Job demands, social support, work satisfaction and...

ESADE WORKING PAPER Nº 233 July 2012

Job demands, social support, work satisfaction and psychological well-being among nurses in Spain

Ronald J. Burke

Scott Moodie

Simon Dolan

Lisa Fiksenbaum

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Depósito Legal: B-3449-2012

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Ronald J. Burke York University, Canada

Scott Moodie ESADE Future of Work Chair

ESADE Business School, Ramon Llull University, Spain

Simon Dolan ESADE Future of Work Chair

ESADE Business School, Ramon Llull University, Spain

Lisa Fiksenbaum York University, Canada

July 2012

Abstract

Background: Nursing has been described as a stressful occupation, with nursing staff reporting

high levels of job dissatisfaction, job burnout and poor well-being in many countries. This research

examined the relationship of job demands (work-family interference, emotional demands and work

overload) and three sources of social support (supervisor. co-worker and spouse/partner, family

and friends) with nurse well-being and work/organizational outcomes.

Method: Data were collected from 2104 nurses in Spain using anonymously completed

questionnaires. Hierarchical regression analyses were used to evaluate nurse wellbeing and

organizational outcomes according to personal demographics, work situation characteristics, job

demands, and social support.

Results: Results showed that job demands had generally significant and negative relationships

with nurse well-being as well as with several work/organizational outcomes. In addition, lack of

social support, particularly from supervisors and co-workers, were associated with deteriorated

nurse wellbeing and more unfavorable work/organizational outcomes.

Implications: This research replicates and extends previous findings obtained in various

countries, including Spain. Given consistent findings across countries, the importance of both

individual- and organizational-level interventions to improve nursing quality of work life is

highlighted. Examples areas of effective interventions are illustrated and discussion of potential

future interventions is offered.

Keywords: Nurses, Spain, Wellbeing, Outcomes, Demands, Social Support, Work

characteristics, Health, Accident propensity

Note: More Information about this paper and other projects connected with Stress, Burnout and quality of life can be

supplied by contacting:

Prof. Simon L. Dolan, ESADE Future of Work Chair

ESADE Business School, Ramon Llull University

Creapolis St Cugat Campus, Av. Torre Blanca, 59 08172

(St Cugat-Barcelona) Spain

Email: [email protected]

Tel: +34 93 4952052 or +93 2806162 (Ext. 2483)

http://www.esade.edu/research-webs/eng/fwc

mailto:[email protected]


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Although various countries have different systems for delivering health care to

their citizens, the health care budget of almost all countries is typically the largest

expense item with the largest share of this budget item devoted to salaries of

employees. Nurses comprise the largest employee group in the health care sector.

Nurses also make a significant contribution to levels of patient satisfaction and

quality of care.

Nurses then play an important role in the delivery of health care. Unfortunately,

there is growing evidence that nurses in several countries have become

increasingly dissatisfied with their work experiences resulting in lower morale,

increased turnover, and a more negative image of the nursing profession in the

views of potential nursing students. Many countries have reported a nursing

shortage that will only get worse, with more developed countries attempting to

attract nurses from still developing countries, reducing the level of nursing staff in

the latter countries. This situation is also adversely affected by financial constraints

currently being undertaken or imposed in many countries (e.g., Greece, Spain,

Italy, Portugal, the UK and Canada, among others) that require health care

systems to do more with less. It is therefore not surprising that considerable

research attention has been devoted to the work experiences and well-being of

nurses. The shortage of nurses is a widespread problem. Berliner & Ginzberg

(2002) contend that the reasons for the current shortages are varied from past

shortages. The current reasons for the shortages are visible at both ends of the

work lifecycle and result from lower job satisfaction, more intention to quit nursing,

fewer new nurses entering the profession, and nurses retiring earlier. The majority

of nurses tend to retire by their late 50s.

Nursing research – a sample

Aiken et al. (2011) reported findings from nine countries, four countries being

added to their 2001 five country study (L. H. Aiken et al. 2001) that included

98,118 bedside nurses from 1406 hospitals in nine countries. High nurse burnout

was found in hospitals in all countries except Germany with 60% of nurses in

South Korea and Japan scoring high. Job dissatisfaction approached 20% in most


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countries with a high of 60% in Japan. About half the nurses in all countries did not

believe that patients could care for themselves after being discharged.

Quality of care rated from fair to poor and ranged from 11% in Canada to 65% in

South Korea. About one quarter to one third of hospitals in each country were

seen as having poor working environments. Nurses working in better work

environments had less burnout, higher levels of job satisfaction, more favorable

quality of care outcomes, and lower levels of intent to quit. In their 2001 study,

Aiken and her colleagues describe this as “Hospital nurses love their work and

hate their jobs.”

A number of research studies have considered work experiences of nurses and

the effects of these on a range of personal and health care organization outcomes.

Work experiences have included job demands or stressors, levels of supervisor

and co-worker support, personal and job resources, work-family conflict, types of

shift schedules, work hours or shift length, staffing ratios, workplace incivility and

bullying, hospital downsizing and restructuring, and value incongruence. Personal

outcomes have addressed job satisfaction, aspects of psychological well-being

such as depression, anxiety, burnout, life satisfaction, medication use and

psychosomatic symptoms. Health-care organization outcomes have considered

intent to quit, absenteeism, turnover, job involvement, work engagement,

accidents and injuries, medical errors, and quality of patient care sometimes

provided by patients and their families themselves. Not surprisingly, nursing is

generally seen as a stressful occupation. Burnout has been one of the most

commonly examined outcomes in recent years in various countries.

A sample of studies examining nursing staff work experiences and various

outcomes follows in order to provide a context for the study reported below. De

Boer et al., (2011) undertook a meta analysis of studies of the relationship of work-

related critical incidents in hospital based health providers and post-traumatic

stress symptoms, finding consistent low- to medium-sized effects.


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Leiter & Maslach, (2009) conducted a study of nurses in Canada and found that

quality of work life experiences predicted levels of burnout which in turn impacted

turnover intentions. In a Canadian sample of new nurses having 18 months of

nursing experience (n=232), Peterson, McGillis Hall, O’Brien-Pallas, & Cockerill

(2011) found that higher job satisfaction was associated with less intention to

leave. Job demands were positively associated with job dissatisfaction and intent

to quit. Social support from supervisors was positively associated with job

satisfaction and co-worker support was related to lower levels of intention to quit.

McManus, Winder, & Gordon (2002) and Graham, Potts, & Ramirez (2002) both

found that health in doctors was associated with scores on the Maslach Burnout

Inventory, particularly poor health being related to higher levels of emotional

exhaustion and lower levels of personal accomplishment or efficacy. Thus data

obtained from various samples of both nurses and doctors generally support the

association of work demands and adverse psychological and physical health

outcomes.

Most of these studies have been carried out in North America, the UK and

Western Europe. Some studies have employed samples of doctors and other

specialists, but the majority have involved samples of nurses.

Nursing research undertaken in Spain

The present investigation of nurses’ work experiences and personal and

organizational outcomes was undertaken in Spain. Research interest in the

experiences of nurses in Spain has increased over the past ten years, with this

work addressing similar concerns as those mentioned above. Thus nursing

research in Spain has devoted considerable attention to nurse burnout. Nursing

research in Spain has considered various areas of work life such as rewards and

fairness, a number of different personal outcomes such as burnout, dissatisfaction

and psychological health, as well as organizational outcomes: such as intent to

quit. There are also a great number of studies of work experiences of nurses in

Spain published in Spanish journals.


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Here is a sample of some of this research. Moreno-Casbas et al (2001) undertook

a Delphi study in 1999 to identify priorities for nursing research in Spain. 189

Professionals involved in different nursing responsibilities provided data in two

rounds. Priority nursing research areas include quality of nursing care, satisfaction

of clients, and the needs of caregivers.

Yuanjie et al (2012) considered the relationship of value incongruence with self-

rated health, turnover intention and accident propensity, as mediated by burnout

levels in a sample of 234 nurses. Economical and Ethical value incongruence

mediated burnout while Economical, Ethical and Emotional value incongruence

predicted intention to turnover. Burnout levels mediated some of these

relationships.

García-Izquierdo & Ríos-Rísquez (2012) examined the relationship of various

psychosocial stressors and the three burnout components of the Maslach Burnout

Inventory (MBI). Workload and lack of emotional support predicted emotional

exhaustion; interpersonal conflict, lack of social support and type of work shift

predicted reduced personal accomplishment or efficacy; and interpersonal conflict,

lack of social support and excessive workload, and type of employment contract

predicted levels of cynicism.

Losa Iglesias, Becerro de Bengoa Vallejo, & Salvadores Fuentes (2010) using a

sample of 538 nurses, reported about 17% experienced bullying at work, with 8%

of these cases occurring weekly or daily. They concluded that bullying was

relatively high among Spanish nurses. Nurses reporting more bullying at work also

indicated lower levels of self-esteem.

Augusto Landa, López-Zafra, Berrios Martos, & Aguilar-Luzón (2010) investigated

relationships among emotional intelligence (EI), work stress, personal

demographic variables and health in a sample of 180 nurses from a general public

hospital. Nurses scoring higher on EI dimensions of clarity and emotional repair

reported lower levels of stress while nurses scoring higher on attention to


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emotions reported higher stress levels. Older, more experienced nurses also

indicated higher levels of stress.

Suner-Soler et al., (2012), in a diverse sample of 1095 health care workers,

studied the relationship of burnout with high health conceived as quality of life.

Their two central findings were that health levels in this sample were lower than

normative values and that respondents reporting high levels on each of three

burnout components also indicated poorer health.

Losa Iglesias et al. (2010), in a study of 80 nurses, reported a significant

relationship of greater use of experiential avoidance a form of denial and

avoidance coping, and higher levels of burnout.

Garcia-Izquierdo, Albar-Marin and Garcia-Ramirez (2008) investigated the role of

three sources of social support in a sample of 210 nurses at three hospitals in

Seville. Each of the three sources of social support (family, co-workers and

supervisor) had significant relationships with emotional exhaustion.

Albar Marin and Garcia-Ramirez (2005), in a sample of 210 nurses from hospitals

in Seville, reported that higher levels of social support were associated with lower

levels of emotional exhaustion.

Garrosa, Moreno-Jiminez, Liang and Gonzalez (2008), based on a sample of 473

nurses from 3 hospitals, examined relationships between social-demographic

characteristics, job stressors, burnout and the hardy personality trait. Age, job

stressors (workload, role ambiguity, relationship conflict, experience with pain and

death) and hardy personality (high scores on commitment, control and challenge)

were significantly associated with level s of burnout. They write that intervening to

reduce levels of burnout should address both increasing personal hardiness as

well as reducing levels of job stressors.

Gil-Monte, Valcarcel and Zornoza (1991), in a sample of 102 nursing

professionals, found that both role conflict and role ambiguity were positively


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related to emotional exhaustion and depersonalization and negatively related to

feelings of personal accomplishment and efficacy on the Maslach Burnout

Inventory.

Zupiria Gorostidi et al. (2007) examined stress sources associated with clinical

practice among 69 nursing students at various stages in their studies. The most

common stressors included lack of competence, uncertainty, powerlessness,

emotional involvement with patients, coming to grips with patient suffering,

relationship with teachers and other students, and overload. The strength of these

stressors however tended to decline with increased student tenure.

Pulido-Martos, Augusto-Landa, & Lopez-Zafra (2012) studied social stressors

among nursing students. The most common source of stress was academic (being

assessed, workload, and clinical stressors such as mistakes, confronting various

ambiguous situations, and the handling of technical equipment.

Quirós & Labrador (2008), in a diverse sample of 76 employees working at

Madrid’s Area-9 hospital emergency care center found relationships between

occupational stress, burnout, and psychosomatic symptoms.

Escribà-Agüir, Martín-Baena, & Pérez-Hoyos (2006), in a sample of 646 female

nurses and 367 male nurses, found that nurses working on rotating shifts were

more dissatisfied with their work hours, as opposed to those working days, or

nights, or both, on a permanent basis.

Experiences of Spanish nurses compared to nursing experiences in other

countries

Very few international and comparative studies of the experiences of nurses have

been carried out. Two large scale studies first compared nursing experiences in

five countries, and then added four more countries to these five to offer a nine

country comparison. Nurses in all nine countries reported considerable

dissatisfaction with their work experiences and there were some large country


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differences. Thus nurses in both Japan and South Korea were significantly less

satisfied than nurses in Germany and Canada. Spain was not included in these

studies.

However, Leiter, Gascón, & Martínez-Jarreta (2010) compared Canadian and

Spanish nurses’ perceptions of six areas of their work lives and on burnout.

Readers should treat their findings with caution since both samples of nurses were

convenience samples and not necessarily representative of nurses in either

country. Their study examined the relevance of a two process model of burnout in

each country. The two nursing groups differed on all study measures but the

direction of difference varied across the measures. Canadian nurses scored higher

on exhaustion and cynicism but also scored higher on personal accomplishment or

efficacy. Spanish nurses indicated lower levels of workload, but more favorable

evaluations of control, reward, community, fairness and value congruence.

Comparing the two groups of nurses with normative values, the Canadian nurses

scored low in exhaustion and high on community. The Spanish nurses had low

levels of workload, exhaustion and cynicism and low satisfaction with control,

resources, community, fairness and value congruence, and on personal

accomplishment or efficacy. Hierarchical regression analyses indicated a workload

effect on burnout for Canadian nurses and a value congruence effect on burnout

for Spanish nurses.

Objectives of the present study

The present study replicates and extends research on the consequences of job

demands and social support in a sample of Spanish nurses. This study employs a

very large sample of nursing staff. Outcome variables included measures of

individual nurse well-being and those having organizational impact. Some of these

have been examined in other investigations, and some included for the first time.

In addition both job demands and levels of social support represented potential

targets for intervention. A research model including four types of predictors and

both nurse well-being and work/organization outcomes was developed. The four

types of predictors were: personal demographics, work situation characteristics,


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job demands and levels of social support. Nurse outcome variables included

absenteeism, intent to quit, burnout, psychological health, and self-rated health:

work/organizational outcomes included work engagement, job involvement,

affective commitment, and propensity for accidents.

Two general hypotheses were considered.

1. Job demands would be associated with less favorable nurse well-being and

work/organization outcomes controlling for both personal demographics and

work situation characteristics.

2. Levels of social support would be associated with more favorable nurse

well-being outcomes and more positive work/organizational outcomes

controlling for personal demographics, work situation characteristics and job

demands.

Method

Procedure

All nurses, in order to practice in Spain, must be registered and qualified by a

regional association. This research was conducted with their support in several

regions in Spain. An on-line survey was developed, pre-tested and validated, and

sent to the regional associations for distribution to their members. We could not

determine the number sent and received, however a total of 2115 surveys were

completed online, with 11 omitted due to missing data resulting in a sample size of

2104. The majority of responding nurses were from Catalunya and Gipuzkoa. Data

were collected in 2010.


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Respondents

Table 1 presents the demographic characteristics of the nursing sample. Most

were female (91%), between 26 and 35 years of age (35%), were married or had a

partner (72%), had 10 years or less of nursing tenure (41%), 5 years of less of unit

tenure (35%), 2 years of less of position tenure (35%),most worked full-time

(86%), most had no nursing specialty (67%), most worked the day shift (84%),

most worked stable (non-rotating) shifts (80%), and most worked in units of 5 or

fewer staff (29%)

- - - - - - - - - - - - - - - - - - - - - - Enter Table 1 About Here

- - - - - - - - - - - - - - - - - - - - - -

Measures

Personal demographics

Personal demographics were measured by single items (see Table 1). These

included age, gender, marital status, and having a second job among others.

Work situation characteristics

Work situation characteristics were also measured by single items (see Table 1).

These included work status, unit size, having a nursing specialty, and nursing,

organizational and job tenures, among others.

Job Demands

Three job demands were examined.

Emotional demands were assessed by a six-item scale (α=.88) developed

by Van Veldhoven & Meijman (1994). Respondents indicated how often

they experienced each item on a five point Likert scale (1=never, 3-


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regualry, 5=always). A sample item was “Is your work emotionally

stressful?”

Work overload was measured by a six item scale (α=.87) developed by

Karasek et al. (1998). Responses were made on a five point frequency

scale (1=never, 3=regularly, 5=always). A sample item was “Do you have

to work very fast?”

Work-family interference was assessed by three items (α=.77) developed

by Geurts, (2000).Respondents again indicated how frequently they

experienced each item (1=never, 3=regularly, 5=always).

Social support

Three types of social support were measured by three items each developed by

Dolan, van Ameringen, & Arsenault (1992). Respondents indicated on a four point

scale how much each of three sources of social support went out of their way to do

things and made their work life easier for them. (1=not at all, 4=very much).

Supervisor support (α.86) - a sample item was “How easy is it for you to talk

with your supervisor?’

Co-worker support (α=.81) – “How much can your colleagues at work be

relied on when things get difficult (stressful) at work?”

Spouse/partner support (α=96) -”How attentive are your partner, friends or

relatives to your personal problems?”

Nurse well-being

Four nurse well-being indicators were included.

Burnout was measured by the 12 item SMBM (α=.96) developed by Shirom

& Melamed (2006) assessing three types of burnout: physical, emotional

and cognitive. Respondents indicated how frequently each item described


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their feelings on a 7point Likert scale (1=almost never, 4=sometimes,

7=almost always)

Sample items included “I feel physically exhausted.” and “I have difficulty

concentrating.”

Medication use was measured by a six item composite measure.

Respondents indicated whether they were currently or had recently taken

medication for six common illnesses (yes/no). Items included hypertension,

insomnia and diabetes.

Psychological well-being was assessed using scales to measure anxiety

and depression developed by Arsenault & Dolan (1983), each having four

items combined into a single score (α=.73) Respondents indicated (yes/no)

whether they had experienced each item during the last 3 months. Items

included ”worrying a lot” and “feeling hopeless”.

Self rated overall health was assessed by a single item used previously by

Benyamini & Idler (1999). Respondents rated their “general state of health” on a

five-point Likert scale (1=poor, 3=good, 5=excellent).

Organizational and work outcomes

Six organizational and work outcomes were included

Self-reported Absenteeism was measured by a single item

Respondents indicated (yes/no) whether they had been absent at any time during

the past two years.

Intent to quit was measured by 3 items (α=.94). Respondents indicated

their agreement with each item on a five point Likert scale (1=totally


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disagree, 3=neither agree nor disagree, 5=totally agree). A sample item

was “I am planning to leave my job for another in the near future.”

Job involvement was assessed by a four item scale (α=.70) developed by

Frone & Rice (1987).

Respondents indicated their agreement with each item on a seven point Likert

scale (1=totally disagree, 4-neither agree nor disagree, 7=totally agree). A sample

item was “The most important things that happen to me involve my job.”

Affective commitment was measured by a six item scale (α=.84) developed

by Meyer, Allen, & Smith (1993). Respondents indicated their agreement

with each item on the same seven point Likert scale. A sample item was “I

feel as if this organization’s problems are my own.”

Work engagement, included three components (vigor, dedication,

absorption) with each having three items, was measured by The UWES

scale developed by Schaufeli & Bakker (2003) (α=.92). Respondents

indicated how frequently they experienced each item on a seven point

Likert scale (0=never, 3=a few times a month, 6=everyday). Items included:

“At my work I feel bursting with energy”, “I get carried away when I am

working.” And “I am proud of the work that I do.”

Accident propensity was assessed by a seven item scale (α=.91) created

by the research team specifically for this study. Respondents indicated the

likelihood or probability that they might be involved in each of seven

possible work-related accidents in the next six months. Respondents

indicated this probability on a four point Likert scale (1=small probability.

4=large probability). Items included: “incorrect medication given”, “injured

on the job (slip or fall, stuck with syringe, etc.)”. 1

1 Due to size constraints, a copy of the correlation matrix of study measures is not included, but can

be obtained from the authors.


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Results

Analysis plan

Hierarchical regression analyses were undertaken in which predictor variables

were entered in blocks in a specified order. The first block of predictors were

personal demographic characteristics (n=4) including age, sex, marital status, and

having a second job. The second block of predictors were work situation

characteristics (n=6) including work status (full/part time), having a nursing

specialty, working on day versus night shift, and tenures in job and work unit. The

third block of predictors included the job demands (n=3) of emotional demands,

work-family interference or conflict, and work overload. The fourth block of

predictors included sources of social support from supervisors, co-workers and

spouse/partner (n=3). Separate hierarchical regressions were carried out for each

factor of nurse well being and organizational outcome. When a block of predictors

accounted for a significant amount or increment in explained variance (p<.05) on a

given outcome variable, individual items or variables within such blocks having

significant and independent relationships with a given outcome variable were

identified (p<.05). This approach to analysis allows for an examination of job

demands and social support on the various outcome measures controlling for both

personal demographics and work situation characteristics.

Nurse Well-Being

Table 2 presents the results of the hierarchical regression analyses in which the

four indicators of nurse wellbeing (Burnout, Medication Use, Psychological

Wellbeing and Self Rated Health) were separately regressed on the four blocks of

predictors (personal demographics, work situation characteristics, job demands,

social support). The following comments are offered in summary.

- - - - - - - - - - - - - - - - - - - - - - Enter Table 2 About Here

- - - - - - - - - - - - - - - - - - - - - -


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Burnout: Nurses reporting higher levels of work-family interference, emotional

demands and work overload indicated higher levels of burnout (βs=.31, 26 and

.08, respectively). Nurses reporting lower levels of both supervisor and co-worker

support also reported higher levels of burnout (βs =.15 and -.15, respectively).

Psychological Well-Being: Nurses indicating higher levels of work-family

interference and emotional demands also reported lower levels of psychological

wellbeing (in terms of greater anxiety and depression (βs =-.31 and -.26,

respectively) Nurses indicating higher levels of all three sources of social support

(supervisor, co-workers, spouse/partner, family and friends) also reported higher

levels of psychological well-being (βs =.09, .08, and .04, respectively).

Medication use: Nurses indicating higher levels of work-family interference and

emotional demands reported higher levels of medication use (βs =.19 and .12,

respectively). Nurses indicating higher levels of social support from supervisors

indicated less medication use (β =-.07).

Self-rated overall health: Nurses reporting higher levels of work-family interference

and emotional demands also indicated less positive assessments of their overall

health (βs =-21 and -.10, respectively); nurses reporting higher levels of social

support from spouse/partners, family and friends, and from their co-workers, also

reported more positive assessments of their overall health (βs =.08 and .07,

respectively.

Some general comments on these findings seem warranted. First, older nurses

generally reported more negative appraisals of their wellbeing outcomes. Second,

job demands were significantly associated with each nurse well-being outcome,

with work-family interference and emotional demands associated in each case.

The presence of work-family interference may reflect the predominantly female

sample since women have more responsibility for work-home functioning than do

men. Third, social support was a significant predictor of nurse wellbeing in all

analyses with the importance of support from both supervisors and co-workers

being common.


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Organizational and work outcomes

Table 3 shows the results of hierarchical regression analyses in which six

organizational and work outcomes (Absenteeism, Intent to Quit, Job Involvement,

Affective Commitment, Engagement and Accident Propensity) were separately

regressed on the four blocks of predictors. The following summary is offered.

- - - - - - - - - - - - - - - - - - - - - -

Enter Table 3 About Here - - - - - - - - - - - - - - - - - - - - - -

Self-reported absenteeism: Nurses reporting more work-family interference

indicated higher levels of self-reported absenteeism (β=.06). Nurses reporting

lower levels of social support from supervisors and higher levels of social support

from spouses/partners, family and friends indicated higher levels of absenteeism

(βs=.08 and -.05 respectively).

Intention to quit: Nurses indicating higher levels of each of the three job demands-

work-family interference, emotional work overload - indicated a greater intention to

quit (βs= .17, .14, and .11, respectively). Nurses indicating higher levels of

supervisors support and co-worker support reported a lower intention to quit (βs =

-.19 and -.12, respectively).

Job involvement: Nurses indicating higher levels of work-family interference

reported more job involvement (β =.26); nurses reporting more support form

supervisors also indicated more job involvement (β =.14)

Affective commitment: Nurses reporting higher levels of emotional demands

indicated less affective commitment (β =-.06); nurses indicating higher levels of

supervi9sor and co-worker support also reported higher levels of affective

commitment (βs =.24 and .11, respectively).

Work engagement: Nurses reporting higher levels of work overload, lower

emotional demands and less work-family interference also reported higher levels

of work engagement (βs =.11, -.12 and -.06, respectively). Nurses indicating


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higher levels of social support from supervisors, co-workers and spouse/partners

family and friends also reported higher levels of work engagement (βs=.20, .13

and .06, respectively).

Accident propensity: Nurses indicating higher levels of both emotional demands

and work-family interference indicated a higher probability of future accidents

(βs=.15 and .13, respectively); nurses reporting more supervisor support also

indicated a lower probability of future accidents (β =-.06).

Some general observations seemed appropriate. First, work situation

characteristics had more significant associations with organizational and work

outcomes than they did with nurse well being indicators (see Table 2). Second, job

demands emerged as an important predictor of each work outcome with work-

family interference and emotional demands having significant relationships with

each of the work outcomes. Third, social support from others in the workplace

(supervisors and co-workers) was notably important with support from supervisors

having a significant and widespread relationship with all work and organizational

outcomes.

Discussion

This investigation had the objective of replicating and extending previous nursing

research on the relationship of work experiences of nursing staff and both nurse

wellbeing and work/organizational outcomes. Earlier work had been carried out in

Spain, the location of the present study, and in a number of other countries.

The findings provide considerable support for the two general hypotheses

underlying this study. First, high levels of job demands or stressors had negative

relationships with indicators of nursing staff wellbeing (see Table 2) and

work/organizational outcomes (see Table 3). Second, that higher levels of social

support in the workplace would be associated with more positive nurse wellbeing

and work/organizational outcomes (again see Tables 2 and 3 respectively).


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Hierarchical regression analyses, controlling for both personal demographic and

work situation characteristics, produced findings consistent with our hypotheses

and with earlier published work (eg., Albar Marin & Garcia-Ramirez, 2005; Gil-

monte, Valcaárcel, & Zornoza, 1993; Leiter & Maslach, 2009; Suner-Soler et al.,

2012)

This body of work has produced relatively consistent findings using a number of

different indicators of work experiences and outcomes in samples of nursing

students, nurses and doctors working in a number of different health care settings

in a variety of countries. This work suggests that nursing, and health care more

broadly, is likely a stressful occupation, that nurses in several countries are

dissatisfied with their working lives, that nurse dissatisfaction with their work

experiences is associated with a diminished nursing staff well-being and

organizational outcomes relevant to patient care, and that the quality of patient

care may be deteriorating as well.

These observations highlight the importance that health care organizations,

nursing professional associations, and nurses themselves, initiate actions to

address issues and concerns that these research studies have shown to be

problematic.

Practical Applications

Both levels of job demands and of social support are amenable to intervention.

Social support can be enhanced in various ways. First, supervisors can be trained

to increase their levels of social support in management development workshops.

Second, nurses themselves can take part in in-service education offerings that

address the importance of social support and training in the attitudes and skills

required for effective social support. Third, doctors and nurses can themselves

work on developing more constructive relationships. Fourth, nurses in other

settings have found that the development of more cohesive and effective work

teams produced substantial benefits to nurses, patients and organizations. These

benefits included giving nurses a greater voice in their workplaces, increasing


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nurses’ feelings of empowerment, better communication, more complete learning

in the interests of improving patient care and safety, a higher quality of patient

care, and higher levels of social support.

Job demands can also be addressed at both the individual and organizational

level. Emotional demands can be decreased by encouraging employee discussion

when emotional events and concerns arise, allowing nursing staff to voice their

feelings to each other, their supervisors and administrators. Workload concerns

can also be addressed in team meetings that foster the search for better ways of

working.

Intervention studies conducted in nursing samples

Interventions with nursing staff have involved initiatives to reduce workplace

incivility, increase nurse well-being by increasing levels of nursing staff

empowerment, and increasing levels of nursing staff well-being by increasing

transformational leadership of nursing supervisors. Leiter, Laschinger, Day, &

Oore (2011) conducted a 6 month longitudinal study in 41 nursing units, with 8

having an intervention and the remaining 33 serving as controls, found that greater

improvements were found in the intervention groups on co-worker civility,

supervisor civility, respect, less cynicism, greater job satisfaction, greater trust in

management and less absenteeism. Osatuke, Moore, Ward, Dyrenforth, & Belton

(2009) also found that interventions among employees at the US veteran’s health

administration reduced levels of workplace incivility. Kelloway, Barling, & Helleur

(2000) trained 40 health care managers in transformational leadership and

reported increases in nursing staff well-being. Kelloway & Barling (2010) reviewed

studies linking leadership to individual well-being and safety in organizations and

outcomes of training intervention evaluations. Leiter & Maslach (2005) lay out six

strategies for addressing levels of burnout, ways to assess the work experiences

of staff, as well as suggestions for working with organizations to begin an

intervention project: Leiter & Maslach (2000) describe an intervention package that

addresses burnout and engagement. In addition, writing on the implementation of

intervention projects that identifies best approaches as well as pitfalls can be


22

found in Biron, Karanika-Murray, & Cooper (2012), Biron, Burke, & Cooper (2013),

and Maslach, Leiter, & Jackson (2012).

Limitations

Some limitations of this study should be noted to place the results in a wider

context. First, all data were collected using self-report questionnaires raising the

slight possibility of response set tendencies. Second, all data were collected at

one point in time making it difficult to determine cause-effect relationships. Third,

albeit the fact that the sample was very large, it was not possible to determine its

representativeness or other a response rate biases given that the data collection

procedure employed. Fourth, the large sample size resulted in relatively small

correlations and βs reaching levels of statistical significance. Fifth, many of the

nurse and work/organizational outcomes were themselves significantly correlated

with each other, raising a potential problem of multicolinearity which might have

inflated the number of statistically significant relationships reported.

Future research directions

Several promising research and intervention avenues follow from the findings of

this research. First, incorporating objective data such as absenteeism records,

patient satisfaction information, and patient care data would add to the strength of

the conclusions. Second, undertaking intervention projects targeted at reducing

particular job demands, increasing levels of support, and increasing both job and

individual resources with the necessity for sound evaluation, though complex and

difficulty, seem to be warranted given our knowledge of the work lives of nursing

staff.


23

Footnotes

1. Preparation of this manuscript was supported in part by the Future of Work Chair in ESADE and York University. We acknowledge the cooperation of the regional nursing associations and our respondents in carrying out the research, particularly the Col-legi Official d’Infermeres de Barcelona and the Hospital Valle d’Hebron. 2. Financial support was provided by the Spanish Ministry of Education and Technology (MEC) under the Project label: NUEVOS MÉTODOS DE PREVENCIÓN DEL SÍNDROME DE BURNOUT EN COLECTIVOS PROFESIONALES CON RIESGO PSICOSOCIAL”, with reference number: SEJ2007-67618


24

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Table 1 Demographic Characteristics of Sample

Gender N % Outside Hrs. last Mo. N %

Male 195 9,3 5 or less 96 20,8

Female 1.900 90,7 Nursing Tenure N % 6-10 135 29,2

Undisclosed 9 - 5 or less 418 20,4 11-15 75 16,2

6-10 413 20,2 16-20 61 13,2

Age N % 11-15 279 13,6 21-30 56 12,1

25 & younger 211 10,1 16-20 253 12,3 31 or more 39 8,4

26-35 730 34,8 21-25 190 9,3 Undisclosed 24 -

36-45 451 21,5 26-30 240 11,7

46-55 566 27 31 or more 256 12,5 Size of Unit N %

56 & older 137 6,5 Undisclosed 55 - 5 or less 554 28,6

Undisclosed 9 - 6-10 374 19,3

Position Tenure N % 11-20 390 20,1

Lives w/ Partner N % 2 or less 695 34,6 21-30 232 12

Yes 1.466 71,8 3-5 460 22,9 31 or more 388 20

No 575 28,2 6-10 371 18,5 Undisclosed 166 -

Undisclosed 63 - 11-15 157 7,8

16-20 180 9 Work Status N %

Outside Employment N % 21 or more 144 7,2 Full Time 1.797 86,1

Yes 486 23,4 Undisclosed 97 - Part Time 290 13,9

No 1.588 76,6 Undisclosed 17 -

Undisclosed 30 - Unit Tenure N %

2 or less 357 17,4 Reg. Shift Changes N %

Works in Public Hosp. N % 3-5 356 17,3 Yes 665 32,7

Yes 773 36,74 6-10 366 17,8 No 1.369 67,3

No 1.331 63,26 11-15 221 10,8 Undisclosed 70 -

Undisclosed 0 - 16-20 280 13,6

21-30 300 14,6 Work a Rotation N %

Nursing Specialty N % 31 or more 172 8,4 Yes 421 20,4

Yes 677 32,7 Undisclosed 52 - No 1.641 79,6

No 1.395 67,3 Undisclosed 42 -

Undisclosed 32 -


29

Table 2 Predictors of Nursing Staff Well-Being

Burnout (n=1744) R R2 ΔR2 P Psychological Well-Being (n=1740) R R2 ΔR2 P

Personal demographics .09 .01 .01 .01

Personal demographics .04 .00 .00 NS

Outside Employment (β= .08)

Work situation characteristics .07 .00 .00 NS

Work situation characteristics .13 .02 .01 .05

Job demands .52 .27 .27 .001

Job demands .60 .36 .34 .001

Work-family interference (β= .31)

Work - family interference (β= .32 )

Emotional demands (β= .25)


Social support .54 .29 .02 .001

Work overload (β= .08)

Supervisor (β= -.09)


Co-worker (β= -.08)


Spouse/partner (β= -.06)


Medication use (n=1785) R R2 ΔR2 P

Self-Reported Health (n=1778) R R2 ΔR2 P



Age (β= .08)

Age (β= -.12 )

Marital status (β= .05)



Job Demands .36 .13 .10 .001

Job demands .30 .09 .08 .001

Work-family interference (β= -.21)


Emotional demands (β= -.11)




Spouse/partner (β= .08)

Supervisor (β= -.07) Co-worker (β= .07)


30

Table 3 Predictors of Work/Organization Outcomes

Absenteeism (n=1738) R R2 ΔR2 P Intent to Quit (n=1748) R R2 ΔR2 P



Gender (β= -.09)


Marital status (β= .07)

Unit tenure (β= -.16)


Work status (β= -.06)

Job demands .20 .04 .02 .001

Nursing specialty (β= -.06)


Job demands .46 .21 .16 .001


Work family interference (β= .17)

Supervisor (β= .08)


Spouse/partner (β= -.06)



Work Engagement (n=1740) R R2 ΔR2 P




Outside Employment (β= -.08)


Affective Commitment (n=1747) R R2 ΔR2 P

Shift type (β= -.07)


Work status (β= .07)

Marital status (β= -.04)

Unit tenure (β= -.08)


Job demands .26 .07 .05 .001

Unit tenure (β= .17)




Work days or nights (β= .07)

Work family interference (β= -.06)

Job demands .27 .08 .03 .001





Co-worker (β= .13)


Spouse/partner (β= .056)

Co-worker (β= .11)

Accident Propensity (n=1734) R R2 ΔR2 P

Job Involvement (n=1743) R R2 ΔR2 P


Personal demographics .07 .00 .00 NS

Age (β= -12)




Work in hospital (β= -.10)

Job demands .28 .08 .06 .001

Job demands .34 .11 .07 .001




Work family interference (β= .15)





31

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