all measurement items using unrotated principal component extraction. The rationale is that if a single factor emerges, or if one factor accounts for a majority of the variance (typically 50% or more), it may suggest the presence of common method variance [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. In this study, all items from the work engagement, work performance, and organizational commitment scales were included in the analysis. The results revealed that the first factor accounted for only 22.3% of the total variance, well below the 50% cutoff. This indicates that common method bias is unlikely to pose a serious threat to the validity of the study's findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic characteristics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays participant sociodemographic characteristics. Most participants were aged 30\u0026ndash;39 years (54.3%) and female (96.9%). The majority were married (72.0%), while 37.0% had 1\u0026ndash;2 children. Over half held a bachelor's degree or higher (61.4%), and slightly more than half (50.4%) had less than five years of work experience.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of children\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor's degree and higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork experience (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRank\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff midwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior midwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrincipal midwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive statistics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the descriptive statistics for the study variables. Organizational commitment showed a mean score of 3.05 (SD\u0026thinsp;=\u0026thinsp;0.54) with a median of 3.06. Work engagement demonstrated a mean of 2.41 (SD\u0026thinsp;=\u0026thinsp;0.96) and median of 2.56. Work performance recorded the lowest mean score at 2.01 (SD\u0026thinsp;=\u0026thinsp;0.67), with a median of 2.06.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics of study variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOrganizational commitment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.542\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork engagement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.963\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork performance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.672\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eNote: \u0026ldquo;CI\u0026rdquo; denotes confidence interval, \u0026ldquo;SD\u0026rdquo; denotes standard deviation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eCorrelation analysis\u003c/h2\u003e \u003cp\u003eAs presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the correlation analysis results supported all three hypotheses. Hypothesis \u003cspan refid=\"FPar1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, which posited that midwives\u0026rsquo; organizational commitment would affect their work engagement, was accepted, as a significant positive correlation was observed (r\u0026thinsp;=\u0026thinsp;0.125, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Hypothesis \u003cspan refid=\"FPar2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, which suggested that midwives\u0026rsquo; work engagement would affect their work performance, was supported by a strong, significant positive correlation (r\u0026thinsp;=\u0026thinsp;0.662, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Hypothesis \u003cspan refid=\"FPar3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, which proposed that midwives\u0026rsquo; organizational commitment would affect their work performance, was also accepted, with a significant positive correlation (r\u0026thinsp;=\u0026thinsp;0.166, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation between organizational commitment, work engagement, and work performance\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrganizational commitment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWork engagement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWork performance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOrganizational commitment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork engagement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.125*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork performance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.166*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.662*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e*Statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eMediation analysis\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the simple mediation analysis examined work engagement's mediating effect between organizational commitment and work performance. Results revealed that organizational commitment significantly predicted work engagement (β\u0026thinsp;=\u0026thinsp;0.124, SE\u0026thinsp;=\u0026thinsp;0.111, p\u0026thinsp;=\u0026thinsp;0.046), which in turn significantly predicted work performance (β\u0026thinsp;=\u0026thinsp;0.651, SE\u0026thinsp;=\u0026thinsp;0.033, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). While the direct effect of organizational commitment on work performance was non-significant (β\u0026thinsp;=\u0026thinsp;0.085, SE\u0026thinsp;=\u0026thinsp;0.090, p\u0026thinsp;=\u0026thinsp;0.072), the indirect effect through work engagement was significant (β\u0026thinsp;=\u0026thinsp;0.078, SE\u0026thinsp;=\u0026thinsp;0.061, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), demonstrating full mediation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These findings support Hypothesis \u003cspan refid=\"FPar4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, confirming that midwives\u0026rsquo; work engagement would mediate the relationship between their organizational commitment and work performance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDirect and indirect effects of organizational commitment on work performance through work engagement among midwives\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel pathway\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnstandardized\u003c/p\u003e \u003cp\u003eCoefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStd. Error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCritical\u003c/p\u003e \u003cp\u003eRatio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandardized\u003c/p\u003e \u003cp\u003eCoefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(B)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(Beta)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect Effect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork Engagement \u003cb\u003e\u0026lt;---\u003c/b\u003eOrganizational Commitment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.046*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork Performance \u003cb\u003e\u0026lt;---\u003c/b\u003eWork Engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.454\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.788\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.651\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork Performance \u003cb\u003e\u0026lt;---\u003c/b\u003eOrganizational Commitment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndirect Effect\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork Performance \u003cb\u003e\u0026lt;---\u003c/b\u003e Work Engagement \u003cb\u003e\u0026lt;---\u003c/b\u003e Organizational Commitment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e*Statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the mediating effect of work engagement in the relationship between organizational commitment and work performance among midwives. The study\u0026rsquo;s outcomes contribute to the literature by confirming and extending existing theoretical frameworks on worker engagement and performance, particularly in healthcare settings within low- and middle-income countries. By linking these findings with previous research, this study offers new insights into the dynamics of work engagement, organizational commitment, and work performance in the context of maternal healthcare.\u003c/p\u003e \u003cp\u003eThe first hypothesis, which proposed that organizational commitment would affect work engagement levels among midwives, was supported by statistically significant results. This result is consistent with past studies by Khalid and Khalid [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], Ces\u0026aacute;rio and Chambel [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], and Arcadio et al [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], which reported that organizational commitment influences work engagement. These studies support the notion that when workers feel loyalty and identification with their organization, they are more likely to engage enthusiastically in their work. However, this study extends the literature by confirming this relationship among midwives within the Ghanaian healthcare context, where systemic challenges, such as staffing shortages and resource limitations, often impact morale [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This study\u0026rsquo;s results underline that organizational commitment is not merely a contributing factor but a foundational determinant of work engagement among midwives. However, it is worth noting that not all research supports this association. For instance, Jackson [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e] found no significant relationship between organizational commitment and work engagement in their study. This discrepancy suggests that although the link between commitment and engagement is generally strong, it may not be universal. There might be potential influence of contextual factors such as organizational culture, leadership style, and work environment.\u003c/p\u003e \u003cp\u003eThe second hypothesis, which proposed that work engagement would influence work performance, was also supported. This finding is consistent with earlier studies by Sekhar et al [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], Sittar [\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e], and Mundhra and Pramanik [\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e], who similarly reported that work engagement impacts worker performance. In the present study, high engagement translated into improved work performance, particularly in midwifery care, which is essential for achieving better patient outcomes. This study adds to existing literature by demonstrating that promoting work engagement among midwives could have broader public health implications, especially since midwives' performance directly impacts maternal and neonatal health [\u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e]. While some studies have suggested that other variables, like creativity and job satisfaction, mediate the relationship between engagement and performance [\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e], this study challenges this view. It highlights that even in resource-constrained environments, intrinsic motivation derived from engagement can independently drive performance improvements. Therefore, fostering a sense of purpose and encouraging teamwork can further enhance work engagement and performance, especially in high-stakes professions like midwifery.\u003c/p\u003e \u003cp\u003eThe third hypothesis, which proposed that organizational commitment would influence work performance levels among midwives, was supported by the data. This result corroborates previous studies by Dinc [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], Suharto et al [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e], Krishnanathan and Mangaleswaran [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e], Beigi and Lajevardi [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e], and Cobbinah et al [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e], which have established that organizational commitment is a significant predictor of work performance. This study adds depth by confirming the role of organizational commitment in improving work performance specifically among midwives [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Nonetheless, it is important to acknowledge conflicting findings in other studies, such as Tawiah [\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e] and James [\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e], where organizational commitment did not affect work performance. These divergent results could be due to variations in organizational culture or work environment.\u003c/p\u003e \u003cp\u003eFinally, the fourth hypothesis, which proposed that work engagement would mediate the relationship between organizational commitment and work performance, was confirmed through full serial mediation. This finding is aligned with Suharto and Suprapto [\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e], who indicated that organizational commitment does not directly affect worker performance but operates through work engagement. Similarly, studies by Yalabik et al [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e] and Ces\u0026aacute;rio and Chambel [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] demonstrated that workers with strong organizational commitment exhibit higher levels of work engagement, which in turn drives superior performance. Furthermore, research by Lo et al [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] revealed that workers with high organizational commitment experience a greater sense of purpose and belonging, which positively influences their engagement and work performance. Importantly, this study provides insights that challenge simplistic interpretations of the commitment-performance relationship. While some literature has suggested that commitment alone is sufficient for performance improvements [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e], this study presents a deeper perspective, showing that engagement is a critical mediator that enables the commitment-performance link. These findings have significant implications for healthcare organizations aiming to improve maternal care outcomes. Policies and programs should target both organizational commitment and work engagement to achieve sustainable performance gains. By prioritizing strategies that foster both commitment and engagement, healthcare organizations can enhance the overall work performance and well-being of midwives, ultimately improving the quality of care they provide.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eAlthough this study offers valuable insights, several limitations should be considered. First, the sample was confined to midwives within a specific region, which may limit the generalizability of the findings to other healthcare professionals or settings. Second, the cross-sectional design of the study prevents us from making causal inferences, as the observed relationships could be influenced by unmeasured third variables. Third, the self-reported nature of the data may introduce response biases, such as social desirability or recall bias, which could impact the accuracy of the results.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides valuable insights into the relationships among organizational commitment, work engagement, and work performance in midwives. Our findings demonstrate that enhancing midwives' organizational commitment significantly improves both their work engagement and performance. The results further reveal that increased work engagement leads to substantially better performance, with work engagement serving as a full mediator between organizational commitment and work performance. These results suggest that organizational commitment boosts work performance primarily through its positive effect on work engagement, highlighting the crucial role of engagement in translating commitment into improved performance.\u003c/p\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003ePractical implications\u003c/h2\u003e \u003cp\u003eThe Ministry of Health (MoH) in Ghana should incorporate organizational commitment and work engagement strategies into national healthcare policies, particularly by developing frameworks that recognize work engagement's mediating role in performance enhancement. Healthcare institutions should cultivate supportive work environments that value midwives' contributions through incentive programs, open communication channels, and continuous professional development opportunities. These measures will help maintain high engagement levels and motivation among midwifery staff, ultimately improving healthcare service delivery.\u003c/p\u003e \u003cp\u003eWhile this study clarifies work engagement's mediating role, future research should explore additional mediators and moderators in the commitment-performance relationship. Longitudinal studies would particularly strengthen our understanding of these causal relationships over time. We encourage continued investigation in this area to develop targeted interventions that enhance midwives' performance, recommending that stakeholders support such evidence-based research to improve Ghana's healthcare system.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge all midwives who voluntarily participated in this study. We also extend our sincere appreciation to the three public health facilities for their support throughout the research process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI.S.M., A.W., M.M.I., L.C., and B.A.N. contributed to the study design and manuscript development, including writing the background, methodology, and editing/proofreading. I.S.M., M.M.I., and L.C. collected the data. M.M.I. conducted formal analysis and data visualization. A.W. and B.A.N. validated the results. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used and/or analyzed in this research are available from the corresponding author upon reasonable request, provided that participants’ confidentiality is maintained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Committee on Human Research, Publications, and Ethics at Kwame Nkrumah University of Science and Technology (CHRPE/AP/013/24). Written informed consent was obtained from all study participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDeussom R, Mwarey D, Bayu M, Abdullah SS, Marcus R. Systematic review of performance-enhancing health worker supervision approaches in low- and middle-income countries. Hum Resour Health. 2022;20(1):2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNyande FK, Avor WMK, Dartey AF. Ghanaian midwives\u0026rsquo; perspective of muddling through challenges with use of non-adjustable delivery beds: A descriptive exploratory study. 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Walden Dissertations and Doctoral Studies. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSittar K. Relationship of Work Engagements and Job Performance of University Teachers. Bull Educ Res. 2020;42(1):167\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMundhra E, Pramanik A. The Impact of Work Engagement on Employee Work Performance: Mediation Role of Work Autonomy. Int J Indian Psychol. 2024;12(1):1786\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNove A, Friberg IK, Bernis L, McConville F, Moran AC, Najjemba M, et al. Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: A Lives Saved Tool modelling study. Lancet Glob Health. 2021;9(1):e24\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsmail HN, Iqbal A, Nasr L. Employee engagement and job performance in Lebanon: The mediating role of creativity. Int J Prod Perform Manag. 2019;68(3):506\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalbes CAJ, Quines LA. The Mediating Effect of Job Satisfaction on the Relationship Between Work Engagement and Individual Work Performance Among Public School Teachers. Am J Multidiscip Res Innov. 2022;1(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTawiah AD. Effects Of Organizational Commitment On Performance: A Case Study Of Senior Staff. Kwame Nkrumah University Of Science And Technology. University of Cape Coast; 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJames M. Organisational Commitment, Job Performance and Job Satisfaction Among Employees of Concern for the Girl Child (Cgc) in Kampala District. Makerere University; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuharto B, Suprapto S. The Role of Organizational Commitment and Employee Engagement in Mediating The Impact of Perceived Organizational Support on Employee Performance. Dinasti Int J Manag Sci. 2023;4(6):1215\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Organizational commitment, work engagement, work performance, midwives","lastPublishedDoi":"10.21203/rs.3.rs-6037580/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6037580/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMidwives are at the heart of maternal and child health. However, their performance is significantly influenced by their organizational commitment and work engagement.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThis study investigated the mediating effect of work engagement in the relationship between organizational commitment and work performance among midwives.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eUsing an analytical cross-sectional design, data were collected from 254 midwives using validated scales measuring organizational commitment, work engagement, and work performance. Data analysis was conducted using SPSS Statistics and AMOS.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMost participants were female (96.9%) and aged 30\u0026ndash;39 years (54.3%). Organizational commitment was positively correlated with work engagement (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.125, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and work performance (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.166, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Work engagement also showed a strong positive correlation with work performance (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.662, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Mediation analysis confirmed that work engagement fully mediates the relationship between organizational commitment and work performance (β\u0026thinsp;=\u0026thinsp;0.078, \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.061, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe results of the study highlight the vital role of work engagement as a positive and significant mediator between organizational commitment and work performance among midwives. Investing in strategies that boost midwives\u0026rsquo; commitment and engagement is essential for strengthening maternal healthcare quality and workforce sustainability.\u003c/p\u003e","manuscriptTitle":"Work Engagement: The Key Driver in Transforming Organizational Commitment into Enhanced Work Performance among Midwives - A Structural Equation Modelling Approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-30 11:25:56","doi":"10.21203/rs.3.rs-6037580/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-26T23:42:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-26T04:16:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-18T20:07:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-16T15:08:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89299131953033280920784796793167224957","date":"2025-05-14T04:42:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276447678455862044261835961489842669463","date":"2025-05-12T17:55:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203321841927839376087036750664150770169","date":"2025-05-10T11:33:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97336052380259266193696628898636463099","date":"2025-05-10T08:50:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-07T17:29:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64147491446533336739229964833382988180","date":"2025-04-18T07:50:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-18T00:20:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-15T02:44:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-04-13T21:04:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f9d5ff10-2b61-4a95-bb63-308d7bb10ceb","owner":[],"postedDate":"April 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:14:49+00:00","versionOfRecord":{"articleIdentity":"rs-6037580","link":"https://doi.org/10.1186/s12913-025-13062-4","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-07-01 15:57:40","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2025-04-30 11:25:56","video":"","vorDoi":"10.1186/s12913-025-13062-4","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13062-4","workflowStages":[]},"version":"v1","identity":"rs-6037580","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6037580","identity":"rs-6037580","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}