A Literature Review on Quality of Working Life : A Case of Healthcare Workers

Article history: Received on: 28/02/2016 Revised on: 09/04/2016 Accepted on: 12/05/2016 Available online: 28/07/2016 Objectives: The purpose of the study was to explore the characteristic of Quality of Working Life (QWL) research studies related to healthcare sector. Methods: We systematically searched PubMed, Science Direct, and Cochrane Library databases till February 2015. We uses those search term that are ‘health occupation’, ‘health personnel’, ‘medical staff’, ‘nurse health care manpower’, ‘health manpower’, ‘healthcare manpower’, ‘health professional’, ‘practitioner’, ‘quality of working life’, ‘quality of work life’, ‘QWL’ and ‘QoWL’. Results: A total of 56 articles researching QWL were identified, of which 16 papers met the inclusion criteria. In those papers, the first study of QWL was published in 1994. Asia, America, and Europe had published seven, six and four papers, respectively. The number of papers that focus on QWL of nurses (n=9, 52.9%) was the most concerned sector. There are over 200 participants (n=9, 52.9%)in the major studies. The factors that affect QWL are job satisfaction, homework interface, working conditions, compensation, human relations, managementpersonnel relations and support. Conclusion: Nowadays, there are nine countries that focus on QWL of healthcare staffs by researching and assessing concerned factors to enhance worker’s satisfaction and support workers to be better manager change and transition.


INTRODUCTION
In the trend of changes in a number of aspects from environment to technology as well as the rise of employee unions, employers are suggesting salary as compensation and also create specific benefits to form a quality working environment that will fascinate and keep the talented brains in whole fields.In the past, the concepts of the quality of work life were various by many researchers through all the dimensions of QWL.Despite of existing since 1960s, during the international labour relations conference in Rome, Hian and Einstein have indicated the original term "Quality of Work Life" (QWL) as first being introduced in 1972(Hian and Einstein, 1990).The definition of Quality of working life is as need satisfaction getting from an interaction of employees' basic needs such as survival and self-actualization needs and others correlated resources of organizations for meeting them (Efraty and Sirgy, 1990).QWL, in healthcare organizations, has been explicated as a compound of advantages and disadvantages in the work surrounding (Boonrod, 2009).
After a QWL program for work reforms was launched by United Auto Workers and General Motors Company in the United States of America to make jobs more satisfied, QWL got a number of concerns.QWL has been a multi-dimensional concept and it might not be eternal or universal.Individual has different needs linking to their jobs; the level their QWL is proved by whether those needs are being achieved.While some people could be satisfied with a simple minimum salary job that afford to pay the bills, others would search for such a position to be highly displeasing such a job to be so tedious or request too much physical labour(Jain and Thomas).Walton attributes the evolution of QWL to variable periods in history.Followed by the unionization change in the 1930's and 1940's, legislation enacted in early 20 th century that protected workers from incidents and eliminated job conditions were the initial stages (Walton, 1973).
The emphasis was given on following factors, including working condition, job security, work place and economic gains, positive relationship between morale and productivity, equal employment opportunity, human needs and expectations, and relationship between motivation and leadership(Venkata Subrahmanyam C.V., 2013).In the health care system, the pressure to offer more effective service using the equivalent or cutoff resources is going to continue for the foreseeable future.Given transitions in third-party reimbursement increased contention from other healthcare infrastructures, especially set reimbursement amounts for a pointed diagnosis.Besides, healthcare organizations must enhance productivity for organizational existent to meet managed care requirements.However, if achieved at the expense of the quality of workers' working life, rise of productivity is likely to be fugitive (Brooks and Anderson, 2005) QWL is considered a pivotal in decisions on apportion of the quality of life.A high QWL is an integral part of organizations to appeal and maintain employees.QWL is program-designated and comprehensive to enhance employee's satisfaction, support workplace learning and help workers better manager transition and alteration (Boonrod, 2009)In recent years, there is a numbers of QWL studies for many purposes (Mirkamali and Thani, 2011;Rethinam and Ismail, 2007;Rose et al, 2006).But up to until now, no study provides a comprehensive view of characteristics of QWL studies in healthcare.This study systematically reviews the studies of QWL related to healthcare worker explore factors affect QWL

MATERIALS AND METHODS
The electronic search was conducted based on PubMed, Science Direct and the Cochrane Library databases during the period of February 2015.We searched using the following search terms: 'health occupation', 'health personnel', 'medical staff', 'nurse health care manpower', 'health manpower', 'healthcare manpower', 'health professional', 'practitioner', 'quality of working life', 'quality of work life', 'QWL' and 'QoWL'.To get more eligible articles, we scanned the reference lists of the papers we selected to assess.From each study, we extracted year published and conducted, countries investigated, instruments used to assess QWL, sector, design of research assessed in the study, sample analysed in each study, period of time conducting, factors of assessment, results of article with related to methodological quality or factors of QWL.As our searched studies had a diversity of designsthose are quasi-experimental study, two-wave survey study, descriptive study.There are some limited descriptions of methods, so we cannot assess their methodological quality without available valid and reliable quality assessment instrument.This study sets out to identify and includes all published articles that (i) research quality of work life (QWL) (ii) use specific instruments and scales to assess QWL (iii) object is people working in medical organizations.Studies were excluded if they did not present both sides: the quality of working life and health professional.Studies were also rejected if they were not used English, not in health sector and not have full text.

RESULT
The flow diagram describing the process of systematic review is provided (figure 1).The combined searches found 47 potential titles.Of these, we rejected 25 articles after reviewing title/abstract as well as 9 articles for duplication and not writing by English.Of the total 13 articles, we excluded 6 articles not have full text.Next, we looked for eligible papers in reference lists of remaining papers.Finally, there are 16 papers included in our report.

General characteristics of publications
In 16 articles we found 1 (table 1), the first study of QWL is published in 1994.Until 2002, another study had been conducted.From 2002 to 2009, there are one or two papers focusing on QWL every year.2011 and 2012 are two remarkable years when having the most papers published-4 papers each year.Besides, Asia had the most articles (n=7, 43.8%), the other articles were from America (n=6, 37.5%) and Europe (n=3, 18.8%).Especially, Canada and USA published three papers per country.
The second concerned factor is target employee of studies.Generally, studies classified three groups of respondents including doctors, nurses and staffs working in health care system.The most concerned health professional QWL was nurses (n=8, 50%), while physicians had the least concern (n=3, 18.8%).The others researched QWL of healthcare staffs (n=5, 31.3%).In the term of applied method, most of papers designed in descriptive research (n=9, 56.3%).Descriptive study measures the illness or conditions and adequate factors at a specific point in time for a chosen population.Descriptive studies can involve a one-time interaction with groups of people (cross-sectional study) or a study might follow individuals over time (longitudinal study).Those in which the researcher interacts with the participant, may involve surveys or interviews to collect the necessary information.The others are consisted of one quasi-experimental study, 2 two-wave studies and one paper did not mention its design.
As for sample of research, this study split them into three intervals to get the overview about the range of sample used.Most of studies (n=11, 68.8%) are conducted on the large sample, over 200, the others were under 200 participants (n=5, 31.2%).There are a number of publications mentioning that authors use Likert scale for questionnaire.The number of articles using 5-point scale to score each item of dimensions or sub-dimensions including management-personnel relations and support, work aspects, job promotion, salary and rewards, and autonomy and so on was the most concerned (n=8, 50%).
Moreover, those papers use one or two software to analysis surveys.Most of them use SPSS, especially SPSS version 11 (n=5, 31.3%).Furthermore, most of papers (n=11, 68.8%) did not mention how long the research lasted.The other studies included four articles conducting within 3 months and two articles within 1 month.The period of time was difference depending on characteristic of study.

Factors related to QWL
Studies are not only about QWL but also other factors relating to the work of medical staffs.Some factors which appeared in many studies are job satisfaction, homework interface, working conditions, compensation, human relations, managementpersonnel relations and support.Some papers focused on factors that related to only QWL (Cole et al, 2005;Hosseinabadi et al, 2012;Hsu and Kernohan, 2006).There is one study just listed questionnaire without mentioning specific dimension or factor (Beasley et al, 2004).Three articles restricted research in four .factors: Work life/home life, work design, work context and work world (Almalki et al, 2012), Work life/home life, work design, work context and work world (Almalki et al, 2012), Hospital performance: rationale, open systems, internal process, human relations (Minvielle et al, 2008).Those gave accurately assessment and easy control.Some articles were highlighted with the factors more than other studies (Boonrod, 2009;Hornung et al, 2011;Krueger et al, 2002).
On the other hand, the results of those papers focused on: the mutual influence of factors (An et al, 2011;Hornung et al, 2011); the level of employee satisfaction with the given elements (Almalki et al, 2012;Beasley et al, 2005;Beasley et al, 2004;Minvielle et al, 2008;Nayeri et al, 2011); the differences between the study groups (Hosseinabadi et al, 2012;Sale and Smoke, 2007), the factors that impact on the QWL (Almalki et al, 2012;Boonrod, 2009;Cole et al, 2005;Hsu and Kernohan, 2006;Pronost et al, 2012;Smith et al, 1994) and important predictors of job satisfaction (Krueger et al, 2002).
We would clarify those main core of results at some important points.In the term of how the concerned factors were, we have two different issues.Those were the link of leadership dimension and idiosyncratic deals, the correlation between organizational culture, QWL and organizational effectiveness as well as the relation of QWL and turnover intention.Researches indicated some interesting results such as factor "Consideration" had compatible positive effects on idiosyncratic deals regarding both Professional development and Working time flexibility (Hornung et al, 2011) or organizational culture affected nurses' quality of work life (An et al, 2011).The second one is about how employees assessed their QWL as well as other dimensions based on some given factors.
Those factors are work life/home life, work design, work context and work world, hospital performance, work satisfaction, practice issues, outcomes, management-personnel relations and support, work aspects, job promotion, salary and rewards, and autonomy.The results are distinctive when researchers analysed different group of factors.Some level of the satisfaction could be listed.A paper concluded that the "shared values/ organizational climate" dimension was the most important factor (Minvielle et al, 2008).Another demonstrated the strong positive correlation between satisfaction with the heath care organizations and the physician's perceived ability to achieve professional goal, the perceived quality of care (Beasley et al, 2004).
We also should aggregate the typical opinions.Significant aspects nurses' QWL were human relationships, job value and self-actualization (Hsu and Kernohan, 2006).Moreover, the QWL was inversely related primarily to the lack of recognition, the lack of time, the poor consideration for patients and their families, the lack of training and the lack of collaboration (Pronost et al, 2012) and also positively related to job characteristics, organizational climate, organizational commitment and job satisfaction (Boonrod, 2009).Those are so helpful to give a holistic view so as to improving QWL.

DISCUSSION
Quality of work life has emerged as a popular concept.In the area of health care, the number of articles on QWL is increasing.It shows the proper attention of organizations on this important issue.QWL researches are conducted in many countries with different objects.Each study uses separate methodologies, tools to survey to assess the related factors to get high reliable result.According to our results, Idiosyncratic deals consisted of development as well as flexibility idiosyncratic deals.Leader consideration positively effects on idiosyncratic deals related to both items Professional development and Working time flexibility.Those two kinds had distinctive effects on two factors related to QWL (Hornung et al, 2011).Idiosyncratic deals mention to negotiated deflections from organizational practices related to standardized work and employment conditions.Furthermore, idiosyncratic deals have been implied to be reciprocally beneficial for employees and employers by enhancing the suitability between people and working and by that it provides conditions supporting the employee's well-being and sustained performance.Besides, that finding has been implied that idiosyncratic deals could play as a bond between employee-oriented leadership and QWL (Hornung et al, 2011).In addition, organizational culture had been significant related with QWL as well as organizational effectiveness.Organizational culture is a definition of a set of beliefs, values, behavioural patterns, and assumptions between members in organization (An et al, 2011).Chances for growth and improvement of employees can have an impact to organizational culture as well as organizational effectiveness.Furthermore, organizational culture directly and indirectly affect to QWL.So that the strategy to enhance organizational effectiveness is based on organizational culture.Since individual culture of organization is distinctive, study on organizational culture is mentioned crucial in organizational effectiveness study.According to results, intact organizational culture and QWL of nurses will definitely enhance organizational effectiveness.(An et al, 2011) In additional, turnover intention was significantly correlation with QWLas results indicated that the respondents were dissatisfied with their work life, with almost 40% mentioning a turnover intention from their present primary health care (PHC) centres.Turnover of nurse has been a major issue for a number of health care organisations.Turnover of qualified nurses has unwanted results for both health organisations and the profession.Nurse turnover can have a negative affection on the capacity to meet patient needs and provide quality care.This result could be concerned to find out appropriate strategies to enhance QWL and to decline the turnover of PHC nurses.Sustaining a healthy work life for PHC nurses is essential to enhance their QWL, raise retention, improve performance and productivity and promote safe nursing care (Almalki et al., 2012).
In the studies of nurses' QWL, studies based on Brooks' research to assess QWL.The Brooks' survey of QWL of nurse (Brooks, 2001) has been appeared in other published studies in the USA and Iran with increasing global interest.Additionally, queries to applied Brooks' questionnaire have been come from scientists and graduate students in Greece, Estonia, Canada (Ontario, Quebec), India, Iran, Australia, Malaysia, Turkey, and Taiwan (Almalki et al, 2012) Of 17 papers, there are six papers mentioning time they conducted study, mainly about step of survey or interview.The period of time is different among the studies.Time for conducting research is one of the most necessary items.It affects the accuracy of the research, the necessary funds, the number of respondents and research scope.In the case of tools used in the study, we assessed the scale used for the survey questions.The scales used in each article are different.In addition, there are some articles that uses many different scales, depending on the type of questions, concerned issues or respondents.Most of the studies used 5-point scale-point scale.There are some reasons indicating the suitability of this scale: It provides enough differentiation to allow respondents to tell you how they really feel, they would not be slowed down trying to choose between multiple ratings, the option in the middle will suit anyone who does not have an opinion.Therefore, results will be precise and reasonable.However, some opinions indicate disadvantages of that scale.For example, some people would think their distinctive capacity for perceived welfare to be limited to five levels of experience.Besides, there are some scale-construction factors that tend to reduce the effective choices.So expanding the number of scale points gives chances to improve questionnaire and the adequate scale format may be a 10-point, end-defined scale (Cummins and Gullone, 2000).In conclusion, the choice of researchers depends on concerned factors to use the most suitable scale for their study.Nowadays, there are different kinds of analysis tool in the world.In these articles, the tool used most is SPSS software, especially SPSS version 11.SPSS is a flexible and comprehensive statistical analysis and data management solution.They have large data sets, complex data interaction, accurate statistical analysis, strong field to graph and table scheduling, reporting and aggregating data, but weaker on some statistical procedures as reliable estimation method and absence of data analysis method according to the sample schema.So that, in other papers, researchers used different software being suitable for their result.However, six articles do not mention analysis software used.This is major deficiency because of making difficult for the readers in assessing the accuracy of the research as well as in the application of this research method.
This study has two important limitations.The main problem links to the quantity and the aim of the literature.Although we conducted a comprehensive search, we found only a limited group of publications with quantitative data.A second limitation is about summarizing the factors of QWL and result of them as well as how they affect positively or negatively to QWL.Since each paper is conducted with different aim and they did not just research QWL but other issues so there are many factors are mentioned and accessed.

CONCLUSION
QWL is concerned more and more in order to improve quality and productivity of working in organizations.Moreover, the study reveals some factors affecting the QWL such as job satisfaction, homework interface, working conditions, compensation, human relations, management-personnel relations and support to be better manager change and transition.They are so important to recognize and access the advantages and disadvantages of environmental working to get the appropriate solution addressing limiting factors and improve QWL.

Table 1 :
Countries and published year of QWL publications.