Journal of Nursing Management, 2015, 23, 736–743
Hospital nurses’ wellbeing at work: a theoretical model KATI UTRIAINEN
PhD
1
, LEENA ALA-MURSULA
PhD
2
€ and HELVI KYNGAS
PhD
3
1
Coordinator, 2Professor (acting), Occupational Health Services and 3Professor, Nursing Science, Institute of Health Sciences, University of Oulu, Oulu, Finland
Correspondence Kati Utriainen Occupational Health Services Institute of Health Sciences University of Oulu PO Box 5000 University of Oulu PO Box 5000 90014 Oulu Finland E-mail: [email protected]
UTRIAINEN K., ALA-MURSULA L. & KYNGA¨S H.
(2015) Journal of Nursing Management 23, 736–743. Hospital nurses’ wellbeing at work: a theoretical model Aim To develop a theoretical model of hospital nurses’ wellbeing at work. Background The concept of wellbeing at work is presented without an exact definition and without considering different contents. Method A model was developed in a deductive manner and empirical data collected from nurses (n = 233) working in a university hospital. Explorative factor analysis was used. Results The main concepts were: patients’ experience of high-quality care; assistance and support among nurses; nurses’ togetherness and cooperation; fluent practical organisation of work; challenging and meaningful work; freedom to express diverse feelings in the work community; well-conducted everyday nursing; status related to the work itself; fair and supportive leadership; opportunities for professional development; fluent communication with other professionals; and being together with other nurses in an informal way. Conclusions Themes included: collegial relationships; enhancing high-quality patient care; supportive and fair leadership; challenging, meaningful and well organised work; and opportunities for professional development. Objectdependent wellbeing was supported. Implications for nursing management Managers should focus on strengthening the positive aspect of wellbeing at work, focusing on providing fluently organised work practices, fair and supportive leadership and togetherness while allowing nurses to implement their own ideas and promote the experience of meaningfulness. Keywords: nurses, theoretical model, wellbeing at work
Accepted for publication: 5 November 2013
Background Wellbeing at work as a positive concept Wellbeing at work is a commonly presented and widely used concept in the field of occupational health and scientific research, yet it lacks a universal definition. The concept refers to a positive viewpoint of a phenomenon. The background of the concept can be located in positive psychology (Seligman & Csikszentmihalyi 2000, Sheldon & King 2001), which is the scientific 736
study of ordinary human strengths and virtues. The main interest is in finding out what works, what is right and what is improving (Sheldon & King 2001). There is a long research history regarding the negative viewpoint of work life and as a result we have extensive knowledge of work stress and burnout. Instead, the scope should be more focused on a positive viewpoint of work life and promoting employee wellbeing through strengthening those factors that have a positive effect on wellbeing at work. Some other concepts in this area DOI: 10.1111/jonm.12203 ª 2014 John Wiley & Sons Ltd
Hospital nurses, wellbeing at work
focus on the positive viewpoint. A concept of work engagement (Schaufeli & Bakker 2010) has been used. Work engagement consists of vigour, dedication and adsorption. Work engagement captures how workers experience their work as something stimulating and energetic to which they really want to devote time and effort (the vigour component), a significant and meaningful pursuit (dedication) and something engrossing, on which they are fully concentrated (absorption) (Schaufeli & Bakker 2010). Therefore, work engagement can be seen as being linked to the motivational aspect towards work. Job satisfaction is a traditional concept used in this area, which is defined as the degree of positive affect towards a job or its components (Adams & Bond 2000). Therefore this concept highlights a scope of affect and also an attitude towards work.
Definitions of wellbeing at work Similarly, the concept of wellbeing at work is a positive exposition which, furthermore, resolves to describe this phenomenon as a positive emotional and experimental state in a work context. The basic concept of wellbeing itself refers to a condition, existence or state of a person or community (Glanze et al. 1986, Myers et al. 2000, Oxford University Press 2007). As mentioned previously, the concept is rather new in a work context and only some definitions exist. According to Schulte and Vainio (2010), wellbeing is a summative concept characterising the quality of working lives, including aspects of occupational safety and health. It may also be a major determinant of productivity at individual, enterprise and societal levels (Schulte & Vainio 2010). Wellbeing at work is also defined as: ‘…the worker’s experience of the safety and healthiness of work, good leadership, competence, change management and the organisation of work, the support of the work community to the individual, and how meaningful and rewarding the person finds work’ (Anttonen & R€ as€ anen 2009). In M€akitalo’s (2005) study, this research area is expanded by discovering a concept of object-dependent wellbeing, outlining that work-related emotions depend on the object of the work and the employee’s success in this area. In the same study, the relevance of disturbances in the flow of work were also recognised as a reason for increased physical and psychological workload (disturbance load). Analogous to the findings on object-dependent wellbeing (M€ akitalo 2005), Lu et al. (2012) have proposed that satisfaction or dissatisfaction with work does not depend solely on the nature ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 736–743
of the job, but also on the individuals’ expectations of what their job should provide. This also highlights the individual view – the importance of the object of work and success with it – as well as the viewpoint of providing something important through work. Based on earlier research, some conclusions can be made in order to define the concept of wellbeing at work. First, it is proved to be dependent on the object of the work and the success achieved in that (M€ akitalo 2005). Second, the concept is multidimensional and related to several aspects, varying from the individual level to productivity and the social level (Anttonen & R€as€anen 2009, Schulte & Vainio 2010). However, this concept of wellbeing at work remains at a general level and fails to connect with a specific type of work or field of operation. In particular, if wellbeing at work is understood in connection with the object and aims of work (M€akitalo 2005), it should be clarified in certain fields of operation and even work contexts. Referring to this requirement and in addition to the need to clarify the general understanding, there is also a need to focus research into more specific areas and fields of operation to bring specific themes closer to different areas of work. In this study, the focus is on nursing work and a theoretical model is developed to describe wellbeing at work of hospital nurses. The theoretical model is developed to organise knowledge of wellbeing at work and to indicate the main concepts that describe the nurses’ wellbeing at work in a hospital context.
Nurses’ wellbeing at work and nursing leadership Some systematic reviews have focused on a positive view and nurses’ job satisfaction in a hospital setting, where sources of job satisfaction have been summarised. Therefore this study is founded on earlier research findings of this subject instead of specific nursing theory. In Utriainen and Kyng€as’s (2009) systematic review, two themes seem to be most significant to nurses’ job satisfaction: interpersonal relationships between nurses and patient care. Organising nursing work is also a significant predictor of wellbeing at work. In a systematic review of Lu et al. (2012), the sources of nurses’ job satisfaction in a hospital setting were physical working conditions, relationships with fellow workers and managers, staffing and scheduling, pay, promotion, job security, responsibility, recognition from managers and hours of work. In terms of wellbeing at work, a theoretical model focusing on ageing hospital nurses has been developed and tested using statistical methods (Utriainen et al. 2011). Wellbeing at 737
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work has been used as a core concept in a nursing context in Brazilian (Alves et al. 2012) and Finnish studies (Koivu et al. 2012), among others. From the viewpoint of nursing management, nurse leaders have a key role in promoting wellbeing at work. Taking care of nurses’ wellbeing is a one part of leadership, while leaders also have a responsibility of ensuring sufficiency of human resources. Nurses’ turnover is a threat to this sufficiency and has been recognised as a widespread problem in nursing work. Therefore, it is essential that nurse leaders recognise the importance of wellbeing factors such as job satisfaction and happiness at work as predictors of intention to stay in nursing work (Cowden & Cummings 2012) and understand factors that promote wellbeing and the structure of wellbeing at work. In line with present concepts of wellbeing at work, this study focuses on a positive viewpoint of work life and promoting employee wellbeing through strengthening factors that have a positive effect on wellbeing at work in a nursing context. The theoretical model developed in this study will help nurse leaders understand the totality of nurses’ wellbeing at work and take these factors into account in their management work to promote wellbeing and careers in nursing work.
Method Development of theoretical model Owing to the lack of theoretical definitions of wellbeing at work, especially in the context of nursing work, a theoretical model was developed. Theoretical models can be developed using either an inductive or a
deductive approach, depending on the focus of interest and the nature of previous research (McEwen 2007, Fawcett 2009, Kanste et al. 2009). A deductive approach was used in this study, such that the development of the theoretical model is based on earlier studies and the empirical data collected via questionnaires. The purpose of empirical testing is to verify the structure and concepts and their associations by using statistical methods. Development of a theoretical model is a continuous and dynamic process whereby theoretical propositions are examined empirically. As a result of this testing, the theoretical propositions are modified and further refined (McEwen 2007, Fawcett 2009, Kanste et al. 2009). The quantitative data were analysed using the software SPSS for Windows (IBM, New York, NY, USA). Explorative factor analysis using varimax rotation was applied. This method is well suited for theory development because it allows the study of conceptual structures (Pett et al. 2003, Munro 2005). Factors were estimated using eigenvalues, the lowest acceptable value being 1. Items were estimated using communalities (limited to between 0 and 1, the higher the better). Communalities were high (between 0.522 and 0.877), indicating that the items measured the factors’ reliably (Table 1 and Appendix S1). The reliability of the scale (internal consistency) was assessed using Cronbach’s alpha coefficient, and the results ranged from 0.66 to 0.91 (Table 2). According to Nunnally and Bernstein (1994), Cronbach’s alpha coefficient should be >0.60, while Polit and Hungler (1999) consider >0.70 to be sufficient and >0.80 desirable. Factor loadings were expected to be over 0.40. In the case of lower loading, the item was deleted.
Table 1 Factor model of hospital nurses’ wellbeing at work Factor number and name Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor
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1: Patients’ experience of high-quality care 2: Assistance and support among nurses 3: Nurses’ togetherness and collaboration 4: Satisfying practical organisation of work 5: Challenging and meaningful work 6: Freedom to express diverse feelings in work community 7: Well-conducted everyday nursing 8: Status related to the work itself 9: Fair and supportive leadership 10: Opportunities for professional development 11: Fluent communication with other professionals 12: Being together with colleagues in an informal way 13: Cooperation and good spirit 14: Completion of everyday work tasks 15: Allowing nurse autonomy 16: Positive feedback and commendation 17: Working in pairs or groups
Number of items
Explained variance (%)
Eigenvalue
Factor loadings
7 9 8 7 6 4 4 5 3 3 3 2 2 1 2 2 1
35.8 4.3 3.9 3.1 2.8 2.6 2.4 2.1 2.0 1.9 1.7 1.6 1.5 1.4 1.4 1.3 1.3
29.4 3.5 3.2 2.6 2.3 2.1 1.9 1.7 1.6 1.5 1.4 1.3 1.3 1.2 1.1 1.1 1.9
0.502–0.778 0.414–0.744 0.511–0.762 0.525–0.686 0.457–0.762 0.405–0.750 0.477–0.654 0.425–0.707 0.601–0.752 0.724–0.748 0.540–0.758 0.656–0.707 0.651–0.706 0.688 0.403–0.427 0.486–0.583 0.653
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Properties of the scale A scale consisting of 82 items was developed in this study. The aim of this study was to create a general theoretical model of hospital nurses wellbeing at work and in consistence with this goal, items are based on relevant earlier research findings in this area. Items were based on the validated scale measuring ageing hospital nurses’ wellbeing at work (Utriainen & Kyng€ as 2011), a literature review of studies on nurse job satisfaction (Utriainen & Kyng€ as 2009) and on empirical data on young nurses’ wellbeing at work (Utriainen K. & Kyng€ as H., unpublished data). The scale and items were based on earlier research findings. The scale used as a basis in this study was psychometrically valid (a = 0.79–0.98) but because of its focus on ageing nurses’ wellbeing at work the significance of each item was re-evaluated by a researcher. All respondents representing ageing nurses had extensive experience in nursing work (almost one-third had worked in health care for more than 31 years and one-quarter had between 26 years and 30 years of experience), therefore reflecting views of long-experience nurses from the same generation. Based on this evaluation, three age-specific items (referring to themes specific only to ageing and experienced nurses) were removed, and six items were removed for content reasons (having the same content as other items). Eighteen items were added based on studies bringing forward themes that have a positive influence on the wellbeing at work of young nurses or nurses of different ages (Utriainen & Kyng€ as 2009, Utriainen K. & Kyng€ as H., unpublished data). These items linked to relationships between nurses and physicians, fluency of communication, resourcing of work, leadership and development opportunities at work. The scale measured the importance of the various propositions for nurses. The items of the scale were answered on a five-point Likert scale, with 5 representing ‘to a very great extent’ and 1 representing ‘to a very small extent’. A Likert scale is suitable when items in a questionnaire or survey express a viewpoint on something and the respondents are thus asked to indicate the degree to which they agree or disagree with the statement (Polit & Hungler 1999).
for the people in northern Finland and medical services to Scandinavia and other parts of the world. With more than 3000 staff, the hospital also serves as a teaching institution for medical and nursing students. Data collection was carried out in cooperation with unit head nurses. An information letter and questionnaire forms were sent to head nurses of different units (19 units). The units represented different specialities, such as intensive care, surgery, internal medicine and neurology. The head nurses informed about the study and all of the volunteers had an opportunity to participate in the study by answering the questionnaire. Following the principle of informed consent, participants were informed in the cover letter about the purpose of the study, anonymity, voluntariness, confidentiality and source of contact information, as well as the researcher’s contact information. The head nurses gathered and returned the questionnaires to the researcher by post.
Respondents The respondents were nurses who conducted work on a practical level and represented four different nursing care specialities: surgery (45%), internal medicine (33%), intensive care (18%) and neurology (2%). The majority of respondents therefore represented internal medicine and surgery. In terms of age, the respondents were born between 1946 and 1987. Age was classified according to the generational classification of the nursing profession (Boychuk Duchscher & Cowin 2004) into the following groups: Baby Boomers (born 1946–1964), Generation X (1965–1979) and Millennials (1980–1987). Forty-one per cent belonged to Generation X, 34% belonged to the Baby Boomers and 24% belonged to the Millennials. The majority of respondents (73%) had a tenured full-time job and 17% had a terminable full-time job. Sixty-two per cent of respondents had work experience of 15 years or less and 18% had very long work experience (26 years or more) in health care. Fifty-one per cent of respondents had worked in their current assignment 6–20 years; 37% had worked in their current assignment 5 years or less and 13% had worked 21 years or more.
Data collection The data were collected in spring 2010 from registered nurses (n = 233) working in a university central hospital in northern Finland. The hospital provides demanding treatment in different braches of medicine ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 736–743
Data analysis Seventeen factors emerged in the factor analysis (Appendix S1). Thirteen items were deleted owing to low factor loadings and redundancy. Items included in 739
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Table 2 Number of items and Cronbach alpha coefficients of final factor model Factor name Patients’ experience of high-quality care Assistance and support among nurses Nurses’ togetherness and collaboration Satisfying practical organisation of work Challenging and meaningful work Freedom to express diverse feelings at work Well-conducted everyday nursing Status related to the work itself Fair and supportive leadership Opportunities for professional development Fluent communication with other professionals Being together with colleagues in an informal way
Items (n)
a
8 9 10 7 6 4 5 7 3 3 3 2
0.895 0.914 0.876 0.870 0.849 0.793 0.814 0.889 0.844 0.865 0.887 0.662
factors 13 (two items), 14 (one item) and 15 (two items) were transferred into other factors (Factors 3, 7 and 8). Some of the items loaded on several factors. Transfer was allowed based on Cronbach’s alpha coefficients, and content review also supported this decision. Two factors were deleted (Factors 16 and 17). Their Eigenvalues were low (1.065 and 1.032) and there was only one item in each factor after another item from factor 16 was transferred into factor 1. The final theoretical model to describe hospital nurses wellbeing at work consisted of 12 factors (comprising 67 items): patients’ experience of high-quality care, assistance and support among nurses, nurses’ togetherness and cooperation, satisfying practical organisation of work, challenging and meaningful work, freedom to express diverse feelings in the work community, wellconducted everyday nursing, status related to the work itself, fair and supportive leadership, opportunities for professional development, fluent communication with other professionals, and being together with other nurses in an informal way (see Table 2).
Results The theoretical model presented is supported by the parameter estimates of the factor analysis. Therefore, the empirical evidence validated the 12-factor theoretical model of hospital nurses’ wellbeing at work. According to the theoretical model, the wellbeing at work of hospital nurses is constructed from patients’ experience of high-quality care, assistance and support among nurses, nurses’ togetherness and cooperation, satisfying practical organisation of work, challenging and meaningful work, freedom to express diverse feelings in the work community, well-conducted everyday nursing, status related to the work itself, fair and supportive leadership, opportunities for professional development, fluent communication with other professionals and being together with other nurses in an informal way (Figure 1).
Discussion The aim of this study was to develop a theoretical model of hospital nurses’ wellbeing at work. The development process was deductive and grounded in the findings of earlier study findings (Utriainen & Kyng€as 2009, 2011) (Utriainen K. & Kynga¨s H., unpublished data). The model was empirically tested using statistical methods (factor analysis), which showed that the construct validity of the theoretical model was good, and its reliability was evaluated by for internal consistency using Cronbach’s alpha coefficient. The theory was therefore confirmed. According to the theoretical model, the wellbeing at work of hospital nurses is constructed from patients’ experience of high-quality care, assistance and support among nurses, nurses’ togetherness and cooperation,
Figure 1 Wellbeing at work of hospital nurses: a theoretical model.
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satisfying practical organisation of work, challenging and meaningful work, freedom to express diverse feelings in the work community, well-conducted everyday nursing, status related to the work itself, fair and supportive leadership, opportunities for professional development, fluent communication with other professionals and being together with other nurses in an informal way. Some major themes can be recognised and discussed based on these emerged concepts. Social relationships with colleagues play a major role in nurses’ wellbeing at work. This appears at a practical level (assistance among nurses, fluent communication) and at an emotional level (nurses’ togetherness and cooperation, freedom to express feelings, informal social intercourse). The importance of similar factors related to the work community has been confirmed in earlier studies in terms of job satisfaction (Adams & Bond 2000, Newman & Maylor 2002, Dunn et al. 2005, McLennan 2005). As a challenge to nursing management, the theme of leadership was concentrated in two themes: fairness and support. In terms of status related to the work itself, head nurses’ permission for nurses to implement their own ideas was also emphasised. Fairness is worth noting: there is research evidence that the extent to which people are treated with fairness in workplaces predicts their health (Kivim€ aki et al. 2004). Within nursing, patients’ satisfaction with care has an important role in nurses’ wellbeing at work. Patients’ experience of high-quality care and nurses’ own experience of well-conducted everyday nursing emerged. In terms of job satisfaction, the importance of patients and high-quality patient care to nurses has been confirmed in earlier studies (McNeese-Smith 1999, Newman & Maylor 2002, M€ akinen et al. 2003, Begat et al. 2005, Dunn et al. 2005, McLennan 2005, Perry 2005). Nurses want their work to be organised well with regard to wellconducted everyday nursing. Nurses also look for challenges in their work and opportunities for professional development. When compared with a theoretical model of ageing nurses (Utriainen et al. 2011), the viewpoint of professional development is one major difference. This might relate to differences between generations and ageing nurses’ calling and patient-centred attitude towards nursing. Another explanation relates to the stages of a career, where younger nurses are more orientated towards themselves and their career development. According to the theoretical model focusing on ageing nurses, wellbeing at work relates to nurses’ experience of collaboration, cooperation and togetherness with other nurses in a supportive and caring ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 736–743
work environment. The aim and possibility of highquality patient care in an atmosphere where nurses and nursing are appreciated are also related to the wellbeing of ageing nurses. When evaluating the similarities between the two models, the importance of social relationships with colleagues and high-quality patient care appear to be highlighted. The emerging concepts reveal the importance of creating conceptions in an occupational level. There seem to be specific themes related to wellbeing at work in nursing. In the field of nursing, social relationships with colleagues are major determinants, as well as patients’ satisfaction with their care. When evaluating the content of the model, the patients’ role as a determinant of wellbeing at work needs to be discussed specifically. When evaluating the model from the viewpoint of object-dependent wellbeing (M€ akitalo 2005) the importance of patients’ determinant role is highlighted and needs to be further explored. According to the concept of object-dependent wellbeing, work-related emotions are dependent on the object of work and success in this area. In agreement with this, in this study, patients as an object of nursing work and their satisfaction as an indication of success were found to be significant to nurses’ wellbeing at work. However, this study cannot explain the phenomenon at work-place level but it reveals that success with patients is an important determinant in the wellbeing at work of hospital nurses. The strength of this model is that it brings forward themes specific to nursing to promote wellbeing at work. As mentioned in the introduction, work stressors are very well known in this area. In this model, the viewpoint is instead positive, in accordance with the main point of positive psychology and growing interest in this area. From this viewpoint, this model offers a new perspective to nursing managers and leaders. The theoretical model helps one to recognise factors promoting wellbeing at work in a hospital setting. Previous conceptions suggest that there should be greater focus on the factors promoting wellbeing at work. Using this model, nurse leaders can, in dialogue with their personnel, evaluate realisation of factors promoting wellbeing.
Limitations One limitation of the study is that the number of respondents is quite small and the data was collected in one medical centre and in one country. Nevertheless, the theoretical model offers a starting point to expand knowledge. The model can also be tested and 741
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developed in different countries and contexts to observe cultural differences.
circumstances and individual expectations towards work in wellbeing at work.
Conclusions and implications
Source of funding
In conclusion, factors concerning colleague relationships on a practical and emotional level, enhancing high-quality patient care, supportive and fair leadership, challenging, meaningful and well-organised work and opportunities for professional development play a major role in hospital nurses’ wellbeing. From the viewpoint of conceptions of wellbeing at work, the theme of object-dependent wellbeing was supported. Nurses’ experience of success with patients and with patient care seems to play a major role as a source of meaningfulness and, furthermore, a source of wellbeing at work. In conclusion, two main themes can be recognised. First, the patient-centred personal meaning of nursing was supported, including success with patients and with nursing work. Second, togetherness among nurses was revealed to still be important, especially in terms of respectfulness and fluent cooperation. Hospital nurses’ wellbeing at work can be defined as meaningful and patient-centred work in fluent cooperation with colleagues. An implication for nursing management is that managers should focus on strengthening the abovementioned wellbeing factors, especially the possibility of providing high-quality patient care, organising work practices in a satisfying way and ensuring opportunities for professional development and for challenging and meaningful work. Furthermore, in terms of leadership, there should be a focus on fair actions and decisions and management’s supportive role while allowing nurses to implement their own ideas. Despite the major role of management, there are some implications for the nurses themselves. In a work community, social relationships play a strong role in terms of wellbeing at work. Every nurse can have a positive influence on strengthening nurses’ togetherness, cooperation, assistance and support. An implication for education is that students should be prepared for what they can expect from managers and how nurses should cooperate to ensure each other’s wellbeing. A research implication is that the concept of wellbeing at work needs clarification. Research should focus on clarifying the role of general definitions versus understandings in one field of occupation. This study has strengthened the viewpoint of focusing on specialities in one field of occupation and on more local understanding. Further studies are needed to clarify the role of general
This study was funded by the Northern Ostrobothnia Hospital District and The Finnish Foundation of Nursing Education.
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Ethical approval The study was approved by the Northern Ostrobothnia Hospital District. There was no need for ethical approval in an organisational level. The principle of informed consent was followed with participants.
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Supporting information Additional Supporting Information may be found in the online version of this article: Appendix S1: Factor Matrix.
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Hospital nurses’ wellbeing at work: a theoretical model KATI UTRIAINEN
PhD
1
, LEENA ALA-MURSULA
PhD
2
€ and HELVI KYNGAS
PhD
3
1
Coordinator, 2Professor (acting), Occupational Health Services and 3Professor, Nursing Science, Institute of Health Sciences, University of Oulu, Oulu, Finland
Correspondence Kati Utriainen Occupational Health Services Institute of Health Sciences University of Oulu PO Box 5000 University of Oulu PO Box 5000 90014 Oulu Finland E-mail: [email protected]
UTRIAINEN K., ALA-MURSULA L. & KYNGA¨S H.
(2015) Journal of Nursing Management 23, 736–743. Hospital nurses’ wellbeing at work: a theoretical model Aim To develop a theoretical model of hospital nurses’ wellbeing at work. Background The concept of wellbeing at work is presented without an exact definition and without considering different contents. Method A model was developed in a deductive manner and empirical data collected from nurses (n = 233) working in a university hospital. Explorative factor analysis was used. Results The main concepts were: patients’ experience of high-quality care; assistance and support among nurses; nurses’ togetherness and cooperation; fluent practical organisation of work; challenging and meaningful work; freedom to express diverse feelings in the work community; well-conducted everyday nursing; status related to the work itself; fair and supportive leadership; opportunities for professional development; fluent communication with other professionals; and being together with other nurses in an informal way. Conclusions Themes included: collegial relationships; enhancing high-quality patient care; supportive and fair leadership; challenging, meaningful and well organised work; and opportunities for professional development. Objectdependent wellbeing was supported. Implications for nursing management Managers should focus on strengthening the positive aspect of wellbeing at work, focusing on providing fluently organised work practices, fair and supportive leadership and togetherness while allowing nurses to implement their own ideas and promote the experience of meaningfulness. Keywords: nurses, theoretical model, wellbeing at work
Accepted for publication: 5 November 2013
Background Wellbeing at work as a positive concept Wellbeing at work is a commonly presented and widely used concept in the field of occupational health and scientific research, yet it lacks a universal definition. The concept refers to a positive viewpoint of a phenomenon. The background of the concept can be located in positive psychology (Seligman & Csikszentmihalyi 2000, Sheldon & King 2001), which is the scientific 736
study of ordinary human strengths and virtues. The main interest is in finding out what works, what is right and what is improving (Sheldon & King 2001). There is a long research history regarding the negative viewpoint of work life and as a result we have extensive knowledge of work stress and burnout. Instead, the scope should be more focused on a positive viewpoint of work life and promoting employee wellbeing through strengthening those factors that have a positive effect on wellbeing at work. Some other concepts in this area DOI: 10.1111/jonm.12203 ª 2014 John Wiley & Sons Ltd
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focus on the positive viewpoint. A concept of work engagement (Schaufeli & Bakker 2010) has been used. Work engagement consists of vigour, dedication and adsorption. Work engagement captures how workers experience their work as something stimulating and energetic to which they really want to devote time and effort (the vigour component), a significant and meaningful pursuit (dedication) and something engrossing, on which they are fully concentrated (absorption) (Schaufeli & Bakker 2010). Therefore, work engagement can be seen as being linked to the motivational aspect towards work. Job satisfaction is a traditional concept used in this area, which is defined as the degree of positive affect towards a job or its components (Adams & Bond 2000). Therefore this concept highlights a scope of affect and also an attitude towards work.
Definitions of wellbeing at work Similarly, the concept of wellbeing at work is a positive exposition which, furthermore, resolves to describe this phenomenon as a positive emotional and experimental state in a work context. The basic concept of wellbeing itself refers to a condition, existence or state of a person or community (Glanze et al. 1986, Myers et al. 2000, Oxford University Press 2007). As mentioned previously, the concept is rather new in a work context and only some definitions exist. According to Schulte and Vainio (2010), wellbeing is a summative concept characterising the quality of working lives, including aspects of occupational safety and health. It may also be a major determinant of productivity at individual, enterprise and societal levels (Schulte & Vainio 2010). Wellbeing at work is also defined as: ‘…the worker’s experience of the safety and healthiness of work, good leadership, competence, change management and the organisation of work, the support of the work community to the individual, and how meaningful and rewarding the person finds work’ (Anttonen & R€ as€ anen 2009). In M€akitalo’s (2005) study, this research area is expanded by discovering a concept of object-dependent wellbeing, outlining that work-related emotions depend on the object of the work and the employee’s success in this area. In the same study, the relevance of disturbances in the flow of work were also recognised as a reason for increased physical and psychological workload (disturbance load). Analogous to the findings on object-dependent wellbeing (M€ akitalo 2005), Lu et al. (2012) have proposed that satisfaction or dissatisfaction with work does not depend solely on the nature ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 736–743
of the job, but also on the individuals’ expectations of what their job should provide. This also highlights the individual view – the importance of the object of work and success with it – as well as the viewpoint of providing something important through work. Based on earlier research, some conclusions can be made in order to define the concept of wellbeing at work. First, it is proved to be dependent on the object of the work and the success achieved in that (M€ akitalo 2005). Second, the concept is multidimensional and related to several aspects, varying from the individual level to productivity and the social level (Anttonen & R€as€anen 2009, Schulte & Vainio 2010). However, this concept of wellbeing at work remains at a general level and fails to connect with a specific type of work or field of operation. In particular, if wellbeing at work is understood in connection with the object and aims of work (M€akitalo 2005), it should be clarified in certain fields of operation and even work contexts. Referring to this requirement and in addition to the need to clarify the general understanding, there is also a need to focus research into more specific areas and fields of operation to bring specific themes closer to different areas of work. In this study, the focus is on nursing work and a theoretical model is developed to describe wellbeing at work of hospital nurses. The theoretical model is developed to organise knowledge of wellbeing at work and to indicate the main concepts that describe the nurses’ wellbeing at work in a hospital context.
Nurses’ wellbeing at work and nursing leadership Some systematic reviews have focused on a positive view and nurses’ job satisfaction in a hospital setting, where sources of job satisfaction have been summarised. Therefore this study is founded on earlier research findings of this subject instead of specific nursing theory. In Utriainen and Kyng€as’s (2009) systematic review, two themes seem to be most significant to nurses’ job satisfaction: interpersonal relationships between nurses and patient care. Organising nursing work is also a significant predictor of wellbeing at work. In a systematic review of Lu et al. (2012), the sources of nurses’ job satisfaction in a hospital setting were physical working conditions, relationships with fellow workers and managers, staffing and scheduling, pay, promotion, job security, responsibility, recognition from managers and hours of work. In terms of wellbeing at work, a theoretical model focusing on ageing hospital nurses has been developed and tested using statistical methods (Utriainen et al. 2011). Wellbeing at 737
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work has been used as a core concept in a nursing context in Brazilian (Alves et al. 2012) and Finnish studies (Koivu et al. 2012), among others. From the viewpoint of nursing management, nurse leaders have a key role in promoting wellbeing at work. Taking care of nurses’ wellbeing is a one part of leadership, while leaders also have a responsibility of ensuring sufficiency of human resources. Nurses’ turnover is a threat to this sufficiency and has been recognised as a widespread problem in nursing work. Therefore, it is essential that nurse leaders recognise the importance of wellbeing factors such as job satisfaction and happiness at work as predictors of intention to stay in nursing work (Cowden & Cummings 2012) and understand factors that promote wellbeing and the structure of wellbeing at work. In line with present concepts of wellbeing at work, this study focuses on a positive viewpoint of work life and promoting employee wellbeing through strengthening factors that have a positive effect on wellbeing at work in a nursing context. The theoretical model developed in this study will help nurse leaders understand the totality of nurses’ wellbeing at work and take these factors into account in their management work to promote wellbeing and careers in nursing work.
Method Development of theoretical model Owing to the lack of theoretical definitions of wellbeing at work, especially in the context of nursing work, a theoretical model was developed. Theoretical models can be developed using either an inductive or a
deductive approach, depending on the focus of interest and the nature of previous research (McEwen 2007, Fawcett 2009, Kanste et al. 2009). A deductive approach was used in this study, such that the development of the theoretical model is based on earlier studies and the empirical data collected via questionnaires. The purpose of empirical testing is to verify the structure and concepts and their associations by using statistical methods. Development of a theoretical model is a continuous and dynamic process whereby theoretical propositions are examined empirically. As a result of this testing, the theoretical propositions are modified and further refined (McEwen 2007, Fawcett 2009, Kanste et al. 2009). The quantitative data were analysed using the software SPSS for Windows (IBM, New York, NY, USA). Explorative factor analysis using varimax rotation was applied. This method is well suited for theory development because it allows the study of conceptual structures (Pett et al. 2003, Munro 2005). Factors were estimated using eigenvalues, the lowest acceptable value being 1. Items were estimated using communalities (limited to between 0 and 1, the higher the better). Communalities were high (between 0.522 and 0.877), indicating that the items measured the factors’ reliably (Table 1 and Appendix S1). The reliability of the scale (internal consistency) was assessed using Cronbach’s alpha coefficient, and the results ranged from 0.66 to 0.91 (Table 2). According to Nunnally and Bernstein (1994), Cronbach’s alpha coefficient should be >0.60, while Polit and Hungler (1999) consider >0.70 to be sufficient and >0.80 desirable. Factor loadings were expected to be over 0.40. In the case of lower loading, the item was deleted.
Table 1 Factor model of hospital nurses’ wellbeing at work Factor number and name Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor Factor
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1: Patients’ experience of high-quality care 2: Assistance and support among nurses 3: Nurses’ togetherness and collaboration 4: Satisfying practical organisation of work 5: Challenging and meaningful work 6: Freedom to express diverse feelings in work community 7: Well-conducted everyday nursing 8: Status related to the work itself 9: Fair and supportive leadership 10: Opportunities for professional development 11: Fluent communication with other professionals 12: Being together with colleagues in an informal way 13: Cooperation and good spirit 14: Completion of everyday work tasks 15: Allowing nurse autonomy 16: Positive feedback and commendation 17: Working in pairs or groups
Number of items
Explained variance (%)
Eigenvalue
Factor loadings
7 9 8 7 6 4 4 5 3 3 3 2 2 1 2 2 1
35.8 4.3 3.9 3.1 2.8 2.6 2.4 2.1 2.0 1.9 1.7 1.6 1.5 1.4 1.4 1.3 1.3
29.4 3.5 3.2 2.6 2.3 2.1 1.9 1.7 1.6 1.5 1.4 1.3 1.3 1.2 1.1 1.1 1.9
0.502–0.778 0.414–0.744 0.511–0.762 0.525–0.686 0.457–0.762 0.405–0.750 0.477–0.654 0.425–0.707 0.601–0.752 0.724–0.748 0.540–0.758 0.656–0.707 0.651–0.706 0.688 0.403–0.427 0.486–0.583 0.653
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Properties of the scale A scale consisting of 82 items was developed in this study. The aim of this study was to create a general theoretical model of hospital nurses wellbeing at work and in consistence with this goal, items are based on relevant earlier research findings in this area. Items were based on the validated scale measuring ageing hospital nurses’ wellbeing at work (Utriainen & Kyng€ as 2011), a literature review of studies on nurse job satisfaction (Utriainen & Kyng€ as 2009) and on empirical data on young nurses’ wellbeing at work (Utriainen K. & Kyng€ as H., unpublished data). The scale and items were based on earlier research findings. The scale used as a basis in this study was psychometrically valid (a = 0.79–0.98) but because of its focus on ageing nurses’ wellbeing at work the significance of each item was re-evaluated by a researcher. All respondents representing ageing nurses had extensive experience in nursing work (almost one-third had worked in health care for more than 31 years and one-quarter had between 26 years and 30 years of experience), therefore reflecting views of long-experience nurses from the same generation. Based on this evaluation, three age-specific items (referring to themes specific only to ageing and experienced nurses) were removed, and six items were removed for content reasons (having the same content as other items). Eighteen items were added based on studies bringing forward themes that have a positive influence on the wellbeing at work of young nurses or nurses of different ages (Utriainen & Kyng€ as 2009, Utriainen K. & Kyng€ as H., unpublished data). These items linked to relationships between nurses and physicians, fluency of communication, resourcing of work, leadership and development opportunities at work. The scale measured the importance of the various propositions for nurses. The items of the scale were answered on a five-point Likert scale, with 5 representing ‘to a very great extent’ and 1 representing ‘to a very small extent’. A Likert scale is suitable when items in a questionnaire or survey express a viewpoint on something and the respondents are thus asked to indicate the degree to which they agree or disagree with the statement (Polit & Hungler 1999).
for the people in northern Finland and medical services to Scandinavia and other parts of the world. With more than 3000 staff, the hospital also serves as a teaching institution for medical and nursing students. Data collection was carried out in cooperation with unit head nurses. An information letter and questionnaire forms were sent to head nurses of different units (19 units). The units represented different specialities, such as intensive care, surgery, internal medicine and neurology. The head nurses informed about the study and all of the volunteers had an opportunity to participate in the study by answering the questionnaire. Following the principle of informed consent, participants were informed in the cover letter about the purpose of the study, anonymity, voluntariness, confidentiality and source of contact information, as well as the researcher’s contact information. The head nurses gathered and returned the questionnaires to the researcher by post.
Respondents The respondents were nurses who conducted work on a practical level and represented four different nursing care specialities: surgery (45%), internal medicine (33%), intensive care (18%) and neurology (2%). The majority of respondents therefore represented internal medicine and surgery. In terms of age, the respondents were born between 1946 and 1987. Age was classified according to the generational classification of the nursing profession (Boychuk Duchscher & Cowin 2004) into the following groups: Baby Boomers (born 1946–1964), Generation X (1965–1979) and Millennials (1980–1987). Forty-one per cent belonged to Generation X, 34% belonged to the Baby Boomers and 24% belonged to the Millennials. The majority of respondents (73%) had a tenured full-time job and 17% had a terminable full-time job. Sixty-two per cent of respondents had work experience of 15 years or less and 18% had very long work experience (26 years or more) in health care. Fifty-one per cent of respondents had worked in their current assignment 6–20 years; 37% had worked in their current assignment 5 years or less and 13% had worked 21 years or more.
Data collection The data were collected in spring 2010 from registered nurses (n = 233) working in a university central hospital in northern Finland. The hospital provides demanding treatment in different braches of medicine ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 736–743
Data analysis Seventeen factors emerged in the factor analysis (Appendix S1). Thirteen items were deleted owing to low factor loadings and redundancy. Items included in 739
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Table 2 Number of items and Cronbach alpha coefficients of final factor model Factor name Patients’ experience of high-quality care Assistance and support among nurses Nurses’ togetherness and collaboration Satisfying practical organisation of work Challenging and meaningful work Freedom to express diverse feelings at work Well-conducted everyday nursing Status related to the work itself Fair and supportive leadership Opportunities for professional development Fluent communication with other professionals Being together with colleagues in an informal way
Items (n)
a
8 9 10 7 6 4 5 7 3 3 3 2
0.895 0.914 0.876 0.870 0.849 0.793 0.814 0.889 0.844 0.865 0.887 0.662
factors 13 (two items), 14 (one item) and 15 (two items) were transferred into other factors (Factors 3, 7 and 8). Some of the items loaded on several factors. Transfer was allowed based on Cronbach’s alpha coefficients, and content review also supported this decision. Two factors were deleted (Factors 16 and 17). Their Eigenvalues were low (1.065 and 1.032) and there was only one item in each factor after another item from factor 16 was transferred into factor 1. The final theoretical model to describe hospital nurses wellbeing at work consisted of 12 factors (comprising 67 items): patients’ experience of high-quality care, assistance and support among nurses, nurses’ togetherness and cooperation, satisfying practical organisation of work, challenging and meaningful work, freedom to express diverse feelings in the work community, wellconducted everyday nursing, status related to the work itself, fair and supportive leadership, opportunities for professional development, fluent communication with other professionals, and being together with other nurses in an informal way (see Table 2).
Results The theoretical model presented is supported by the parameter estimates of the factor analysis. Therefore, the empirical evidence validated the 12-factor theoretical model of hospital nurses’ wellbeing at work. According to the theoretical model, the wellbeing at work of hospital nurses is constructed from patients’ experience of high-quality care, assistance and support among nurses, nurses’ togetherness and cooperation, satisfying practical organisation of work, challenging and meaningful work, freedom to express diverse feelings in the work community, well-conducted everyday nursing, status related to the work itself, fair and supportive leadership, opportunities for professional development, fluent communication with other professionals and being together with other nurses in an informal way (Figure 1).
Discussion The aim of this study was to develop a theoretical model of hospital nurses’ wellbeing at work. The development process was deductive and grounded in the findings of earlier study findings (Utriainen & Kyng€as 2009, 2011) (Utriainen K. & Kynga¨s H., unpublished data). The model was empirically tested using statistical methods (factor analysis), which showed that the construct validity of the theoretical model was good, and its reliability was evaluated by for internal consistency using Cronbach’s alpha coefficient. The theory was therefore confirmed. According to the theoretical model, the wellbeing at work of hospital nurses is constructed from patients’ experience of high-quality care, assistance and support among nurses, nurses’ togetherness and cooperation,
Figure 1 Wellbeing at work of hospital nurses: a theoretical model.
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satisfying practical organisation of work, challenging and meaningful work, freedom to express diverse feelings in the work community, well-conducted everyday nursing, status related to the work itself, fair and supportive leadership, opportunities for professional development, fluent communication with other professionals and being together with other nurses in an informal way. Some major themes can be recognised and discussed based on these emerged concepts. Social relationships with colleagues play a major role in nurses’ wellbeing at work. This appears at a practical level (assistance among nurses, fluent communication) and at an emotional level (nurses’ togetherness and cooperation, freedom to express feelings, informal social intercourse). The importance of similar factors related to the work community has been confirmed in earlier studies in terms of job satisfaction (Adams & Bond 2000, Newman & Maylor 2002, Dunn et al. 2005, McLennan 2005). As a challenge to nursing management, the theme of leadership was concentrated in two themes: fairness and support. In terms of status related to the work itself, head nurses’ permission for nurses to implement their own ideas was also emphasised. Fairness is worth noting: there is research evidence that the extent to which people are treated with fairness in workplaces predicts their health (Kivim€ aki et al. 2004). Within nursing, patients’ satisfaction with care has an important role in nurses’ wellbeing at work. Patients’ experience of high-quality care and nurses’ own experience of well-conducted everyday nursing emerged. In terms of job satisfaction, the importance of patients and high-quality patient care to nurses has been confirmed in earlier studies (McNeese-Smith 1999, Newman & Maylor 2002, M€ akinen et al. 2003, Begat et al. 2005, Dunn et al. 2005, McLennan 2005, Perry 2005). Nurses want their work to be organised well with regard to wellconducted everyday nursing. Nurses also look for challenges in their work and opportunities for professional development. When compared with a theoretical model of ageing nurses (Utriainen et al. 2011), the viewpoint of professional development is one major difference. This might relate to differences between generations and ageing nurses’ calling and patient-centred attitude towards nursing. Another explanation relates to the stages of a career, where younger nurses are more orientated towards themselves and their career development. According to the theoretical model focusing on ageing nurses, wellbeing at work relates to nurses’ experience of collaboration, cooperation and togetherness with other nurses in a supportive and caring ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 736–743
work environment. The aim and possibility of highquality patient care in an atmosphere where nurses and nursing are appreciated are also related to the wellbeing of ageing nurses. When evaluating the similarities between the two models, the importance of social relationships with colleagues and high-quality patient care appear to be highlighted. The emerging concepts reveal the importance of creating conceptions in an occupational level. There seem to be specific themes related to wellbeing at work in nursing. In the field of nursing, social relationships with colleagues are major determinants, as well as patients’ satisfaction with their care. When evaluating the content of the model, the patients’ role as a determinant of wellbeing at work needs to be discussed specifically. When evaluating the model from the viewpoint of object-dependent wellbeing (M€ akitalo 2005) the importance of patients’ determinant role is highlighted and needs to be further explored. According to the concept of object-dependent wellbeing, work-related emotions are dependent on the object of work and success in this area. In agreement with this, in this study, patients as an object of nursing work and their satisfaction as an indication of success were found to be significant to nurses’ wellbeing at work. However, this study cannot explain the phenomenon at work-place level but it reveals that success with patients is an important determinant in the wellbeing at work of hospital nurses. The strength of this model is that it brings forward themes specific to nursing to promote wellbeing at work. As mentioned in the introduction, work stressors are very well known in this area. In this model, the viewpoint is instead positive, in accordance with the main point of positive psychology and growing interest in this area. From this viewpoint, this model offers a new perspective to nursing managers and leaders. The theoretical model helps one to recognise factors promoting wellbeing at work in a hospital setting. Previous conceptions suggest that there should be greater focus on the factors promoting wellbeing at work. Using this model, nurse leaders can, in dialogue with their personnel, evaluate realisation of factors promoting wellbeing.
Limitations One limitation of the study is that the number of respondents is quite small and the data was collected in one medical centre and in one country. Nevertheless, the theoretical model offers a starting point to expand knowledge. The model can also be tested and 741
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developed in different countries and contexts to observe cultural differences.
circumstances and individual expectations towards work in wellbeing at work.
Conclusions and implications
Source of funding
In conclusion, factors concerning colleague relationships on a practical and emotional level, enhancing high-quality patient care, supportive and fair leadership, challenging, meaningful and well-organised work and opportunities for professional development play a major role in hospital nurses’ wellbeing. From the viewpoint of conceptions of wellbeing at work, the theme of object-dependent wellbeing was supported. Nurses’ experience of success with patients and with patient care seems to play a major role as a source of meaningfulness and, furthermore, a source of wellbeing at work. In conclusion, two main themes can be recognised. First, the patient-centred personal meaning of nursing was supported, including success with patients and with nursing work. Second, togetherness among nurses was revealed to still be important, especially in terms of respectfulness and fluent cooperation. Hospital nurses’ wellbeing at work can be defined as meaningful and patient-centred work in fluent cooperation with colleagues. An implication for nursing management is that managers should focus on strengthening the abovementioned wellbeing factors, especially the possibility of providing high-quality patient care, organising work practices in a satisfying way and ensuring opportunities for professional development and for challenging and meaningful work. Furthermore, in terms of leadership, there should be a focus on fair actions and decisions and management’s supportive role while allowing nurses to implement their own ideas. Despite the major role of management, there are some implications for the nurses themselves. In a work community, social relationships play a strong role in terms of wellbeing at work. Every nurse can have a positive influence on strengthening nurses’ togetherness, cooperation, assistance and support. An implication for education is that students should be prepared for what they can expect from managers and how nurses should cooperate to ensure each other’s wellbeing. A research implication is that the concept of wellbeing at work needs clarification. Research should focus on clarifying the role of general definitions versus understandings in one field of occupation. This study has strengthened the viewpoint of focusing on specialities in one field of occupation and on more local understanding. Further studies are needed to clarify the role of general
This study was funded by the Northern Ostrobothnia Hospital District and The Finnish Foundation of Nursing Education.
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Ethical approval The study was approved by the Northern Ostrobothnia Hospital District. There was no need for ethical approval in an organisational level. The principle of informed consent was followed with participants.
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Supporting information Additional Supporting Information may be found in the online version of this article: Appendix S1: Factor Matrix.
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