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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
ESADE Working Papers Series Available from ESADE Knowledge
Web: www.esadeknowledge.com
© ESADE
Avda. Pedralbes, 60-62
E-08034 Barcelona
Tel.: +34 93 280 61 62
ISSN 2014-8135
Depósito Legal: B-3449-2012
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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: simon.dolan@esade.edu
Tel: +34 93 4952052 or +93 2806162 (Ext. 2483)
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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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
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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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.
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
6
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.
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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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
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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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
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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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
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
10
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,
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
11
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.
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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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
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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-
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
13
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
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
14
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
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
15
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.
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
16
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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Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
17
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.
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
18
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
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
19
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).
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
20
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
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
21
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
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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.
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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 -
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
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)
Emotional demands (β= .26)
Social support .54 .29 .02 .001
Work overload (β= .08)
Supervisor (β= -.09)
Social support .64 .41 .05 .001
Co-worker (β= -.08)
Supervisor (β= -.15)
Spouse/partner (β= -.06)
Co-worker (β= -.13)
Medication use (n=1785) R R2 ΔR2 P
Self-Reported Health (n=1778) R R2 ΔR2 P
Personal demographics .11 .01 .01 .001
Personal demographics .17 .03 .03 .001
Age (β= .08)
Age (β= -.12 )
Marital status (β= .05)
Work situation characteristics .18 .03 .00 NS
Work situation characteristics .12 .01 .00 NS
Job Demands .36 .13 .10 .001
Job demands .30 .09 .08 .001
Work-family interference (β= -.21)
Work-family interference (β= .19)
Emotional demands (β= -.11)
Emotional demands (β= .12)
Social support .38 .14 .01 .001
Social support .31 .10 .01 .05
Spouse/partner (β= .08)
Supervisor (β= -.07) Co-worker (β= .07)
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
30
Table 3 Predictors of Work/Organization Outcomes
Absenteeism (n=1738) R R2 ΔR2 P Intent to Quit (n=1748) R R2 ΔR2 P
Personal demographics .14 .02 .02 .001
Personal demographics .17 .03 .03 .001
Gender (β= -.09)
Work situation characteristics .22 .05 .02 .001
Marital status (β= .07)
Unit tenure (β= -.16)
Work situation characteristics .16 .02 .00 NS
Work status (β= -.06)
Job demands .20 .04 .02 .001
Nursing specialty (β= -.06)
Work-family interference (β= .06)
Job demands .46 .21 .16 .001
Social support .22 .05 .01 .01
Work family interference (β= .17)
Supervisor (β= .08)
Emotional demands (β= .14)
Spouse/partner (β= -.06)
Work overload (β= .11)
Social support .52 .27 .06 .001
Work Engagement (n=1740) R R2 ΔR2 P
Supervisor (β= -.19)
Personal demographics .08 .01 .01 .05
Co-worker (β= -.12)
Outside Employment (β= -.08)
Work situation characteristics .16 .02 .01 .001
Affective Commitment (n=1747) R R2 ΔR2 P
Shift type (β= -.07)
Personal demographics .16 .02 .02 .001
Work status (β= .07)
Marital status (β= -.04)
Unit tenure (β= -.08)
Work situation characteristics .23 .05 .03 .001
Job demands .26 .07 .05 .001
Unit tenure (β= .17)
Emotional demands (β= -.12)
Work status (β= .08)
Work overload (β= .11)
Work days or nights (β= .07)
Work family interference (β= -.06)
Job demands .27 .08 .03 .001
Social support .38 .14 .07 .001
Emotional demands (β= -.06)
Supervisor (β= .20)
Social support .42 .18 .10 .001
Co-worker (β= .13)
Supervisor (β= .28)
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 .15 .02 .02 .001
Personal demographics .07 .00 .00 NS
Age (β= -12)
Work situation characteristics .14 .02 .02 .001
Work situation characteristics .20 .04 .02 .001
Work status (β= .09)
Work in hospital (β= -.10)
Job demands .28 .08 .06 .001
Job demands .34 .11 .07 .001
Work-family interference (β= .26)
Emotional demands (β= .15)
Social support .32 .10 .02 .001
Work family interference (β= .15)
Supervisor (β= .14)
Social support .34 .12 .01 .05
Supervisor (β= -.06)
Job demands, social support, work satisfaction and psychological well-being among nurses in Spain
31
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