Journal of Nursing Management, 2015, 23, 661–673
A literature review of factors related to hospital nurses’ healthrelated quality of life YUMIKO OYAMA
RN, MPH
1
and HIROKI FUKAHORI
RN, PhD
2
PhD Student, Doctoral Program in Comprehensive Health Nursing Science, 2Associate Professor, Department of System Management in Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
1
Correspondence Yumiko Oyama Doctoral Program in Comprehensive Health Nursing Science Department of System Management in Nursing Graduate school of Health Care Sciences Tokyo Medical and Dental University 1-5-45 Yushima Bunkyo-ku Tokyo 113–8510 Japan E-mail: [email protected]
(2015) Journal of Nursing Management 23, 661–673. A literature review of factors related to hospital nurses’ health-related quality of life
OYAMA Y. & FUKAHORI H.
Aim To conduct a literature review in order to determine the predictors of nurses’ health-related quality of life and to clarify the implications for nursing management and future study in this area. Background Good health is essential to the performance of health care workers. Evaluation Relevant studies were retrieved from PubMed, Medline, CINAHL, the Japan Medical Abstract Society, and the Technology Information Aggregator, Electronic. The studies selected for this review were published in English or Japanese between 1995 and 2012, investigated nurses’ health-related quality of life. The identified predictive factors of each study were categorised according to type. Key issues Based on the criteria, 22 studies were reviewed. The predictive factors of nurses’ health-related quality of life were classified into eight categories. Conclusions Age and occupational stress should be considered when examining unknown predictive factors of nurses’ health-related quality of life. In addition, it may be useful to adopt a conceptual framework and consider patient and organisational factors in future research. Implications for nursing management It is necessary to identify nurses’ occupational stressors and consider age during job placement in order to support their health. Keywords: health personnel, health-related quality of life, literature review, narrative review, nurses Accepted for publication: 24 September 2013
Introduction Good health is essential to the performance of health care workers (Fronteira & Ferrinho 2011). It has been pointed out that lower nurses health status could result in a decline in the quality and safety of care that they provide (Leary & Francis 2007, Wu et al. 2011a). Others have reported that lower health status in nurses is a risk factor for adverse outcomes such as medication errors, which were linked to aspects of nursing practice (Wilkins & Shields 2008, Arimura DOI: 10.1111/jonm.12194 ª 2013 John Wiley & Sons Ltd
et al. 2010). Thus, nurse health is important for not only nurses but also patients. Health problems in nurses have been reported worldwide. In Canada, the prevalence of specific chronic conditions such as back problems, migraines, and sleep disorders was high among nurses in comparison with employed people in general (Shields & Wilkins 2006). In addition, approximately 50% and 19% of a sample of European nurses reported that they suffered from musculoskeletal disorders and mental disorders, respectively (Estryn-Behar et al. 2005). 661
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Approximately 50% of Japanese hospital nurses reported physical symptoms such as back pain and chronic sleep deprivation (Japanese Nursing Association 2008), and approximately 70% experienced symptoms of chronic fatigue (Japanese Federation of Medical Workers’ Union 2010, Japanese Nursing Association 2010). Overall, human resources costs at health care institutions are reduced when nurses are retained, which is more likely in environments that support nurse health (O’Brien-Pallas et al. 2011); however, concrete strategies to support nurse health at health care institutions appear to be lacking. Discussion of the current state of research on nurse health may facilitate further improvement in working environment and inform nursing policy. Fronteira and Ferrinho (2011) conducted a literature review of nurse health status, focusing on physical health and the prevalence or incidence of diseases or disorders such as musculoskeletal disorders, bloodborne pathogens and tuberculosis. However, such traditional measures of morbidity provide information about only the lowest levels of health (Center for Disease Control & Prevention 2000). The World Health Organisation (1997) defines health as ‘a state of complete physical, mental, and social well-being not merely the absence of disease’. Therefore, it may be insufficient to measure health status by defining health in terms of freedom from disease. Health-related quality of life (HRQol) is an individual’s satisfaction or happiness with the dimensions of life insofar they affect or are affected by health (Wang et al. 2008). Subjective measures provide insight into matters of human concern such as pain, suffering, or depression that could not be deduced solely from physical measurements (McDowell 2006). Healthrelated quality of life has been introduced as a method for assessment of health status and, in recent years, has been increasingly recognised as an important health outcome among healthy populations, including workers (Wang et al. 2008, Silva et al. 2010). The importance of HRQol as a health outcome is no exception for nurses: nurses’ feelings about their own health tend to influence the health care services they deliver and, by extension, the health of the population at large (Trinkoff et al. 2001, Wu et al. 2010b). Furthermore, Jordan et al. (2003) stated that HRQol is reported to be a predictor of morbidity among a general healthy population; thus, measuring the health status by HRQol might influence nurse managers or policy makers to consider healthy work environments for nurses. Therefore, it is important to understand the current findings for nurse health status as mea662
sured by HRQol. However, to the best of our knowledge, no previous literature review has systematically synthesised data on the HRQol of nurses.
Objective We conducted a review of the existing literature in an attempt to determine the predictors of nurses’ HRQol and to clarify the implications for nursing management and future study in this area.
Methods Data source and search strategy We referred to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher et al. 2009) and the report guidelines for medical study (Lang & Secic 2011) for this literature review. PubMed, Medline and CINAHL were used to search original works in peer-reviewed journals published in English. The Japan Medical Abstract Society (in Japanese: ‘Ichu-shi nWeb’) and the Japan Science and Technology Information Aggregator, Electronic, were used to search original works in peer-reviewed Japanese journals published in Japanese or English. Table 1 lists the keywords used. We retrieved studies published between 1995 and 2012.
Eligibility criteria for studies and literature synthesis Three eligibility criteria were applied to select studies for this literature review. First, only studies that investigated the HRQol of nurses using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) or its short versions, SF-12 or SF-8, were retrieved. We established this criterion because these scales have been the most commonly used in a wide Table 1 Keywords used to search databases Keywords #1 Nurses AND Quality of life #2 Nurses AND Health status #3 Health personnel AND Quality of life #4 Health personnel AND Health status #5 Nurses AND SF-36 #6 Nurses AND SF-12 #7 Nurses AND SF-8 #8 Health personnel AND SF-36 #9 Health personnel AND SF-12 #10 Health personnel AND SF-8
‘Nurses’, ‘Quality of life’, ‘Health personnel’ and ‘Health status’ were thesaurusised. ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
Nurses’ HRQoL: literature review
range of areas and are comparable between countries. Furthermore, many countries have certified the psychometric properties of these scales. The SF-36 is a questionnaire used to measure health status in general and consists of 36 items and eight subscales: physical functioning, role-physical, body pain, general health perception, vitality, social functioning, role-emotional, and mental health. Scores on these eight subscales can be used to compute summary indices of physical health (PCS) and mental health (MCS) (Fukuhara et al. 1998). The SF-12 and SF-8 are the shorter versions of the SF36 and consist of 12 and eight items, respectively. Both the PCS and MCS can be calculated from the SF-8, SF12 and SF-36. Consequently, we excluded studies that used other HRQol measurements such as a disease-specific measurement or a measurement devised by the authors for the study. Second, we only included studies using three observational epidemiological study designs: cohort, case-control and cross-sectional. We followed the definition of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) to evaluate the three study designs (Vandenbroucke et al. 2007). The third eligibility criterion was that studies must have been written in English or in Japanese. We checked these three criteria by reviewing the titles and/or abstracts. The main text of all studies that fulfilled the three eligibility criteria were confirmed and then studies using HRQol alone as an outcome variable were selected for review; thus, we excluded studies that used HRQol as a
potentially relevant factor for any other outcome variable. We carried out narrative synthesis for this review because the studies had used various measurement techniques for independent variables. We categorized the identified predictive factors of each study according to type (Davey et al. 2009).
Results Literature selection The results of the literature selection are shown in Figure 1. We retrieved 132 studies based on the eligibility criteria; of those, we excluded 77 duplicates, and 55 candidate studies remained for review. Of these, we excluded 33 because: (1) the HRQol score was used as an independent variable (n = 16); (2) the study conducted a score comparison only (n = 5); (3) the study was a test of a conceptual model (n = 1); (4) the study focused on the effect of specific exposures such as terrorism or the experience of caring for patients with severe acute respiratory syndrome on HRQol (n = 3); (5) the main aim was examining the effect of diseases such as urinary incontinence and headache on HRQol (n = 7); (6) we could not determine whether nurses were included in the study (n = 1). The final pool contained 22 studies (Table 2). Of these, only one employed a cohort study design (Cheng et al. 2000); the others used cross-sectional designs. There were no case–control studies in the
Figure 1 Flow diagram of literature selection. ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
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pool of literature reviewed. Most of the participants in the 23 studies were women, and some studies used samples comprising only women to avoid a confounding effect. Only two studies used theoretical frameworks (Letvak 2005, Ueda et al. 2006). In the studies reviewed that had carried out multivariate analysis, model fit was calculated to be approximately 35%.
Predictive factors of HRQol of nurses As shown in Table 2, the factors related to the HRQol of nurses were categorised into eight types of predictive factors: personal characteristics, health behaviours, job-related personal characteristics, organisational characteristics, interpersonal relationships, perceived work environment, occupational stress and stress coping. ‘Personal characteristics’ included age, sex, race, marital status and household condition. Age was reported to be a predictive factor of HRQol in 10 studies (Lambert et al. 2004a, 2007b, Shen et al. 2005, Chang et al. 2006, 2007, Musshauser et al. 2006, Shiao et al. 2010, Wu et al. 2010b, 2011a,b). The common results of these 10 studies were that increased age was related to worse physical health and better mental health. Although many studies considered the household conditions of nurses, only two studies found a significant relationship between household conditions and HRQol (Lambert et al. 2004a, Musshauser et al. 2006). ‘Health behaviour’ included sleep, diet, exercise, and drinking habits. Four studies considered health behaviour a predictive factor of the HRQol of nurses, and four studies reported a significant relationship between diet and the physical and mental health of nurses. However, the measurement of dietary habits varied in each study (Wu et al. 2010b, 2011a,b, Asaoka et al. 2011). For example Asaoka et al. (2011) measured dietary habits as changing food intake and eating snacks during non-working periods, while Wu et al. (2011a) measured it as diet regularity. Furthermore, Ueda et al. (2006) found no relationship between health behaviour and the HRQol of nurses. Exercise and drinking habits were not reported as predictive factors of the HRQol of nurses. ‘Job-related personal characteristics’ included variables related to employment, such as years of experience as a nurse or in a unit, work time, education level, night shift, and/or intention to leave. Greater number of years of experience as a nurse or in a unit were significantly related to better mental health 664
(Letvak 2005, Chang et al. 2006, 2007, Ueda et al. 2006). Longer working time (Wu et al. 2010b, 2011a, b) and having intention to leave (Lambert et al. 2004a,b, 2007b) were related to worse physical and mental health. Other variables included in this category did not yield consistent results. Lambert et al. (2004a) reported that education level was a predictor of nurse health status; however, other studies did not yield the same findings, even though most studies considered it in the analysis. ‘Organisational characteristics’ described the current work environments of nurses. Most of the studies considered a nurse’s clinical unit an organisational characteristic; however, only one study reported a significant relationship with the HRQol of nurses (Shiao et al. 2010). Although Uehara et al. (2008) considered bed occupancy rate and average length of hospital stay predictive factors of HRQol of nurses, they could not find any significant relationship. ‘Interpersonal relationships’ measured conflict with other nurses, physicians, patients and family members. The results of this category were inconsistent across studies, even when the same measurement scale was used. For example, four studies reported that interpersonal relationships were significantly related to poor physical and mental health (Lambert et al. 2004a, 2007a,b, Ueda et al. 2006); however, Chang et al. (2006) did not report interpersonal relationships as a predictor of the HRQol of nurses. ‘Perceived work environment’ included nurse perceptions of workload, job satisfaction, job control and support in the workplace. Excessive physical workload and mental workload were consistently related to worse physical and mental health (Lambert et al. 2004a,b, 2007a,b, Chang et al. 2006, Ueda et al. 2006, Aust et al. 2007, Escriba-Ag€ uir & Perez-Hoyos 2007). In contrast, job satisfaction, job control, and support in the workplace were positively related to the mental health of nurses (Shen et al. 2005, Ueda et al. 2006, Aust et al. 2007, Uehara et al. 2008, Wu et al. 2010b). ‘Occupational stress’ included job-related physical and mental stress experienced by nurses. This category also included burnout, as the concepts of occupational stress and burnout are closely linked (Davey et al. 2009). Thirteen studies considered occupational stress. Any type of occupational stress was related to worse physical and mental health. ‘Stress coping’ referred to the toughness of nurses and their ability to handle stressors. Seven studies considered it a predictive factor of the HRQol of nurses, and higher ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
Crosssectional
Japan
Beijing, Wuhan, and Xi’an, China
Beijing, Wuhan, and Xi’an, China
Lambert et al.(2004b)
Lambert et al.(2007a)
Lambert et al. (2007b)
Crosssectional
Crosssectional
Design
Study setting
Study
Table 2 (Continued)
480 hospital nurses
480 hospital nurses
310 hospital nurses
Participants
To determine which combination of variables was the best predictor of both physical health and mental health
To examine the relationships that exist among workplace stressors, coping strategies, psychological hardiness, demographic characteristics, and physical and mental health
To examine which workplace stressors, coping mechanisms, and demographic characteristics were the best predictors of both physical and mental health
Study objectives related to nurses’ HRQOL
–
–
Personal characteristics Number of people in the household
–
Personal characteristics Age
+
Interpersonal relationships Conflict with other nurses Conflict with physicians Perceived work environment Workload Occupational stress Psychological stress Stress coping Psychological + hardiness Emotion-focused coping (escaping or avoiding) Problem-focused coping (confrontive coping style) Emotion-focused coping (distancing)
Perceived work environment Workload
Physical health
Theoretical framework
+
Job-related personal characteristics Turnover intention Interpersonal relationships
Emotion-focused coping (escaping or avoiding) Problem-focused coping (confrontive coping style) Problem-focused coping (seeking social support) Problem-focused coping (self control)
Job-related personal characteristics Turnover intention Perceived work environment Lack of support Stress coping Emotion-focused coping (escaping or avoiding) Interpersonal relationships Conflict with other nurses Conflict with physicians Perceived work environment Workload Occupational stress Psychological stress Stress coping Psychological + hardiness Emotion-focused coping (distancing)
Problem-focused coping (positive reappraisal)
Mental health
Nurses’ HRQoL: literature review
667
668
Shizuoka, Japan
Austria
Taiwan
Mizuura et al. (2006)
Musshauser et al. (2006)
Shen et al. (2005)
Taiwan
USA
Letvak (2005)
Shiao et al. (2010)
Study setting
Study
Table 2 (Continued)
Crosssectional
Crosssectional
Crosssectional
Crosssectional
Crosssectional
Design
889 hospital nurses
544 psychiatric hospital’s nurses
1083 hospital staff, including 667 nurses
136 hospital nurses
240 hospital nurses aged 50 years or over
Participants
To identify whether such assaults would have potential effects on the nurses’ HRQOL
To explore the work-related stress and risk factors of nurses in psychiatric institutions in Taiwan
To identify possible sociodemographic and gender-coded family-related factors as well as work characteristics influencing women’s health
To examine the relationships between demographic variables, job attributes (job satisfaction, control over practice, and job demands), and physical and mental health To investigate nurses’ health status and living conditions
Study objectives related to nurses’ HRQOL
–
–
–
–
Karasek and Theorell’s DemandControl model
Theoretical framework
Perceived work environment Job control Occupational stress
Occupational stress Psychological distress Personal characteristics Age Domestic duties
Occupational stress Occupational stress Stress coping Problem-focused coping (seeking social support) Psychological hardiness Problem-focused coping (confrontive coping style)
Physical health
+
+
+
Perceived work environment Dissatisfaction with work schedule Personal characteristics Age Perceived work environment Job control Workplace social support Occupational stress Occupational stress Personal characteristics Age Organisational characteristics Unit type (psychiatric vs. general) Perceived work environment Job control Occupational stress
Personal characteristics Domestic duties
Stress coping Problem-focused coping (seeking social support) Psychological hardiness Emotion-focused coping (escaping or avoiding) Job-related personal characteristics Years as a registered nurse
Conflict with other nurses Perceived work environment Workload
Mental health
+
+
+
+ +
+
+
+
+
Y. Oyama and H. Fukahori
ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
Crosssectional
Japan
Beijing, Wuhan, and Xi’an, China
Beijing, Wuhan, and Xi’an, China
Lambert et al.(2004b)
Lambert et al.(2007a)
Lambert et al. (2007b)
Crosssectional
Crosssectional
Design
Study setting
Study
Table 2 (Continued)
480 hospital nurses
480 hospital nurses
310 hospital nurses
Participants
To determine which combination of variables was the best predictor of both physical health and mental health
To examine the relationships that exist among workplace stressors, coping strategies, psychological hardiness, demographic characteristics, and physical and mental health
To examine which workplace stressors, coping mechanisms, and demographic characteristics were the best predictors of both physical and mental health
Study objectives related to nurses’ HRQOL
–
–
Personal characteristics Number of people in the household
–
Personal characteristics Age
+
Interpersonal relationships Conflict with other nurses Conflict with physicians Perceived work environment Workload Occupational stress Psychological stress Stress coping Psychological + hardiness Emotion-focused coping (escaping or avoiding) Problem-focused coping (confrontive coping style) Emotion-focused coping (distancing)
Perceived work environment Workload
Physical health
Theoretical framework
+
Job-related personal characteristics Turnover intention Interpersonal relationships
Emotion-focused coping (escaping or avoiding) Problem-focused coping (confrontive coping style) Problem-focused coping (seeking social support) Problem-focused coping (self control)
Job-related personal characteristics Turnover intention Perceived work environment Lack of support Stress coping Emotion-focused coping (escaping or avoiding) Interpersonal relationships Conflict with other nurses Conflict with physicians Perceived work environment Workload Occupational stress Psychological stress Stress coping Psychological + hardiness Emotion-focused coping (distancing)
Problem-focused coping (positive reappraisal)
Mental health
Nurses’ HRQoL: literature review
667
668
Shizuoka, Japan
Austria
Taiwan
Mizuura et al. (2006)
Musshauser et al. (2006)
Shen et al. (2005)
Taiwan
USA
Letvak (2005)
Shiao et al. (2010)
Study setting
Study
Table 2 (Continued)
Crosssectional
Crosssectional
Crosssectional
Crosssectional
Crosssectional
Design
889 hospital nurses
544 psychiatric hospital’s nurses
1083 hospital staff, including 667 nurses
136 hospital nurses
240 hospital nurses aged 50 years or over
Participants
To identify whether such assaults would have potential effects on the nurses’ HRQOL
To explore the work-related stress and risk factors of nurses in psychiatric institutions in Taiwan
To identify possible sociodemographic and gender-coded family-related factors as well as work characteristics influencing women’s health
To examine the relationships between demographic variables, job attributes (job satisfaction, control over practice, and job demands), and physical and mental health To investigate nurses’ health status and living conditions
Study objectives related to nurses’ HRQOL
–
–
–
–
Karasek and Theorell’s DemandControl model
Theoretical framework
Perceived work environment Job control Occupational stress
Occupational stress Psychological distress Personal characteristics Age Domestic duties
Occupational stress Occupational stress Stress coping Problem-focused coping (seeking social support) Psychological hardiness Problem-focused coping (confrontive coping style)
Physical health
+
+
+
Perceived work environment Dissatisfaction with work schedule Personal characteristics Age Perceived work environment Job control Workplace social support Occupational stress Occupational stress Personal characteristics Age Organisational characteristics Unit type (psychiatric vs. general) Perceived work environment Job control Occupational stress
Personal characteristics Domestic duties
Stress coping Problem-focused coping (seeking social support) Psychological hardiness Emotion-focused coping (escaping or avoiding) Job-related personal characteristics Years as a registered nurse
Conflict with other nurses Perceived work environment Workload
Mental health
+
+
+
+ +
+
+
+
+
Y. Oyama and H. Fukahori
ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
Y. Oyama and H. Fukahori
should have been considered. The health of nurses is affected by many different factors, including individual factors, job-related factors, workplace factors, and system characteristics (Kerr et al. 2002). Hence, we believe that organisational characteristics, including patient characteristics such as case type, must be considered for future research. As with all research, this study has its limitations. We did not include grey literature to retain the reproducibility of literature retrieval. In addition, we only retrieved studies written in English or Japanese. Therefore, this literature review might have excluded some important research.
Conclusion This review has revealed that age and occupational stress should be considered when examining predictive factors of the HRQol of nurses. One implication for nursing management suggested by this review is that nurses’ age should be considered during job placement and the identification of occupational stressors in order to support nurses’ HRQol. Further studies that are formulated according to a common conceptual framework and that investigate patient and organisational characteristics will be needed to devise evidence-based policies for work environment of nurses.
Sources of funding This study was supported by a grant from the Policy Based Medical Service Foundation in Japan.
Ethical approval This study is a literature review study. Then, we did not approve to a ethical committee to conduct this study.
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2010. Available at: http://www.nurse.or.jp/nursing/practice/ shuroanzen/jikan/pdf/02_05_09.pdf, accessed 31 July 2012. Jordan K., Ong B.N. & Croft P. (2003) Previous consultation and self-reported health status as predictors of future demand for primary care. Journal of Epidemiology and Community Health 57, 109–113. Kerr M., Laschinger H., Severin C. et al. (2002) Monitoring the Health of Nurses in Canada. Available at: http://www.chsrf. ca/Migrated/PDF/ResearchReports/OGC/kerr_final.pdf, accessed 23 October 2012. Lambert V.A., Lambert C.E., Itano J. et al. (2004a) Cross-cultural comparison of workplace stressors, ways of coping and demographic characteristics as predictors of physical and mental health among hospital nurses in Japan, Thailand, South Korea and the USA (Hawaii). International Journal of Nursing Studies 41, 671–684. Lambert V.A., Lambert C.E. & Ito M. (2004b) Workplace stressors, ways of coping and demographic characteristics as predictors of physical and mental health of Japanese hospital nurses. International Journal of Nursing Studies 41, 85–97. Lambert V.A., Lambert C.E., Petrini M., Li X.M. & Zhang Y.J. (2007a) Workplace and personal factors associated with physical and mental health in hospital nurses in China. Nursing & Health Sciences 9, 120–126. Lambert V.A., Lambert C.E., Petrini M., Li X.M. & Zhang Y.J. (2007b) Predictors of physical and mental health in hospital nurses within the People’s Republic of China. International Nursing Review 54, 85–91. LaMontagne A.D., Keegel T., Vallance D., Ostry A. & Wolfe R. (2008) Job strain-attributable depression in a sample of working Australians: assessing the contribution to health inequalities. BMC Public Health 8, 181. Lang T.A. & Secic M. (2011) Synthesizing the results of related studies: reporting systematic reviews and meta-analysis. In How to Report Statistics in Medicine: Annotated Guidelines for Authors, Editors, and Reviewers, 2nd edn, pp. 215–235 (Japanese Translation Version). Nakayama Shoten, Tokyo. Leary S. & Francis C. (2007) Healthy staff will enhance outcomes. Health Service Journal 117, 26–27. Letvak S. (2005) Health and safety of older nurses. Nursing Outlook 53, 66–72. McDowell I. (2006) Measuring Health: A Guide to Rating Scale and Questionnaires. Oxford University Press, Oxford, UK. Mizunuma K., Suzuki Y., Eto R. & Inaba K. (2006) Hospital nurses’ health status and living condition. Journal of Hamamatsu Rosai Hospital 2005, 108–111. Moher D., Liberati A., Tetzlaff J. & Altman D.G. (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Journal of Clinical Epidemiology 62, 1006–1012. Musshauser D., Bader A., Wildt B. & Hochleitner M. (2006) The impact of sociodemographic factors vs. gender roles on female hospital workers’ health: do we need to shift emphasis? Journal of Occupational Health 48, 383–391. O’Brien-Pallas L. & Hayes L. (2011) Nursing workforce and health policy. In Shaping Health Policy through Nursing Research (A.S. Hinshaw & P.A. Grady eds), pp. 231–249. Springer Publishing Company, New York, NY. O’Brien-Pallas L., Thomson D., McGillis Hall L. et al. (2004) Evidence-Based Standards for Measuring Nurse Staffing and Performance. Available at: http://fhs.mcmaster.ca/nru/ ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
documents/_VTI_CNF/Evidence%20Based%20Standards% 20for%20Measuring%20Nurse%20Staffing%20and%20Performance.pdf, accessed 30 July 2012. O’Brien-Pallas L., Meyer R.M., Hayes L.J. & Wang S. (2011) The Patient Care Delivery Model – an open system framework: conceptualisation, literature review and analytical strategy. Journal of Clinical Nursing 20, 1640–1650. Shen H.C., Cheng Y., Tsai P.J., Lee S.H. & Guo Y.L. (2005) Occupational stress in nurses in psychiatric institutions in Taiwan. Journal of Occupational Health 47, 218–225. Shiao J.S., Tseng Y., Hsieh Y.T., Hou J.Y., Cheng Y. & Guo Y.L. (2010) Assaults against nurses of general and psychiatric hospitals in Taiwan. International Archives of Occupational and Environmental Health 83, 823–832. Shields M. & Wilkins K. (2006) Finding from the 2005 National Survey of the Work and Health of Nurses. Available at: http://www.statcan.gc.ca/pub/83–003-x/83–003-x2006001eng.pdf, accessed 18 October 2012. Silva A.A., Souza J.M., Borges F.N. & Fischer F.M. (2010) Health-related quality of life and working conditions among nursing providers. Revista Sa ude P ublica 44, 718–725. Trinkoff A.M., Storr C.L. & Lipscomb J.A. (2001) Physically demanding work and inadequate sleep, pain medication use, and absenteeism in registered nurses. Journal of Occupational and Environmental Medicine 43, 355–363. Ueda E., Furukawa F. & Kobayashi T. (2006) Influences of job stressors, buffer factors, and individual characteristics on the HRQOL in staff nurses. Journal of Japan Society of Nursing Research 29, 39–47. Uehara K., Arima M. & Takahashi K. (2008) Job satisfaction and health-related quality of life of nursing staff. Journal of Japanese Nursing Society: Multidiscipline Nursing 39, 33–35. Vandenbroucke J.P., von Elm E., Altman D.G. et al. (2007) Strengthening the reporting of observational studies in epidemiology (STROBE) explanation and elaboration. Epidemiology 18, 805–835. Wang R., Wu C., Zhao Y. et al. (2008) Health related quality of life measured by SF-36: a population-based study in Shanghai, China. BMC Public Health 8, 292. Wilkins K. & Shields M. (2008) Correlates of medication error in hospitals. Health Reports 19, 7–18. World Health Organisation (1997) WHOQOL: Measuring Quality of Life. Available at: http://www.who.int/mental_health/media/68.pdf, accessed 30 July 2012. Wu S.Y., Li H.Y., Zhu W., Li J. & Wang X.R. (2010a) A structural equation model relating work stress, coping resource, and quality of life among Chinese medical professionals. American Journal of Industrial Medicine 53, 1170–1176. Wu S.Y., Zhu W., Li H. et al. (2010b) Quality of life and its influencing factors among medical professionals in China. International Archives of Occupational and Environmental Health 83, 753–761. Wu S.Y., Li H.Y., Tian J. et al. (2011a) Health-related quality of life and its main related factors among nurses in China. Industrial Health 49, 158–165. Wu S.Y., Li H.Y., Wang X.R., Yang S.J. & Qiu H. (2011b) A comparison of the effect of work stress on burnout and quality of life between female nurses and female doctors. Archives of Environmental and Occupational Health 66, 193–200.
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psychological toughness was related to better mental and physical health (Lambert et al. 2007a,b). However, no consistent pattern was found in terms of how nurses handled stressors. For example, Chang et al. (2006) and Wu et al. (2010b) used the same measurement instrument to examine how nurses handle stressors. Chang and colleagues reported that an emotion-focused coping style was related to better mental health; however, Wu and associates reported the opposite finding. Furthermore, although Lambert et al. (2007a,b) conducted two studies using the same sample, the results were contradictory because of the different analysis techniques used.
Discussion We conducted this literature review to identify the predictors of the HRQol of nurses and to refine the design of a future study. Not surprisingly, the main variables reported as consistent predictive factors of HRQol of nurses among the studies reviewed were age and occupational stress. A general population survey has reported that in terms of HRQol of women, physical health gradually deteriorates while mental health gradually improves with increasing age (Fukuhara & Suzukamo 2004). The HRQol of older nurses is relatively lower than that of younger nurses, therefore nursing tasks that require high physical burden might be not suitable for older nurses. In addition, older nurses are more susceptible to injury and take longer to recover (O’Brien-Pallas & Hayes 2011). However, they are needed to ensure that enough experienced nurses are available in the future to mentor younger nurses. Regarding occupational stress, there is consensus that nurses are more likely to be exposed to stressful situations than other occupational groups. Another general population survey reported that occupational stress affects mental health status (LaMontagne et al. 2008). The results from the studies reviewed are consistent with previous findings. Hence, it might be necessary to consider occupational stress when examining predictive factors of the HRQol of nurses. We found that occupational stress had the strongest negative effect on HRQol of nurses in the present review; however, stressors varied among studies. An initial step towards reducing occupational stress is to understand the stressors present in the health care environment (Happell et al. 2013). Nurse managers will then need to understand precisely what the stressors are for nurses in their workplace. Most of the results of the studies reviewed were varied or contradictory. One possible reason is the failure to use conceptual frameworks. Only two studies used ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
a conceptual framework; few of the studies reviewed provided rationales for the inclusion of variables as predictive factors of the HRQol of nurses. Failing to include a conceptual framework might lead to relatively lower model fit statistics in studies involving multivariate analysis. It is notable that the variables that should be considered were not included. Similarly, the existence of unconsidered variables may have resulted in insufficient confounding adjustments among the 22 studies that used convenience or relatively small samples. In addition, most of the reviewed studies analysed data at the individual level only, even though the data originated from multiple organisations or units. The work environment in each organisation or unit might affect the health status of nurses. Overall, it is problematic to identify which variables have a real effect on nurses’ HRQol, making it difficult to discern concrete implications for clinical practice or health policy. It is becoming increasingly apparent that evidence-based policies and strategies are urgently needed to support the physical and mental health of nurses. Such policies and strategies may also have the added benefit of improving patient outcomes, especially in relation to improved nurse-specific outcomes and patient safety (Kerr et al. 2002). Therefore, studies employing a common conceptual framework are needed to accumulate knowledge and conduct meta-analyses of the HRQol of nurses. Most of the studies reviewed included the type of clinical unit as the only organisational characteristic. However, it is highly possible that other organisational factors affect the HRQol of nurses, as work comprises a major and important part of an individual’s daily life (Cimete et al. 2003). To integrate possible organisational factors into research on the HRQol of nurses, a structured theoretical model would be useful for developing a conceptual model. For example, the patient care delivery model (PCDM) developed by O’Brien-Pallas et al. (2004) provides a valuable framework for managing the delivery of nursing services and for achieving desired organisational outcomes, and it clarifies the dynamic multilevel relationships between nursing units and other organisational structures for research purposes (O’Brien-Pallas et al. 2011). Nurse health status, which is measured by HRQol, has been placed in organisational outputs as a nurse outcome in the PCDM. Organisational and patient characteristics are also considered organisational inputs. The statistical models in the studies reviewed yielded relatively lower model coefficients for predicting the HRQol of nurses, meaning they might have overlooked some important variables that 671
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should have been considered. The health of nurses is affected by many different factors, including individual factors, job-related factors, workplace factors, and system characteristics (Kerr et al. 2002). Hence, we believe that organisational characteristics, including patient characteristics such as case type, must be considered for future research. As with all research, this study has its limitations. We did not include grey literature to retain the reproducibility of literature retrieval. In addition, we only retrieved studies written in English or Japanese. Therefore, this literature review might have excluded some important research.
Conclusion This review has revealed that age and occupational stress should be considered when examining predictive factors of the HRQol of nurses. One implication for nursing management suggested by this review is that nurses’ age should be considered during job placement and the identification of occupational stressors in order to support nurses’ HRQol. Further studies that are formulated according to a common conceptual framework and that investigate patient and organisational characteristics will be needed to devise evidence-based policies for work environment of nurses.
Sources of funding This study was supported by a grant from the Policy Based Medical Service Foundation in Japan.
Ethical approval This study is a literature review study. Then, we did not approve to a ethical committee to conduct this study.
References Arimura M., Imai M., Okawa M., Fujimura T. & Yamada N. (2010) Sleep, mental health status, and medical errors among hospital nurses in Japan. Industrial Health 48, 811–817. Asaoka S., Komada Y., Abe T., Okajima I. & Sasai T. (2011) Effect of sleep, exercise, and dietary habits on obesity and quality of life in nurses engaged in shift work. Research and Report for Meiji Yasuda Life Foundation of Health and Welfare 26, 15–23. Augusto Landa J.M., L opez-Zafra E., Berrios Martos M.P. & Aguilar-Luz on M.C. (2008) The relationship between emotional intelligence, occupational stress and health in nurses: a questionnaire survey. International Journal of Nursing Studies 45, 888–901.
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Aust B., Rugulies R., Skakon J., Scherzer T. & Jensen C. (2007) Psychosocial work environment of hospital workers: validation of a comprehensive assessment scale. International Journal of Nursing Studies 44, 814–825. Center for Disease Control and Prevention (2000) Measuring Healthy Days: Population Assessment of Health-Related Quality of Life. Available at: http://www.cdc.gov/hrqol/pdfs/mhd.pdf, accessed 12 November 2012. Chang E.M., Daly J., Hancock K.M. et al. (2006) The relationships among workplace stressors, coping methods, demographic characteristics, and health in Australian nurses. Journal of Professional Nursing 22, 30–38. Chang E.M., Bidewell J.W., Huntington A.D. et al. (2007) A survey of role stress, coping and health in Australian and New Zealand hospital nurses. International Journal of Nursing Studies 44, 1354–1362. Cheng Y., Kawachi I., Coakley E.H., Schwartz J. & Colditz G. (2000) Association between psychosocial work characteristics and health functioning in American women: prospective study. BMJ 320, 1432–1436. Cimete G., Gencalp N.S. & Keskin G. (2003) Quality of life and job satisfaction of nurses. Journal of Nursing Care Quality 18, 151–158. Davey M.M., Cummings G., Newburn-Cook C.V. & Lo E.A. (2009) Predictor of nurse absenteeism in hospitals: a systematic review. Journal of Nursing Management 17, 312–330. Escrib a-Ag€ uir V. & Perez-Hoyos S. (2007) Psychological wellbeing and psychosocial work environment characteristics among emergency medical and nursing staff. Stress & Health: Journal of the International Society for the Investigation of Stress 23, 153–160. Estryn-Behar M., Le Nezet O. & Jasseron C. (2005) Health and Satisfaction of Healthcare Workers in France and in Europe. Available at: http://www.next.uni-wuppertal.de/EN/index.php? articles-and-reports, accessed 18 October 2012. Fronteira I. & Ferrinho P. (2011) Do nurses have a different physical health profile? A systematic review of experimental and observational studies on nurses’ physical health. Journal of Clinical Nursing 20, 2404–2424. Fukuhara S. & Suzukamo Y. (2004) Manual of the SF-8 Japanese Version. Institute for Health Outcomes & Process Evaluation Research, Kyoto. Fukuhara S., Bito S., Green J., Hsiao A. & Kurokawa K. (1998) Translation, adaption, and validation of the SF-36 health survey for use in Japan. Journal of Clinical Epidemiology 51, 1037–1044. Happell B., Dwyer T., Reid-Searl K., Burke K.J., Caperchione C.M. & Gaskin C.J. (2013) Nurses and stress: recognizing causes and seeking solutions. Journal of Nursing Management 21, 638–647. Japanese Federation of Medical Workers’ Union (2010) A Report on the Actual Working Condition Survey of Nursing Staff. Available at: http://www.irouren.or.jp/jp/html/menu6/ pdf/201007iryouroudou.pdf, accessed 31 July 2012. Japanese Nursing Association (2008) A Report on the Actual Survey of Overtime, Night Shift and Shift Work of Nursing Staff in 2008. Available at: http://www.nurse.or.jp/nursing/ practice/shuroanzen/jikan/pdf/02_05_09.pdf, accessed 31 July 2012. Japanese Nursing Association (2010) A Report on the Actual Survey of Night Shift and Shift Work of Nursing Staff in ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
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2010. Available at: http://www.nurse.or.jp/nursing/practice/ shuroanzen/jikan/pdf/02_05_09.pdf, accessed 31 July 2012. Jordan K., Ong B.N. & Croft P. (2003) Previous consultation and self-reported health status as predictors of future demand for primary care. Journal of Epidemiology and Community Health 57, 109–113. Kerr M., Laschinger H., Severin C. et al. (2002) Monitoring the Health of Nurses in Canada. Available at: http://www.chsrf. ca/Migrated/PDF/ResearchReports/OGC/kerr_final.pdf, accessed 23 October 2012. Lambert V.A., Lambert C.E., Itano J. et al. (2004a) Cross-cultural comparison of workplace stressors, ways of coping and demographic characteristics as predictors of physical and mental health among hospital nurses in Japan, Thailand, South Korea and the USA (Hawaii). International Journal of Nursing Studies 41, 671–684. Lambert V.A., Lambert C.E. & Ito M. (2004b) Workplace stressors, ways of coping and demographic characteristics as predictors of physical and mental health of Japanese hospital nurses. International Journal of Nursing Studies 41, 85–97. Lambert V.A., Lambert C.E., Petrini M., Li X.M. & Zhang Y.J. (2007a) Workplace and personal factors associated with physical and mental health in hospital nurses in China. Nursing & Health Sciences 9, 120–126. Lambert V.A., Lambert C.E., Petrini M., Li X.M. & Zhang Y.J. (2007b) Predictors of physical and mental health in hospital nurses within the People’s Republic of China. International Nursing Review 54, 85–91. LaMontagne A.D., Keegel T., Vallance D., Ostry A. & Wolfe R. (2008) Job strain-attributable depression in a sample of working Australians: assessing the contribution to health inequalities. BMC Public Health 8, 181. Lang T.A. & Secic M. (2011) Synthesizing the results of related studies: reporting systematic reviews and meta-analysis. In How to Report Statistics in Medicine: Annotated Guidelines for Authors, Editors, and Reviewers, 2nd edn, pp. 215–235 (Japanese Translation Version). Nakayama Shoten, Tokyo. Leary S. & Francis C. (2007) Healthy staff will enhance outcomes. Health Service Journal 117, 26–27. Letvak S. (2005) Health and safety of older nurses. Nursing Outlook 53, 66–72. McDowell I. (2006) Measuring Health: A Guide to Rating Scale and Questionnaires. Oxford University Press, Oxford, UK. Mizunuma K., Suzuki Y., Eto R. & Inaba K. (2006) Hospital nurses’ health status and living condition. Journal of Hamamatsu Rosai Hospital 2005, 108–111. Moher D., Liberati A., Tetzlaff J. & Altman D.G. (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Journal of Clinical Epidemiology 62, 1006–1012. Musshauser D., Bader A., Wildt B. & Hochleitner M. (2006) The impact of sociodemographic factors vs. gender roles on female hospital workers’ health: do we need to shift emphasis? Journal of Occupational Health 48, 383–391. O’Brien-Pallas L. & Hayes L. (2011) Nursing workforce and health policy. In Shaping Health Policy through Nursing Research (A.S. Hinshaw & P.A. Grady eds), pp. 231–249. Springer Publishing Company, New York, NY. O’Brien-Pallas L., Thomson D., McGillis Hall L. et al. (2004) Evidence-Based Standards for Measuring Nurse Staffing and Performance. Available at: http://fhs.mcmaster.ca/nru/ ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
documents/_VTI_CNF/Evidence%20Based%20Standards% 20for%20Measuring%20Nurse%20Staffing%20and%20Performance.pdf, accessed 30 July 2012. O’Brien-Pallas L., Meyer R.M., Hayes L.J. & Wang S. (2011) The Patient Care Delivery Model – an open system framework: conceptualisation, literature review and analytical strategy. Journal of Clinical Nursing 20, 1640–1650. Shen H.C., Cheng Y., Tsai P.J., Lee S.H. & Guo Y.L. (2005) Occupational stress in nurses in psychiatric institutions in Taiwan. Journal of Occupational Health 47, 218–225. Shiao J.S., Tseng Y., Hsieh Y.T., Hou J.Y., Cheng Y. & Guo Y.L. (2010) Assaults against nurses of general and psychiatric hospitals in Taiwan. International Archives of Occupational and Environmental Health 83, 823–832. Shields M. & Wilkins K. (2006) Finding from the 2005 National Survey of the Work and Health of Nurses. Available at: http://www.statcan.gc.ca/pub/83–003-x/83–003-x2006001eng.pdf, accessed 18 October 2012. Silva A.A., Souza J.M., Borges F.N. & Fischer F.M. (2010) Health-related quality of life and working conditions among nursing providers. Revista Sa ude P ublica 44, 718–725. Trinkoff A.M., Storr C.L. & Lipscomb J.A. (2001) Physically demanding work and inadequate sleep, pain medication use, and absenteeism in registered nurses. Journal of Occupational and Environmental Medicine 43, 355–363. Ueda E., Furukawa F. & Kobayashi T. (2006) Influences of job stressors, buffer factors, and individual characteristics on the HRQOL in staff nurses. Journal of Japan Society of Nursing Research 29, 39–47. Uehara K., Arima M. & Takahashi K. (2008) Job satisfaction and health-related quality of life of nursing staff. Journal of Japanese Nursing Society: Multidiscipline Nursing 39, 33–35. Vandenbroucke J.P., von Elm E., Altman D.G. et al. (2007) Strengthening the reporting of observational studies in epidemiology (STROBE) explanation and elaboration. Epidemiology 18, 805–835. Wang R., Wu C., Zhao Y. et al. (2008) Health related quality of life measured by SF-36: a population-based study in Shanghai, China. BMC Public Health 8, 292. Wilkins K. & Shields M. (2008) Correlates of medication error in hospitals. Health Reports 19, 7–18. World Health Organisation (1997) WHOQOL: Measuring Quality of Life. Available at: http://www.who.int/mental_health/media/68.pdf, accessed 30 July 2012. Wu S.Y., Li H.Y., Zhu W., Li J. & Wang X.R. (2010a) A structural equation model relating work stress, coping resource, and quality of life among Chinese medical professionals. American Journal of Industrial Medicine 53, 1170–1176. Wu S.Y., Zhu W., Li H. et al. (2010b) Quality of life and its influencing factors among medical professionals in China. International Archives of Occupational and Environmental Health 83, 753–761. Wu S.Y., Li H.Y., Tian J. et al. (2011a) Health-related quality of life and its main related factors among nurses in China. Industrial Health 49, 158–165. Wu S.Y., Li H.Y., Wang X.R., Yang S.J. & Qiu H. (2011b) A comparison of the effect of work stress on burnout and quality of life between female nurses and female doctors. Archives of Environmental and Occupational Health 66, 193–200.
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A literature review of factors related to hospital nurses’ healthrelated quality of life YUMIKO OYAMA
RN, MPH
1
and HIROKI FUKAHORI
RN, PhD
2
PhD Student, Doctoral Program in Comprehensive Health Nursing Science, 2Associate Professor, Department of System Management in Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
1
Correspondence Yumiko Oyama Doctoral Program in Comprehensive Health Nursing Science Department of System Management in Nursing Graduate school of Health Care Sciences Tokyo Medical and Dental University 1-5-45 Yushima Bunkyo-ku Tokyo 113–8510 Japan E-mail: [email protected]
(2015) Journal of Nursing Management 23, 661–673. A literature review of factors related to hospital nurses’ health-related quality of life
OYAMA Y. & FUKAHORI H.
Aim To conduct a literature review in order to determine the predictors of nurses’ health-related quality of life and to clarify the implications for nursing management and future study in this area. Background Good health is essential to the performance of health care workers. Evaluation Relevant studies were retrieved from PubMed, Medline, CINAHL, the Japan Medical Abstract Society, and the Technology Information Aggregator, Electronic. The studies selected for this review were published in English or Japanese between 1995 and 2012, investigated nurses’ health-related quality of life. The identified predictive factors of each study were categorised according to type. Key issues Based on the criteria, 22 studies were reviewed. The predictive factors of nurses’ health-related quality of life were classified into eight categories. Conclusions Age and occupational stress should be considered when examining unknown predictive factors of nurses’ health-related quality of life. In addition, it may be useful to adopt a conceptual framework and consider patient and organisational factors in future research. Implications for nursing management It is necessary to identify nurses’ occupational stressors and consider age during job placement in order to support their health. Keywords: health personnel, health-related quality of life, literature review, narrative review, nurses Accepted for publication: 24 September 2013
Introduction Good health is essential to the performance of health care workers (Fronteira & Ferrinho 2011). It has been pointed out that lower nurses health status could result in a decline in the quality and safety of care that they provide (Leary & Francis 2007, Wu et al. 2011a). Others have reported that lower health status in nurses is a risk factor for adverse outcomes such as medication errors, which were linked to aspects of nursing practice (Wilkins & Shields 2008, Arimura DOI: 10.1111/jonm.12194 ª 2013 John Wiley & Sons Ltd
et al. 2010). Thus, nurse health is important for not only nurses but also patients. Health problems in nurses have been reported worldwide. In Canada, the prevalence of specific chronic conditions such as back problems, migraines, and sleep disorders was high among nurses in comparison with employed people in general (Shields & Wilkins 2006). In addition, approximately 50% and 19% of a sample of European nurses reported that they suffered from musculoskeletal disorders and mental disorders, respectively (Estryn-Behar et al. 2005). 661
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Approximately 50% of Japanese hospital nurses reported physical symptoms such as back pain and chronic sleep deprivation (Japanese Nursing Association 2008), and approximately 70% experienced symptoms of chronic fatigue (Japanese Federation of Medical Workers’ Union 2010, Japanese Nursing Association 2010). Overall, human resources costs at health care institutions are reduced when nurses are retained, which is more likely in environments that support nurse health (O’Brien-Pallas et al. 2011); however, concrete strategies to support nurse health at health care institutions appear to be lacking. Discussion of the current state of research on nurse health may facilitate further improvement in working environment and inform nursing policy. Fronteira and Ferrinho (2011) conducted a literature review of nurse health status, focusing on physical health and the prevalence or incidence of diseases or disorders such as musculoskeletal disorders, bloodborne pathogens and tuberculosis. However, such traditional measures of morbidity provide information about only the lowest levels of health (Center for Disease Control & Prevention 2000). The World Health Organisation (1997) defines health as ‘a state of complete physical, mental, and social well-being not merely the absence of disease’. Therefore, it may be insufficient to measure health status by defining health in terms of freedom from disease. Health-related quality of life (HRQol) is an individual’s satisfaction or happiness with the dimensions of life insofar they affect or are affected by health (Wang et al. 2008). Subjective measures provide insight into matters of human concern such as pain, suffering, or depression that could not be deduced solely from physical measurements (McDowell 2006). Healthrelated quality of life has been introduced as a method for assessment of health status and, in recent years, has been increasingly recognised as an important health outcome among healthy populations, including workers (Wang et al. 2008, Silva et al. 2010). The importance of HRQol as a health outcome is no exception for nurses: nurses’ feelings about their own health tend to influence the health care services they deliver and, by extension, the health of the population at large (Trinkoff et al. 2001, Wu et al. 2010b). Furthermore, Jordan et al. (2003) stated that HRQol is reported to be a predictor of morbidity among a general healthy population; thus, measuring the health status by HRQol might influence nurse managers or policy makers to consider healthy work environments for nurses. Therefore, it is important to understand the current findings for nurse health status as mea662
sured by HRQol. However, to the best of our knowledge, no previous literature review has systematically synthesised data on the HRQol of nurses.
Objective We conducted a review of the existing literature in an attempt to determine the predictors of nurses’ HRQol and to clarify the implications for nursing management and future study in this area.
Methods Data source and search strategy We referred to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher et al. 2009) and the report guidelines for medical study (Lang & Secic 2011) for this literature review. PubMed, Medline and CINAHL were used to search original works in peer-reviewed journals published in English. The Japan Medical Abstract Society (in Japanese: ‘Ichu-shi nWeb’) and the Japan Science and Technology Information Aggregator, Electronic, were used to search original works in peer-reviewed Japanese journals published in Japanese or English. Table 1 lists the keywords used. We retrieved studies published between 1995 and 2012.
Eligibility criteria for studies and literature synthesis Three eligibility criteria were applied to select studies for this literature review. First, only studies that investigated the HRQol of nurses using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) or its short versions, SF-12 or SF-8, were retrieved. We established this criterion because these scales have been the most commonly used in a wide Table 1 Keywords used to search databases Keywords #1 Nurses AND Quality of life #2 Nurses AND Health status #3 Health personnel AND Quality of life #4 Health personnel AND Health status #5 Nurses AND SF-36 #6 Nurses AND SF-12 #7 Nurses AND SF-8 #8 Health personnel AND SF-36 #9 Health personnel AND SF-12 #10 Health personnel AND SF-8
‘Nurses’, ‘Quality of life’, ‘Health personnel’ and ‘Health status’ were thesaurusised. ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
Nurses’ HRQoL: literature review
range of areas and are comparable between countries. Furthermore, many countries have certified the psychometric properties of these scales. The SF-36 is a questionnaire used to measure health status in general and consists of 36 items and eight subscales: physical functioning, role-physical, body pain, general health perception, vitality, social functioning, role-emotional, and mental health. Scores on these eight subscales can be used to compute summary indices of physical health (PCS) and mental health (MCS) (Fukuhara et al. 1998). The SF-12 and SF-8 are the shorter versions of the SF36 and consist of 12 and eight items, respectively. Both the PCS and MCS can be calculated from the SF-8, SF12 and SF-36. Consequently, we excluded studies that used other HRQol measurements such as a disease-specific measurement or a measurement devised by the authors for the study. Second, we only included studies using three observational epidemiological study designs: cohort, case-control and cross-sectional. We followed the definition of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) to evaluate the three study designs (Vandenbroucke et al. 2007). The third eligibility criterion was that studies must have been written in English or in Japanese. We checked these three criteria by reviewing the titles and/or abstracts. The main text of all studies that fulfilled the three eligibility criteria were confirmed and then studies using HRQol alone as an outcome variable were selected for review; thus, we excluded studies that used HRQol as a
potentially relevant factor for any other outcome variable. We carried out narrative synthesis for this review because the studies had used various measurement techniques for independent variables. We categorized the identified predictive factors of each study according to type (Davey et al. 2009).
Results Literature selection The results of the literature selection are shown in Figure 1. We retrieved 132 studies based on the eligibility criteria; of those, we excluded 77 duplicates, and 55 candidate studies remained for review. Of these, we excluded 33 because: (1) the HRQol score was used as an independent variable (n = 16); (2) the study conducted a score comparison only (n = 5); (3) the study was a test of a conceptual model (n = 1); (4) the study focused on the effect of specific exposures such as terrorism or the experience of caring for patients with severe acute respiratory syndrome on HRQol (n = 3); (5) the main aim was examining the effect of diseases such as urinary incontinence and headache on HRQol (n = 7); (6) we could not determine whether nurses were included in the study (n = 1). The final pool contained 22 studies (Table 2). Of these, only one employed a cohort study design (Cheng et al. 2000); the others used cross-sectional designs. There were no case–control studies in the
Figure 1 Flow diagram of literature selection. ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
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pool of literature reviewed. Most of the participants in the 23 studies were women, and some studies used samples comprising only women to avoid a confounding effect. Only two studies used theoretical frameworks (Letvak 2005, Ueda et al. 2006). In the studies reviewed that had carried out multivariate analysis, model fit was calculated to be approximately 35%.
Predictive factors of HRQol of nurses As shown in Table 2, the factors related to the HRQol of nurses were categorised into eight types of predictive factors: personal characteristics, health behaviours, job-related personal characteristics, organisational characteristics, interpersonal relationships, perceived work environment, occupational stress and stress coping. ‘Personal characteristics’ included age, sex, race, marital status and household condition. Age was reported to be a predictive factor of HRQol in 10 studies (Lambert et al. 2004a, 2007b, Shen et al. 2005, Chang et al. 2006, 2007, Musshauser et al. 2006, Shiao et al. 2010, Wu et al. 2010b, 2011a,b). The common results of these 10 studies were that increased age was related to worse physical health and better mental health. Although many studies considered the household conditions of nurses, only two studies found a significant relationship between household conditions and HRQol (Lambert et al. 2004a, Musshauser et al. 2006). ‘Health behaviour’ included sleep, diet, exercise, and drinking habits. Four studies considered health behaviour a predictive factor of the HRQol of nurses, and four studies reported a significant relationship between diet and the physical and mental health of nurses. However, the measurement of dietary habits varied in each study (Wu et al. 2010b, 2011a,b, Asaoka et al. 2011). For example Asaoka et al. (2011) measured dietary habits as changing food intake and eating snacks during non-working periods, while Wu et al. (2011a) measured it as diet regularity. Furthermore, Ueda et al. (2006) found no relationship between health behaviour and the HRQol of nurses. Exercise and drinking habits were not reported as predictive factors of the HRQol of nurses. ‘Job-related personal characteristics’ included variables related to employment, such as years of experience as a nurse or in a unit, work time, education level, night shift, and/or intention to leave. Greater number of years of experience as a nurse or in a unit were significantly related to better mental health 664
(Letvak 2005, Chang et al. 2006, 2007, Ueda et al. 2006). Longer working time (Wu et al. 2010b, 2011a, b) and having intention to leave (Lambert et al. 2004a,b, 2007b) were related to worse physical and mental health. Other variables included in this category did not yield consistent results. Lambert et al. (2004a) reported that education level was a predictor of nurse health status; however, other studies did not yield the same findings, even though most studies considered it in the analysis. ‘Organisational characteristics’ described the current work environments of nurses. Most of the studies considered a nurse’s clinical unit an organisational characteristic; however, only one study reported a significant relationship with the HRQol of nurses (Shiao et al. 2010). Although Uehara et al. (2008) considered bed occupancy rate and average length of hospital stay predictive factors of HRQol of nurses, they could not find any significant relationship. ‘Interpersonal relationships’ measured conflict with other nurses, physicians, patients and family members. The results of this category were inconsistent across studies, even when the same measurement scale was used. For example, four studies reported that interpersonal relationships were significantly related to poor physical and mental health (Lambert et al. 2004a, 2007a,b, Ueda et al. 2006); however, Chang et al. (2006) did not report interpersonal relationships as a predictor of the HRQol of nurses. ‘Perceived work environment’ included nurse perceptions of workload, job satisfaction, job control and support in the workplace. Excessive physical workload and mental workload were consistently related to worse physical and mental health (Lambert et al. 2004a,b, 2007a,b, Chang et al. 2006, Ueda et al. 2006, Aust et al. 2007, Escriba-Ag€ uir & Perez-Hoyos 2007). In contrast, job satisfaction, job control, and support in the workplace were positively related to the mental health of nurses (Shen et al. 2005, Ueda et al. 2006, Aust et al. 2007, Uehara et al. 2008, Wu et al. 2010b). ‘Occupational stress’ included job-related physical and mental stress experienced by nurses. This category also included burnout, as the concepts of occupational stress and burnout are closely linked (Davey et al. 2009). Thirteen studies considered occupational stress. Any type of occupational stress was related to worse physical and mental health. ‘Stress coping’ referred to the toughness of nurses and their ability to handle stressors. Seven studies considered it a predictive factor of the HRQol of nurses, and higher ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
Crosssectional
Japan
Beijing, Wuhan, and Xi’an, China
Beijing, Wuhan, and Xi’an, China
Lambert et al.(2004b)
Lambert et al.(2007a)
Lambert et al. (2007b)
Crosssectional
Crosssectional
Design
Study setting
Study
Table 2 (Continued)
480 hospital nurses
480 hospital nurses
310 hospital nurses
Participants
To determine which combination of variables was the best predictor of both physical health and mental health
To examine the relationships that exist among workplace stressors, coping strategies, psychological hardiness, demographic characteristics, and physical and mental health
To examine which workplace stressors, coping mechanisms, and demographic characteristics were the best predictors of both physical and mental health
Study objectives related to nurses’ HRQOL
–
–
Personal characteristics Number of people in the household
–
Personal characteristics Age
+
Interpersonal relationships Conflict with other nurses Conflict with physicians Perceived work environment Workload Occupational stress Psychological stress Stress coping Psychological + hardiness Emotion-focused coping (escaping or avoiding) Problem-focused coping (confrontive coping style) Emotion-focused coping (distancing)
Perceived work environment Workload
Physical health
Theoretical framework
+
Job-related personal characteristics Turnover intention Interpersonal relationships
Emotion-focused coping (escaping or avoiding) Problem-focused coping (confrontive coping style) Problem-focused coping (seeking social support) Problem-focused coping (self control)
Job-related personal characteristics Turnover intention Perceived work environment Lack of support Stress coping Emotion-focused coping (escaping or avoiding) Interpersonal relationships Conflict with other nurses Conflict with physicians Perceived work environment Workload Occupational stress Psychological stress Stress coping Psychological + hardiness Emotion-focused coping (distancing)
Problem-focused coping (positive reappraisal)
Mental health
Nurses’ HRQoL: literature review
667
668
Shizuoka, Japan
Austria
Taiwan
Mizuura et al. (2006)
Musshauser et al. (2006)
Shen et al. (2005)
Taiwan
USA
Letvak (2005)
Shiao et al. (2010)
Study setting
Study
Table 2 (Continued)
Crosssectional
Crosssectional
Crosssectional
Crosssectional
Crosssectional
Design
889 hospital nurses
544 psychiatric hospital’s nurses
1083 hospital staff, including 667 nurses
136 hospital nurses
240 hospital nurses aged 50 years or over
Participants
To identify whether such assaults would have potential effects on the nurses’ HRQOL
To explore the work-related stress and risk factors of nurses in psychiatric institutions in Taiwan
To identify possible sociodemographic and gender-coded family-related factors as well as work characteristics influencing women’s health
To examine the relationships between demographic variables, job attributes (job satisfaction, control over practice, and job demands), and physical and mental health To investigate nurses’ health status and living conditions
Study objectives related to nurses’ HRQOL
–
–
–
–
Karasek and Theorell’s DemandControl model
Theoretical framework
Perceived work environment Job control Occupational stress
Occupational stress Psychological distress Personal characteristics Age Domestic duties
Occupational stress Occupational stress Stress coping Problem-focused coping (seeking social support) Psychological hardiness Problem-focused coping (confrontive coping style)
Physical health
+
+
+
Perceived work environment Dissatisfaction with work schedule Personal characteristics Age Perceived work environment Job control Workplace social support Occupational stress Occupational stress Personal characteristics Age Organisational characteristics Unit type (psychiatric vs. general) Perceived work environment Job control Occupational stress
Personal characteristics Domestic duties
Stress coping Problem-focused coping (seeking social support) Psychological hardiness Emotion-focused coping (escaping or avoiding) Job-related personal characteristics Years as a registered nurse
Conflict with other nurses Perceived work environment Workload
Mental health
+
+
+
+ +
+
+
+
+
Y. Oyama and H. Fukahori
ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
Crosssectional
Japan
Beijing, Wuhan, and Xi’an, China
Beijing, Wuhan, and Xi’an, China
Lambert et al.(2004b)
Lambert et al.(2007a)
Lambert et al. (2007b)
Crosssectional
Crosssectional
Design
Study setting
Study
Table 2 (Continued)
480 hospital nurses
480 hospital nurses
310 hospital nurses
Participants
To determine which combination of variables was the best predictor of both physical health and mental health
To examine the relationships that exist among workplace stressors, coping strategies, psychological hardiness, demographic characteristics, and physical and mental health
To examine which workplace stressors, coping mechanisms, and demographic characteristics were the best predictors of both physical and mental health
Study objectives related to nurses’ HRQOL
–
–
Personal characteristics Number of people in the household
–
Personal characteristics Age
+
Interpersonal relationships Conflict with other nurses Conflict with physicians Perceived work environment Workload Occupational stress Psychological stress Stress coping Psychological + hardiness Emotion-focused coping (escaping or avoiding) Problem-focused coping (confrontive coping style) Emotion-focused coping (distancing)
Perceived work environment Workload
Physical health
Theoretical framework
+
Job-related personal characteristics Turnover intention Interpersonal relationships
Emotion-focused coping (escaping or avoiding) Problem-focused coping (confrontive coping style) Problem-focused coping (seeking social support) Problem-focused coping (self control)
Job-related personal characteristics Turnover intention Perceived work environment Lack of support Stress coping Emotion-focused coping (escaping or avoiding) Interpersonal relationships Conflict with other nurses Conflict with physicians Perceived work environment Workload Occupational stress Psychological stress Stress coping Psychological + hardiness Emotion-focused coping (distancing)
Problem-focused coping (positive reappraisal)
Mental health
Nurses’ HRQoL: literature review
667
668
Shizuoka, Japan
Austria
Taiwan
Mizuura et al. (2006)
Musshauser et al. (2006)
Shen et al. (2005)
Taiwan
USA
Letvak (2005)
Shiao et al. (2010)
Study setting
Study
Table 2 (Continued)
Crosssectional
Crosssectional
Crosssectional
Crosssectional
Crosssectional
Design
889 hospital nurses
544 psychiatric hospital’s nurses
1083 hospital staff, including 667 nurses
136 hospital nurses
240 hospital nurses aged 50 years or over
Participants
To identify whether such assaults would have potential effects on the nurses’ HRQOL
To explore the work-related stress and risk factors of nurses in psychiatric institutions in Taiwan
To identify possible sociodemographic and gender-coded family-related factors as well as work characteristics influencing women’s health
To examine the relationships between demographic variables, job attributes (job satisfaction, control over practice, and job demands), and physical and mental health To investigate nurses’ health status and living conditions
Study objectives related to nurses’ HRQOL
–
–
–
–
Karasek and Theorell’s DemandControl model
Theoretical framework
Perceived work environment Job control Occupational stress
Occupational stress Psychological distress Personal characteristics Age Domestic duties
Occupational stress Occupational stress Stress coping Problem-focused coping (seeking social support) Psychological hardiness Problem-focused coping (confrontive coping style)
Physical health
+
+
+
Perceived work environment Dissatisfaction with work schedule Personal characteristics Age Perceived work environment Job control Workplace social support Occupational stress Occupational stress Personal characteristics Age Organisational characteristics Unit type (psychiatric vs. general) Perceived work environment Job control Occupational stress
Personal characteristics Domestic duties
Stress coping Problem-focused coping (seeking social support) Psychological hardiness Emotion-focused coping (escaping or avoiding) Job-related personal characteristics Years as a registered nurse
Conflict with other nurses Perceived work environment Workload
Mental health
+
+
+
+ +
+
+
+
+
Y. Oyama and H. Fukahori
ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
Y. Oyama and H. Fukahori
should have been considered. The health of nurses is affected by many different factors, including individual factors, job-related factors, workplace factors, and system characteristics (Kerr et al. 2002). Hence, we believe that organisational characteristics, including patient characteristics such as case type, must be considered for future research. As with all research, this study has its limitations. We did not include grey literature to retain the reproducibility of literature retrieval. In addition, we only retrieved studies written in English or Japanese. Therefore, this literature review might have excluded some important research.
Conclusion This review has revealed that age and occupational stress should be considered when examining predictive factors of the HRQol of nurses. One implication for nursing management suggested by this review is that nurses’ age should be considered during job placement and the identification of occupational stressors in order to support nurses’ HRQol. Further studies that are formulated according to a common conceptual framework and that investigate patient and organisational characteristics will be needed to devise evidence-based policies for work environment of nurses.
Sources of funding This study was supported by a grant from the Policy Based Medical Service Foundation in Japan.
Ethical approval This study is a literature review study. Then, we did not approve to a ethical committee to conduct this study.
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Aust B., Rugulies R., Skakon J., Scherzer T. & Jensen C. (2007) Psychosocial work environment of hospital workers: validation of a comprehensive assessment scale. International Journal of Nursing Studies 44, 814–825. Center for Disease Control and Prevention (2000) Measuring Healthy Days: Population Assessment of Health-Related Quality of Life. Available at: http://www.cdc.gov/hrqol/pdfs/mhd.pdf, accessed 12 November 2012. Chang E.M., Daly J., Hancock K.M. et al. (2006) The relationships among workplace stressors, coping methods, demographic characteristics, and health in Australian nurses. Journal of Professional Nursing 22, 30–38. Chang E.M., Bidewell J.W., Huntington A.D. et al. (2007) A survey of role stress, coping and health in Australian and New Zealand hospital nurses. International Journal of Nursing Studies 44, 1354–1362. Cheng Y., Kawachi I., Coakley E.H., Schwartz J. & Colditz G. (2000) Association between psychosocial work characteristics and health functioning in American women: prospective study. BMJ 320, 1432–1436. Cimete G., Gencalp N.S. & Keskin G. (2003) Quality of life and job satisfaction of nurses. Journal of Nursing Care Quality 18, 151–158. Davey M.M., Cummings G., Newburn-Cook C.V. & Lo E.A. (2009) Predictor of nurse absenteeism in hospitals: a systematic review. Journal of Nursing Management 17, 312–330. Escrib a-Ag€ uir V. & Perez-Hoyos S. (2007) Psychological wellbeing and psychosocial work environment characteristics among emergency medical and nursing staff. Stress & Health: Journal of the International Society for the Investigation of Stress 23, 153–160. Estryn-Behar M., Le Nezet O. & Jasseron C. (2005) Health and Satisfaction of Healthcare Workers in France and in Europe. Available at: http://www.next.uni-wuppertal.de/EN/index.php? articles-and-reports, accessed 18 October 2012. Fronteira I. & Ferrinho P. (2011) Do nurses have a different physical health profile? A systematic review of experimental and observational studies on nurses’ physical health. Journal of Clinical Nursing 20, 2404–2424. Fukuhara S. & Suzukamo Y. (2004) Manual of the SF-8 Japanese Version. Institute for Health Outcomes & Process Evaluation Research, Kyoto. Fukuhara S., Bito S., Green J., Hsiao A. & Kurokawa K. (1998) Translation, adaption, and validation of the SF-36 health survey for use in Japan. Journal of Clinical Epidemiology 51, 1037–1044. Happell B., Dwyer T., Reid-Searl K., Burke K.J., Caperchione C.M. & Gaskin C.J. (2013) Nurses and stress: recognizing causes and seeking solutions. Journal of Nursing Management 21, 638–647. Japanese Federation of Medical Workers’ Union (2010) A Report on the Actual Working Condition Survey of Nursing Staff. Available at: http://www.irouren.or.jp/jp/html/menu6/ pdf/201007iryouroudou.pdf, accessed 31 July 2012. Japanese Nursing Association (2008) A Report on the Actual Survey of Overtime, Night Shift and Shift Work of Nursing Staff in 2008. Available at: http://www.nurse.or.jp/nursing/ practice/shuroanzen/jikan/pdf/02_05_09.pdf, accessed 31 July 2012. Japanese Nursing Association (2010) A Report on the Actual Survey of Night Shift and Shift Work of Nursing Staff in ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
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psychological toughness was related to better mental and physical health (Lambert et al. 2007a,b). However, no consistent pattern was found in terms of how nurses handled stressors. For example, Chang et al. (2006) and Wu et al. (2010b) used the same measurement instrument to examine how nurses handle stressors. Chang and colleagues reported that an emotion-focused coping style was related to better mental health; however, Wu and associates reported the opposite finding. Furthermore, although Lambert et al. (2007a,b) conducted two studies using the same sample, the results were contradictory because of the different analysis techniques used.
Discussion We conducted this literature review to identify the predictors of the HRQol of nurses and to refine the design of a future study. Not surprisingly, the main variables reported as consistent predictive factors of HRQol of nurses among the studies reviewed were age and occupational stress. A general population survey has reported that in terms of HRQol of women, physical health gradually deteriorates while mental health gradually improves with increasing age (Fukuhara & Suzukamo 2004). The HRQol of older nurses is relatively lower than that of younger nurses, therefore nursing tasks that require high physical burden might be not suitable for older nurses. In addition, older nurses are more susceptible to injury and take longer to recover (O’Brien-Pallas & Hayes 2011). However, they are needed to ensure that enough experienced nurses are available in the future to mentor younger nurses. Regarding occupational stress, there is consensus that nurses are more likely to be exposed to stressful situations than other occupational groups. Another general population survey reported that occupational stress affects mental health status (LaMontagne et al. 2008). The results from the studies reviewed are consistent with previous findings. Hence, it might be necessary to consider occupational stress when examining predictive factors of the HRQol of nurses. We found that occupational stress had the strongest negative effect on HRQol of nurses in the present review; however, stressors varied among studies. An initial step towards reducing occupational stress is to understand the stressors present in the health care environment (Happell et al. 2013). Nurse managers will then need to understand precisely what the stressors are for nurses in their workplace. Most of the results of the studies reviewed were varied or contradictory. One possible reason is the failure to use conceptual frameworks. Only two studies used ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 661–673
a conceptual framework; few of the studies reviewed provided rationales for the inclusion of variables as predictive factors of the HRQol of nurses. Failing to include a conceptual framework might lead to relatively lower model fit statistics in studies involving multivariate analysis. It is notable that the variables that should be considered were not included. Similarly, the existence of unconsidered variables may have resulted in insufficient confounding adjustments among the 22 studies that used convenience or relatively small samples. In addition, most of the reviewed studies analysed data at the individual level only, even though the data originated from multiple organisations or units. The work environment in each organisation or unit might affect the health status of nurses. Overall, it is problematic to identify which variables have a real effect on nurses’ HRQol, making it difficult to discern concrete implications for clinical practice or health policy. It is becoming increasingly apparent that evidence-based policies and strategies are urgently needed to support the physical and mental health of nurses. Such policies and strategies may also have the added benefit of improving patient outcomes, especially in relation to improved nurse-specific outcomes and patient safety (Kerr et al. 2002). Therefore, studies employing a common conceptual framework are needed to accumulate knowledge and conduct meta-analyses of the HRQol of nurses. Most of the studies reviewed included the type of clinical unit as the only organisational characteristic. However, it is highly possible that other organisational factors affect the HRQol of nurses, as work comprises a major and important part of an individual’s daily life (Cimete et al. 2003). To integrate possible organisational factors into research on the HRQol of nurses, a structured theoretical model would be useful for developing a conceptual model. For example, the patient care delivery model (PCDM) developed by O’Brien-Pallas et al. (2004) provides a valuable framework for managing the delivery of nursing services and for achieving desired organisational outcomes, and it clarifies the dynamic multilevel relationships between nursing units and other organisational structures for research purposes (O’Brien-Pallas et al. 2011). Nurse health status, which is measured by HRQol, has been placed in organisational outputs as a nurse outcome in the PCDM. Organisational and patient characteristics are also considered organisational inputs. The statistical models in the studies reviewed yielded relatively lower model coefficients for predicting the HRQol of nurses, meaning they might have overlooked some important variables that 671
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should have been considered. The health of nurses is affected by many different factors, including individual factors, job-related factors, workplace factors, and system characteristics (Kerr et al. 2002). Hence, we believe that organisational characteristics, including patient characteristics such as case type, must be considered for future research. As with all research, this study has its limitations. We did not include grey literature to retain the reproducibility of literature retrieval. In addition, we only retrieved studies written in English or Japanese. Therefore, this literature review might have excluded some important research.
Conclusion This review has revealed that age and occupational stress should be considered when examining predictive factors of the HRQol of nurses. One implication for nursing management suggested by this review is that nurses’ age should be considered during job placement and the identification of occupational stressors in order to support nurses’ HRQol. Further studies that are formulated according to a common conceptual framework and that investigate patient and organisational characteristics will be needed to devise evidence-based policies for work environment of nurses.
Sources of funding This study was supported by a grant from the Policy Based Medical Service Foundation in Japan.
Ethical approval This study is a literature review study. Then, we did not approve to a ethical committee to conduct this study.
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