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Reward frustration at work and intention to leave the nursing profession—Prospective results from the European longitudinal NEXT study
International Journal of Nursing Studies 48 (2011) 628–635
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Reward frustration at work and intention to leave the nursing profession—Prospective results from the European longitudinal NEXT study Jian Li a,b,*, Michael Galatsch c, Johannes Siegrist b, Bernd Hans Mu¨ller a, Hans Martin Hasselhorn d European NEXT Study group a
Department of Safety Engineering, University of Wuppertal, Wuppertal, Germany Department of Medical Sociology, University of Duesseldorf, Duesseldorf, Germany Institute of Safety Technology, Nursing Research Section, University of Wuppertal, Wuppertal, Germany d Federal Institute for Occupational Safety and Health, Berlin, Germany b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 May 2010 Received in revised form 23 July 2010 Accepted 10 September 2010
Background: Many countries are facing a serious situation of nursing shortage, and retention of nurses is a challenge. Objectives: To examine whether reward frustration at work, as measured by the effort– reward imbalance model, predicts intention to leave the nursing profession, using data from the European longitudinal nurses’ early exit study. Design: A prospective study with one-year follow-up. Methods: 6469 registered female nurses working in hospitals in seven European countries who did not have intention to leave the nursing profession at baseline were included in our analyses by multivariate Poisson regression. Results: 8.24% nurses newly developed intention to leave during follow-up. High effort– reward imbalance at baseline predicted an elevated risk of intention to leave the profession (relative risk 1.33, 95% confidence interval 1.22–1.45), and reward frustration (poor salary and promotion prospects, lack of esteem) showed the strongest explanatory power. Findings were similar in a majority of the countries. Conclusions: Results suggest that improving the psychosocial work environment, and specifically occupational rewards, may be helpful in retaining nurses and consequently reducing nursing shortage in Europe. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Effort–reward imbalance Intention to leave Nursing shortage
What is already known about the topic? Nursing shortage is an international problem, particularly in rapidly aging societies across Europe. Many nurses have high intention to leave the nursing profession, and retention of nurses is a challenge. * Corresponding author at: Department of Safety Engineering, University of Wuppertal, Gaussstrasse 20, 42119 Wuppertal, Germany. Tel.: +49 202 439 3253; fax: +49 202 439 3828. E-mail address: [email protected] (J. Li). 0020-7489/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2010.09.011
Unfavourable psychosocial work environment causes intention to leave the nursing profession even actual turnover, but the prospective evidence is limited. What this paper adds A large-scale prospective study was conducted covering samples of nurses from seven European countries. Effort reward imbalance, in particular reward frustration, is predictive of intention to leave among European nurses. Improving the psychosocial work environment, and specifically occupational rewards, may help to retain
J. Li et al. / International Journal of Nursing Studies 48 (2011) 628–635
nurses and consequently reduce nursing shortage in Europe. 1. Introduction Nursing shortage and understaffing is a problem of growing concern in many countries, in particular in rapidly aging societies (West et al., 2007). In a recent international survey in 69 countries, 90 out of 105 (86%) nursing unions and organizations reported shortage of nursing personnel and its impact on health care delivery (Clark and Clark, 2003; Lynn and Redman, 2005). While improved strategies of recruiting health professionals, in part from foreign countries, are needed, major efforts should be directed towards maintaining employed nurses in their jobs as long as possible (Westendorf, 2007). To this end, quality of work and employment needs to be critically improved. In order to promote these aims, the availability of detailed research findings from organizational and occupational sciences seems crucial as they can guide targeted interventions and the development of strategies of organizational change. A number of studies have been performed in recent years to tackle this problem by identifying work- and employmentrelated determinants of nursing turnover, intention to leave the nursing profession, and early exit from the labour market (Hayes et al., 2006). One such investigation, the Nurses’ early exit (NEXT) study, explicitly addressed the role of adverse work conditions in explaining professional turnover and intention to leave the job in a comparative perspective, by recruiting nursing staff from 10 European countries (Hasselhorn et al., 2005). Previous findings report strong associations of a stressful psychosocial work environment with intention to leave one’s profession, specifically if measured in terms of two leading models of work-related stress, the combination of high demand and low control (Hasselhorn et al., 2008) and the imbalance between high efforts spent and low rewards received in turn (Hasselhorn et al., 2004). However, with the exception of one report focusing on the former model, available evidence from this comparative study is restricted to crosssectional study designs, thus preventing any interpretation of results in terms of a possible causal direction. To our knowledge, the current study is the first to analyze associations of a stressful psychosocial work environment, as measured by the effort–reward imbalance model, with intention to leave nursing profession in a prospective design, using a broad data base with samples from seven different European countries. This model of an adverse psychosocial work environment is based on the fundamental principle of reciprocity in contractual social exchange, such as the work contract. It posits that failed reciprocity in terms of high effort and low reward elicits strong negative emotions and stress reactions with adverse long-term effects on health and job satisfaction. The model claims that in addition to the imbalance caused by these two extrinsic factors (effort, reward) an intrinsic factor, a distinct motivational pattern of people’s coping with work demands (overcommitment) may modify the effects of effort–reward imbalance at work on health and job satisfaction (Siegrist et al., 2004). Our focus on occupational reward frustration is justified by the fact that this model distinguishes three dimensions of occupa-
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tional rewards, money, career-related rewards (promotion prospects, job security) and non-material rewards (esteem, recognition) which all seem to matter for nurses’ well-being and organizational commitment (van Vegchel et al., 2002). 2. Aims We therefore set out to test whether, and to what extent, the single dimensions of this model (effort, reward, overcommitment) increase the risk of developing intention to leave nursing over a one-year observation period, and to analyse the contribution of a combined measure of effort– reward imbalance towards estimating this risk. Furthermore, we are interested in exploring the consistency of associations across countries and to explain potential deviations from this pattern by referring to distinct macro-structural developments within respective nations. 3. Methods 3.1. Study design and population The details of the NEXT study were described elsewhere (Hasselhorn et al., 2005). In summary, this is a one-year longitudinal study which was approved by the Ethical Committee of the University of Wuppertal. 30,613 nurses in 7 countries (Belgium, Germany, France, Italy, The Netherlands, Poland, and Slovakia) filled in the effort– reward imbalance (ERI) questionnaire at baseline (Hasselhorn et al., 2004). Our present investigation was restricted to 19,290 registered female nurses working in hospitals in order to increase the homogeneity of the sample and the comparability among the participating countries. Among them, 7460 participated in the one-year follow-up survey (overall follow-up rate: 38.67%, ranging from 21.39% in Slovakia to 59.07% in Italy). We further excluded 991 nurses who had the intention to leave (ITL) the nursing profession at baseline. Thus, 6469 registered female nurses working in hospitals in 7 countries were included in the prospective follow-up analysis (see Table 1). 3.2. Measurements 3.2.1. Effort–reward imbalance (ERI) questionnaire The 23-item standardized ERI questionnaire was applied in the baseline survey of the NEXT study. The questionnaire consists of three scales, two scales measuring the extrinsic components ‘effort’ (6 items) and ‘reward’ (11 items, covering the aspects of earnings, promotion prospects, esteem and job security), and one scale measuring the intrinsic component ‘overcommitment’ (6 items), a personal pattern of excessive coping with work demands. Responses to the items of ‘effort’ and ‘reward’ are scored on a 5-point scale where a value of 1 indicates no respective stressful experience, and a value of 5 indicates very high stressful experience. Items of the scale ‘overcommitment’ are scored on a 4-point scale (1 = full disagreement, 4 = full agreement with statement). Consequently, with such a scoring, the range for the scale ‘effort’ is 6–30, for the scale ‘reward’ 11– 55, and for the scale ‘overcommitment’ 6–24, with higher
755 (11.67%) 5714 (88.33%) 77 (14.37%) 459 (85.63%) 153 (11.94%) 1128 (88.06%) 13 (2.01%) 633 (97.99%) ***
*
p < 0.05, difference among countries by Analysis of Variance or Chi-square test. p < 0.001, difference among countries by Analysis of Variance or Chi-square test.
196 (11.86%) 1456 (88.14%) 197 (18.69%) 857 (81.31%) 69 (13.09%) 458 (86.91%)
50 (6.47%) 723 (93.53%)
952 (14.72%) 1518 (23.47%) 3999 (61.81%) 92 (17.16%) 94 (17.54%) 350 (65.30%) 29 (2.26%) 226 (17.64%) 1026 (80.10%) 91 (14.09%) 68 (10.52%) 487 (75.39%) 293 (17.73%) 388 (23.49%) 971 (58.78%) 197 (18.69%) 229 (21.73%) 628 (59.58%) 79 (14.99%) 167 (31.69%) 281 (53.32%)
171 (22.12%) 346 (44.76%) 256 (33.12%)
773 (11.95%) 5287 (81.73%) 409 (6.32%) 30 (5.60%) 462 (86.19%) 44 (8.21%) 56 (4.37%) 1133 (88.45%) 92 (7.18%) 90 (13.93%) 541 (83.75%) 15 (2.32%) 197 (11.92%) 1370 (82.93%) 85 (5.15%) 222 (21.06%) 753 (71.44%) 79 (7.50%) 64 (12.14%) 430 (81.60%) 33 (6.26%)
114 (14.75%) 598 (77.36%) 61 (7.89%)
39.17 8.07 38.08 6.98 37.51 9.52 38.00 9.01
Germany (N = 1054)
38.24 9.04
Table 1 gives information on the sample composition (means and percentages of socio-demographic and occupational characteristics) at baseline. Of the 6469 female
Age (mean SD)* Marital status (N, (%))*** Single Cohabitated Others Shift work (N, (%))*** Regular day shift Irregular day shift Rotating shift (day + night) Position rank (N, (%))*** High Low
4.1. Characteristics of study subjects at baseline
Belgium (N = 527)
4. Results
Table 1 Characteristics of the study subjects at baseline.
Firstly, descriptive statistics were generated. Means and standard deviations (SDs) were investigated for continuous variables, and relative frequencies were examined for categorical variables. Secondly, we applied analysis of variance (for continuous variables) or Chisquare test (for categorical variables) to compare the differences among the participating countries. Finally, multivariate Poisson regression was applied for prospective associations between ERI at baseline and newly developed ITL at follow-up, adjusting for the confounding variables, such as age, marital status, shift work, and position rank, while the analysis of the total sample was also adjusted for country. The results are shown as relative risks (RRs) and 95% confidence intervals (CIs) (Zou, 2004). In the present statistical analysis, quartiles (by country) of the three scales (effort, reward, and overcommitment) and the effort–reward ratio were used to define the levels of adverse psychosocial work conditions. Due to the continuous measure of log-transformed ratio of effort–reward, the RRs were reported for an increase by 1 SD (by country). All analyses were conducted by the program SAS 9.2.
France (N = 773)
3.3. Data analysis
37.88 7.38
Italy (N = 1652)
The Netherlands (N = 646)
3.2.2. Intention to leave (ITL) the nursing profession At both baseline and follow-up, the intention to leave the nursing profession was measured by a single item (‘‘How often during the course of the past year have you thought about leaving nursing?’’). The response categories were ‘‘never’’, ‘‘sometimes a year’’, ‘‘sometimes a month’’, ‘‘sometimes a week’’, ‘‘everyday’’. Nurses indicating to leave the profession ‘‘sometimes a month’’ or ‘‘sometimes a week’’ or ‘‘everyday’’ were considered to ‘‘have ITL’’ (Hasselhorn et al., 2004, 2008). In addition, information on age, marital status, shift work, and position rank was collected at baseline.
37.90 8.92
Poland (N = 1281)
Slovakia (N = 536)
Total (N = 6469)
scores reflecting higher effort, reward and overcommitment. The overall Cronbach’s a coefficients of effort, reward, and overcommitment in this study were 0.73 (ranging from 0.68 in France to 0.75 in Italy), 0.77 (ranging from 0.67 in the Netherlands to 0.80 in Slovakia), and 0.74 (ranging from 0.69 in Slovakia to 0.78 in Germany), respectively. According to a predefined algorithm, a ratio between the two scales ‘effort’ and ‘reward’ (weighted by item numbers) was calculated to quantify the degree of mismatch between high ‘cost’ and low ‘gain’ at work at individual level (Siegrist et al., 2004). Moreover, as defined and justified in previous studies (Pikhart et al., 2001; Li et al., 2006), we also applied the logarithmic transformation of the effort–reward ratio which has the advantage of placing inverse imbalance of the same magnitude in the same distance from 1 (when effort and reward are equal).
38.04 8.21
J. Li et al. / International Journal of Nursing Studies 48 (2011) 628–635
Variables
630
The Netherlands (N = 646)
Effort was highest in German nurses and lowest in Dutch nurses (17.17 vs. 11.55), while the score of reward was highest in the Netherlands (50.39) and lowest in Poland (40.80). Accordingly, the score of effort–reward ratio was lowest in the Netherlands (0.43) and highest in Poland (0.78). Besides, overcommitment was highest in the Slovakian sample and lowest in the Dutch sample (14.98 vs. 11.79). Differences between the countries were highly significant (Table 2).
14.93 4.15 43.42 7.52 0.67 0.30 14.98 2.78 39 (7.28%) 15.95 4.48 40.80 8.03 0.78 0.38 14.19 3.23 101 (7.88%)
Poland (N = 1281)
4.2. Scores of ERI scales at baseline
11.55 3.06 50.39 4.11 0.43 0.13 11.79 2.54 36 (5.57%)
Slovakia (N = 536)
Total (N = 6469)
respondents in this study, the overall mean age was 38.04 years, while the Dutch nurse were youngest (37.51 years) and the Slovakian nurses were oldest (39.17 years). Generally, 81.73% nurses lived with partners, ranging from 71.44% in Germany to 88.45% in Poland. The distribution of shift work in the 7 European countries was uneven, only 33.12% French nurse had the duty of rotating shift (day + night), whereas 80.10% Polish nurses did so. Very few nurses (2.01%) in the Netherlands occupied a high-ranking position (i.e. charge nurse), but the corresponding number in Germany was as high as 18.69%.
631 15.39 4.49 44.85 7.45 0.67 0.31 13.88 3.30 533 (8.24%)
J. Li et al. / International Journal of Nursing Studies 48 (2011) 628–635
***
15.20 4.40 48.36 5.61 0.60 0.23 13.57 3.31 25 (4.74%) Effort*** (mean SD) Reward*** (mean SD) Effort–reward ratio*** (mean SD) Overcommitment*** (mean SD) Incidence of ITL*** (N, (%))
p < 0.001, difference among countries by analysis of variance or Chi-square test.
15.39 4.16 47.23 6.34 0.62 0.23 13.99 3.44 92 (11.90%)
Belgium (N = 527) Variables
Table 2 Scores of ERI at baseline and incidence rates of ITL at follow-up.
As can be seen from Table 3, in the pooled sample of the seven countries, high effort, low reward and high overcommitment at baseline predicted newly developed ITL after one-year follow-up; and the effort–reward ratio (continuous measure of log-transformation) was significantly associated with ITL (P < 0.05). Analyses based on quartiles of the scales revealed a ‘dose–response’ relationship with highest relative risks of leaving in nurses scoring highest in occupational reward frustration. In addition, we also tested the explanatory power of the effort–reward ratio based on quartiles, where similar findings became obvious (data not shown). However, when examining the single national samples, clear differences appeared with relatively strongest effects in France and Germany, modest effects in Belgium, Italy and Poland, and no significant effects in the Netherlands and Slovakia. Considering the single dimensions of the effort– reward imbalance model, most consistent effects were observed for low reward and for the continuous combined measure (log (effort/reward)). Overcommitment was associated with ITL in three out of seven cases, and the effect of effort reached statistical significance in only one country. No significant interaction terms were observed when estimating the combined effects of effort (or reward respectively) with overcommitment (data not shown).
Germany (N = 1054)
4.4. Prospective associations between ERI at baseline and newly developed ITL at follow-up
17.17 4.06 44.64 6.47 0.74 0.27 13.80 3.53 98 (9.30%)
France (N = 773)
Italy (N = 1652)
Among the 6469 nurses who did not have intention to leave the nursing profession at baseline, 533 nurses expressed their intention to leave in the follow-up examination after one-year (incidence rate 8.24%). Relatively highest rates were observed in France, Germany and Italy (>8%), and substantially lower ones in the remaining countries (<8%).
15.53 4.62 44.19 7.38 0.68 0.33 14.22 3.22 142 (8.60%)
4.3. Intention to leave the nursing profession
1.00 0.62 (0.17, 2.24) 1.36 (0.60, 3.05) 1.55 (0.73, 3.28)
1.00 1.01 (0.77, 1.32) 1.48 (1.16, 1.88)** 1.68 (1.31, 2.17)***
5. Discussion
Adjustment for age, marital status, shift work, and position rank (additional adjustment for country in the analysis of the total sample). * p < 0.05, Poisson regression. ** p < 0.01, Poisson regression. *** p < 0.001, Poisson regression.
1.00 1.34 (0.78, 2.29) 1.38 (0.79, 2.42) 1.82 (1.09, 3.03)* 1.00 0.80 (0.37, 1.75) 0.77 (0.28, 2.18) 0.75 (0.30, 1.90) 1.00 1.49 (0.93, 2.40) 1.63 (1.02, 2.61)* 1.74 (1.09, 2.80)* 1.00 0.73 (0.39, 1.36) 1.16 (0.67, 2.00) 1.46 (0.86, 2.48) 1.00 1.05 (0.54, 2.02) 1.74 (1.01, 3.02)* 2.24 (1.27, 3.93)** 1.00 0.88 (0.26, 3.03) 1.42 (0.42, 4.77) 1.72 (0.58, 5.09)
1.86)* 2.24)*** 3.29)*** 1.45)*** (1.06, (1.30, (1.93, (1.22, 1.00 1.41 1.71 2.52 1.33 2.44) 2.16) 3.52) 1.43) (0.34, (0.40, (0.70, (0.81, 1.00 0.91 0.93 1.57 1.08 1.59) 1.92) 2.88) 1.53)* (0.45, (0.60, (0.99, (1.04, 1.00 0.85 1.07 1.69 1.26 2.88) 2.61) 3.67) 1.50) (0.42, (0.39, (0.63, (0.81, 1.00 1.10 1.01 1.57 1.10 2.40) 2.34) 2.81)* 1.41)* (0.94, (0.90, (1.13, (1.03, 1.00 1.50 1.45 1.78 1.20 7.23) 7.86)* 21.99)*** 2.26)*** (0.95, (1.12, (3.61, (1.56, 1.00 2.62 2.97 8.91 1.88 (0.61, (0.51, (1.15, (0.91,
6.39) 4.15) 10.07)* 2.00)
(1.14, (1.30, (2.06, (1.14, 1.00 2.40 2.75 4.19 1.38 1.00 1.98 1.59 3.41 1.35
5.05)* 5.82)** 8.53)*** 1.65)***
1.00 1.21 (0.50, 2.95) 1.20 (0.49, 2.93) 1.75 (0.85, 3.87) 1.00 0.85 (0.42, 1.55) 1.47 (0.86, 2.52) 1.71 (0.98, 2.97) 1.00 1.74 (0.73, 4.18) 1.49 (0.54, 4.10) 1.53 (0.60, 3.92) 1.00 1.10 (0.68, 1.75) 1.14 (0.73, 1.78) 1.28 (0.82, 2.00) 1.00 1.38 (0.71, 2.69) 1.42 (0.73, 2.74) 3.27 (1.83, 5.84)*** 1.00 0.70 (0.38, 1.28) 1.26 (0.75, 2.13) 1.59 (0.94, 2.68) 1.00 0.74 (0.22, 2.52) 0.92 (0.29, 2.86) 1.89 (0.68, 5.23)
Slovakia Poland The Netherlands Italy France Germany Belgium Variables
Effort Q1 (Lowest) Q2 Q3 Q4 (Highest) Reward Q4 (Highest) Q3 Q2 Q1 (Lowest) Log (effort/reward) (per SD) Overcommitment Q1 (Lowest) Q2 Q3 Q4 (Highest)
Table 3 Prospective associations between ERI at baseline and newly developed ITL at follow-up (RR, 95% CI).
1.00 1.09 (0.84, 1.40) 1.19 (0.92, 1.53) 1.76 (1.40, 2.22)***
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The aim of this paper was to analyze whether reward frustration at work, as measured by the scales of the effort– reward imbalance model, influenced nurses’ intention to leave their profession, using a one-year prospective comparative study design covering samples of nurses from seven European countries. Whereas pooled results confirmed these associations two national samples (The Netherlands and Slovakia) deviated from the general pattern of findings. When comparing the single scales of the model, ‘low reward’ produced the strongest effects on risk of intended leaving, in particular in France, Germany, Italy and Belgium. Overall, a 2.5-fold elevated relative risk of turnover intention was observed among nurses who scored highest on the scale measuring ‘low rewards’ compared to those with low scores. The important aspects of low reward contributed to this effect, i.e. earnings and promotion prospects, as well as esteem and recognition. Here, poor salary and promotion prospects exerted relatively strongest effects (data not shown). In line with the theoretical notion, it is the discrepancy between high efforts spent and low rewards received in turn (as measured by the respective ratio) that matters most. In addition, nurses experiencing high level of overcommitment are expected to exaggerate their efforts beyond levels usually considered, in combination with increased susceptibility to reward frustration (Siegrist et al., 2004). These prospective findings are in line with a previous report from the same study that was based on crosssectional data, therefore being subject to the problem of causal interpretations (Hasselhorn et al., 2004). Additional, smaller-scale investigations found similar associations. For instance, a Swedish study investigating conditions that contribute to the decision to leave nursing care observed that unsatisfactory salaries were of primary importance, followed by lack of professional opportunities and restricted professional autonomy (Fochsen et al., 2005). In a report based on data from 787 nurses in US professional dissatisfaction and low organizational commitment were related to increased intention to leave the profession (Lynn and Redman, 2005). Similarly, effort–reward imbalance at work was found to increase the risk of leaving the job at early stages of nurses’ careers in Canada (Lavoie-Tremblay et al., 2008). A Belgian prospective study also confirmed that effort–reward imbalance predicted nurses’ intention to leave (Derycke et al., 2010). It is of interest to note that these associations are not restricted to Western countries but were also observed in several Asian societies (Chan et al., 2009; Takase et al., 2008; Tzeng, 2002), including the Chinese longitudinal NEXT study (Li et al., 2010). Other important aspects of a stressful work environment not represented in the effort–reward imbalance model or respective component were analyzed, and again, a general pattern of findings became obvious. For instance, based on a large Finnish prospective study of 6441 hospital staff, team climate—as indicated by clear and shared goals, continued participation, task orientation and support in favour of innovation—predicted intention to leave the job and actual turnover during the 2–4 year follow-up most strongly (Kivima¨ki et al., 2007). Likewise, a cumulative or
J. Li et al. / International Journal of Nursing Studies 48 (2011) 628–635
emergent job strain, as defined by high demands in combination with low level of task control, was associated with nurses’ manifest intention of leaving their profession (Hasselhorn et al., 2008), and in a 3-year follow-up study in Sweden it was found that being socially isolated or excluded at work increased the risk of job turnover (Josephson et al., 2008). Whereas a majority of findings support the notion that an adverse psychosocial work environment undermines the nurses’ long-term commitment to their profession, the two exceptions observed in the current study, the nurse samples in the Netherlands and in Slovakia, deserve a closer look. It seems that there are different reasons for a lack of association between work stress and intention to leave in the Netherlands and in Slovakia. In the latter case, the follow-up rate was particularly low, and a low rate of ITL was reported. We conducted an additional comparison of the level of work stress in the sample of nurses who participated in the baseline examination only and in the sample that completed additionally the follow-up examination. It became clear that level of work stress and prevalence of ITL were substantially higher in the former group, thus pointing to a selection bias in the follow-up sample that contributed to the attenuation of association. Moreover, the broad labour market in Slovakia was perceived as very restricted. 75.56% Slovakian nurses felt it difficult to find another job. Under these conditions, the prevalence of intention to leave was small. The case of Dutch nurses was quite different. Here, working conditions were reported to be generally of good quality, and occupational reward frustration was rather rare in this sample. Alternative jobs were easily available, thus weakening a link between stressful work and intention to leave the profession. We have also to consider the factors contributing the modest effects of work stress on ITL in Belgium, Italy and Poland. The Belgian nurses had generally favourable psychosocial work conditions and very low rate of ITL like the nurses in the Netherlands, but the follow-up rate in Belgian sample was rather low indicating selection bias; more importantly, the Belgian sample is a combination of two culturally different population, i.e. nurses working in Dutch-speaking areas and French-speaking areas, which made the results mixed. Even the Italian nurses had a comparable effort score with the French sample, and a comparable reward score with the German sample, but less strong associations were observed than in these two countries. Here, the explanation might be psychosocial factors beyond workplace, such as work-family conflict. Our previous findings showed that, among all European nurses the Italian nurses suffered most heavily from a work-family conflict, which was profoundly associated with ITL (Simon et al., 2004). Concerning the results from Polish nurses, whose working and socioeconomic conditions were similar to Slovakian nurses, the relatively high follow-up rate (less selection bias) might be helpful to explain the weak association in the Polish sample, to some extent. The contrasting cases of European nurses from different countries demonstrate the importance of conducting international comparisons, and they high-
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light the moderating influence of macro-structural, labour market-related conditions on associations of stressful work with behavioural and health-related outcomes (Dragano et al., 2010). Countries have traditionally reported fewer problems retaining nurses in times of economic recession as there are fewer alternative options in the labour market. The economic downturn in the early 1990s in the US and UK, for instance, has been regarded as a factor reducing job mobility, keeping nurses in jobs and postponing career breaks (Buchan, 1994). Based on a large sample from 435 hospitals in the US, it was claimed that turnover was related to availability of employment opportunities (Bloom et al., 1992). And the Swedish 3-year followup study confirmed that possibility of getting new job increased the risk of nurse turnover (Josephson et al., 2008). Being ‘locked-in’ in unfavourable, unrewarding jobs with limited options of change and improvement must be considered a powerful determinant of adverse health and risk behaviour (Siegrist, 2000). This report suffers from several methodological limitations. First, the sample loss at follow-up was substantial. Although the final sample did not largely differ in terms of socio-demographic characteristics we cannot exclude a systematic loss of more heavily stressed nurses at baseline, thus resulting in an underestimation of the effect under study. Second, since a self-reported questionnaire survey was used to measure both exposure and outcome variables, common method variance might weaken the validity of reported results although the longitudinal design reduces this threat to some extent (Spector, 2006). Third, we were not able to assess stressful aspects of the nurses’ work experience at follow-up and, thus, to relate changes in work stress to incident intention to leave the profession. Availability of multiple exposure measures would certainly strengthen the argument, and this approach is highly recommended for further investigations (see also Hasselhorn et al., 2008; Li et al., 2010). Despite these limitations, and in view of consistent results with previous, mostly cross-sectional studies, some policy recommendations can be derived from the results of this investigation. Importantly, measures of reducing reward frustration at work seem to be of primary interest. Such measures should focus on improved career prospects based on nurses’ training and achievement, more appropriate remuneration, and ways of providing non-material rewards from organizations. These latter measures may include more formal and informal ways of recognition and esteem of nurses’ contributions to the organizations’ main goals as well as access to special services or privileges offered by the organization (e.g. recreation facilities, access to kindergarten for own children, flexible work time arrangements). Concerning adverse effects of increasing workload, improved policies of personnel development are needed, ideally in combination with programs that strengthen the nurses’ resources of coping with external demands. Some of these measures have already demonstrated their efficacy in reducing the amount of turnover of nurses in hospitals, e.g. in Canada and Norway (Ahlburg and Mahoney, 1996; Holma˚s, 2002). Additional
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positive effects were observed, such as a significant reduction in work-related burnout (Bourbonnais et al., 2006). Furthermore, a literature review from UK suggests that a 10% reduction in the real wage of registered nurses would lower participation in the nurse workforce by around 3%, implying a significant impact of wage change on noticeable nursing participation (Antonazzo et al., 2003). However, raising awareness of psychosocial work environment with attention to organizational well-being and productivity among both nurses and nursing managers should not be ignored, which is an essential step to solve the problem. It has been suggested that a comprehensive approach combining both individual and organizational-directed interventions would be a promising way to promote healthy workplace and job performance (Noblet and Lamontagne, 2006). 6. Conclusions The findings of this comparative longitudinal study of nurses’ self-report level of reward frustration at work indicate that the risk of their intention to leave nursing is critically increased as a function of the amount of nonreciprocity experienced between efforts spent and rewards received in turn. Measures aiming at reducing this imbalance may define a promising approach towards retention of nurses and tackling nursing shortage across European countries. Acknowledgement The authors would like to thank the members of the NEXT Study for their continuing participation and support. Conflict of interest: None declared. Funding: The NEXT Study has been funded by the European Commission (QLK6-CT-2001-00475 /PIIF-GA2008-220641); the current analyses have been also supported by the Belgian Science Policy (WOQUAL study TA/00/033), and by the Berufsgenossenschaft fu¨r Gesundheitsdienst und Wohlfahrtspflege (BGW, Germany). Ethical approval: This study was approved by the Ethical Committee of the University of Wuppertal. References Ahlburg, D.A., Mahoney, C.B., 1996. The effect of wages on the retention of nurses. Canadian Journal of Economics 29 (1), 126–129. Antonazzo, E., Scott, A., Skatun, D., Elliott, R.F., 2003. The labour market for nursing: a review of the labour supply literature. Journal of Health Economics 12 (6), 465–478. Bloom, J.R., Alexander, J.A., Nuchols, B.A., 1992. The effect of the social organization of work on the voluntary turnover rate of hospital nurses in the United States. Social Science and Medicine 34 (12), 1413–1424. Bourbonnais, R., Brisson, C., Vinet, A., Ve´zina, M., Abdous, B., Gaudet, M., 2006. Effectiveness of a participative intervention on psychosocial work factors to prevent mental health problems in a hospital setting. Journal of Occupational and Environmental Medicine 63 (5), 335–342. Buchan, J., 1994. Lessons from America? US magnet hospitals and their implications for UK nursing. Journal of Advanced Nursing 19 (2), 373–384. Chan, M.F., Luk, A.L., Leong, S.M., Yeung, S.M., Van, I.K., 2009. Factors influencing Macao nurses’ intention to leave current employment. Journal of Clinical Nursing 18 (6), 893–901.
Clark, P.F., Clark, D.A., 2003. Challenges facing nurses’ associations and unions: a global perspective. International Labour Review 142 (1), 29–47. Derycke, H., Vlerick, P., Burnay, N., Decleire, C., D’Hoore, W., Hasselhorn, H.M., et al. 2010. Impact of the effort–reward imbalance model on intent to leave among Belgian health care workers: a prospective study. Journal of Occupational and Organizational Psychology, online available 14 November 2009. doi:10.1348/ 096317909X477594. Dragano, N., Siegrist, J., Wahrendorf, M. 2010. Welfare regimes, labour policies and unhealthy psychosocial working conditions: A comparative study with 9917 older employees from 12 European countries. Journal of Epidemiology & Community Health, online available 6 August 2010. doi:10.1136/jech.2009.098541. Fochsen, G., Sjo¨gren, K., Josephson, M., Lagerstro¨m, M., 2005. Factors contributing to the decision to leave nursing care: a study among Swedish nursing personnel. Journal of Nursing Management 13 (4), 338–344. Hasselhorn, H.M., Conway, P.M., Widerszal-Bazyl, M., Simon, M., Tackenberg, P., Schmidt, S.G., et al., 2008. Contribution of job strain to nurses’ consideration of leaving the profession—results from the longitudinal European nurses’ early exit study. Scandinavian Journal of Work Environment and Health 6, 75–82. Hasselhorn, H.M., Tackenberg, P., Peter, R., Next-Study Group, 2004. Effort–reward imbalance among nurses in stable countries and in countries in transition. International Journal of Occupational and Environmental Health 10 (4), 401–408. Hasselhorn, H.M., Muller, B.H., Tackenberg, P., NEXT Scientific Report, 2005. [internet]. University of Wuppertal [cited 16 March 2010]. Available from: http://www.next.uni-wuppertal.de/EN/index.php?articles-and-reports. Hayes, L.J., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F., et al., 2006. Nurse turnover: a literature review. International Journal of Nursing Studies 43 (2), 237–263. Holma˚s, T.H., 2002. Keeping nurses at work: a duration analysis. Journal of Health Economics 11 (6), 493–503. Josephson, M., Lindberg, P., Voss, M., Alfredsson, L., Vinga˚rd, E., 2008. The same factors influence job turnover and long spells of sick leave—a 3year follow-up of Swedish nurses. European Journal of Public Health 18 (4), 380–385. Kivima¨ki, M., Vanhala, A., Pentti, J., La¨nsisalmi, H., Virtanen, M., Elovainio, M., et al., 2007. Team climate, intention to leave and turnover among hospital employees: prospective cohort study. BMC Health Services Research 7, 170. Lavoie-Tremblay, M., O’Brien-Pallas, L., Ge´linas, C., Desforges, N., Marchionni, C., 2008. Addressing the turnover issue among new nurses from a generational viewpoint. Journal of Nursing Management 16 (6), 724–733. Li, J., Fu, H., Hu, Y., Shang, L., Wu, Y.H., Kristensen, T.S., et al., 2010. Psychosocial work environment and intention to leave the nursing profession: results from the longitudinal Chinese NEXT study. Scandinavian Journal of Public Health 38 (Suppl. 3), 69–80. Li, J., Yang, W., Cho, S.I., 2006. Gender differences in job strain, effort– reward imbalance, and health functioning among Chinese physicians. Social Science and Medicine 62 (5), 1066–1077. Lynn, M.R., Redman, R.W., 2005. Faces of the nursing shortage: influences on staff nurses’ intentions to leave their positions or nursing. Journal of Nursing Administration 35 (5), 264–270. Noblet, A., Lamontagne, A.D., 2006. The role of workplace health promotion in addressing job stress. Health Promotion International 21 (4), 346–353. Pikhart, H., Bobak, M., Siegrist, J., Pajak, A., Rywik, S., Kyshegyi, J., et al., 2001. Psychosocial work characteristics and self rated health in four post-communist countries. Journal of Epidemiology and Community Health 55 (9), 624–630. Siegrist, J., Starke, D., Chandola, T., Godin, I., Marmot, M., Niedhammer, I., et al., 2004. The measurement of effort–reward imbalance at work: European comparisons. Social Science and Medicine 58 (8), 1483– 1499. Siegrist, J., 2000. Place, social exchange and health: proposed sociological framework. Social Science and Medicine 51 (9), 1283–1293. Simon, M., Ku¨mmerling, A., Hasselhorn, H.M., Next-Study Group, 2004. Work-home conflict in the European nursing profession. International Journal of Occupational and Environmental Health 10 (4), 384–391. Spector, P.E., 2006. Method variance in organizational research: truth or urban legend? Organizational Research Methods 9 (2), 221–232. Takase, M., Yamashita, N., Oba, K., 2008. Nurses’ leaving intentions: antecedents and mediating factors. Journal of Advanced Nursing 62 (3), 295–306.
J. Li et al. / International Journal of Nursing Studies 48 (2011) 628–635 Tzeng, H.M., 2002. The influence of nurses’ working motivation and job satisfaction on intention to quit: an empirical investigation in Taiwan. International Journal of Nursing Studies 39 (8), 867–878. van Vegchel, N., de Jonge, J., Bakker, A., Schaufeli, W., 2002. Testing global and specific indicators of rewards in the Effort–Reward Imbalance Model: does it make any difference? European Journal of Work and Organizational Psychology 11 (4), 403–421.
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West, E.A., Griffith, W.P., Iphofen, R., 2007. A historical perspective on the nursing shortage. Medsurgery Nursing 16 (2), 124–130. Westendorf, J.J., 2007. The nursing shortage: recruitment and retention of current and future nurses. Plastic Surgery Nursing 27 (2), 93–97. Zou, G., 2004. A modified Poisson regression approach to prospective studies with binary data. American Journal of Epidemiology 159 (7), 702–706.
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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Reward frustration at work and intention to leave the nursing profession—Prospective results from the European longitudinal NEXT study Jian Li a,b,*, Michael Galatsch c, Johannes Siegrist b, Bernd Hans Mu¨ller a, Hans Martin Hasselhorn d European NEXT Study group a
Department of Safety Engineering, University of Wuppertal, Wuppertal, Germany Department of Medical Sociology, University of Duesseldorf, Duesseldorf, Germany Institute of Safety Technology, Nursing Research Section, University of Wuppertal, Wuppertal, Germany d Federal Institute for Occupational Safety and Health, Berlin, Germany b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 May 2010 Received in revised form 23 July 2010 Accepted 10 September 2010
Background: Many countries are facing a serious situation of nursing shortage, and retention of nurses is a challenge. Objectives: To examine whether reward frustration at work, as measured by the effort– reward imbalance model, predicts intention to leave the nursing profession, using data from the European longitudinal nurses’ early exit study. Design: A prospective study with one-year follow-up. Methods: 6469 registered female nurses working in hospitals in seven European countries who did not have intention to leave the nursing profession at baseline were included in our analyses by multivariate Poisson regression. Results: 8.24% nurses newly developed intention to leave during follow-up. High effort– reward imbalance at baseline predicted an elevated risk of intention to leave the profession (relative risk 1.33, 95% confidence interval 1.22–1.45), and reward frustration (poor salary and promotion prospects, lack of esteem) showed the strongest explanatory power. Findings were similar in a majority of the countries. Conclusions: Results suggest that improving the psychosocial work environment, and specifically occupational rewards, may be helpful in retaining nurses and consequently reducing nursing shortage in Europe. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Effort–reward imbalance Intention to leave Nursing shortage
What is already known about the topic? Nursing shortage is an international problem, particularly in rapidly aging societies across Europe. Many nurses have high intention to leave the nursing profession, and retention of nurses is a challenge. * Corresponding author at: Department of Safety Engineering, University of Wuppertal, Gaussstrasse 20, 42119 Wuppertal, Germany. Tel.: +49 202 439 3253; fax: +49 202 439 3828. E-mail address: [email protected] (J. Li). 0020-7489/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2010.09.011
Unfavourable psychosocial work environment causes intention to leave the nursing profession even actual turnover, but the prospective evidence is limited. What this paper adds A large-scale prospective study was conducted covering samples of nurses from seven European countries. Effort reward imbalance, in particular reward frustration, is predictive of intention to leave among European nurses. Improving the psychosocial work environment, and specifically occupational rewards, may help to retain
J. Li et al. / International Journal of Nursing Studies 48 (2011) 628–635
nurses and consequently reduce nursing shortage in Europe. 1. Introduction Nursing shortage and understaffing is a problem of growing concern in many countries, in particular in rapidly aging societies (West et al., 2007). In a recent international survey in 69 countries, 90 out of 105 (86%) nursing unions and organizations reported shortage of nursing personnel and its impact on health care delivery (Clark and Clark, 2003; Lynn and Redman, 2005). While improved strategies of recruiting health professionals, in part from foreign countries, are needed, major efforts should be directed towards maintaining employed nurses in their jobs as long as possible (Westendorf, 2007). To this end, quality of work and employment needs to be critically improved. In order to promote these aims, the availability of detailed research findings from organizational and occupational sciences seems crucial as they can guide targeted interventions and the development of strategies of organizational change. A number of studies have been performed in recent years to tackle this problem by identifying work- and employmentrelated determinants of nursing turnover, intention to leave the nursing profession, and early exit from the labour market (Hayes et al., 2006). One such investigation, the Nurses’ early exit (NEXT) study, explicitly addressed the role of adverse work conditions in explaining professional turnover and intention to leave the job in a comparative perspective, by recruiting nursing staff from 10 European countries (Hasselhorn et al., 2005). Previous findings report strong associations of a stressful psychosocial work environment with intention to leave one’s profession, specifically if measured in terms of two leading models of work-related stress, the combination of high demand and low control (Hasselhorn et al., 2008) and the imbalance between high efforts spent and low rewards received in turn (Hasselhorn et al., 2004). However, with the exception of one report focusing on the former model, available evidence from this comparative study is restricted to crosssectional study designs, thus preventing any interpretation of results in terms of a possible causal direction. To our knowledge, the current study is the first to analyze associations of a stressful psychosocial work environment, as measured by the effort–reward imbalance model, with intention to leave nursing profession in a prospective design, using a broad data base with samples from seven different European countries. This model of an adverse psychosocial work environment is based on the fundamental principle of reciprocity in contractual social exchange, such as the work contract. It posits that failed reciprocity in terms of high effort and low reward elicits strong negative emotions and stress reactions with adverse long-term effects on health and job satisfaction. The model claims that in addition to the imbalance caused by these two extrinsic factors (effort, reward) an intrinsic factor, a distinct motivational pattern of people’s coping with work demands (overcommitment) may modify the effects of effort–reward imbalance at work on health and job satisfaction (Siegrist et al., 2004). Our focus on occupational reward frustration is justified by the fact that this model distinguishes three dimensions of occupa-
629
tional rewards, money, career-related rewards (promotion prospects, job security) and non-material rewards (esteem, recognition) which all seem to matter for nurses’ well-being and organizational commitment (van Vegchel et al., 2002). 2. Aims We therefore set out to test whether, and to what extent, the single dimensions of this model (effort, reward, overcommitment) increase the risk of developing intention to leave nursing over a one-year observation period, and to analyse the contribution of a combined measure of effort– reward imbalance towards estimating this risk. Furthermore, we are interested in exploring the consistency of associations across countries and to explain potential deviations from this pattern by referring to distinct macro-structural developments within respective nations. 3. Methods 3.1. Study design and population The details of the NEXT study were described elsewhere (Hasselhorn et al., 2005). In summary, this is a one-year longitudinal study which was approved by the Ethical Committee of the University of Wuppertal. 30,613 nurses in 7 countries (Belgium, Germany, France, Italy, The Netherlands, Poland, and Slovakia) filled in the effort– reward imbalance (ERI) questionnaire at baseline (Hasselhorn et al., 2004). Our present investigation was restricted to 19,290 registered female nurses working in hospitals in order to increase the homogeneity of the sample and the comparability among the participating countries. Among them, 7460 participated in the one-year follow-up survey (overall follow-up rate: 38.67%, ranging from 21.39% in Slovakia to 59.07% in Italy). We further excluded 991 nurses who had the intention to leave (ITL) the nursing profession at baseline. Thus, 6469 registered female nurses working in hospitals in 7 countries were included in the prospective follow-up analysis (see Table 1). 3.2. Measurements 3.2.1. Effort–reward imbalance (ERI) questionnaire The 23-item standardized ERI questionnaire was applied in the baseline survey of the NEXT study. The questionnaire consists of three scales, two scales measuring the extrinsic components ‘effort’ (6 items) and ‘reward’ (11 items, covering the aspects of earnings, promotion prospects, esteem and job security), and one scale measuring the intrinsic component ‘overcommitment’ (6 items), a personal pattern of excessive coping with work demands. Responses to the items of ‘effort’ and ‘reward’ are scored on a 5-point scale where a value of 1 indicates no respective stressful experience, and a value of 5 indicates very high stressful experience. Items of the scale ‘overcommitment’ are scored on a 4-point scale (1 = full disagreement, 4 = full agreement with statement). Consequently, with such a scoring, the range for the scale ‘effort’ is 6–30, for the scale ‘reward’ 11– 55, and for the scale ‘overcommitment’ 6–24, with higher
755 (11.67%) 5714 (88.33%) 77 (14.37%) 459 (85.63%) 153 (11.94%) 1128 (88.06%) 13 (2.01%) 633 (97.99%) ***
*
p < 0.05, difference among countries by Analysis of Variance or Chi-square test. p < 0.001, difference among countries by Analysis of Variance or Chi-square test.
196 (11.86%) 1456 (88.14%) 197 (18.69%) 857 (81.31%) 69 (13.09%) 458 (86.91%)
50 (6.47%) 723 (93.53%)
952 (14.72%) 1518 (23.47%) 3999 (61.81%) 92 (17.16%) 94 (17.54%) 350 (65.30%) 29 (2.26%) 226 (17.64%) 1026 (80.10%) 91 (14.09%) 68 (10.52%) 487 (75.39%) 293 (17.73%) 388 (23.49%) 971 (58.78%) 197 (18.69%) 229 (21.73%) 628 (59.58%) 79 (14.99%) 167 (31.69%) 281 (53.32%)
171 (22.12%) 346 (44.76%) 256 (33.12%)
773 (11.95%) 5287 (81.73%) 409 (6.32%) 30 (5.60%) 462 (86.19%) 44 (8.21%) 56 (4.37%) 1133 (88.45%) 92 (7.18%) 90 (13.93%) 541 (83.75%) 15 (2.32%) 197 (11.92%) 1370 (82.93%) 85 (5.15%) 222 (21.06%) 753 (71.44%) 79 (7.50%) 64 (12.14%) 430 (81.60%) 33 (6.26%)
114 (14.75%) 598 (77.36%) 61 (7.89%)
39.17 8.07 38.08 6.98 37.51 9.52 38.00 9.01
Germany (N = 1054)
38.24 9.04
Table 1 gives information on the sample composition (means and percentages of socio-demographic and occupational characteristics) at baseline. Of the 6469 female
Age (mean SD)* Marital status (N, (%))*** Single Cohabitated Others Shift work (N, (%))*** Regular day shift Irregular day shift Rotating shift (day + night) Position rank (N, (%))*** High Low
4.1. Characteristics of study subjects at baseline
Belgium (N = 527)
4. Results
Table 1 Characteristics of the study subjects at baseline.
Firstly, descriptive statistics were generated. Means and standard deviations (SDs) were investigated for continuous variables, and relative frequencies were examined for categorical variables. Secondly, we applied analysis of variance (for continuous variables) or Chisquare test (for categorical variables) to compare the differences among the participating countries. Finally, multivariate Poisson regression was applied for prospective associations between ERI at baseline and newly developed ITL at follow-up, adjusting for the confounding variables, such as age, marital status, shift work, and position rank, while the analysis of the total sample was also adjusted for country. The results are shown as relative risks (RRs) and 95% confidence intervals (CIs) (Zou, 2004). In the present statistical analysis, quartiles (by country) of the three scales (effort, reward, and overcommitment) and the effort–reward ratio were used to define the levels of adverse psychosocial work conditions. Due to the continuous measure of log-transformed ratio of effort–reward, the RRs were reported for an increase by 1 SD (by country). All analyses were conducted by the program SAS 9.2.
France (N = 773)
3.3. Data analysis
37.88 7.38
Italy (N = 1652)
The Netherlands (N = 646)
3.2.2. Intention to leave (ITL) the nursing profession At both baseline and follow-up, the intention to leave the nursing profession was measured by a single item (‘‘How often during the course of the past year have you thought about leaving nursing?’’). The response categories were ‘‘never’’, ‘‘sometimes a year’’, ‘‘sometimes a month’’, ‘‘sometimes a week’’, ‘‘everyday’’. Nurses indicating to leave the profession ‘‘sometimes a month’’ or ‘‘sometimes a week’’ or ‘‘everyday’’ were considered to ‘‘have ITL’’ (Hasselhorn et al., 2004, 2008). In addition, information on age, marital status, shift work, and position rank was collected at baseline.
37.90 8.92
Poland (N = 1281)
Slovakia (N = 536)
Total (N = 6469)
scores reflecting higher effort, reward and overcommitment. The overall Cronbach’s a coefficients of effort, reward, and overcommitment in this study were 0.73 (ranging from 0.68 in France to 0.75 in Italy), 0.77 (ranging from 0.67 in the Netherlands to 0.80 in Slovakia), and 0.74 (ranging from 0.69 in Slovakia to 0.78 in Germany), respectively. According to a predefined algorithm, a ratio between the two scales ‘effort’ and ‘reward’ (weighted by item numbers) was calculated to quantify the degree of mismatch between high ‘cost’ and low ‘gain’ at work at individual level (Siegrist et al., 2004). Moreover, as defined and justified in previous studies (Pikhart et al., 2001; Li et al., 2006), we also applied the logarithmic transformation of the effort–reward ratio which has the advantage of placing inverse imbalance of the same magnitude in the same distance from 1 (when effort and reward are equal).
38.04 8.21
J. Li et al. / International Journal of Nursing Studies 48 (2011) 628–635
Variables
630
The Netherlands (N = 646)
Effort was highest in German nurses and lowest in Dutch nurses (17.17 vs. 11.55), while the score of reward was highest in the Netherlands (50.39) and lowest in Poland (40.80). Accordingly, the score of effort–reward ratio was lowest in the Netherlands (0.43) and highest in Poland (0.78). Besides, overcommitment was highest in the Slovakian sample and lowest in the Dutch sample (14.98 vs. 11.79). Differences between the countries were highly significant (Table 2).
14.93 4.15 43.42 7.52 0.67 0.30 14.98 2.78 39 (7.28%) 15.95 4.48 40.80 8.03 0.78 0.38 14.19 3.23 101 (7.88%)
Poland (N = 1281)
4.2. Scores of ERI scales at baseline
11.55 3.06 50.39 4.11 0.43 0.13 11.79 2.54 36 (5.57%)
Slovakia (N = 536)
Total (N = 6469)
respondents in this study, the overall mean age was 38.04 years, while the Dutch nurse were youngest (37.51 years) and the Slovakian nurses were oldest (39.17 years). Generally, 81.73% nurses lived with partners, ranging from 71.44% in Germany to 88.45% in Poland. The distribution of shift work in the 7 European countries was uneven, only 33.12% French nurse had the duty of rotating shift (day + night), whereas 80.10% Polish nurses did so. Very few nurses (2.01%) in the Netherlands occupied a high-ranking position (i.e. charge nurse), but the corresponding number in Germany was as high as 18.69%.
631 15.39 4.49 44.85 7.45 0.67 0.31 13.88 3.30 533 (8.24%)
J. Li et al. / International Journal of Nursing Studies 48 (2011) 628–635
***
15.20 4.40 48.36 5.61 0.60 0.23 13.57 3.31 25 (4.74%) Effort*** (mean SD) Reward*** (mean SD) Effort–reward ratio*** (mean SD) Overcommitment*** (mean SD) Incidence of ITL*** (N, (%))
p < 0.001, difference among countries by analysis of variance or Chi-square test.
15.39 4.16 47.23 6.34 0.62 0.23 13.99 3.44 92 (11.90%)
Belgium (N = 527) Variables
Table 2 Scores of ERI at baseline and incidence rates of ITL at follow-up.
As can be seen from Table 3, in the pooled sample of the seven countries, high effort, low reward and high overcommitment at baseline predicted newly developed ITL after one-year follow-up; and the effort–reward ratio (continuous measure of log-transformation) was significantly associated with ITL (P < 0.05). Analyses based on quartiles of the scales revealed a ‘dose–response’ relationship with highest relative risks of leaving in nurses scoring highest in occupational reward frustration. In addition, we also tested the explanatory power of the effort–reward ratio based on quartiles, where similar findings became obvious (data not shown). However, when examining the single national samples, clear differences appeared with relatively strongest effects in France and Germany, modest effects in Belgium, Italy and Poland, and no significant effects in the Netherlands and Slovakia. Considering the single dimensions of the effort– reward imbalance model, most consistent effects were observed for low reward and for the continuous combined measure (log (effort/reward)). Overcommitment was associated with ITL in three out of seven cases, and the effect of effort reached statistical significance in only one country. No significant interaction terms were observed when estimating the combined effects of effort (or reward respectively) with overcommitment (data not shown).
Germany (N = 1054)
4.4. Prospective associations between ERI at baseline and newly developed ITL at follow-up
17.17 4.06 44.64 6.47 0.74 0.27 13.80 3.53 98 (9.30%)
France (N = 773)
Italy (N = 1652)
Among the 6469 nurses who did not have intention to leave the nursing profession at baseline, 533 nurses expressed their intention to leave in the follow-up examination after one-year (incidence rate 8.24%). Relatively highest rates were observed in France, Germany and Italy (>8%), and substantially lower ones in the remaining countries (<8%).
15.53 4.62 44.19 7.38 0.68 0.33 14.22 3.22 142 (8.60%)
4.3. Intention to leave the nursing profession
1.00 0.62 (0.17, 2.24) 1.36 (0.60, 3.05) 1.55 (0.73, 3.28)
1.00 1.01 (0.77, 1.32) 1.48 (1.16, 1.88)** 1.68 (1.31, 2.17)***
5. Discussion
Adjustment for age, marital status, shift work, and position rank (additional adjustment for country in the analysis of the total sample). * p < 0.05, Poisson regression. ** p < 0.01, Poisson regression. *** p < 0.001, Poisson regression.
1.00 1.34 (0.78, 2.29) 1.38 (0.79, 2.42) 1.82 (1.09, 3.03)* 1.00 0.80 (0.37, 1.75) 0.77 (0.28, 2.18) 0.75 (0.30, 1.90) 1.00 1.49 (0.93, 2.40) 1.63 (1.02, 2.61)* 1.74 (1.09, 2.80)* 1.00 0.73 (0.39, 1.36) 1.16 (0.67, 2.00) 1.46 (0.86, 2.48) 1.00 1.05 (0.54, 2.02) 1.74 (1.01, 3.02)* 2.24 (1.27, 3.93)** 1.00 0.88 (0.26, 3.03) 1.42 (0.42, 4.77) 1.72 (0.58, 5.09)
1.86)* 2.24)*** 3.29)*** 1.45)*** (1.06, (1.30, (1.93, (1.22, 1.00 1.41 1.71 2.52 1.33 2.44) 2.16) 3.52) 1.43) (0.34, (0.40, (0.70, (0.81, 1.00 0.91 0.93 1.57 1.08 1.59) 1.92) 2.88) 1.53)* (0.45, (0.60, (0.99, (1.04, 1.00 0.85 1.07 1.69 1.26 2.88) 2.61) 3.67) 1.50) (0.42, (0.39, (0.63, (0.81, 1.00 1.10 1.01 1.57 1.10 2.40) 2.34) 2.81)* 1.41)* (0.94, (0.90, (1.13, (1.03, 1.00 1.50 1.45 1.78 1.20 7.23) 7.86)* 21.99)*** 2.26)*** (0.95, (1.12, (3.61, (1.56, 1.00 2.62 2.97 8.91 1.88 (0.61, (0.51, (1.15, (0.91,
6.39) 4.15) 10.07)* 2.00)
(1.14, (1.30, (2.06, (1.14, 1.00 2.40 2.75 4.19 1.38 1.00 1.98 1.59 3.41 1.35
5.05)* 5.82)** 8.53)*** 1.65)***
1.00 1.21 (0.50, 2.95) 1.20 (0.49, 2.93) 1.75 (0.85, 3.87) 1.00 0.85 (0.42, 1.55) 1.47 (0.86, 2.52) 1.71 (0.98, 2.97) 1.00 1.74 (0.73, 4.18) 1.49 (0.54, 4.10) 1.53 (0.60, 3.92) 1.00 1.10 (0.68, 1.75) 1.14 (0.73, 1.78) 1.28 (0.82, 2.00) 1.00 1.38 (0.71, 2.69) 1.42 (0.73, 2.74) 3.27 (1.83, 5.84)*** 1.00 0.70 (0.38, 1.28) 1.26 (0.75, 2.13) 1.59 (0.94, 2.68) 1.00 0.74 (0.22, 2.52) 0.92 (0.29, 2.86) 1.89 (0.68, 5.23)
Slovakia Poland The Netherlands Italy France Germany Belgium Variables
Effort Q1 (Lowest) Q2 Q3 Q4 (Highest) Reward Q4 (Highest) Q3 Q2 Q1 (Lowest) Log (effort/reward) (per SD) Overcommitment Q1 (Lowest) Q2 Q3 Q4 (Highest)
Table 3 Prospective associations between ERI at baseline and newly developed ITL at follow-up (RR, 95% CI).
1.00 1.09 (0.84, 1.40) 1.19 (0.92, 1.53) 1.76 (1.40, 2.22)***
J. Li et al. / International Journal of Nursing Studies 48 (2011) 628–635
Total
632
The aim of this paper was to analyze whether reward frustration at work, as measured by the scales of the effort– reward imbalance model, influenced nurses’ intention to leave their profession, using a one-year prospective comparative study design covering samples of nurses from seven European countries. Whereas pooled results confirmed these associations two national samples (The Netherlands and Slovakia) deviated from the general pattern of findings. When comparing the single scales of the model, ‘low reward’ produced the strongest effects on risk of intended leaving, in particular in France, Germany, Italy and Belgium. Overall, a 2.5-fold elevated relative risk of turnover intention was observed among nurses who scored highest on the scale measuring ‘low rewards’ compared to those with low scores. The important aspects of low reward contributed to this effect, i.e. earnings and promotion prospects, as well as esteem and recognition. Here, poor salary and promotion prospects exerted relatively strongest effects (data not shown). In line with the theoretical notion, it is the discrepancy between high efforts spent and low rewards received in turn (as measured by the respective ratio) that matters most. In addition, nurses experiencing high level of overcommitment are expected to exaggerate their efforts beyond levels usually considered, in combination with increased susceptibility to reward frustration (Siegrist et al., 2004). These prospective findings are in line with a previous report from the same study that was based on crosssectional data, therefore being subject to the problem of causal interpretations (Hasselhorn et al., 2004). Additional, smaller-scale investigations found similar associations. For instance, a Swedish study investigating conditions that contribute to the decision to leave nursing care observed that unsatisfactory salaries were of primary importance, followed by lack of professional opportunities and restricted professional autonomy (Fochsen et al., 2005). In a report based on data from 787 nurses in US professional dissatisfaction and low organizational commitment were related to increased intention to leave the profession (Lynn and Redman, 2005). Similarly, effort–reward imbalance at work was found to increase the risk of leaving the job at early stages of nurses’ careers in Canada (Lavoie-Tremblay et al., 2008). A Belgian prospective study also confirmed that effort–reward imbalance predicted nurses’ intention to leave (Derycke et al., 2010). It is of interest to note that these associations are not restricted to Western countries but were also observed in several Asian societies (Chan et al., 2009; Takase et al., 2008; Tzeng, 2002), including the Chinese longitudinal NEXT study (Li et al., 2010). Other important aspects of a stressful work environment not represented in the effort–reward imbalance model or respective component were analyzed, and again, a general pattern of findings became obvious. For instance, based on a large Finnish prospective study of 6441 hospital staff, team climate—as indicated by clear and shared goals, continued participation, task orientation and support in favour of innovation—predicted intention to leave the job and actual turnover during the 2–4 year follow-up most strongly (Kivima¨ki et al., 2007). Likewise, a cumulative or
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emergent job strain, as defined by high demands in combination with low level of task control, was associated with nurses’ manifest intention of leaving their profession (Hasselhorn et al., 2008), and in a 3-year follow-up study in Sweden it was found that being socially isolated or excluded at work increased the risk of job turnover (Josephson et al., 2008). Whereas a majority of findings support the notion that an adverse psychosocial work environment undermines the nurses’ long-term commitment to their profession, the two exceptions observed in the current study, the nurse samples in the Netherlands and in Slovakia, deserve a closer look. It seems that there are different reasons for a lack of association between work stress and intention to leave in the Netherlands and in Slovakia. In the latter case, the follow-up rate was particularly low, and a low rate of ITL was reported. We conducted an additional comparison of the level of work stress in the sample of nurses who participated in the baseline examination only and in the sample that completed additionally the follow-up examination. It became clear that level of work stress and prevalence of ITL were substantially higher in the former group, thus pointing to a selection bias in the follow-up sample that contributed to the attenuation of association. Moreover, the broad labour market in Slovakia was perceived as very restricted. 75.56% Slovakian nurses felt it difficult to find another job. Under these conditions, the prevalence of intention to leave was small. The case of Dutch nurses was quite different. Here, working conditions were reported to be generally of good quality, and occupational reward frustration was rather rare in this sample. Alternative jobs were easily available, thus weakening a link between stressful work and intention to leave the profession. We have also to consider the factors contributing the modest effects of work stress on ITL in Belgium, Italy and Poland. The Belgian nurses had generally favourable psychosocial work conditions and very low rate of ITL like the nurses in the Netherlands, but the follow-up rate in Belgian sample was rather low indicating selection bias; more importantly, the Belgian sample is a combination of two culturally different population, i.e. nurses working in Dutch-speaking areas and French-speaking areas, which made the results mixed. Even the Italian nurses had a comparable effort score with the French sample, and a comparable reward score with the German sample, but less strong associations were observed than in these two countries. Here, the explanation might be psychosocial factors beyond workplace, such as work-family conflict. Our previous findings showed that, among all European nurses the Italian nurses suffered most heavily from a work-family conflict, which was profoundly associated with ITL (Simon et al., 2004). Concerning the results from Polish nurses, whose working and socioeconomic conditions were similar to Slovakian nurses, the relatively high follow-up rate (less selection bias) might be helpful to explain the weak association in the Polish sample, to some extent. The contrasting cases of European nurses from different countries demonstrate the importance of conducting international comparisons, and they high-
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light the moderating influence of macro-structural, labour market-related conditions on associations of stressful work with behavioural and health-related outcomes (Dragano et al., 2010). Countries have traditionally reported fewer problems retaining nurses in times of economic recession as there are fewer alternative options in the labour market. The economic downturn in the early 1990s in the US and UK, for instance, has been regarded as a factor reducing job mobility, keeping nurses in jobs and postponing career breaks (Buchan, 1994). Based on a large sample from 435 hospitals in the US, it was claimed that turnover was related to availability of employment opportunities (Bloom et al., 1992). And the Swedish 3-year followup study confirmed that possibility of getting new job increased the risk of nurse turnover (Josephson et al., 2008). Being ‘locked-in’ in unfavourable, unrewarding jobs with limited options of change and improvement must be considered a powerful determinant of adverse health and risk behaviour (Siegrist, 2000). This report suffers from several methodological limitations. First, the sample loss at follow-up was substantial. Although the final sample did not largely differ in terms of socio-demographic characteristics we cannot exclude a systematic loss of more heavily stressed nurses at baseline, thus resulting in an underestimation of the effect under study. Second, since a self-reported questionnaire survey was used to measure both exposure and outcome variables, common method variance might weaken the validity of reported results although the longitudinal design reduces this threat to some extent (Spector, 2006). Third, we were not able to assess stressful aspects of the nurses’ work experience at follow-up and, thus, to relate changes in work stress to incident intention to leave the profession. Availability of multiple exposure measures would certainly strengthen the argument, and this approach is highly recommended for further investigations (see also Hasselhorn et al., 2008; Li et al., 2010). Despite these limitations, and in view of consistent results with previous, mostly cross-sectional studies, some policy recommendations can be derived from the results of this investigation. Importantly, measures of reducing reward frustration at work seem to be of primary interest. Such measures should focus on improved career prospects based on nurses’ training and achievement, more appropriate remuneration, and ways of providing non-material rewards from organizations. These latter measures may include more formal and informal ways of recognition and esteem of nurses’ contributions to the organizations’ main goals as well as access to special services or privileges offered by the organization (e.g. recreation facilities, access to kindergarten for own children, flexible work time arrangements). Concerning adverse effects of increasing workload, improved policies of personnel development are needed, ideally in combination with programs that strengthen the nurses’ resources of coping with external demands. Some of these measures have already demonstrated their efficacy in reducing the amount of turnover of nurses in hospitals, e.g. in Canada and Norway (Ahlburg and Mahoney, 1996; Holma˚s, 2002). Additional
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positive effects were observed, such as a significant reduction in work-related burnout (Bourbonnais et al., 2006). Furthermore, a literature review from UK suggests that a 10% reduction in the real wage of registered nurses would lower participation in the nurse workforce by around 3%, implying a significant impact of wage change on noticeable nursing participation (Antonazzo et al., 2003). However, raising awareness of psychosocial work environment with attention to organizational well-being and productivity among both nurses and nursing managers should not be ignored, which is an essential step to solve the problem. It has been suggested that a comprehensive approach combining both individual and organizational-directed interventions would be a promising way to promote healthy workplace and job performance (Noblet and Lamontagne, 2006). 6. Conclusions The findings of this comparative longitudinal study of nurses’ self-report level of reward frustration at work indicate that the risk of their intention to leave nursing is critically increased as a function of the amount of nonreciprocity experienced between efforts spent and rewards received in turn. Measures aiming at reducing this imbalance may define a promising approach towards retention of nurses and tackling nursing shortage across European countries. Acknowledgement The authors would like to thank the members of the NEXT Study for their continuing participation and support. Conflict of interest: None declared. Funding: The NEXT Study has been funded by the European Commission (QLK6-CT-2001-00475 /PIIF-GA2008-220641); the current analyses have been also supported by the Belgian Science Policy (WOQUAL study TA/00/033), and by the Berufsgenossenschaft fu¨r Gesundheitsdienst und Wohlfahrtspflege (BGW, Germany). Ethical approval: This study was approved by the Ethical Committee of the University of Wuppertal. References Ahlburg, D.A., Mahoney, C.B., 1996. The effect of wages on the retention of nurses. Canadian Journal of Economics 29 (1), 126–129. Antonazzo, E., Scott, A., Skatun, D., Elliott, R.F., 2003. The labour market for nursing: a review of the labour supply literature. Journal of Health Economics 12 (6), 465–478. Bloom, J.R., Alexander, J.A., Nuchols, B.A., 1992. The effect of the social organization of work on the voluntary turnover rate of hospital nurses in the United States. Social Science and Medicine 34 (12), 1413–1424. Bourbonnais, R., Brisson, C., Vinet, A., Ve´zina, M., Abdous, B., Gaudet, M., 2006. Effectiveness of a participative intervention on psychosocial work factors to prevent mental health problems in a hospital setting. Journal of Occupational and Environmental Medicine 63 (5), 335–342. Buchan, J., 1994. Lessons from America? US magnet hospitals and their implications for UK nursing. Journal of Advanced Nursing 19 (2), 373–384. Chan, M.F., Luk, A.L., Leong, S.M., Yeung, S.M., Van, I.K., 2009. Factors influencing Macao nurses’ intention to leave current employment. Journal of Clinical Nursing 18 (6), 893–901.
Clark, P.F., Clark, D.A., 2003. Challenges facing nurses’ associations and unions: a global perspective. International Labour Review 142 (1), 29–47. Derycke, H., Vlerick, P., Burnay, N., Decleire, C., D’Hoore, W., Hasselhorn, H.M., et al. 2010. Impact of the effort–reward imbalance model on intent to leave among Belgian health care workers: a prospective study. Journal of Occupational and Organizational Psychology, online available 14 November 2009. doi:10.1348/ 096317909X477594. Dragano, N., Siegrist, J., Wahrendorf, M. 2010. Welfare regimes, labour policies and unhealthy psychosocial working conditions: A comparative study with 9917 older employees from 12 European countries. Journal of Epidemiology & Community Health, online available 6 August 2010. doi:10.1136/jech.2009.098541. Fochsen, G., Sjo¨gren, K., Josephson, M., Lagerstro¨m, M., 2005. Factors contributing to the decision to leave nursing care: a study among Swedish nursing personnel. Journal of Nursing Management 13 (4), 338–344. Hasselhorn, H.M., Conway, P.M., Widerszal-Bazyl, M., Simon, M., Tackenberg, P., Schmidt, S.G., et al., 2008. Contribution of job strain to nurses’ consideration of leaving the profession—results from the longitudinal European nurses’ early exit study. Scandinavian Journal of Work Environment and Health 6, 75–82. Hasselhorn, H.M., Tackenberg, P., Peter, R., Next-Study Group, 2004. Effort–reward imbalance among nurses in stable countries and in countries in transition. International Journal of Occupational and Environmental Health 10 (4), 401–408. Hasselhorn, H.M., Muller, B.H., Tackenberg, P., NEXT Scientific Report, 2005. [internet]. University of Wuppertal [cited 16 March 2010]. Available from: http://www.next.uni-wuppertal.de/EN/index.php?articles-and-reports. Hayes, L.J., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F., et al., 2006. Nurse turnover: a literature review. International Journal of Nursing Studies 43 (2), 237–263. Holma˚s, T.H., 2002. Keeping nurses at work: a duration analysis. Journal of Health Economics 11 (6), 493–503. Josephson, M., Lindberg, P., Voss, M., Alfredsson, L., Vinga˚rd, E., 2008. The same factors influence job turnover and long spells of sick leave—a 3year follow-up of Swedish nurses. European Journal of Public Health 18 (4), 380–385. Kivima¨ki, M., Vanhala, A., Pentti, J., La¨nsisalmi, H., Virtanen, M., Elovainio, M., et al., 2007. Team climate, intention to leave and turnover among hospital employees: prospective cohort study. BMC Health Services Research 7, 170. Lavoie-Tremblay, M., O’Brien-Pallas, L., Ge´linas, C., Desforges, N., Marchionni, C., 2008. Addressing the turnover issue among new nurses from a generational viewpoint. Journal of Nursing Management 16 (6), 724–733. Li, J., Fu, H., Hu, Y., Shang, L., Wu, Y.H., Kristensen, T.S., et al., 2010. Psychosocial work environment and intention to leave the nursing profession: results from the longitudinal Chinese NEXT study. Scandinavian Journal of Public Health 38 (Suppl. 3), 69–80. Li, J., Yang, W., Cho, S.I., 2006. Gender differences in job strain, effort– reward imbalance, and health functioning among Chinese physicians. Social Science and Medicine 62 (5), 1066–1077. Lynn, M.R., Redman, R.W., 2005. Faces of the nursing shortage: influences on staff nurses’ intentions to leave their positions or nursing. Journal of Nursing Administration 35 (5), 264–270. Noblet, A., Lamontagne, A.D., 2006. The role of workplace health promotion in addressing job stress. Health Promotion International 21 (4), 346–353. Pikhart, H., Bobak, M., Siegrist, J., Pajak, A., Rywik, S., Kyshegyi, J., et al., 2001. Psychosocial work characteristics and self rated health in four post-communist countries. Journal of Epidemiology and Community Health 55 (9), 624–630. Siegrist, J., Starke, D., Chandola, T., Godin, I., Marmot, M., Niedhammer, I., et al., 2004. The measurement of effort–reward imbalance at work: European comparisons. Social Science and Medicine 58 (8), 1483– 1499. Siegrist, J., 2000. Place, social exchange and health: proposed sociological framework. Social Science and Medicine 51 (9), 1283–1293. Simon, M., Ku¨mmerling, A., Hasselhorn, H.M., Next-Study Group, 2004. Work-home conflict in the European nursing profession. International Journal of Occupational and Environmental Health 10 (4), 384–391. Spector, P.E., 2006. Method variance in organizational research: truth or urban legend? Organizational Research Methods 9 (2), 221–232. Takase, M., Yamashita, N., Oba, K., 2008. Nurses’ leaving intentions: antecedents and mediating factors. Journal of Advanced Nursing 62 (3), 295–306.
J. Li et al. / International Journal of Nursing Studies 48 (2011) 628–635 Tzeng, H.M., 2002. The influence of nurses’ working motivation and job satisfaction on intention to quit: an empirical investigation in Taiwan. International Journal of Nursing Studies 39 (8), 867–878. van Vegchel, N., de Jonge, J., Bakker, A., Schaufeli, W., 2002. Testing global and specific indicators of rewards in the Effort–Reward Imbalance Model: does it make any difference? European Journal of Work and Organizational Psychology 11 (4), 403–421.
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West, E.A., Griffith, W.P., Iphofen, R., 2007. A historical perspective on the nursing shortage. Medsurgery Nursing 16 (2), 124–130. Westendorf, J.J., 2007. The nursing shortage: recruitment and retention of current and future nurses. Plastic Surgery Nursing 27 (2), 93–97. Zou, G., 2004. A modified Poisson regression approach to prospective studies with binary data. American Journal of Epidemiology 159 (7), 702–706.