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Assessing the Quality of Nursing Work Life

Article  in  Nursing administration quarterly · April 2007

DOI: 10.1097/01.NAQ.0000264864.94958.8e · Source: PubMed

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J Nurs Care Qual

Vol. 19, No. 3, pp. 269–275

c 2004 Lippincott Williams & Wilkins, Inc.

Nursing Work Life

in Acute Care
Beth A. Brooks, PhD, RN, CHE; Mary Ann Anderson, PhD, RN
The purpose of this project was to explore how acute care nurses in a midwestern state rate
the quality of their work life. A simple random sample of 1500 registered nurses was surveyed.
Data were collected using Brooks’ Quality of Nursing Worklife Survey (Brooks BA. Development
of an Instrument to Measure Quality of Nursing Work Life [unpublished doctoral dissertation].
Chicago: University of Illinois at Chicago; 2001). Findings suggested that nursing workload was
too heavy, and there was not enough time to do the job well. This study revealed that there re-
main ongoing and fundamental work life concerns for staff nurses that the profession has neither
addressed nor resolved in any meaningful, long-term way. Key words: acute care, descriptive
study, nursing job, quality of nursing work life, staff nurses

N URSE and hospital administrators have

traditionally measured job satisfaction of
employees. Job satisfaction focuses on em-
ployees’ “likes” and “dislikes” and posits the
solution to problems as something for man-
agement to “fix.”1–3 As much as 30% of the
variance explained in job satisfaction surveys
is a function of personality, something an em-
ployer can do little to change.4–6 Unlike qual-
ity of nursing work life (QNWL), job satisfac-
tion is an unsatisfactory construct to assess
either the work itself or employees’ feelings
about work and the work environment (B. A.
Brooks, unpublished data, 2003).
Quality of nursing work life focuses on pro-
viding opportunities for nurses to make mean-
ingful contributions to their organization. A
multidimensional concept, QNWL has been
used to describe the interaction of nurses’
work life with home life along with the de-
sign and context of nurses’ work, the relation-
From the Departments of Public Health, Mental
Health, and Administrative Nursing (Dr Brooks) and
Medical Surgical Nursing (Dr Anderson), College of
Nursing, University of Illinois at Chicago, Chicago,
Ill.
Corresponding author: Beth A. Brooks, PhD, RN, CHE,
College of Nursing, University of Illinois at Chicago,
845 South Damen Ave, Chicago, IL 60612 (e-mail:
brooksbe@uic.edu).
Accepted for publication: October 9, 2003
ships with the work world, and how these
facets interact to affect healthcare productiv-
ity measures such as cost, quality, and patient
outcomes.7–9 As the largest single employer of
nurses, hospitals and their employee nurses
have many common interests. Acute care hos-
pitals are ideal places to start improvement
in QNWL since many parties, nurse, patient,
and hospital stand to benefit. The assessment
of QNWL focuses on those areas in which
the interests of nurses and the organization
coincide and suggests aspects of the work-
place or work itself that could be modified to
improve nursing work life and organizational
productivity.
Improved organizational productivity fol-
lows improvements in the quality of work
life for employees. Classic empirical evidence
suggests that efforts to improve productiv-
ity are achieved through changes in organi-
zational structure, communication and feed-
back, management style, compensation, labor
relations, job redesign, and greater worker
participation.
There appears to be a basic set of needs
and work environment characteristics that
are universally important for all nurses, but
the importance of any particular need is not
known.8,10–12 Better comprehension of the
characteristics of a quality work environment
from nurses’ perspective is needed. Thus, the
purpose of this project was to explore how
269
LWW/JNCQ AS291-13 May 5, 2004 13:51 Char Count= 0
270 JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2004
acute care nurses in a midwestern state rate
the quality of their work life.
METHODS
Design and sample
A survey approach was used in this study.
Using a computer-generated list obtained
from the Illinois department of professional
regulation, a simple random sample of 1500
registered nurses (RNs) was selected. The
population of RNs in this state closely paral-
lels RNs in the nation in terms of educational
preparation, income, ethnic group, and ur-
ban/rural distribution. The only criterion used
for sample inclusion was that the nurse was
employed in a hospital setting. Respondents
could be staff nurses, charge nurses, or team
leaders currently working in hospital settings.
Instrument
Using the O’Brien-Pallas and Baumann
framework,7 a questionnaire to measure the
QNWL was developed.13 There are 4 sub-
scales in the QNWL tool: (1) work life/home
life, (2) work design, (3) work context, and (4)
work world.9 The work life/home life dimen-
sion is defined as the interface between the
nurses’ work and home life. The work design
dimension is the composition of nursing work
and describes the actual work nurses per-
form. The work context dimension includes
the practice settings in which nurses’ work
and explores the impact of the work environ-
ment on both nurse and patient systems. Fi-
nally, the work world dimension is defined as
the effects of broad societal influences and
change on the practice of nursing.
The survey was pilot tested with a conve-
nience sample of RNs who closely resembled
the RNs in the sample. Test-retest reliability
was 0.90. Cronbach’s alphas for the dimen-
sions were: work life/home life .56, work de-
sign .58, work context .88, and work world
.60. The questionnaire ranked at a seventh-
grade reading level using the Flesch-Kincaid
formula and required 9 to 13 minutes to com-
plete. The rating scale was “1 = strongly dis-
agree” to “6 = strongly agree.” Space was pro-
vided for respondents to make written com-
ments to elaborate on the quantitative data.No
attempt was made by the research team at a
formal qualitative analysis of these comments.
Such remarks were used only for anecdotal ev-
idence to enrich the discussion section pre-
sented later.
Procedure
Following approval from the institutional
review board, a cover letter, notice of in-
formed consent, the QNWL questionnaire,
and a prepaid return envelope were mailed
via First Class. Return of the survey implied
consent to participate in the study. One week
later, a postcard follow-up was sent to all re-
cipients of the first mailing. The text of the
follow-up postcard was written as a thank you
for those who had already returned their sur-
vey and a reminder to those who had not.
A second follow-up survey with letter was
mailed to nonrespondents 3 weeks from the
original mailing date.
Procedures to increase the response rates
of a survey were incorporated into the project
protocols.14 Cover letters were personalized.
Original mailing labels were affixed to the
envelopes; no photocopies of labels were
used. Signatures were originals. Business re-
ply postage was used. Subjects were also told
that research findings would be made avail-
able to them. Any surveys returned to the re-
searcher by the post office were remailed to
the subject when the US Postal Service pro-
vided a forwarding address. Conducting mail
surveys using the above method has realized
a 50% to 78% return rate.14
Data analysis
Data were analyzed using SAS System Ver-
sion 8 for Windows. Descriptive statistics,
item summary statistics, and total scale and
subscale scores were computed.
RESULTS
Respondent demographic data
The overall response rate was 48.2% (n =
723); however, only 47% (n = 341) of the 723
LWW/JNCQ AS291-13 May 5, 2004 13:51 Char Count= 0
respondents were staff nurses, charge nurses,
or team leaders in hospital settings. Advanced
practice nurses, faculty, nursing administra-
tors, and other nurses in nonacute care set-
tings returned blank surveys as instructed, but
were not eligible to participate. Only surveys
from staff nurses, charge nurses, and team
leaders were retained. The typical respondent
was a female (n = 391, 93%), Caucasian (n =
269, 79%), aged between 31 and 65 years
(n = 289, 82%), and married (n = 253, 75%).
Sixty-five percent were working full time in a
staff position (n = 264) on such units as crit-
ical care, telemetry, medical-surgical, obstet-
rics, and emergency services among others.
Describing nursing work life
To facilitate analysis, the rating scale of
Brooks’ QNWL survey was truncated into 2 ar-
eas of agree and disagree. The results reported
here and subsequent sections are the percent-
age of nurses who responded with ratings of
agree to strongly agree (ratings of 4, 5, and 6)
or the percentage of nurses who responded
with ratings of strongly disagree to disagree
(ratings of 1, 2, and 3).
Ninety-five percent of the respondent
nurses (n = 323) agreed that a private break
area designated for nurses was needed, 80%
(n = 270) agreed that on-site nursing de-
gree granting programs were important, 62%
(n = 207) agreed their family-medical leave
was adequate, and 57% (n = 194) agreed their
salaries were adequate. Conversely, 74% (n =
248) did not think society had an accurate im-
age of nurses, 67% (n = 230) did not have en-
ergy left after work, 66% (n = 226) felt rotat-
ing schedules negatively affected their lives,
and 66% (n = 209) were unable to balance
work with their family needs.
Workload, staffing, and quality of care is-
sues were of concern. Sixty-seven percent
(n = 227) of respondents indicated that their
workload was too heavy, 59% (n = 199) re-
sponded that there were not enough RNs on
their units, and only 47% (n = 181) indicated
they had enough time to do their job well.
Even in light of these results, 78% (n = 265)
said they provided good quality patient care.
Nursing Work Life in Acute Care 271
Many hospitals have changed their skill mix
from skilled to unskilled workers in cost-
saving efforts. Only 54% (n = 178) of the
nurse respondents in this study agreed they
had sufficient amounts of assistance from un-
licensed assistive personnel (UAP), and only
59% (n = 198) agreed they received quality
assistance from the UAPs.
In terms of relationships with unit manage-
ment, 72% (n = 242) agreed they communi-
cated well with the nurse manager, and 72%
(n = 240) received feedback from the nurse
manager. Less positive were nurses’ partici-
pation in decisions made by the nurse man-
ager (50%, n = 169) and how often they were
recognized for their accomplishments by the
nurse manager (62%, n = 206). Only 37% (n =
125) of the nurses in this sample felt respected
by the upper management. Surprisingly, 70%
(n = 236) of this sample felt respected by
physicians, and 80% (n = 299) said that they
communicated well with physicians.
Finally, 78% (n = 262) of the respondents
thought it was important to have on-site child
care, and 70% (n = 234) thought on-site child
care for ill children was important. Only 56%
(n = 187) of these respondents thought on-
site day care for elderly parents was impor-
tant. Also, the respondents agreed that friend-
ships with coworkers, teamwork, feeling like
one “belongs,”and communication with other
allied health professionals were important.
Nearly 74% (n = 248) of the nurses in this
study agreed that society does not have an ac-
curate image of nurses. Of concern, however,
was that only 65% (n = 201) of the respon-
dents felt that the hospital security depart-
ment provided a secure environment or that
they were safe from personal harm. In addi-
tion, many were concerned about their safety
in the work place. One nurse commented,
“Security needs to be increased to allow the
nurse to perform her duties without fear.”
Rating quality of nursing work life
The purpose of having a composite scale
score is to discriminate quantitatively about
the quality of work life. The total possi-
ble scale score for the 42-item questionnaire
LWW/JNCQ AS291-13 May 5, 2004 13:51 Char Count= 0
272 JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2004
Table 1. Total scale scores and subscale scores for Brooks’ Quality of Nursing Work Life Survey
(n = 330)
Scale Possible score range
42-Item scale
7-Item work life/home life subscale
10-Item work design subscale
20-Item work context subscale
5-Item work world subscale
ranged from 42 to 252. A low total scale score
indicates a low overall QNWL while a high
total scale score indicates a high QNWL. For
each subscale the same is true, a high score
indicating a more favorable environment. In
general, respondents had a higher than av-
erage score on the quality of nursing work
life subscales, which suggests that they were
pleased overall with their nursing work life
situations. However, this finding should be
viewed with some caution since this is a
newly developed instrument with limited use.
To date, few comparisons have been made, so
“true”averages for the subscales are still spec-
ulative (Table 1).
DISCUSSION
The purpose of this project was to explore
how acute care nurses rate the quality of
their work life. Findings suggested that nurs-
ing workload was too heavy, and that there
was not enough time to do the job well. Re-
spondents had little energy left after work,
were unable to balance their work and fam-
ily lives, and stated that rotating schedules
negatively affected their lives. More striking
was that only half agreed that they had suf-
ficient amounts of assistance or quality assis-
tance from UAPs. Few nurses felt respected by
the upper management, were able to partici-
pate in decisions, or felt their manager recog-
nized them for their accomplishments. Impor-
tant to nurses was a private break area for only
nurses, on-site nursing degree granting pro-
grams, day care, and day care for an ill child.
Actual range Mean (SD)
42–252 79–226 164.00 (24.19)
7–42 9–40 25.71 (5.25)
10–60 19–54 39.00 (6.00)
20–120 23–115 80.39 (15.07)
5–30 3–30 18.40 (3.81)
Many felt society does not have an accurate
image of nurses.
Standardized measures are valuable be-
cause they are objective, produce quantifiable
results, are economical to use, allow consis-
tent communication of findings, and can be
used to make scientific generalizations. How-
ever, the value of any standardized measure
is predicated on whether those who ask the
questions intend to “fix” problem areas. This
is the fatal flaw of measures of job satisfaction.
Since much of the satisfaction or dissatisfac-
tion with a job is related to intrinsic personal-
ity traits, an employer is wont to remedy such
factors. The quality of work life, however, and
more specifically the QNWL is amenable to
employer’s intervention.
Not unexpected were the respondents’
views on salary with slightly more than half
of the respondents viewing their salary as ad-
equate. Many nurses commented on their low
salaries, salaries that were not competitive
with other industries, and the lack of shift dif-
ferentials or bonus programs for those who ro-
tate shifts. One nurse commented, “I am not
going to work in nursing any longer. I am over-
worked and underpaid—my sister’s Christmas
bonus was more than I made the last year I
worked.” Nurses’ salaries have not increased
in the past decade and are not commensurate
with increased responsibilities.
Nurse educators are not preparing nurses
for the rapidly changing healthcare indus-
try, and healthcare executives are concerned
about the RN workforce.8 Findings suggest
that discretionary employee benefits enhance
the work life quality of nurses, and nurse
LWW/JNCQ AS291-13 May 5, 2004 13:51 Char Count= 0
executives should take notice. Competitive
salaries, on-site nursing degree granting pro-
grams, and a variety of schedule options are
needed. In collaboration with their colleagues
in human resources, nurse executives can de-
velop and implement employee benefit pro-
grams that would improve the work life of
nurses.
Nursing is a female dominated profession,
and not surprisingly the multiple and often
conflicting roles that women assume were
reflected in the findings. Two nurses com-
mented: “I’m leaving hospital nursing not be-
cause of salary but because of failure to pro-
vide support services to decrease burnout,”
and “I am working in a hospital, but the
stress is too much.” Many nurses in this
study were unable to balance work with their
family needs. One nurse stated: “Because of
extensive call requirements, staff shortages,
rotating shifts, poor nurse patient ratio, and
unsupportive management, my family was suf-
fering.” A majority of the respondents agreed
that rotating shifts negatively affected their
lives and many commented that salaries, shift
differentials, and bonus programs for off-shifts
had been decreased or eliminated.
Findings suggest that workplace interac-
tions and recognition are important compo-
nents of work life quality. The staff nurses
raised many issues centered on their rela-
tionships and interactions with the nurse
manager, including recognition for accom-
plishments and the need for adequate sup-
port and supplies. Participative decision mak-
ing was not a part of most of the nurses’
workplace; less than half of the respondents
were able to participate in decisions made
by the nurse manager. One respondent com-
mented, “Question #33 [I am recognized for
my accomplishments by my nurse manager]
is the most important question on the sur-
vey.”While 70% (n = 236) of the respondents
had adequate supplies and equipment, one
nurse commented that “short of doing the
hospital laundry, nurses do everything else.
We have no transporters on nights, we run out
of clean linen by 7 p.m., and are always out of
supplies.”
Nursing Work Life in Acute Care 273
Collegial relationships are critical to the
workplace quality. Most agreed that teamwork
was in their work setting and that friendships
with coworkers were important. It also ap-
pears that sexism is a part of the workplace.
One male nurse commented, “the gossiping
and constant chatter regarding other people
and their affairs that occurs on my unit is
extremely tiring.” Even though this study did
not directly ask about the effectiveness of the
nurse manager, one nurse commented, “The
turnover on my unit is horrendous. The nurse
manager can’t even figure out how to staff the
unit appropriately. It’s not all her fault though,
no one is helping her learn how to be a good
manager.” These quantitative and qualitative
findings point to areas that the nursing pro-
fession, nurse executives, and nurse managers
can strengthen to improve nursing work life.
However, if nurses are disillusioned with
the profession, the effectiveness of any ef-
forts to improve nursing work life is likely to
be limited. One respondent commented, “I
graduated with an ADN in nursing in ’94 and
started working in May ’95 at the age of 47. I
have a bachelor’s degree in home economics.
I am very disillusioned with the profession of
nursing. It is outrageous what nurses are ex-
pected to do in the time frame allotted.” An-
other stated, “I just graduated from nursing
school. I’m 23 years old. At no time in my ed-
ucation was I prepared for what I’ve encoun-
tered in the hospital. I am looking to leave the
profession.”
Concern about the quality of patient care
was evident. Although over three fourths of
the respondents agreed that they were able
to provide quality patient care, one respon-
dent commented, “I am horrified by what I
perceive to be a shocking decline in quality
of care given to patients. I am also dismayed
by an overall decrease, if not abandonment, of
professionalism among the nurses of my hos-
pital.”Another stated, “Patients deserve better
care than I am able to provide. I can’t stand
feeling like I’m providing inadequate care. I’m
leaving the profession.”
Methods to reward and recognize nurses’
contribution to patient care are needed.
LWW/JNCQ AS291-13 May 5, 2004 13:51 Char Count= 0
274 JOURNAL OF NURSING CARE QUALITY/JULY–SEPTEMBER 2004
Shared governance, clinical ladders, and self-
scheduling are a few of the strategies that
could be implemented in the clinical setting
to improve nursing work life. Results clearly
suggest that hospitals need to provide vig-
orous and ongoing management skill devel-
opment so that managers can develop the
competencies needed to be effective man-
agers. Likewise, education of nurse managers
is needed so they are better able to recog-
nize staff for a job well done. Training also is
needed for UAPs so they are able to fully sup-
port the nurse; nurses may need assistance in
how to delegate properly.
Further research is needed to understand
the work life concerns of nurses in other set-
tings. This study focused on acute care nurses,
but little is known about the QNWL for nurses
in long-term care and home care, or among ad-
vanced practice nurses.
LIMITATIONS
The findings of this study should be inter-
preted with caution as the sample size was
small and from only one midwestern state.
Likewise, generalizations to nurses in other
settings or to advanced practice nurses should
be made carefully as these nurses may have
work life concerns that differ from acute care
nurses.
CONCLUSION
Nurses’ concerns about their work life
remain unresolved at best15 and in some
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