The impact of perceived workload on nurse satisfaction with work-life balance and intention to leave the occupation

Applied Nursing Research 49 (2019) 70–76

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The impact of perceived workload on nurse satisfaction with work-life balance and intention to leave the occupation

T

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Peter Hollanda, Tse Leng Thamb, , Cathy Sheehanc, Brian Cooperc a

Department of Management and Marketing, Swinburne Business School, Swinburne University of Technology, John Street, Hawthorn, VIC 3122, Australia School of Management, RMIT University, 445 Swanston Street, Melbourne, VIC 3000, Australia c Department of Management, Monash University, 900 Dandenong Road, Caulfield East, VIC 3145, Australia b

A R T I C LE I N FO

A B S T R A C T

Keywords: Workload Intention to leave Work-life balance Retention High involvement work practices (HIWPs) Nursing

Background and aim: In the drive to make the health sector more economically efficient and effective, what is potentially being lost is the need to look after the well-being of those who work within this profession. Nurses are the largest group in the health sector workforce and the frontline of patient care. Workload perceptions are known to be impacting nurses' well-being and are becoming a critical concern for the retention of this workforce. In response, this study aims to examine the relationships among perceived workload, satisfaction with work-life balance (an indicator of well-being), and intention to leave the occupation. Additionally, high involvement work practices (HIWPs) are examined as a form of organisational support that may buffer the negative impact of perceived workload on nurses' well-being and intention to leave the occupation. Method: A 2016 online survey of the nursing profession in Australia yielded 2984 responses. We assessed the impact of perceived workload on nurses' well-being and intention to leave the occupation, and the role of HIWPs in ameliorating the negative impact of perceived workload. Results and conclusion: Our results show that perceived workload is associated with increasing intention to leave the occupation and is mediated by nurses' satisfaction with work-life balance. Where organisational support is provided through HIWPs, this can mitigate such intentions. These aspects are within the control of those who manage this workforce and should be central to human resource management strategies in the health care sector.

1. Introduction Nurses are the largest body of employees in the healthcare system and the frontline of patient care in health care. However, it is widely recognised that in Australia, as in many other Advanced Market Economies (AME), there is increasing concern regarding the retention of this workforce (Chen, Brown, Bowers, & Chang, 2015). Changes in hospital management systems focused on cost control have served to increase the focus on patient throughput (Hogan, Moxham, & Dwyer, 2007). This has expanded nursing services but not staffing levels (Holland, Allen, & Cooper, 2011). Combined with higher patient turnaround, these issues have contributed to increased perceived workload among nurses and have been shown to negatively impact well-being and the turnover intention of nurses (Jourdain & Chenêvert, 2010). The issue of retention is already a concern of the Australian federal government, with a major commissioned report indicating that population health trends, combined with poor retention rates in the nursing

workforce will lead to an imminent and acute nursing shortfall (AFHW, 2014). Further, a federal government report identified that an exponential decline in the average number of hours worked by nurses per week as they get older is also an issue (AIHW, 2015), and may be a precursor to intention to leave the occupation. These predicted shortages and reduced working hours come at a time when demand for healthcare services is on the rise, in part because of the ageing population, and an expectation of high-quality health care by the population. These predictions are also in line with an Australian Productivity Commission report (2008), which identified increases in demand for healthcare services. Given these combinations of factors, the effective retention of skilled and experienced nurses is a highly significant issue. Given the importance of workforce retention in this sector of healthcare, there is a burgeoning body of research investigating the drivers of nurses' intentions to leave the profession. Key drivers included reduced quality of work life (e.g., work arrangement, workload, work-life balance) (Lee et al., 2017), low job autonomy (Yamaguchi,

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Corresponding author. E-mail addresses: [email protected] (P. Holland), [email protected] (T.L. Tham), [email protected] (C. Sheehan), [email protected] (B. Cooper). https://doi.org/10.1016/j.apnr.2019.06.001 Received 13 March 2019; Received in revised form 25 June 2019; Accepted 25 June 2019 0897-1897/ © 2019 Published by Elsevier Inc.

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buffer the resource-depleting impact of perceived workload on nurse wellness and assist in maintaining a healthy work-life balance and thus, reduce intention to leave the occupation. Practically, our research answer calls for more focus on retention policies and practices to avert the potential workforce shortage crisis in the Australian nursing sector (AIHW, 2015). HIWPs can be an effective management strategy focusing on improving communication, empowerment and participation, with employees (Searle et al., 2011), and importantly are factors within the control of management (Holland et al., 2011; Moseley, Jeffers, & Paterson, 2008). HIWPs focus on providing greater scope for employee involvement in managing work patterns and practices to improve the work efficiency, employee skills and well-being to enhance organisational effectiveness, employee satisfaction, commitment and therefore retention (Boxall & Purcell, 2016). As Boxall, Hutchison, and Wassenaar (2015) found, when studying HIWPs, greater opportunity for discretion in the decisions that concern the workforce, create the conditions for greater involvement and, in turn, contribute to their well-being. Although they note, as do Boxall and Purcell (2016), that the nature of their effectiveness will relate to the type of work and environment. Changes associated with well-being, including increased satisfaction with work-life balance (Qu & Zhao, 2012), have been identified as a key concern for this workforce in their decision to leave the profession (Shacklock & Brunetto, 2012; Shields & Ward, 2001). However, to date, there is a paucity of comprehensive research on these issues (Cheng, Bartram, Karimi, & Leggat, 2013).

Inoue, Harada, & Oike, 2016), poor states of well-being (e.g., burnout) (Moloney, Boxall, Parsons, & Sheridan, 2017), and stressors such as work-life conflict (Brewer, Kovner, Greene, & Cheng, 2009). Congruent to these findings, a preliminary thematic analysis of qualitative data collected via an open-ended response question in the survey of our current study, revealed key themes around workload leading to decreased well-being, and specifically, lower satisfaction with work-life balance. Typical responses extracted from the sample are highlighted below relate to job demands and management included: “The workload does NOT fit the time frame of any allocated shift. Paperwork is time consuming and is often competed after the shift is over, in the staff members' own time and is therefore unpaid. I have observed that staff are expected to stay on after to complete and attend to further nursing duties. In my view it is an extremely poor way to treat people.” “We as a group (nurses) are exhausted by the demands of employers and patients…These expectations are unreasonable and will not be met without more staff… “Overworked mentally and physically with little or no help support from management...” “Many feel that we cannot go any harder or faster and are looking to leave”. “Being made to work to exhaustion every week is why I am getting out of nursing...” “.,.if staff identify they are struggling to cope, automatic response is that they need to become more resilient, when in fact they are very resilient but the demands on them are now intolerable...it has become an easy way for managers to blame employees...”

2. Job Demands–Resources Model The theoretical framework used to examine the impact of job demands (perceived workload) and the ability to manage and replenish individuals' resources, is the Job Demands–Resources Model (JD-R) (Bakker, Demerouti, & Euwema, 2005; Schaufeli & Bakker, 2004). The theory states that whilst job demands are not necessarily negative, problems arise when the demands and stressors associated with the job (perceived workload) outstrip the opportunity to replenish a resource. A key element is the role of the organisation in supporting the workforce in achieving this balance (Mauno, Kinnunen, Makikangas, & Young, 2010). Job demands are framed in terms of characteristics of an individual's job role driven by the requirements of the work environment. As a form of job demand that strips an individual of his/her resources, high levels of perceived workload could have a negative impact on individual well-being (e.g., satisfaction with work-life balance) and this, in turn, could lead to an increased intention to leave the profession (Chen et al., 2015; Jourdain & Chenêvert, 2010). This is particularly so if appropriate support from the organisation is not available to assist in the replenishment of individuals' lost resources (Schaufeli & Bakker, 2004). Research by Bakker and Demerouti (2007) and Mauno et al. (2010) indicate that supportive working conditions facilitated by HIWPs, which can include ensuring employees achieve satisfaction with work-life balance, are important resources in mitigating the demands of the work (Macky & Boxall, 2008). Such resources also serve as a buffer to perceived high levels of job demands and workload. HIWPs therefore, potentially allow employees to replenish their resources (Macky & Boxall, 2008). This places the policies and practices of management at the centre of strategies to minimise the negative impact high perceived workload have on employee well-being. Such policies and practices are likely to provide the opportunity to ensure better satisfaction with the balance between work and life and therefore, reduce intention to leave the occupation (Cottini, Kato, & Westergaard-Nielsen, 2011; Holland, Allen, & Cooper, 2013). For instance, Cottini et al. (2011) found HIWPs to be an important factor in mitigating the impact of adverse working conditions on labour turnover. In the nursing profession, Chênevert, Jourdain, and Vandenberghe (2016) demonstrated that higher levels of HIWPs had a negative and indirect effect on organisational and

The area that generated substantial comment was issues with worklife balance: “I feel like that is what I have let go of, finding the family work life balance”. “Many of our senior colleagues are burnt out and I am concerned about experienced people leaving. My work life balance would be improved ……” With regard to intention to leave: “Work load of an RN (registered nurse) in the aged care sector is absolutely ridiculous. It is not humanly possible to carry out all the tasks required of you in the shift times you are rostered for. This is why I have made the decision to leave nursing ....” Parallel to the themes identified in our preliminary study, literature has highlighted that nurses' experiences of inability to balance work and family demands is significantly linked to intention to leave the profession (Brewer et al., 2009; Simon, Kümmerling, & Hasselhorn, 2004). However, others have found the contrary, where such inability to maintain a healthy balance between work and family demands did not significantly impact intention to leave the nursing profession (Yamaguchi et al., 2016). The first major contribution of our research is to clarify these contrasting findings in the Australian context. Drawing on the Job Demand-Resources (JD-R) Model, our second contribution is, in response to calls to clarify the possible relationship between the work-family interface and nurses' intentions to leave the profession (Yamaguchi et al., 2016), and to examine the impact of perceived workload as a factor in the depletion of nurses' resources. The depletion of resources in maintaining a healthy balance between their work and family domains (an indicator of well-being) may act as a driver of nurses' intentions to leave the profession. Our final contribution is to build on understanding the impact of workload on nurse wellness and intention to leave the profession by examining high involvement work practices (HIWPs) as a form of organisational support which may be helpful in this regard. The argument is made that HIWPs may be able 71

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occupational turnover. The argument for the importance of managerial practices is reinforced by Allen, Holland, and Reynolds (2015), who established that healthcare management changes alter the nature and focus of nurse work patterns and practices.

H3. Perception of HIWPs will moderate the indirect relationship between perceived workload and intention to leave the occupation through satisfaction with work-life balance, such that the relationship will be weaker under higher levels of perceived HIWPs.

2.1. Development of hypotheses

3. Method

In Australia, as in other AMEs influenced by neoliberal management strategies, there has been a fundamental shift to a cost control approach to managing healthcare to increase cost-based efficiency and performance measurements through higher patient throughput and decrease in the average length of stay of patients in hospitals (Allen et al., 2015; Drach-Zahavy & Marzuq, 2012; Hogan et al., 2007). Whilst these are important goals, we, like Alexander (2017) and Bodenheimer and Sinsky (2014), argue that the wellness of the health sector workforce as a goal, is a significant omission. The increased complexity of healthcare with an ageing population, has expanded the requirement for nursing services but in most cases, this has not been accompanied by an increase in staffing resources. From an employee retention point of view, this is very problematic as there is substantial research evidence to support a link between increases in job demands or work overload and increases in professional turnover (e.g., see Chen et al., 2015; Holland et al., 2013; Jourdain & Chenêvert, 2010; Lee et al., 2017). Indeed, dissatisfaction with working conditions, workplace climate and organisational support have been identified as the key reason why nurses choose to leave the profession (Allen et al., 2015; Moloney et al., 2017; Shields & Ward, 2001; Tzeng, 2002). Increasingly, dissatisfaction with work-life balance has not only been linked to the perception of high workload but has also been identified as a key driver of occupational turnover intention in sectors such as the events industry (see Nizam & Kam, 2018; Yu, 2014). As such, we argue that the wellness of the nursing workforce needs to be a central aspect in the development of quality improvements in the health sector. A key contribution of this study will therefore be to examine the effect of perceived workload on satisfaction with work-life balance of nurses, and in turn, their intention to leave the profession. The study also examined whether a form of organisational support, HIWPs, serve as a resource in buffering the negative impact of perceived workload on satisfaction with work-life balance and intention to leave the occupation. The key elements underpinning these aspects of the work environment are that they are within the control of management, and arguably long-term factors in increasing retention of this critical workforce. From the literature review and JD-R theory, we develop the following hypotheses described below and the study's conceptual model is summarised in Fig. 1:

3.1. Sample and procedures In collaboration with the Australian Nursing and Midwifery Federation (ANMF), a quantitative, cross-sectional correlational field study (survey) was carried out (Tharenou, Donohue, & Cooper, 2007) and data were collected via a nationwide online survey in Australia in 2016. The population for this study were members of the ANMF employed in Australian States and Territories at the time of the survey. In total, the survey yielded 2984 responses. Eighty-nine percent of respondents reported being nurses, with a much smaller proportion of midwives (9%), most of whom are also qualified nurses. The mean age of respondents was 47.00 years (SD = 11.65) and primarily, the sample were female (92%). Predominantly, respondents reported working in a hospital setting (69%) and at a part-time capacity (60%). On average, respondents reported having worked at their organisation for 9.32 years (SD = 8.76). A comparison of our study's sample demographics with that of the wider national demographic statistics of the nursing profession (AIHW, 2015) indicates that our sample is largely reflective of the wider population being studied. 3.2. Measures The measures utilised in the current study have been previously validated and have demonstrated acceptable psychometric properties. Perceived workload. Perception on workload was assessed using Spector and Jex's (1998) five-item measure of quantitative workload. Responses to each item were captured on a five-point scale, ranging from 1 = less than once per month to 5 = several times per day. Work-life balance. Nurses' satisfaction with work-life balance was measured with Valcour's (2007) five-item scale where responses were captured on a five-point scale from 1 = very dissatisfied to 5 = very satisfied. Occupational turnover intention. Blau's (1985) three-item measure was employed to capture nurses' intentions to leave the occupation. Responses to these items were recorded on a five-point likelihood scale ranging from 1 = very unlikely to 5 = very likely. High involvement work practices (HIWPs). This study measured employee perceptions of HIWPs using Searle et al.'s (2011) nine items that capture employees' perceptions of a set of HIWPs such as familyfriendly work practices. Responses to these items were recorded on a five-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Control variables. Following previous research (e.g., Holland et al.,

H1. Perceived workload will be positively related to nurses' intention to leave the occupation. H2. Nurses' satisfaction with work-life balance will mediate the relationship between perceived workload and intention to leave the occupation.

Fig. 1. The study's conceptual model. 72

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occupation were in accordance with our overall predictions.

2013), we included several control variables including the setting of employment (coded 1 = hospital, 0 = other setting), age, organisational tenure (both measured in years), and employment status (coded 1 = full-time, 0 = part-time). Given over 90% of respondents were female, we did not include gender as a control variable.

5.1. Results of analysis of reliability and validity As indicated in Table 1, the measures used in this study reported acceptable internal consistency reliabilities which exceeded the minimum of 0.70 (Nunnally, 1978). To assess discriminant validity, we conducted a series of CFAs for perceived workload, satisfaction with work-life balance, occupational turnover intention, and HIWPs. These results were summarised in Table 2. Accordingly, the overall model fit of the hypothesised four-factor model was acceptable (χ2 [df = 364] = 2901.75, CFI = 0.94, TLI = 0.92, RMSEA = 0.067). Results from the chi-square difference tests recorded in Table 2 also denote that the alternative models had poorer fit. As such, these results attest the construct validity of the measures used in the current study.

4. Quantitative analysis strategy 4.1. Analysis of reliability and validity of measures First, to verify that the measures used in this study have demonstrated construct validity, we conducted a confirmatory factor analysis (CFA) using AMOS 25 (Hair, Black, Babin, & Anderson, 2014), using full information maximum likelihood (FIML) estimation in handling missing data as recommended by Enders and Bandalos (2001). To evaluate model fit, this study reports several model fit statistics including the chi-square goodness-of-fit test, comparative fit index (CFI) and Tucker-Lewis index (TLI) and the conventional approximate fit index, root mean square error of approximation (RMSEA) (Steiger, 1998). Model fit was deemed acceptable where RMSEA values are below 0.06 and CFI and TLI values are 0.90 and above (Hu & Bentler, 1999). In consideration of the cross-sectional and single-source nature of this study's data, the influence of common method variance (CMV) on the results may be of concern (Fuller, Simmering, Atinc, Atinc, & Babin, 2016). As such, we ran a one-factor measurement model to check the potential influence of CMV (Podsakoff, MacKenzie, & Podsakoff, 2012). Specifying all indicators of a measurement model to load onto a single factor, a poorer model fit will denote the absence of significant CMV in the data (Mossholder, Bennett, Kemery, & Wesolowski, 1998).

5.2. Results of hypotheses testing Hypothesis H1 predicted that perceived workload is positively related to occupational turnover intention. Referring to Table 3 (Model I), results indicate a significant positive relationship between perceived workload and intention to leave the occupation (β = 0.21. p < .01). Therefore, this lends support to hypothesis H1. Hypothesis H2 postulated that satisfaction with work-life balance will mediate the relationship between perceived workload and intention to leave the occupation. As indicated in Table 3 (Model II and III), perceived workload was negatively related to satisfaction with worklife balance (β = −0.34, p < .01), and satisfaction with work-life balance was negatively related to the outcome variable, intention to leave the occupation (β = −0.35, p < .01). A bootstrap test based on the suggested 5000 bootstrap samples (Hayes, 2013) indicated that the indirect effect of perceived workload on intention to leave the occupation, through satisfaction with work-life balance was 0.12 (95% C.I. 0.10 to 0.15). As zero was not included in the 95% confidence interval for the indirect effect, this hypothesis was supported. This suggests that higher levels of perceived workload were related to lower levels of satisfaction with work-life balance. This, in turn, was associated with higher levels of intention to leave the occupation. As noted in Table 3 (Model III), the relationship between perceived workload and intention to leave the occupation remains significant in the mediation model (β = 0.10, p < .01). This suggests that the relationship between perceived workload and intention to leave the occupation was only partially mediated by satisfaction with work-life balance. The final hypothesis proposed that the indirect effect of perceived workload on intention to leave the occupation, via satisfaction with work-life balance will be moderated by HIWPs. The index of moderated mediation (index = −0.01, 95% C.I. = −0.02 to −0.001) was statistically significant as zero was not within the 95% confidence interval. Additionally, results in Table 3 (Model IV) show that the relationship between perceived workload and satisfaction with work-life balance relationship was moderated by perceptions of HIWPs (β = 0.04, p < .05). Together, these lend support to the conditional indirect effect as proposed in H3. We then examined the conditional indirect effect at one standard deviation (SD) above the mean, at the mean, and one SD below the mean of the moderator, HIWPs. As summarised in Table 4, the results indicate that the conditional indirect effect for satisfaction with worklife balance was weakest at one SD above the mean for HIWPs (bootstrapped indirect effect = 0.07, 95% C.I. = 0.05 to 0.09). In line with hypothesis H3's expectations, the indirect effect of perceived workload on intention to leave the occupation via work-life balance was weaker for respondents who indicated higher levels of perceived HIWPs. Hence, in accordance with hypothesis H3, higher levels of HIWPs perceptions buffer the negative impact of perceived workload on the satisfaction of work-life balance. Collectively, these results support hypothesis H3.

4.2. Analysis of study's hypotheses To test the hypotheses, ordinary least squares regression with the SPSS PROCESS macro v. 3 plug-in was used. To test the mediation hypothesis H2, a bootstrap based on the recommended 5000 bootstrap samples (Hayes, 2013) was conducted. The hypothesis predicting the conditional indirect effect of HIWPs on the mediation relationship between perceived workload and intention to leave the profession through satisfaction with work-life balance (H3) was examined using the index of moderated mediation (Hayes, 2015). The index of moderated mediation quantifies the effect of the proposed moderator on the indirect effect. As such, a nonzero weight for the index of moderated mediation serves as a statistical test for detecting the presence of significant moderation of a mediated relation. This study followed Hayes' (2015) recommendation wherein a bootstrap confidence interval for each of the conditional effects at low (− 1SD), moderate (mean), and high (+ 1SD) values of the moderator is estimated to probe the nature of the conditional mediation relation. Prior to conducting the analyses, we screened the data to ascertain that the assumptions of linearity and normality were satisfied and that there were no univariate and multivariate outliers present. Whilst no cases had z-scores beyond the acceptable range of ± 3.29 (Pallant, 2013), six potential multivariate outliers were identified as these cases had Mahalanobis distance values exceeding the critical chi-square value of 18.467 at the 0.001 level (Tabachnick & Fidell, 2013). However, none of these cases had Cook's distance values that exceeded 1. As Tabachnick and Fidell (2013) note that cases with Cook's distance values beyond 1 are regarded as problematic in regression, these cases were kept for proceeding analysis. 5. Results The study's variable means, standard deviations, and intercorrelations are summarised in Table 1. Correlations among perceived workload, satisfaction with work-life balance, and intention to leave the 73

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Table 1 Means, standard deviations and inter-correlations of study variables. Variable

M

SD

1

2

3

4

(1) (2) (3) (4)

4.30 3.08 2.68 2.85

0.85 0.98 1.23 0.79

0.90 −0.35⁎⁎ 0.21⁎⁎ −0.26⁎⁎

0.94 −0.37⁎⁎ 0.47⁎⁎

0.92 −0.43⁎⁎

0.87

47.00 0.69 9.32 0.60

11.65 0.46 8.76 0.49

−0.07⁎⁎ 0.12⁎⁎ 0.00 0.00

0.12⁎⁎ −0.08⁎⁎ 0.03 0.14⁎⁎

0.01 0.02 0.01 0.03

−0.07⁎⁎ −0.04⁎ −0.05⁎⁎ 0.00

Perceived workload Work-life balance Intention to leave occupation HIWPs

Controls (5) Age (6) Working in hospital (7) Organisational tenure (8) Part time ⁎⁎ ⁎

5

6

7

8

– −0.17⁎⁎ 0.40⁎⁎ 0.02

– 0.14⁎⁎ 0.02

– −0.03

–

p < .01. p < .05.

Table 2 Comparison of model fit indices and chi-square differences of alternate and baseline models. Model

χ2

df

χ2 diff

TLI

CFI

RMSEA

Hypothesised four-factor model Three-factor model: Work-life balance and HIWPs combined One-factor model

2901.75 8805.43 22,470.27

203 206 209

5903.68⁎⁎ 19,568.52⁎⁎

0.92 0.75 0.37

0.94 0.80 0.48

0.067 0.12 0.19

** p < .01. * p < .05. Table 3 Results of regression analysis testing hypotheses. Variables

Model I: Intention to leave occupation

Age Working in hospital Organisational tenure Part or full-time Perceived workload Work-life balance HIWPs HIWPs x perceived workload R2

Model II: Work-life balance ⁎⁎

0.02 −0.00 0.00 0.03 0.21⁎⁎

⁎⁎

0.05 −0.02 0.01 0.08 0.10⁎⁎ −0.35⁎⁎

0.07 −0.04⁎ 0.02 0.14⁎⁎ −0.34⁎⁎

0.05⁎

Model III: Intention to leave occupation

0.14⁎⁎

0.15⁎⁎

Model IV: Work-life balance 0.11⁎⁎ −0.04 0.03 0.14⁎⁎ −0.24⁎⁎ 0.42⁎⁎ 0.04⁎ 0.32⁎⁎

Note: Standardised regression coefficients reported. ⁎⁎ p < .01. ⁎ p < .05.

on their individual well-being by reducing their satisfaction in being able to maintain a healthy work-life balance. As such, nurses are then more likely to express intentions to leave the occupation. This finding is in line with previous research highlighting workload (Lee et al., 2017) and ability to maintain a healthy work-life interface (Brewer et al., 2009; Simon et al., 2004) as significant determinants of nurses' intentions to leave the occupation. Finally, Hypothesis H3 confirmed the importance of HIWPs in buffering the relationship between perceived workload and intention to leave the profession via satisfaction with work-life balance. It is clear from the findings that the demands of the job can be mitigated by workplace policies and practices that focus on the wellness of these key frontline professionals. Importantly, these practices are all within the realm of management to design, manage and control. As Chen et al. (2015) also argue, in focusing on issues of efficiency and effectiveness of the health system, there needs to be a broader emphasis on including wellness of the health sector workforce which we argue is currently a significant omission. Such an approach would enhance key economic aspects of efficiency and effectiveness of the health sector espoused in influential strategies such as the Triple Aim Healthcare initiative (Berwick, Nolan, & Whittington, 2008). This is also reinforced by research on HIWPs by Boxall et al. (2015), who found that HIWPs that offer employees greater opportunity for discretion, and involvement in the decisions that concern them, contributes to their well-

Table 4 Conditional indirect bootstrap estimates for testing H3. Levels of HIWPs

− 1 SD M + 1 SD

Indirect effect

0.09 0.08 0.07

SE

0.01 0.01 0.01

95% C.I. Lower

Upper

0.07 0.07 0.05

0.12 0.10 0.09

Note: Bootstrap sample size = 5000.

6. Discussion Overall, the results provide support for the three hypotheses. As the analysis of Hypothesis H1 indicates, the perception that workload is associated with increased job demands that deplete nurses of their resources (and wellness) and thus, is leading them to actively consider leaving the profession. This is concerning, as the profession is already expected to see a workforce shortfall over the coming decades, simply based on the demands of an ageing population. Hypothesis H2 indicates that higher levels of perceived workload had a negative impact on satisfaction with work-life balance and that, in turn, increased intention to leave the occupation. This suggests that a higher level of workload is stripping resources from an individual, and this has a negative impact 74

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being. This is also supported by Wood and De Menezes (2011), who found enriched work involvement is positively associated with wellbeing. The key findings from this research are that initiatives to improve the experience and the wellness of nurses is integral in sustaining this workforce. As such, we argue that careful management of the nurse workforce, in particular, providing organisational support via high involvement work practices needs to be a central aspect in the development of quality improvements in the health sector.

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