QUALITY OF WORKING LIFE AND TURNOVER INTENTIONS: IMPLICATIONS FOR NURSING MANAGEMENT

The main purpose of this study was to explore the s atu of Quality of Working Life (QWL) among hospit al nurses in Isfahan, Iran. A survey study was conduct ed based on a sample of 296 hospital nurses using a valid and reliable QWL questionnaire. Hospital nurs es reported low levels of QWL. The most important predictor of QWL was disturbance handling, followed by job proud, job security and job stress. Since Q WL have strong correlation with turnover intention, it is very important to reinforce it by applying the right human resources policies.


INTRODUCTION
A high Quality of Working Life (QWL) is critical for healthcare organisations to attract and retain qualified, committed and motivated employees. Quality of working life refers to an employee's satisfaction with working life. It shows the relationship between employees and their physical, social and economic work environment. It is a multi-dimensional concept and covers an employee's feelings about various dimensions of work. These include the job content, working conditions, fair and adequate compensation, career development opportunities, task discretion, participation in decision-making, occupational health and safety, work stress, job security, organisational and interpersonal relations and work-life balance (Adhikari and Gautam, 2010;Connell, 2009;Hsu and Kernohan, 2006;Mosadeghrad et al., 2011).
QWL provides employees with the motivation and the opportunity to perform well. Improving employees' QWL is a prerequisite to increase their organisational productivity (Dolan et al., 2008;Bragard et al., 2012;Nayeri et al., 2011). High QWL organisations achieve better productivity and become highly competitive.
QWL enhances employees' dignity through job satisfaction and humanising the work by assigning meaningful jobs, giving opportunities to develop human capacity to perform well, ensuring job security and adequate pay and benefits and providing safe, healthy, participative and supportive working conditions (Adhikari and Gautam, 2010).
Improving nurses' QWL may result in a higher level of delivered quality of care to patients (Hsu and Kernohan, 2006). Very little research in the literature is available on the level of QWL among Iranian hospital nurses. This study aims to overcome this gap.

Purpose and Objectives
The main purpose of this study was to determine the level of QWL among hospital nurses in Isfahan, Iran. Doing so has practical relevance for designing and implementing strategies and interventions to improve QWL among hospital employees.

Design
The study utilised cross-sectional, descriptive and correlational design and survey methodology.

Setting
The study was carried out at six hospitals, three Ministry of Health hospitals (two educational and one non educational), one Social Security and two private hospitals. The six hospitals of the study were selected to represent the three dominant hospital care systems in Iran.

Population and Sample
Two hundred and seventy five nurses were selected for this research after a pilot study by using the following formula (N = 964, d = 0.05, z = 1.96 and s = 0.50). Employees who had less than 6 months working experience were excluded from this study. A sample size of 316 nurses was selected assuming a response rate of 85%:

Instrument
A survey instrument was designed to measure levels of QWL among employees of hospitals. The items of this questionnaire were gathered by means of a literature review (Argentero et al., 2007;Cole et al., 2005;Gifford et al., 2002;Sale and Smoke, 2007) and a Delphi method. In total, nine dimensions of QWL were defined ( Table 1). This questionnaire has 36 items (four items in each domain). Ratings were completed on a five -point scale (from very low = 1 to very high = 5).
A pilot study was undertaken to test the relevance and clarity of the questions and to refine them as needed to avoid misunderstanding. The questionnaires were found to be understandable and acceptable. In this research, nine QWL constructs have content and face validity since they were derived from an extensive review of the literature and evaluations by academics and practitioners. Cronbach's alpha was computed for each scale using the SPSS-11 statistical package. The reliability coefficient was 0.86 for QWL questionnaire ( Table 1).

Data Collection
The sampling method was stratified random sampling. Data collection was undertaken in September 2008. Informed consent was obtained from all subjects following receipt of information on the purpose of the study, assurances of anonymity and confidentiality.

Data Analysis
All data were analysed using the Statistical Package for the Social Sciences (SPSS 11). In order to normalize the Likert scale on 1-5 scales for each domain of QWL questionnaire, the sum of raw scores of items in each domain was divided by the numbers of items in each domain (4) and for overall QWL, sum of raw scores of items were divided by 36 respectively. The possible justified scores were varied between 1 and 5.

RESULTS
A total of 296 nurses filled out the questionnaires (93.6%). The characteristics of the sample are summarized in Table 2. Almost three fourth of the participants were females (72.6%) and married (76.7%). The majority had bachelors degree (61.9%). Almost half of the employees (48.8%) had incomes of less than 3,000,000 Rials (poverty line in Iran in 2008). The average employee age was 34 years (SD = 8.31) with the youngest 21 years and oldest 65 years. The majority of the respondents were aged 20-30 years, followed by 31-40 years. Employees had worked an average of 10 years (SD = 8.05) in their career with a minimum of 1 year and a maximum of 32 years.  The mean score of nurses' QWL was 2.51 on a 5 scale implying that overall the level of QWL was low. The overall scores ranged from 1.47 to 4.64 (possible range 1-5). QWL was very low, low, medium, high and very high in 16.6, 56.1, 22, 5.1 and 0.3 percent of hospital nurses (Table 3).

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In correlation analysis between QWL and its nine dimensions, job promotion (r = 0.817), participation and involvement (r = 0.766), job proud (r = 0.740), job security (r = 0.736), disturbance handling (r = 0.714) and wages and salaries (r = 0.685) respectively had the highest effect on nurses' QWL. The results of the stepwise regression model indicate that 87 percent of the variance in overall QWL is explained by job promotion, job security and job proud. The variables-fair job promotion, management support, stressful working conditions, relationships between employees and managers, fair fringe benefits and providing opportunities for developing nurses' skills and abilities were the most influential factor in QWL.
There was strong correlation between QWL of nurses and their education level and type of employment (p<0.05). Nurses' QWL in semi public hospitals was less than public and private hospitals (Table 4). However, the differences between values of nurses' QWL in these hospitals were not statistically significant (p>0.05).
Nurses were more likely than head nurses to be satisfied with their QWL (Table 5). However, the differences between values were not statistically significant (p>0.05).
Thirty-five percent of nurses stated that they would leave the hospital if they find another job opportunity. QWL was negatively (p<0.001) associated with turnover intentions ( Table 6). About 42 percent of nurses were happy to recommend a close friend to join and work in their hospital. QWL was positively (p<0.001) associated with recommending the hospital to others for work. Significant relationships were found between nurses' turnover intention and their age (p = -0.04).

DISCUSSION
This study set out to assess the degree of QWL among Iranian hospital nurses. Hospital nurses reported low levels of QWL. The results showed that job promotion, job security, job proud, participation, management support and pay and benefit were key factors in nurses' quality of working life. These findings are consistent with other similar studies that found moderate to low levels of nurses' QWL because of increased workload, poor staffing, insufficient pay, lack of professional development opportunities, job insecurity, inappropriate working environment and lack of facilities (Almalki et al., 2012;Boonrod, 2009;Nayeri et al., 2011;Rastegari et al., 2010).
Job insecurity was found in this study a factor that negatively influences nurses' QWL. Comparing the 'r' figures, it is observed that job insecurity threatens the private sector more than the public sector. Since private hospitals are profit oriented, there is redundancy resulting from over staffing.
The current study showed that promotion opportunities were another significant predictor of QWL among hospital nurses. Unfair promotion policies perceived by nurses may negatively affect their QWL. Employees should be considered as developing human assets. Life-long learning, professional growth and advancement promote employees' job satisfaction and enable continued provision of high-quality healthcare services (Donner and Wheeler, 2001;Mosadeghrad et al., 2008). Dissatisfaction with promotion opportunities has been shown to have a stronger impact on employees' turnover (Shields and Ward, 2001). It is therefore, recommended that managers provide equal promotion opportunities for employees. Management should put in place localization programmes and initiatives that would promote employees to key positions and increase their involvement in decisionmaking. If nursing administrators want to improve nurses' QWL, they must be more supportive and give nurses opportunities for advancement.
The critical role of the leadership and management practices on nurses' QWL was highlighted in previous studies (Brooks et al., 2007;Dolan et al., 2008). According to Dolan et al. (2008), management support explains more than 20% of the variance in QWL. Nurses prefer more consultative, democratic and participative managers who show adequate respect and recognition and get them involved in decision making process (Mosadeghrad and Ferdosi, 2013). Similarly, good relationship with coworkers plays a crucial role in the nurses' QWL (Dargahi and Seragi, 2007;Hsu and Kernohan, 2006).
Working schedule and shift working are also important predictors of nurses' QWL (Brooks et al., 2007;Gurses et al., 2009;Hsu and Kernohan, 2006). In a study conducted by Gurses et al. (2009) nurses working in the night shift reported higher fatigue and stress and lower QWL. Nursing administrators may apply strategies such as flexible scheduling, selfscheduling, part-time work and alternative shift systems to improve nurses' QWL (Vagharseyyedin et al., 2011). In addition, heavy workloads and high job demands are negatively correlated with nurses' QWL (Dolan et al., 2008;Gurses et al., 2009).
The majority of nurses in this study stated that their pay was inadequate. This finding is consistent with the results of other studies conducted in Iran Saraji and Dargahi, 2006). Nurses' satisfaction of pay and fringe benefits has been recognized as one of the most important predictors of QWL Hsu and Kernohan, 2006). Lewis et al. (2001) found that pay and benefits explained 40% of the variance in QWL satisfaction.
This study revealed a reverse relationship existing between QWL and turnover intention. Improving QWL will ultimately lead to increased job satisfaction and reduced turnover intention among nurses. It is recommended that particular attention be given to improving nurses' QWL through organisational change programmes. Although recruiting more nurses and increased wages and fringe benefits offset nurses dissatisfaction in the short term, improving QWL would be a more long-term approach to improving nurses' retention and reducing turnover. However, the success of QWL initiatives depends on organisational culture and partnership between management and employees.
The goal of QWL programmes is to improve the work design and requirements, the working conditions and environment and organisational effectiveness. It aims to create more involving, satisfying and effective jobs and work environment for employees at all levels of the organisation. A decentralized organisational structure, a commitment to flexible working hours, an emphasis on professional autonomy and improved communication between management and employees result in improved QWL, increased employee job satisfaction and lower turnover (Mosadeghrad et al., 2011). Techniques such as autonomous work groups, self managed teams and employees-management committees help decentralise organisational structure.
It seems that a key factor in the success of QWL is the employee's involvement in and commitment to the improvement of the work process. Empowered employees have more autonomy and control over their Science Publications IJRN work conditions and as a result are more likely to have higher job satisfaction and organisational commitment and lower job stress and burnout (Kuokkanen et al., 2003). However, introduction and implementation of QWL programmes involving greater employees' involvement in the decision making process may pose difficulties in countries where there is a greater power distance and separation of management and employee roles. Such programmes would probably meet with resistance from those people who would be adversely affected.
Iran scored high on power distance index (House et al., 2004). Iranian managers might be somewhat reluctant to accept changes in their subordinates' and their own job responsibilities where this change meant a reduced power distance. Therefore, any attempt to apply participative management techniques in Iranian context should be adjusted. QWL efforts will require innovative thinking to construct a unique stance regarding the involvement of the employee in the decision-making process.
QWL programmes involve change. These changes will be resisted by people in cultures characterised by a high uncertainty avoidance index. Therefore, in countries with high uncertainty avoidance like Iran (Hofstede, 1984) adequate rules and regulations are required to provide structure and certainty in the changing conditions created by QWL programmes. This assures that the employees are not overwhelmed with anxiety.
When introducing QWL to various cultures, attention must be also given to the relative individual versus collective emphasis. Organisations operating in countries low on individualism may tend to deemphasise individual incentives and rewards and prefer to provide group incentives and opportunities for group problem-solving. In such countries with low individualism, organisational QWL programmes are likely to be group oriented. However, in nations high on individualism such as Iran (Moghadam and Assar, 2008), individual decisions are thought to be better than group decisions and as a result individual initiative is socially encouraged.
The implementation of QWL often leads to changes in the nature of work. The job characteristics can be manipulated in a positive way to increase job meaning and therefore employee motivation. Techniques such as job rotation (alternating task assignments), job enlargement (expanding the scope of the job by adding more task variety) and job enrichment (expanding the depth of the job by adding more responsibility and authority) are examples of job redesign interventions to improve employee satisfaction.
Iran scored considerably lower on the Hofstede (1984) masculinity/femininity index. Hofstede (1984) indicated that in more masculine cultures, humanised jobs should provide more opportunities for recognition, advancement and challenge whereas in less masculine cultures, the emphasis would be more on cooperation and good working atmosphere. Thus, in lower masculine countries, organisations should not interfere with the private lives of their employees, whereas in higher masculine countries this interference in private lives is seen to be more legitimate.

CONCLUSION
In a cross sectional study, the levels of QWL and factors contributing to it among a group of hospital nurses in Iranian hospitals were examined. Hospital nurses reported low levels of QWL. Factors that may influence the level of employees' QWL are demographic variables of type of the hospital, type of employment and the nine dimensions of QWL as indicted in Table 1. Job promotion, management support, working conditions, relationships between employees and managers, fair fringe benefits, providing opportunities for developing nurses' skills and abilities and security of employment exhibit the most direct effects on employees' QWL. Nurses who experienced lower QWL had more intention to leave the hospital, if they find another job opportunity. Individual variable of the age and the nine QWL dimensions play a significant role in nurses' turnover intention.
Since QWL is correlated with nurses' turnover intention, it is very important to improve it by applying the right human resources polices. The most contributor to employees QWL in this study were inadequate pay, lack of recognition and promotion prospects, lack of job security and lack of management support. Hospital managers and nursing administrators must manage these organisational variables more constructively in a way to improve nurses' QWL.
The results of this study suggest that nursing administrators might be able to improve the level of QWL by increasing nurses' satisfaction with job security professional recognition, work conditions, work schedule, workload and nursing staffing. Changes in nursing management thoughts, systems, structures and policies are required. Changes in organisational climate, job chracteristics, pay and benefit scales and demonstrating value to staff could increase employees' QWL and decrease their turnover. However, improving employees' QWL requires a context-specific approach.
Jobs should be designed in ways that provide meaning, motivation and opportunities for nurses to use their skills and abilities. Workload should be is in line Science Publications IJRN with nurses' capabilities and resources. Nurses' roles and responsibilities should be clearly defined. They should be given opportunities to participate in decisions and actions affecting their jobs. Workplace discrimination should be minimized and preferable eliminated.

Limitations and Implications for Future Research
This study contributed to understanding the relationships between QWL and turnover intention among a sample of hospital nurses. Furthermore, this study identified factors that appeared to be related to nurses' QWL and turnover intention. However, some caution is needed in interpreting the results. In this study, nurses' participation was voluntary and was conducted at six hospitals in Isfahan city, Iran an Islamic country. Therefore, the findings should be interpreted with caution. More research in this area is needed before generalizing the study findings.
This study may serve as a foundation for future studies in different countries, on a larger scale. More studies which involve hospital nurses from other countries would enrich the literature on hospital nurses' QWL which could in turn generate strategies to improve the global retention of hospital nurses.