An Investigation of the Relationship between Perceived Organizational Support and Organizational Outcomes among Nurses in Selected Mission Hospitals in Ghana

The study investigated the relationship between perceived organizational support and organizational outcomes among nurses of selected mission hospitals in Ghana. Compared with Public Sector hospitals, Mission hospitals in Ghana operate with very limited resources. Thus, they have very little to incentivize their staff. Nonetheless, there is the general assumption that employers who demonstrate generous disposition towards their employees will reap reciprocal benefits. Such employees work beyond the job demands even in periods of serious financial difficulties. Phenomenology research design under the qualitative research method was used to find answers to the research questions. A sample size of 40 was drawn through purposive sampling technique from five selected Mission Hospitals in Bono and Bono East Regions of Ghana. Data collection tools used in the study were interview and observation. The data analysis went through compiling, disassembling, reassembling, interpreting and concluding, phases. The text was sorted based on predefined themes. Illustrative words from the original field notes were selected and placed in a table. Initial (level 1) codes mimicked the original information in the case of semantic coding process and, in the case of latent coding, meanings imbedded in the text were generated; this was presented in a form of discourse analysis. When the perceptible index of employees is made up of benevolence, care and celebration; when employees perceive employers who are concerned about their goals and values, and are willing to help them when they need special favour, they become a part of the organization and are ready to work beyond the job demands. Hence, organizations are advised to resource their human resource departments adequately to be able to respond to the needs and aspirations of their employees.


Introduction
Employees have a general belief concerning the level at which the organizations they work for appreciate their contribution and care about their well-being (Eisenberger, Fasolo, & Davis-LaMastro, 1990;Rhoades & Eisenberger, 2002;Shore & Shore, 1995). This belief usually emanate from organizational support that they are bound to receive. POS initiates a social exchange process wherein employees feel obligated to help their organizations achieve their goals and objectives. In addition, POS fulfils socio-emotional needs, resulting in greater identification and commitment to the organization, an increased desire to help the organization succeed, and greater psychological well-being. about their welfare, they are likely to reciprocate by increasing the level of their conscientiousness, involvement and innovation as well as other patriotic behaviours. The positive perception of employer and employee of their exchanges leads to synergetic effect on organizational outcomes; higher than the additive effect. This is supported by the self-enhancement process that finds an inverse relationship between perceived organizational support and job stress, burnout, and work-family conflict (Casimir et al.). This is also consistent with the findings of Dawley, Houghton & Bucklew (2010) that perceived organizational support correlates with in-role performance, organizational citizenship behaviour and reduced turnover intentions.
Compared with Public Sector hospitals, Mission hospitals in Ghana operate with very limited resources. Thus, they have very little to incentivize their staff. Nonetheless, there is the general assumption that employers who demonstrate generous disposition towards their employees will reap reciprocal benefits. Such employees work beyond the job demands even when the organization they work for is faced with serious financial difficulties. They resist the temptation to map effort to benefit. This is in keeping with the social exchange theory -defined sometimes as "value exchange" -which asserts that benevolent actions unlock loyalty and commitment (Blau 1964).
From a preliminarily account, nurses who work at some mission hospitals and have benefited from the benevolent gestures of their employers have turned out to be patriotic, and have worked to exceed in-role behaviours. This, therefore, indicates that nurses place more weight on what the organization gives them than what it does not give them. It was, therefore, not curious to note that despite the stressful nature of the work of the nurses, they were able to present a positive outlook in contributing to the organizational outcomes.
However, individual differences played out prominently in the assessment of the staffs" perceived organizational support. This is because, for some staff, availability of work materials alone is enough to boost their emotional attachment (Battistelli et al., 2015;Sharma & Dhar, 2016). In such instance, employees are less likely to leave the organization (Nazir et al., 2016). But with others, provision of other tangible materials such as accommodation and means of transportation are a necessary consideration. For instance, some employees characteristically reciprocate a good done them while others take a holistic view of circumstances before acting on them. The researchers are, therefore, of the view that perceived organizational support (POS) is associated with greater psychological well-being, a more positive orientation toward the organization, and behavioural outcomes helpful to the attainment of organizational goals (Allen, Shore, & Griffeth, 2003;Rhoades & Eisenberger, 2002). For these reasons, the researchers undertook an investigation of the relationship between perceived organizational support and organizational outcomes among nurses in selected mission hospitals in Ghana in order to understand how perceived organizational support could provide basis for organizational outcomes (Rhoades & Eisenberger, 2002).
Available studies in antecedent of perceived organizational support have looked at the interplay between personality and POS. For instance, works on perceived organizational support are well noted but outcomes between POS and its mechanisms are very few (Rhoades & Eisenberger 2002). Again, there is a paucity of information on the extent to which a generosity extended to the referent third person can influence the attitudes of the other peers, particularly nurses working in Mission hospitals who are constrained by resources. To fill this lacuna, the researchers sought to understand: What are the organizational supports that are available to nurses of the selected mission hospitals in Ghana? How can higher perceived organizational support contribute to achieving the organizational outcomes, such that support extended to colleague employees can have a spiralling effect on the other staff?

Perceived organizational support
Perceived organizational support is about the perception employees develop about the extent to which their organization values their contribution and cares for their well-being. It is believed that when the input of employees is valued they develop affective commitment for the organization which in turn leads to job satisfaction and other favourable behavioural outcomes. It is a form of social exchange where employees come to develop a sense of obligation to help the organization achieve its goals and objectives and if achieved they are rewarded for their effort. It is believed that the more employees demonstrate affective commitment to the cause of the organization by engaging in in-role and extra-role activities, the more their socio-emotional needs, as well as psychological well-being, will be taken care of (Kurtessis et al. 2015). This relationship is characterized by exchange of beliefs that a generous giver will be paid back, either in kind or in tangible reward (Eisenberger & Stinglhamber 2011). It is generally believed that when employees are motivated and well treated they develop loyalty and citizenship behaviours and in certain cases work to exceed employer"s expectations (Baran, Shanock and Miler 2012).
However, if employees come to the realization that their organization cares little about their opinions and shows very little concern about them, they become aliens and remaining in the organization becomes a matter of convenience rather than a genuine desire to help the cause of the organization. Likewise, when employees" evaluation of the condition of the relationship with their employer falls below their expectation, they begin to feel that their employers have breached their psychological contract and as a result, they demonstrate affective and cognitive reactions such as anger, deviancy and absenteeism. Gupta et al. (2016) advocated the need to build psychological bond with employees, including supportive work environment, to get the desired results. In their studies on the role of perceived organization support to gain work engagement and extra-role behaviour among nurses in Pakistan, Islam et. al. (2018) found that perceived organizational support predicts nurses" work outcomes. This implies that when nurses develop affective commitment for their organization because they perceive their organization to be supportive, cares about their emotions, makes them feel special, honours and celebrates them for their successes, they do not perceive psychological contract breach.
In another study by Islam et al. (2018e) to identify how organizational support help mitigate turnover among nurses in Pakistan, they found that when nurses perceive psychological contract breach, citizenship behaviour reduces; nurses reduce extra-role behaviours. Another study by Paille (2015) to examine the mediating role of psychological contract violation relative to perceived organizational support, trust, job satisfaction, organizational commitment and intention to leave, found that psychological contract violation partially mediate the relationship between trust in organization, commitment, satisfaction and turnover intentions. The study also showed that psychological contract violation negatively influences the relationship between perceived organizational support and individual"s civic virtue. In other words, employees are able to overcome frustrations (PCV) when they realize that the organization they work for is supportive and ready to assist them in times of great difficulty.
This view is further explained by job demand and job resource model (Demerouti et al. 2001). Demerouti and his colleagues evinced that resource specific working conditions predict perceived organizational support more than character specific. Adding that every occupation has its associated risk factors termed as job demand and resource demand. Whereas job demands are associated with psychological costs, job resources focus on how to achieve work goals, how to reduce physiological and psychological costs associated with work goals achievement. Additionally, job resource is also concerned with how to stimulate personal growth and development. Job resource is under the assumption that irrespective of job type or occupation, burnout and job stress will develop when certain job demands are higher than job resources. In other words, whereas badly job design or high job demand would tell on employees" mental and physical health, absence of job resources would negatively affect employees" motivation, and consequently make them cynical as well as affect their organizational citizenship behaviours with the ultimate effect on job performance.

Job Performance
According to Kasekende (2017) job performance is about the level of engagement of employee at work. Many factors determine employee"s readiness to deliver at optimal levels. With some employees, their satisfaction is derived from the extent to which they are engaged in the work processes. Such employees have internal locus of control and their satisfaction depends on how effectively they are able to contribute to organizational goals. With others who need prodding to functions at their best, organizational arrangements, processes and events have to be planned with them in mind.
According to Katou (2015) human resource process higher than content, has a stronger impact on organizational performance. As observed by Katou (2015), reward system as well as training components of human resource management is effective catalyst for organizational performance. That, when human resources process (reward and training) constitutes employee psychological contract, their provision grants them the needed satisfaction to up their performance. However, where due to austerity measures organizations limit or scrap the perceived organization supports, employees whose psychological contract depend on external locus become psychologically drained -they become unwilling to give of their best. In other instances where employers limit the application of the reward systems to high utility staff due to lack of resources, such measures draw undesirable reaction from those who may deem it unfair (Fu & Cheng, 2014).

Social Exchange Theory
Social exchange has been defined as any form of human interaction that is based on the belief that out of one"s voluntary benevolent action something of a value will flow from it; and that value exchange is the basis of human interaction (Blau 1964). Actors engage in "utilitarian" assessment of rewards that flow from and or to them and that what is given out is a function of what is received. According to Birtch, Chaing & Esch (2015), trust, fairness and justice predict organizational commitment and reciprocal behaviour and stability of most relationships depends on this. Trust, as either benevolence or credibility based, is associated with long-term strategic cooperation between partners. Benevolent trust is about reciprocity; a conscious effort on the part of the partners to support, share and understand (Colquitt et al. 2013). In credibility trust, parties make judgment on partner"s intents and ability to fulfil their obligation (Cullen et al. 2000). For instance, social exchange between a client and a vendor is based on both credibility and benevolent trust. In this relationship, the long and repetitive actions predict the actions of the client because of historical antecedents. The vendor"s subjective assessment is based on the fact that the client had always acted in good faith and it is assumed that he will do same this time around too.
Social exchange is about give and take where actors trade off resources (cost), tangible or intangible, in the form of time, energy, money, etc. to achieve their desired ends (Cook and Emerson 1978). Reward is the utility or satisfaction players in any relationship receive. It is generally the belief of the actors that if the outcome of their relationship is high, the utility to be derived will also be high. They do so by engaging in economizing (Satisficing) behaviours by calculating the direct and opportunity cost of what is received and given out. In this exchange, what actors are willing to give out are either equal or less than what they trade off.
It also looks at power distribution in exchange of resources or rewards. It is based on the principles that individuals who give more rewards than others or have monopoly over resource wield more power. Those who are unable to give, relative to others, become dependent on others. However, power diminishes when alternative forms of rewards are found, and that failure to comply, results in the withdrawal of resources by those who provide them (Toth et al. 2014).
Social exchange is also based on expectations. There are general, particular and comparative expectations. General expectations are rooted in social norms and this influences the demands partners make in the relationship. With this background knowledge and information, individuals come into relationship with the expectations of what they hope to receive. Regarding the particular expectations, there are cost and reward sides. Stability of relationship depends on individuals" cognitive assessment of the relationship. Relationship that is rewarding is likely to be stable. Unsatisfactory relationship, however, could be stable if there were no better alternatives (Toth et al. 2014). Individuals compare levels of alternatives to make decisions as to whether they are staying in a relationship or they are leaving. If the outcome or satisfaction to be derived from the alternative relationship is higher, individuals may leave. Alternatively, if there are no alternatives, irrespective of how bad the relationship is, individuals may let the status quo remain.
There is also the cost side of dependence; that, people may still be in a relationship for cost reasons. Dependence is about degree of reliability on others for relationship outcomes. When the cost of leaving is higher than the cost of remaining, individuals in a relationship are likely to remain (Tekleab 1982 cited in Sabatelli, Lee and Ripoll-Nunez 2018). There are also internal and external barriers as cost in relationship. Internal cost may be due to obligations or indebtedness which could place psychological obligation on the obligate, as in the case of husband and wife (Toth et al., 2014;Gelles, 1976). External cost could be pressure from community or the legal process.
Social exchange is, therefore, based on the principles of reciprocity, trust, power and commitment (Wu, Chuang & Hsu, 2014). The norm of reciprocity asserts that those who give something of a value must be given something of a value in return (tit for tat not tat for tit). That, a value of a reward is greater than or proportionate to reward previously given; and the value of a reward is determined by the current needs of the recipient. That, giving is voluntary and the donor can only give what is within his/her resources. That, those who had previously given beneficial rewards should not be put in a harm"s way (Gouldner 1960, cited in Gundelach & Traunmuller 2014. That, norm of reciprocity applies differently in cultures and societies; and exceptions are made to children and those who are mentally and physically challenged (Emerson 1976, cited in Tanskanen 2015. According to Toth et al. (2014), satisfactory or rewarding relationship is likely to be stable. However, unsatisfactory relationship can only be stable if there is no better alternative. Nonetheless, it is too simplistic to assume that all relationships are subject to trade-offs. In the opinion of Ventilborgh et al. (2015) there are many other forms of relationships which are not based on trade-offs. For instance in relational and ideological variants of psychological contract theory, individuals could remain in a relationship for other reasons. For instance, relationship between husband and wife, father and son/daughter are open, constructive and long term based.
Again, people who are not satisfied could still remain in a relationship not because they have not found a better alternative but for different reasons. For instance people remain in unsatisfactory relationships to provide buffers and checks for aberrations (Gelles 1976;Gullen, Johnson & Sakano 2000).

Methods
The study was to investigate the relationship between POS and organizational outcomes among nurses of selected mission hospitals in Ghanaunderstanding the linkages or mechanisms that influence nurses" decision to give their best to their organisation. This is best studied when qualitative research method is used. Hence, the use of this research approach. Using the qualitative research method helped researchers to understand complex problems or situations that perceived organizational support has on organizational outcomes, because the more facets the researchers uncover, the better; the more unpredictable aspects that surface, the better. This enabled researchers to hear multiple voices from many participants and gathered multiple perspectives, which made them to develop multiple themes. The specific research designed used by the researchers was phenomenology. This method helped in describing the structures of experience as nurses present themselves to consciousness, without recourse to theory, deduction, or assumptions from other disciplines. At the point of analysing the data collected, the researchers set aside, as far as humanly possible, all preconceived experiences to best understand the experiences of the nurses in the study, because of the use of the phenomenology research method.
Population for the study was made up of Nursing Officers, Staff Nurses, Staff Midwives, Enrolled Nurses and Community Health Nurses at five Mission Health facilities in Ghana. A sample size of 40 was drawn from the population using purposive sampling technique -because the researchers were interested in selecting a unique case that could provide insight into the phenomenon that was being studied (Creswell, 2014). The choice of purposive sampling method over other methods, including convenience sampling, snowballing, random sampling was also that the researchers were interested in "retrospective information" from staff who had certain aspirations that they expect their employers to help them achieve (Yin, 2011).
To achieve credibility, transferability, dependability and confirmability the researchers triangulated the data sources by using face-to-face interview, focus group discussion and observation (Creswell 2007). In view of the fact that in qualitative data collection methodology participant"s involvement is paramount, the researchers relied on interview, observation and focus group discussion as tools for collecting data for the study. The interviewing was a form of interaction that occurred between the interviewers and respondents in a methodical manner, in order to aid the researchers to gain valuable information for a systematic study. This did not only include the verbal interactions but also picking lessons from the subjects' gestures, demeanour, as well as their environment. As Trochim and Donnelly (2007) noted, observation as a systematic viewing of a particular phenomenon in its natural form or setting aids in assembling data for a particular study. The use of observation also helped the researchers to check for non-verbal expressions and feelings. It also allowed the researchers to generate a richly detailed account, whose interpretations confirmed or otherwise of the descriptions of behaviours, intentions, situations and events that the researcher got from the respondents through interview and Focus Group Discussion. FGD has been associated with efficiency because sometimes a particular research topic may not be satisfactorily answered by collecting data through the other traditional methods (Yin). Participants in focus group discussion picked on hints and cues from co-panellists to dilate on. This was not available in the face-to-face in-depth interview. The composition of the focus-group was 8 (eight) persons (Creswell 2014).
On receipt of appropriate clearance from the governing bodies of these facilities (Christian Health Association of Ghana and Ahmadiyya Muslim Health Service, Ghana), the researchers contacted the Health Services Administrators or the Matrons who sent information around, with some posting notices on the Notice Boards with a request to nursing staff to cooperate. Temporary arrangements were made at either the Nursing Bays within the wards or in dedicated offices to enable the researchers engage in face-to-face in-depth interview with the nurses. Where key informants were not available within the health facility, special arrangements were made to meet them at places of their choice. Interview guide, in all cases, was given to participants way ahead of time to enable them organize their thoughts. Respondents were made to sign Consent Forms in duplicate so they could keep copies. They were also made aware that the interviews would be recorded. In few instances, interviewees declined to go ahead with the interview when the issue of recording was raised.
The researchers intensely listened to the interviewees, asked follow up questions and probed if gaps were identified; and sustained a healthy conversation. The researchers spoke in "modest amounts", were not directional, stayed neutral, maintained rapport and analysed when interviewing (Yin 2011, p. 136-139). Originality of terms and local expressions, labels, words and phrases of interviewees were captured and maintained. Bradley (1995) recommends that when studying the "culture of a people" it is important to capture their language or get "into their heads" (pp. 7-8). Between 2 nd and 15 th December, 2018, 40 informants (nurses) were interviewed in Techiman Ahmadiyya Muslim Hospital, Techiman Seventh Day Adventist Hospital, Techiman Holy Family Hospital, Wenchi Methodist Hospital and Nkoranza St. Theresa"s Hospital in the Bono and Bono East Regions of Ghana. Between 45 minutes to one hour was spent with each respondent. Nonetheless, when the need arose to extend the time, special arrangement was made with the consent of the respondent.
Through transcription, all the observational notes, in-depth interviews and focus group discussion were put together. During the data collection stage, the researchers gathered or came across a plethora of information and concepts. This information was found at different "conceptual levels" (Yin, 2011, p. 187). To forestall inaccuracies and errors in capturing or reporting the observations and transcription, "compiling" took place the same day of the interview. The data analysis went through "compiling", "disassembling", "reassembling", "interpreting" and "concluding" phases (Yin,p.177). The text was sorted based on predefined themes. Illustrative words from the original field notes were selected and placed in a table. Initial (level 1) codes mimicked the original information in the case of semantic coding process and, in the case of latent coding meanings imbedded in the text were generated. According to Saldana (2009, p.3), "in vivo code" or open codes could be similar to the "original item". In certain cases, category (level 2) codes were generated. Finally, the categories that were generated were later pruned to three themes, which are acknowledgement of individual success, appreciation and employer benevolence as the perceived organizational support that their employers offer in their respective facilities.
The themes generated were presented in a form of discourse analysis to portray respondents account variously. Discourse analysis can be an examination of what is said and what is written (Quested & Rudge, 2003;Traynor, 2006), and has gained popularity recently in the fields of nursing, management, organization and human resource management; and is said to be employed where what lies hidden or overlooked is sought to be revealed (Lupton 1992).
In reporting the findings, the researchers were candid and threw in caveat on how professional and socio-cultural backgrounds could cloud judgments and conclusions. To enhance the validity of the study, the researchers identified a colleague who critiqued and gave feedback on weaknesses occasioned by personal biases. An external auditor in the person of a senior nursing officer gave feedback on validity of the account, accuracy of the transcription and the relevancy of the data to the research questions (Creswell 2014).

Ethical consideration
The researchers took note of the proliferation of social media platforms and concluded that it imposed a lot of ethical responsibility on them. Permission of participants was sought before recording. The researchers ensured that respondents did not suffer from any physical or emotional harm, discomfort, embarrassment or loss of privacy.

Findings from research question one
What are the organizational supports that are available to nurses of the selected mission hospitals in Ghana? A study into the relationship between perceived organizational support and organizational outcome required information on the number of years that the respondents had practiced their profession with their respective health organizations. It emerged from the respondents that one person had worked less than two (2) years in her organization. The majority of the respondents, which is twenty-six (26) out of the forty (40), had worked between two and five years. In Addition, eleven (11) of the respondents had worked for a period that span between five (5) and ten (10) years. Last but not the least is one person who had worked for more than ten (10) years.

Perceived organizational support
Findings of the study show that the majority of the respondents place much value on the belief employees have about how much their organization cares for and values them. In this respect, two things stood out as the most effective ways to increase POS: (a) treat people fairly, and (b) be a supportive employer. Among the elements of POS that the respondents dilated in the interview were goals and values identification, caring attitude and provision of material and logistical support. The respondents underscored the fact that when these essential factors are not available they rob them of the commitment and job satisfaction that they need to deliver on organizational outcomes. The following sub-themes emerged from perceived organizational support major theme; acknowledgment, appreciation, care, celebration, employer benevolence:

 Acknowledgement of individual success
Twenty-seven (27)

 Appreciation
Some respondents were magnanimous in their commendation of their health facilities for supporting them to improve themselves academically. They posited that it was only natural that they paid back the benevolent giver by increasing their output. They, however, took issues with those who, without recourse to the structures and policy guidelines of the health facilities, undertook self-improvements and expected the facilities to give them the needed recognition (upgrade). Similarly, SDAH4 and SDAH 6 said:

I was chosen as Quality Assurance
There is a system in place for all to follow so even if you upgrade yourself by your own means then getting to be put on a higher level presents problems. As for this when you followed the laid down procedures you will have all the support of the facility and it encourages the staff to work hard.
When I was coming I was told about the opportunities for growththis facility is better than several others in the health service because we were told that after your service you will have opportunities to improve yourself and I think it is really happening because some of those who came ahead of us are in school as I talk to you.
HFH2 took exception to the views of HFH1 and SDAH4. S/he put forth that organizations don"t always give support willingly; sometimes staff resort to petitions to get things done fairlyand when sometimes these are not done it detracts from their willingness to contribute meaningfully to organizational success: The thing is this, why are we working? We are all humans and we work to upgrade ourselves. So, there are certain basic needs that are supposed to be met. So, if these basic needs are not being met it means we have a petition to put out there. Because whilst we are all upgrading ourselves, when we work we need money; we need motivation, so when you are in a facility and all these are not coming in a way it diminishes your work output level.

 Employer benevolence
The link between giving a hand of support and how it encourages, inspires and impels staff to work extra was emphasized by some respondents. To the respondents concerned, just as the quantum of support is necessary, the timing is of much significance. It was stated that when support is given at a time it is much needed, its effect is everlasting; stressing that timely support gave them the safeguards and assurances that in their times of great need, they have a supportive employer to lean on its benevolent support. This was expressed inter alia: When my father passed on the hospital gave me support. They gave me a vehicle to convey all my relatives and I was happy. It has made me to feel a part of the facility. Sometimes, when you want to move from your accommodation they provide you the facility's vans to convey your personal effects; at times they organize community durbar just to bring out who they think is best worker for the year and they do appreciate. I think that if you are appreciated it will encourage you to work hard.
While some other respondents acknowledged the benevolent attitude of their employers, others were of the view that individuals react to motivation differently. They argued that the one motivating must show repetitively that he/she can be trusted. They added further that employees take a holistic view of circumstances to respond. They took the view that, when an employer does not show a discernible sincerity s/he could be misconstrued as attempting to bait; the effect on output is limited in such circumstances. This was expressed inter alia: Individual difference will make some nurses satisfied and committed, while others will not. Someone who had benefitted, because of other issues, it will not translate into job satisfaction. There will also be the case that where some benefit and others don't … it will bring down his/her moral [job satisfaction]. (MHW4) Meanwhile, other respondents took a negative view of their facilities in as far as empathy and care was concerned. They held the view that their facilities had not been caring enough and that affected their job satisfaction and commitment in a way. They argued that they have had to struggle out of their own problem. In one instance HFH2, expressed his view as:

Findings for research question Two
How can higher perceived organizational support contribute to achieving the organization's outcomes, such that support extended to colleague employees can have a spiralling effect on the other staff?
Respondents demonstrated that benefits extended to their colleagues can influence their own attitudes. They were of the view that the best form of assurance is the one done to a close associate who can easily be identified with. Specifically, MHW4 said: End of the year they give us small token. When they do all these things it motivates usbecause when you are in a facility and the facility is not helping you, you don'tyou wake up and you don't feel like going; so you say let me stay at home and rest. So when they do these things it motivates us to work. But generally the hospital has been very supportive. My friend was involved in a motor accident, they were three; the facility helped themtheir bills were paidyes, when they recovered you could see change in how they workedalways coming to work and this resonated with all of us.
Views expressed by some respondents on how support to their colleagues could unlock personal loyalty, commitment and job satisfaction were positive.
I know of a situation which happened recently in the ward. A staff had a needle prick and then he informed the quality assurance people. They went to see her, and that very day she had the money to go and buy drugs; it is inspiring because if I am at a place and my safety is assured, why not? So, yes, next time when I find myself in a similar situation they will assist me (STH4) According to the findings, staff of mission health facilities rated their managements highly on perceived organizational support. When the outlook of staff assessment of their employers is positive they are able to work beyond the job demand. The view of HFH1 echoes this: The facility has been supportiveduring weddings, funerals; everyone has been supportive. This helps to boost your commitment level. In anything that you are doing you get the feeling that there are people behind you. There are people who never sought for help but the organization was ready to assist them. (HFH1)

Discussion of Findings
Evidence from the data analysis supports the fact that nurses of mission hospitals rate their employers highly on the score of perceived organizational support. Themes such as acknowledgement, appreciation, employer benevolence, care and celebration emerged to underscore how these nurses perceive their employers. According to Casimir et al. (2014) when employer values the contribution of their employees and is concerned about their welfare, they are likely to reciprocate by increasing the level of their conscientiousness, involvement and innovation as well as other patriotic behaviours.
This finding reveals important information about how the theory of social exchange applies in the relationship between nurses and their employers. For employees to work in conditions of inadequate incentives, the employer must be credible and trustworthy. Studies suggest that employees" current actions reflect certain historical antecedents (Cullen et. al., 2000). Where the record of the actions of the employer is the type which can be trusted, employees are likely to gloss over the current challenges. It is also significant to note that this study took place at a time mission hospitals had received substantial number of staffing from the State, in keeping with its strategic partnership. This naturally made it difficult for the management of mission hospitals to extend their support to all their staff. It was, therefore, not curious that although majority of the nurses had not benefitted from their facilities, yet they were able to draw conclusions based on the generous disposition of their employers. It was also the case that the staff appreciated the predicament of their employers in terms of strains on resources at their disposal to adequately cater for the well-being of all their employees. The findings further reinforce job demand-resource model of Demerouti et al. (2001) in the literature review which states that resource specific working conditions predict perceived organizational support more than character specific. In other words, burnout and job stress are likely to occur in any healthcare environment; perceived organizational support, in the form of meeting employees at the point of their need acts as a counterbalancing measure.
It was observed, and from the accounts of staff during the interviews, that mission hospitals are not doing badly in terms of helping their employees to achieve their career goals. In terms of the provision of requisite tools and equipment, mission hospitals are not better resourced compared with the public hospitals; yet, where a particular resource is not available, the nursing profession has an inbuilt mechanism to deal with the conditions. Improvising is one such mechanism. From the account of staff, nurses who have benefited from the benevolent gestures of their facilities have turned out to be patriotic and have worked to exceed in-role behaviours. This, therefore, indicates that nurses place more weight on what the organization gives them than the stress aspects of the job. It is, therefore, not curious to note that despite the stressful nature of the work of nurses, they are able to present a positive outlook.
However, individual differences were noted in the staff assessment of perceived organizational support. For instance, the staff demonstrated that characteristically some individuals reciprocate a good done them by increasing their commitment and other patriotic behaviours while others take a holistic view of circumstances. Sincerity in the application of organizational support such that procedures laid down are not side-stepped is deemed a necessary requirement. In all cases, procedural and distributive justices in application of organizational support should not be said to have been done, rather they must be manifestly seen to have been upheld. This is because, when a benevolent giver does not show a demonstrable sincerity s/he intentions will be construed. This, therefore, means that mission hospitals have to do more to improve on the perception of their staff in terms of support extended to them.

Managerial Implications
Perceived organizational support which basically relates to the opinions of employees regarding how their employers (organisations) appreciate and deal with issues concerning their inputs and welfare. This has serious implications for organizations and human resource practitioners. The key issues here are identification and perfect fithow well management is able to connect organizational goals to the aspirations and welfare of their employees; and how best to provoke employees" sense of security to deal with uncertainties and fears. It, therefore, means that managers of organisations should be in constant search -finding out both the "little" things as well as the "bigger" things that could have a profound impact on their employees.
Not only that but also, managers who endeavour to create the ideal supportive work environment, together with a good psychological bond with employees succeed in gaining work engagement and extra-role behaviours of their employees. This is so because, positive perception of employer and employee of their exchanges leads to synergetic effect on organizational outcomes. By motivating and treating employees humanely, organizations succeed in engendering the ideal citizenship behaviour and loyalty capable of helping them to achieve organisational goals and expectations. Additionally, when there is a higher sense of perceived organizational support, trust increases and employee turnover reduces. The desired organisational support could further bring about a high level of employee engagement at work leading to high job performance.
The study underscores the importance of developing and implementing human resource policies that are all-encompassing. This goes a long way to mitigate situations where employee of selected religious, ethnic and educational backgrounds would feel discriminated against. In other words, where policies accommodate employees of diverse backgrounds, they stand a better chance to bring about trust, fairness and social justice at the work place. Managers should equally pay attention to important factors such as worker sensitivity, self-fulfilment and self-esteem that could influence employee equity considerations. Simply put, when the outlook of staff assessment of their employers is positive they are able to work beyond the job demand (Lazarus & Folkman, 1984).

Conclusion
The study investigated the relationship between perceived organizational support and organizational outcomesidentifying the mechanisms that motivate employees to contribute optimally to organizational goals. Based on the findings that emerged from the analysis of the data collected, the researchers conclude that employees" appreciation of benevolence, care and celebration; concern for goals and values extended to them results in identification, patriotism and conscientiousness as well as the willingness to remain with the organization all their working life. It also identified a perfect fit between perceived organizational support and organizational outcomes, such that when both employer and employee work together the effect is higher than if each had worked alone.