The impact of perceived workload on nurse satisfaction with work-life balance and intention to leave the occupation
Introduction
Nurses are the largest body of employees in the healthcare system and the frontline of patient care in health care. However, it is widely recognised that in Australia, as in many other Advanced Market Economies (AME), there is increasing concern regarding the retention of this workforce (Chen, Brown, Bowers, & Chang, 2015). Changes in hospital management systems focused on cost control have served to increase the focus on patient throughput (Hogan, Moxham, & Dwyer, 2007). This has expanded nursing services but not staffing levels (Holland, Allen, & Cooper, 2011). Combined with higher patient turnaround, these issues have contributed to increased perceived workload among nurses and have been shown to negatively impact well-being and the turnover intention of nurses (Jourdain & Chenêvert, 2010).
The issue of retention is already a concern of the Australian federal government, with a major commissioned report indicating that population health trends, combined with poor retention rates in the nursing workforce will lead to an imminent and acute nursing shortfall (AFHW, 2014). Further, a federal government report identified that an exponential decline in the average number of hours worked by nurses per week as they get older is also an issue (AIHW, 2015), and may be a pre-cursor to intention to leave the occupation. These predicted shortages and reduced working hours come at a time when demand for healthcare services is on the rise, in part because of the ageing population, and an expectation of high-quality health care by the population. These predictions are also in line with an Australian Productivity Commission report (2008), which identified increases in demand for healthcare services. Given these combinations of factors, the effective retention of skilled and experienced nurses is a highly significant issue.
Given the importance of workforce retention in this sector of healthcare, there is a burgeoning body of research investigating the drivers of nurses' intentions to leave the profession. Key drivers included reduced quality of work life (e.g., work arrangement, workload, work-life balance) (Lee et al., 2017), low job autonomy (Yamaguchi, Inoue, Harada, & Oike, 2016), poor states of well-being (e.g., burnout) (Moloney, Boxall, Parsons, & Sheridan, 2017), and stressors such as work-life conflict (Brewer, Kovner, Greene, & Cheng, 2009). Congruent to these findings, a preliminary thematic analysis of qualitative data collected via an open-ended response question in the survey of our current study, revealed key themes around workload leading to decreased well-being, and specifically, lower satisfaction with work-life balance. Typical responses extracted from the sample are highlighted below relate to job demands and management included:
“The workload does NOT fit the time frame of any allocated shift. Paperwork is time consuming and is often competed after the shift is over, in the staff members' own time and is therefore unpaid. I have observed that staff are expected to stay on after to complete and attend to further nursing duties. In my view it is an extremely poor way to treat people.”
“We as a group (nurses) are exhausted by the demands of employers and patients…These expectations are unreasonable and will not be met without more staff…
“Overworked mentally and physically with little or no help support from management...”
“Many feel that we cannot go any harder or faster and are looking to leave”.
“Being made to work to exhaustion every week is why I am getting out of nursing...”
“.,.if staff identify they are struggling to cope, automatic response is that they need to become more resilient, when in fact they are very resilient but the demands on them are now intolerable...it has become an easy way for managers to blame employees...”
The area that generated substantial comment was issues with work-life balance:
“I feel like that is what I have let go of, finding the family work life balance”.
“Many of our senior colleagues are burnt out and I am concerned about experienced people leaving. My work life balance would be improved ……”
With regard to intention to leave:
“Work load of an RN (registered nurse) in the aged care sector is absolutely ridiculous. It is not humanly possible to carry out all the tasks required of you in the shift times you are rostered for. This is why I have made the decision to leave nursing ....”
Parallel to the themes identified in our preliminary study, literature has highlighted that nurses' experiences of inability to balance work and family demands is significantly linked to intention to leave the profession (Brewer et al., 2009; Simon, Kümmerling, & Hasselhorn, 2004). However, others have found the contrary, where such inability to maintain a healthy balance between work and family demands did not significantly impact intention to leave the nursing profession (Yamaguchi et al., 2016). The first major contribution of our research is to clarify these contrasting findings in the Australian context. Drawing on the Job Demand-Resources (JD-R) Model, our second contribution is, in response to calls to clarify the possible relationship between the work-family interface and nurses' intentions to leave the profession (Yamaguchi et al., 2016), and to examine the impact of perceived workload as a factor in the depletion of nurses' resources. The depletion of resources in maintaining a healthy balance between their work and family domains (an indicator of well-being) may act as a driver of nurses' intentions to leave the profession. Our final contribution is to build on understanding the impact of workload on nurse wellness and intention to leave the profession by examining high involvement work practices (HIWPs) as a form of organisational support which may be helpful in this regard. The argument is made that HIWPs may be able buffer the resource-depleting impact of perceived workload on nurse wellness and assist in maintaining a healthy work-life balance and thus, reduce intention to leave the occupation. Practically, our research answer calls for more focus on retention policies and practices to avert the potential workforce shortage crisis in the Australian nursing sector (AIHW, 2015).
HIWPs can be an effective management strategy focusing on improving communication, empowerment and participation, with employees (Searle et al., 2011), and importantly are factors within the control of management (Holland et al., 2011; Moseley, Jeffers, & Paterson, 2008). HIWPs focus on providing greater scope for employee involvement in managing work patterns and practices to improve the work efficiency, employee skills and well-being to enhance organisational effectiveness, employee satisfaction, commitment and therefore retention (Boxall & Purcell, 2016). As Boxall, Hutchison, and Wassenaar (2015) found, when studying HIWPs, greater opportunity for discretion in the decisions that concern the workforce, create the conditions for greater involvement and, in turn, contribute to their well-being. Although they note, as do Boxall and Purcell (2016), that the nature of their effectiveness will relate to the type of work and environment. Changes associated with well-being, including increased satisfaction with work-life balance (Qu & Zhao, 2012), have been identified as a key concern for this workforce in their decision to leave the profession (Shacklock & Brunetto, 2012; Shields & Ward, 2001). However, to date, there is a paucity of comprehensive research on these issues (Cheng, Bartram, Karimi, & Leggat, 2013).
Section snippets
Job Demands–Resources Model
The theoretical framework used to examine the impact of job demands (perceived workload) and the ability to manage and replenish individuals' resources, is the Job Demands–Resources Model (JD-R) (Bakker, Demerouti, & Euwema, 2005; Schaufeli & Bakker, 2004). The theory states that whilst job demands are not necessarily negative, problems arise when the demands and stressors associated with the job (perceived workload) outstrip the opportunity to replenish a resource. A key element is the role of
Sample and procedures
In collaboration with the Australian Nursing and Midwifery Federation (ANMF), a quantitative, cross-sectional correlational field study (survey) was carried out (Tharenou, Donohue, & Cooper, 2007) and data were collected via a nationwide online survey in Australia in 2016. The population for this study were members of the ANMF employed in Australian States and Territories at the time of the survey. In total, the survey yielded 2984 responses. Eighty-nine percent of respondents reported being
Analysis of reliability and validity of measures
First, to verify that the measures used in this study have demonstrated construct validity, we conducted a confirmatory factor analysis (CFA) using AMOS 25 (Hair, Black, Babin, & Anderson, 2014), using full information maximum likelihood (FIML) estimation in handling missing data as recommended by Enders and Bandalos (2001). To evaluate model fit, this study reports several model fit statistics including the chi-square goodness-of-fit test, comparative fit index (CFI) and Tucker-Lewis index
Results
The study's variable means, standard deviations, and intercorrelations are summarised in Table 1. Correlations among perceived workload, satisfaction with work-life balance, and intention to leave the occupation were in accordance with our overall predictions.
Discussion
Overall, the results provide support for the three hypotheses. As the analysis of Hypothesis H1 indicates, the perception that workload is associated with increased job demands that deplete nurses of their resources (and wellness) and thus, is leading them to actively consider leaving the profession. This is concerning, as the profession is already expected to see a workforce shortfall over the coming decades, simply based on the demands of an ageing population. Hypothesis H2 indicates that
Implications
The implications of this study are in the drive for more economic efficiencies in the health sector, what is potentially being lost is the need to look after the health and well-being of those who work within this sector. As Chen et al. (2015) and Sawatzky, Enns, and Legare (2015) note, high nurse turnover impacts patient safety and organisational effectiveness. For policy makers, our study indicates that priority should be given to initiatives that enhance organisational support aimed at
Conclusion
It is clear from the research we are seeing a workforce increasingly pushed to a point where the opportunity to recover is being tested in a demanding work environment. What is important to note is that management is in a position to address these issues before these highly-skilled employees exit the profession. The current research suggests that when higher perceived workload is combined with lower levels of organisational support, in the form of policies and practices that replenish
Declarations of Competing Interest
None.
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