Quality level of nursing work life and improvement interventions: Systematic review

Abstract

Objective

To identify the quality level of nursing work life and interventions for improvement.

Method

A systematic review was conducted. Literature was gathered from several databases – Science Direct, Pro-Quest, EBSCO, Google Scholar, Scopus, Wiley Online, and Emerald Insight – using the following keywords: “quality of work life (QWL) and nurse”, “quality of nursing work life (QNWL)”, “quality of work life (QWL) and nurse and intervention”, and “quality of nursing work life (QNWL) and intervention”.

Results

Our study demonstrated that studies of QNWL level from eight countries are low (28.6%), moderate (52.4%), and high (19%). Interventions for QNWL improvement include long-term care (LTC) team talks, empowerment models, integrating focus groups and round-table brainstorming, positive thinking training, stress inoculation programs, and participative teamwork and transactive memory improvement programs.

Conclusions

Quality of nursing work life is mostly at a moderate level and needs improvement interventions.

Introduction

Quality of work life is an employee's perception toward their work, organization, and employer, while the quality of nursing work life (QNWL) is the degree to which registered nurses can satisfy their personal needs through experiences at work organization while achieving the organization's goals.^1,2

The quality level of nursing work life was still diverse, ranging from low, moderate, and high. Quality of nursing work life is influenced by their relationships with colleagues, decision-making latitude, leadership and management style, demographic characteristics, salary and benefits, shifts, and workload.¹ Akter et al.³ reveal that the best predictor for the quality of nursing work life is monthly income, followed by work environment, organizational commitment, and job stress.

The quality of nursing work life has several impacts on nurses, nursing services, and organizations. Several studies revealed^3–11 that the quality of nursing work life was related to nursing care quality, work productivity, job burnout, job satisfaction, performance obstacles, horizontal violence, religious coping, organizational effectiveness, and organizational commitment. Brooks et al.¹² state that when organizations assess nursing work life, it can help them understand how work design, work environments, societal influences, and work and home life balance impacts nurses, and therefore impact organizational productivity. In addition, by assessing the quality of nursing work life, organizations will know which areas of work life need to be improved.

Quality of nursing work life improvements recommended a lot; however, they did not specify what steps should be taken. Lee et al.¹³ propose that nurse managers provide effective interventions to improve respect and autonomy aspects of nursing work life quality. As well, Faraji et al.¹⁴ propose to apply an effective strategy by creating a favorable work environment for improving the quality level of nursing work life.

Our study aims to identify the quality level of nursing work life and interventions for quality improvement through study literature.

Method

This study was conducted using a systematic review method. Several databases were searched for literature – Science Direct, Pro-Quest, EBSCO, Google Scholar, Scopus, Wiley Online, and Emerald Insight – using the following keywords: “quality of work life (QWL) and nurse”, “quality of nursing work life (QNWL)”, “quality of work life (QWL) and nurse and intervention”, and “quality of nursing work life (QNWL) and intervention”.

Literature was selected by the following inclusion criteria: (1) articles published from 2014 to 2018, (2) articles published in English, (3) articles focused on quality of nursing work life, and (4) articles focused on intervention for the quality of nursing work life improvement. The study was performed March–July 2018.

Results

Initially, there were 153 articles from Science Direct, 182 articles from Wiley, 149 articles from Scopus, 807 articles from Pro-Quest, 247 articles from EBSCO, and 6,753 articles from Emerald Insight. Of the 8,291 articles, 27 were selected that matched the inclusion criteria. The articles selection process is shown in Fig. 1. Twenty-one papers focused on the quality level of nursing work life, and six papers focused on intervention for the quality of nursing work life improvement.

Figure 1.

Articles selection process.

Quality level of nursing work life

Quality levels of nursing work life collected in this study are from studies in eight countries, Iran, Egypt, Mexico, Ethiopia, Bangladesh, Saudi Arabia, India, and Turkey. The results showed the quality of nursing work life mostly at the moderate level (52.4%). Only 19% of the studies reached a high level (Table 1), which were found in Iran, India, and Egypt. The studies were conducted mostly in low and middle-income countries (Table 2).

Table 1.

Quality levels of nursing work life (n = 21).

Quality level of nursing work life	f	%
Low	6	28.6
Moderate	11	52.4
High	4	19

Table 2.

Quality levels of nursing work life in several countries (n = 21).

Quality level of nursing work life	Country
Low	Iran,^14,15 Egypt,^7,16 Ethiopia,^17 Mexico^18
Moderate	Bangladesh,^3 Iran,^4,5,9,10,19 Saudi Arabia,^20,21 India,^22,23 Turkey^11
High	Iran,^24,25 India,^6 Egypt^8

Quality of nursing work life improvement intervention

Six studies about various interventions used to improve the quality of nursing work life were conducted in several countries, such as the United States, Indonesia, Israel, Iran, Canada, and France. The interventions included long-term care (LTC) team talks, empowerment models, integrating focus groups and round-table brainstorming, positive thinking training, stress inoculation programs, and participative teamwork and transactive memory improvement programs. Studies about these improvement interventions used several research methods to examine the effectiveness of the intervention, such as mixed methods, quasi-experiments, case studies, clinical trials, and cross sectionals. The results revealed significant improvements in the quality of nursing work life after intervention (Table 3).

Table 3.

Quality of nursing work life improvement intervention.

Intervention	Method	Important findings
Long Term Care (LTC) Team Talk^26The intervention involved Certified Nurse Aide (CNA) to lead the scheduled five-minute debriefing sessions at the end of the day shift. Program participants included CNA, floor nurses, and interdisciplinary team members. While leading the sessions, CNA will ask the staff three questions about activities that have been done, activities that need to be improved, and the need for improvement	Mixed method	Each quality of work life subscale scores were improved (e.g., teamwork and communication, coworker and supervisor support, wing characteristics, job demands and decision authority, and job intentions after the intervention). According to the qualitative research result after the intervention, participants realized that their ability to deal with teamwork and communication problems improved and discussed looking for the root of the problem together.
Empowerment Model^27The intervention used an empowerment model for structural and psychological empowerment	Mixed method	Quality of nursing work life increased by 39.7% as a result of the structural empowerment model. Three important indicators in structural empowerment were support, information, and resources. QNWL can be directly improved by the empowerment model while providing opportunities in work involvement, rewards, coordination, and communication to enable nurses to think critically, solve problems, and develop leadership skills.
Integrating Focus Groups and Round-Table Brainstorming^28The intervention was conducted in two phases. The first phase, focus group discussions (FGD) was done in three groups: two nurse groups and one district nurse inspector group (each of whom supervised 8–10 clinics). Each group consists of 8–9 members. FGD was conducted twice in each group with 90-minute discussions. The second phase, round-table brainstorming, was conducted by involving all FGD participants, nurses, clinical managers, and nurse supervisors to discuss the themes from the FGD results and make plans to improve the quality of nursing work life	Case study	The strategies succeeded in giving nursing management the basic strength and realistic arguments that make work life relevant to the community and gives nurses good conditions to meet their assignments and greater professional self-respect
Positive Thinking Training^29Training was conducted through social networking application Telegrams. Telegram was sent during three months. The intervention was done by sending messages containing positive thinking skills, motivational quotes, and happy songs. Different types of media were sent, including audio (3 messages), video (1 message) and picture (12 messages)	Quasi experiment	Pre- and post-intervention revealed improvements and significant differences in the mean total scores of quality of nursing work life in the dimensions of home life (p < 0.001), work design (p < 0.001), work context (p < 0.001), and the work world (p = 0.003). Covariance analysis also showed a significant difference between the pre- and post-intervention mean total scores of quality of nursing work life in the intervention group and the control group
Stress Inoculation Program^30The program was conducted in two sessions. The first session explained the nature and consequences of stress, identifying participants’ coping abilities and relaxation training. At the end of the first session, practical assignments were given to do during the week and participants suggested practicing relaxation techniques daily. Time management and cognitive restructuring were taught to participants at the second session	Clinical trial	There were significant improvements in the quality of nursing work life mean total scores from pre-intervention (80–13.8) to post-intervention (86.7–18.7) and the one-month follow up (88.3–17.6). Also, the total mean scores in the intervention group were higher than the control group (p < 0.005)
Participative Teamwork and Transactive Memory^31Participative teamwork is an organizational model based on the existence and availability of vocational training and nurse participation in nursing services, regular interdisciplinary staff meetings, and certain care service projects. Transactive memory is a way for nurses to encode, store, and retrieve knowledge collectively	Cross sectional	Participative teamwork and transactive memory were positively associated with quality of nursing work life. Organizational support and justice that nurses receive mediated the relationship between participative teamwork and their work life quality. Improving transactive memory can directly improve the quality of nursing work life

Discussion

Quality levels of nursing work life based on literature analyses in several countries were still varied and mostly moderate. The variations appear not only in different countries but also within singular countries. In Iran, for example, variation in quality of nursing work life can be seen in two studies.^14,15 The results showed the quality level of nursing work life as low, which differed from several studies^4,5,9,10,19 whose results showed a moderate level and two studies which showed a high level.

There are important things to learn from a high level quality of nursing work life. The high quality of nursing work life found in Prasad⁶ was related to the high level of nurse satisfaction with their job and career, general wellbeing, and home–work interface. El-Sayed et al.’s⁸ study showed that the high level quality of nursing work life related to nurses’ satisfaction with their colleagues, develop opportunity, management and supervision, and work environment. Moreover, Sadat et al.’s²⁴ results showed that the high quality of nursing work life was related to age and high level nurse education, job location, job position, and having a second nursing job in another hospital.

Meanwhile, a moderate quality level of nursing work life was related to several important things, such as work environment, monthly income, nurse productivity, personal accomplishments,^3,5,19 lack of satisfaction with training and development, facilities, work environment, relation, and cooperation.²³ The moderate quality levels of nursing work life in our review were mostly conducted in tertiary level hospitals, educational hospitals in low and middle-income countries, which may affect our result.

Improving the quality of nursing work life is important to make better nursing services. Several studies showed that improvement of the quality of nursing work life by conducting an intervention was successfully done in several countries. This study showed a specific quality of nursing work life improvement interventions with the steps to achieve them through study literature. These results could be used as references for healthcare management when they want to improve the quality of nursing work life in their hospital.

Our limitation is that literatures in this study were mostly focused on primary nurses; only one literature focused on nurse managers’ quality of work life. The finding can be used as consideration for another researcher to conduct studies that focus on nurse managers’ quality of nursing work life.

The quality of nursing work life still varies and is mostly at a moderate level; therefore, the focus is needed on developing nurses’ participation in organizations and nurses’ personal development as interventions.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgements

This work is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1843/UN2/R3.1/HKP.05.00/2018.