Quality of Nursing Work Life

*MSc in Nursing,** MSc in Midwifery, Nursing & Midwifery Faculty ,Ilam University Of Medical Science,Ilam,IR-(Iran).

Abstract

Background And Aim: Nurses suffer from the high demands of their profession, and often complain of overwork and underpay. Problems persist with the nurses’ job satisfaction, burnout, organizational commitment and intent to leave. The aim of this study was to explore how nurses in an Iranian state rate the quality of their work life.
Material and Methods: This descriptive survey study was performed at the ISFAHAN Hospitals, IR, during the year 2007. The research instrument used was the Brooks and Anderson scale. A sample of 120 registered nurses (RNs) was enrolled into the study, using a simple random sample method. Data were analyzed using SPSS Version 11.5. Descriptive statistics, item summary statistics, and total scale and subscale scores were computed.
Result: Eighty two percent nurses who were included in this study believed that their workload was heavy, salaries were inadequate (95%), nurses were dissatisfied (63%), skill mix was found to be inadequate (72%) and a majority of nurses were unable to complete their work in the time available (54%). 79% nurses indicated that they did not have the autonomy to make patient care decisions. Respondents had little energy left after work (80%), were unable to balance their work and family lives (76%) and stated that rotating schedules negatively affected their lives (69%). Few nurses felt respected by the upper management (35%) and were able to participate in decisions (29%). Many of the nurses felt that society does not have an accurate image of nurses (62%) and indicated that their work settings did not provide career advancement (62%).
Discussion and Conclusion: Nurses' job satisfaction, salary, workload, staffing issues, skill mix, communication, autonomy, recognition and empowerment remain problematic.These findings provide information for policy makers and nursing managers on areas that need to be addressed, to retain nurses within community nursing and for important implications for nurse education administrators. Also needed is outcome-driven research examining the effectiveness, efficacy, and cost-benefit of specific strategies aimed at improving the QNWL and organizational productivity

Quality of work life, Nursing, nurses' job burnout

Introduction
In recent decades, interest in work and organizational psychology in relation to the quality of working life (QWL), has increased (1). QWL is essentially a multidimensional concept, and is a way of reasoning about people, work and the organization. It seems that the relationship between QWL and the degree of the nurse’s involvement in their work, is a critical factor in achieving higher levels of quality of care delivery (2). In health care organizations, QWL factors have recently been recognized to significantly influence the performance of staff members, and QWL also refers to strengths and weaknesses in the total work environment (3).

Quality of Nursing Work Life (QNWL) focuses on the degree to which registered nurses are able to satisfy important personal needs through their experiences in the work organization, while achieving the organization's goals , to make meaningful contributions to their organization (4).

Brooks and Anderson (2004), in an assessment of quality of nursing work life in acute care in a Midwestern state, concluded that nursing workload was too heavy, and that there was not enough time to do the job well. Respondents had little energy left after work, were unable to balance their work and family lives and stated that rotating schedules negatively affected their lives (5).
Preliminary evidence suggests that improvement of QNWL is a prerequisite to increasing productivity in hospitals. Thus, QNWL is in need of scholarly investigation (4). Identifying the nurse’s quality of work life can provide critical information for nursing managers in their efforts to design managerial programs that will enhance retention and work productivity. The purpose of this study was to explore how nurses in an Iranian state rate the quality of their work life.

Material and Methods

This descriptive study was performed at the Isfahan Hospitals, IR, University of Medical Sciences, during the year 2007. The study was approved by the institutional Ethics Committee. A sample of 120 registered nurses (RN) was enrolled into the study, using a simple random sample method .The only criterion used for sample inclusion, was that the nurse was employed in a hospital setting. The research instrument used was the Brooks and Anderson scale (2005) (4).There are 4 subscales in the QNWL tool: (1) work life/home life, (2) work design, (3) work context, and (4) work world. A demographic questionnaire was also distributed, and the items included age, gender, marital status and work experience.

The first is termed the ‘work life-home life dimension’, or the interface between the nurse’s work and home life. Since nurses are primarily female, this dimension reflects the role of mother (child care), daughter (elderly parent care), and spouse (family needs, available energy). The work design dimension is the composition of nursing work, and describes the actual work nurses perform. The work context dimension includes the practice settings in which nurses work and explores the impact of the work environment on both nurse and patient systems. Finally, the work world dimension is defined as the effect of broad social influences and change on the practice of nursing (5). Brooks and Anderson (2004) report acceptable reliability for all subscales (work life/home life .56, work design .58, work context .88, and work world .60)(5).

The survey was pilot tested with a convenience sample of RNs who closely resembled the RNs in the sample. Cronbach’s alphas for the dimensions were: work life/home life .75, work design .78, work context .90, work world .83 and total scale 0.93 (Table/Fig 1). The rating scale was “1 = strongly disagree� to “6 = strongly agree�

To facilitate analysis, the rating scale of Brooks’ QNWL survey was truncated into 2 areas of agrees and disagrees. The results reported here and in subsequent sections, are the percentage of nurses who responded with ratings of agree to strongly agree (ratings of 4, 5, and 6), or the percentage of nurses who responded with ratings of strongly disagree to disagree (ratings of 1, 2, and 3) (Table/Fig 2). The total possible scale score for the 42-item questionnaire ranged from 42 to 252. A low total scale score indicates a low overall QNWL, while a high total scale score indicates a high QNWL. For each subscale, the same is true, a high score indicating a more favourable environment. Data were analyzed using SPSS Version 11.5. Descriptive statistics, item summary statistics, and total scale and subscale scores were computed.

Results

The typical respondents were females (n = 89, 74.2%), mean aged 32.2 (±6.3) years and married (n = 80, 66.7%). Eighty percent were working full time in a staff position (n = 97) (Table/Fig 3). The mean work experience of the nursing staff was 8.2(±6.6) years .The frequency of agreed or disagreed responses to the questions included in the questionnaires, have been depicted in (Table/Fig 4).

Discussion

The purpose of this study was to explore how nurses in an Iranian state rate the quality of their work life.

Work Life/Home Life Dimension
The findings from the present study are consistent with the findings from a previous study on acute care nurses by Brooks and Anderson (2004), in a Midwestern state, rating the quality of their work life (5). Shift patterns have been related to turnover intention, job dissatisfaction, and job commitment (6), (7). Flexible working conditions and shift patterns were found to be most important sources of job dissatisfaction among 130 nurses and midwives in four London hospitals (8). Allowing nurses to influence shift patterns and accommodating preferred shift pattern, were positively associated with commitment to nursing (6). Rotating shifts also have been shown to increase nurse turnover (8).

Work Design Dimension
Hegney et al (2006) conclude that nurses found that their workload was heavy, and a majority of nurses were unable to complete their work in the time available. Workload has been cited as the principle cause for nurses considering leaving their workplace and their profession (9). Respondents in this study believed that there were not enough RNs on their units. Recent research has linked low staffing levels with poor patient welfare and longer patient stay (10). In the study by Aiken et al (2002), the authors found that each additional patient per nurse was associated with a 23% increase in the odds of nurse burnout and a 15% increase in the odds of job dissatisfaction (11).Workload and related issues such as understaffing or inappropriate staffing can cause turnover, which then compounds the problem (9).

Work Context Dimension
Few nurses felt respected by the upper management, and were able to participate in decisions. Day (2005) concluded that 65% of nurses believed that the administration did not listen or respond to their concerns and ideas. The results suggest that there needs to be an improvement in the line of management attitudes, with greater valuing of nurses (9).

Van and Lucas examined the relationship between management practices and anticipated turnover, and found that a more participated (vs. authoritarian) management style is associated with a less anticipated turnover. Gifford et al found that cultures that focus on building trust, which emphasize cohesion and encourage participatory decision making and open communication between managers and staff, are associated with a higher level of job satisfaction (12).
Respondents also indicated that their work settings did not provide career advancement opportunities, and skill mix was often inadequate. Rout (2000) found that nurses perceived a lack of opportunity for career development, and reported lower work satisfaction (13).

The potential for achievement, recognition, and growth have been identified as important motivators in the pursuit for excellence in the nursing practice. Strategies to enhance the nurse’s professional status and personal accomplishment should be effective in increasing the nurse’s life satisfaction (8).

In order to ensure job satisfaction and to prevent frustration, it is essential to create motivation to be useful, and to promote personal growth and development (14). Skill mix is a major identified factor affecting the nursing environment. Hegney et al (2006) concluded that staffing numbers and skill mix are factors having impact on patient safety, length of stay and patient outcomes; they were also shown to have a major effect on the staff morale of nurses in Queensland (9).

In addition, the nurse’s collaboration with other health care personnel can influence their job satisfaction. Collaboration with other professionals as well as with colleagues, is important for their professional development, and quality of care and forms is an important issue for the clinical nurse leadership (15).

Work World Dimension
Many felt that society does not have an accurate image of nurses. The findings of this study are in line with studies carried out concerning the socio-cultural status of nurses in Japan. Another important factor that has contributed to the nursing problem is the poor social position of RNs in Iran. People think of RNs as assistants to the physicians, and many physicians also regard nurses only as their helpers and do not consider them as specialists in the art of caring (14). A poor public image of nursing may affect not only nursing recruitment, but also the nurse’s attitudes towards work (16). To enhance the nurse’s job performance and to reduce their turnover intentions, it is important to improve both the public image and self-image of nurses. In Taiwan, Yin and Yang (2002) concluded that salary and fringe benefits were the strongest factors related to nursing turnover in hospitals (17). Focus group discussions showed that the nurse’s salaries differ in term of the hospital salary system, and pay was a buffer for them to stay in nursing (2). In another study in Jordan, Abu Alrub concluded that underpayment of nurses is one of the major reason for the nurse’s dissatisfaction and intention to leave hospitals (18). The nurse’s salaries have not increased in the past decade, and are not commensurate with increased responsibilities (5). Remuneration is often touted as the principal reason for job dissatisfaction, and certainly is identified by nurses as being a major reason for considering leaving a job.

A survey of staff nurses in North Carolina asked nurses why they stayed with their employer. Good mentors and colleagues, satisfactory pay, desirable benefits, flexible scheduling, and positive relationships with physicians, were the top 5 reasons cited by registered nurses (12).

Nurse educators are not preparing nurses for the rapidly changing healthcare industry, and healthcare executives are concerned about the RN workforce. This study highlights the importance of improving the nurses working environment and relieving the nurse’s heavy workload. Also, more of the dissatisfaction involved with nurses in this study is directly related to nurse’s salary. Findings suggest that discretionary employee benefits enhance the work life quality of nurses, and nurse executives should take notice of the same. Competitive salaries and a variety of schedule options are needed. In collaboration with their colleagues in human resources, nurse executives can develop and implement employee benefit programs that would improve the work life of nurses. Methods to reward and recognize the nurse’s contribution to patient care are needed. Shared governance, clinical ladders, and self-scheduling, are a few of the strategies that could be implemented in the clinical setting to improve nursing work life (5).

Conclusion

Results clearly suggest that hospitals need to provide vigorous and ongoing management skill development, so that managers can develop the competencies needed to be effective administrators. Likewise, education of nurse managers is needed so that they are better able to recognize staff for a job well done. Further research is needed to understand the work life concerns of nurses in other settings.

Findings from this study suggest that salaries were inadequate and nurses were dissatisfied, nursing workload was too heavy, and that there was not enough time for the job. Respondents had little energy left after work, were unable to balance their work and family lives and stated that rotating schedules negatively affected their lives. To conclude, nursing job satisfaction, turnover, workload, staffing issues, skill mix, communication, autonomy, rewards, recognition, and empowerment remain problematic. This research provides a beginning step in understanding the work life of nurses in an Iranian setting. Also, there is a need for outcome-driven research examining the effectiveness, efficacy, and cost-benefit of specific strategies aimed at improving the QNWL and organizational productivity.

Acknowledgement

We thank the staff of ISFAHAN, IR, hospitals, for providing the necessary support for successfully completing this study.