Factor Affecting the Quality of Work Life Among Nurses: A Systematic Review

Introduction

The World Health Organization (WHO) defines an individual’s Quality of Life (QOL) as their subjective perception of their life situation within the cultural and value systems of their environment. This perception is contextualized in relation to personal goals, expectations, norms, and concerns. The concept of quality of life has been evolving in recent years.¹ One example is the concept of health-related quality of life (HRQOL), which is defined as “a comprehensive concept that includes all factors that affect a person’s life”.¹ Moreover, the scope of quality of life extends beyond health-related considerations. Organizational behavior scientists and management scholars study Quality Work Life (QWL), which is a crucial area of research in QWL development.² The assessment of the quality of work life has become increasingly popular in current research, indicating a rising concern for comprehending and enhancing the general welfare of individuals in the workplace.

According to Van et al³ quality of work life (QWL) refers to an employee’s perception and evaluation of their work in the context of their life. QWL extends to encompass an individual’s life, which, in turn, may influence their work experiences.⁴ Quality of work life (QWL) is a measure of an employee’s quality of life within the context of work. It assesses factors of the work environment as well as factors of life outside of work. QWL also considers the relationship between work and life outside of work for employees.

The concept of Quality of Work Life (QWL) is multidimensional and encompasses an employee’s feelings about various aspects of their work.⁵ Given that individuals possess diverse needs in connection to their work, the level of QWL experienced can vary, contingent upon the fulfillment or non-fulfillment of these needs. Consequently, the QWL of the workforce emerges as a critical consideration for employers to address.³ Recognizing and understanding the nuanced dimensions of QWL is pivotal for employers seeking to create environments that foster the well-being and satisfaction of their employees, ultimately contributing to a more positive and productive workplace.

Other than that, assessing QWL allows employers to identify challenges or barriers within the work environment that may affect issues such as job satisfaction or employee retention.⁶ A high quality of work life (QWL) is crucial for an organization’s ability to attract and retain employees.⁷ Numerous studies have shown that quality of life has a positive effect on various organizational and personal components, such as employee commitment and organizational effectiveness. On the other hand, quality of work life has a negative correlation with turnover, absenteeism, resignation, and work-life conflict.^8–10 These insights emphasize the critical role of QWL in shaping organizational dynamics and individual experiences within the workplace.

In recent decades, Quality of Work Life (QWL) has garnered increased attention, particularly within healthcare settings.¹¹ Research shows that positive outcomes for healthcare organizations, providers, and patients can be achieved by implementing practices that promote a healthy quality of work life.¹² Research has shown that inadequate healthcare can lead to reduced effectiveness and quality of care provided by nurses, increased complaints, and higher direct medical costs.¹³ Considering the quality of work life (QWL) of healthcare workers has become a crucial factor in healthcare delivery, particularly for nurses.

According to Li et al,¹⁴ nurses are the most significant group among healthcare professionals, and the stability of their team significantly affects the quality of care. The specific quality of nursing work life is defined as the extent to which nurses are able to meet important personal needs through their experience in the organization and the extent to which nurses are able to meet important organizational goals.¹⁵ The quality of nurses’ working life is a crucial concern for health service organizations as it affects the productivity of achieving optimal care.^16,17 Additionally, attention to nurses’ quality of work life (QWL) is critical to the delivery of quality healthcare services, helping to prevent nurse turnover, increase motivation and retention, and improve productivity for both nurses and organizations.¹⁸

It is currently understood that the quality of work life has both positive and negative impacts on individuals and organizations. Several factors affecting quality of work life (QWL) for healthcare workers such as job satisfaction, compensation, working conditions were identified by Phan and Vo.⁷ However, the factors that have an impact on the quality of work life for nurses are still unclear. Identifying the predictors of nurses’ quality of work life will not only provide baseline data but also serve as evidence for organizations to plan and design strategies to retain nurses and increase their productivity, ultimately leading to the provision of high-quality care.¹⁹

To our knowledge, there has been no systematic review of the factors that influence nurses’ quality of work life. The purpose of this review is to discuss the factors that may affect nurses’ quality of work life, which may ultimately improve their overall well-being, work experience, and create a more supportive and fulfilling work environment in the nursing field. This literature review is designed to help other researchers understand how to conduct validation and to inform future research on interventions, solutions, and strategies to improve nurses’ work quality.

Materials and Methods

We conducted a literature review by searching and analyzing preliminary data collected from research-relevant databases using a systematic literature review (SLR) approach. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for design, conduct, and reporting. Relevant articles published between 2013 and 2023 were identified using electronic databases such as Scopus, PubMed, SAGE Journal, and SpringerLink. The aim of this review is to synthesize the factors that affect the quality of work life of nurses. Similar keywords and terms related to nurses’ quality of working life were used based on previous studies. Synonyms and related words were also included. The study focused on the quality of work life among nurses and other medical professionals. The keywords included were “quality of”, “work” or “labor”, “life” or “soul”, “among”, “nurses” or “health manpower” or “medical nurse”, “QWL” or “QWOL” or “Work related quality of life” or “quality of working life” or “quality of work life”. To ensure eligibility, a four-step process was followed, which included identification, filtering, eligibility, and inclusion.

In order to provide a comprehensive understanding of the quality of working life for nurses, inclusion and exclusion criteria were established based on research topics. Following the inclusion and exclusion criteria, we evaluated the titles and abstracts of the remaining studies. The research studies included in this analysis met the following criteria: (1) measured factors that affect the quality of work life for nurses, (2) included eligible registered nurses (of all ages and genders) working in hospital or clinical settings, (3) were published in English and available in full-text, and (4) were published between January 2013 and January 2023. (5) Only articles from the healthcare sector were considered.

We selected publications from 2013–2023 because there has been a lack of studies on the quality of working life in nurses. The last 10 years provide enough articles related to the quality of working life in nurses to ensure reference reliability and relevance to current circumstances. Thematic analysis was initiated by immersing in the data and gaining familiarity with the content of the article on the study’s purpose. The next steps involved reading the titles and abstracts of each article and sorting them according to the agreed inclusion criteria. After selecting articles that met the established criteria, we conducted a more detailed analysis of each article. This involved focusing on key aspects such as the authors, publication year, country, study objectives, design, and conclusions, and extracting repeated subject terms. The study analyzed full-text articles to determine eligibility and independently extracted data by the writers. Descriptive data including author, country, year of publication, measures of Quality of Work Life, number of participants, gender of participants and possible predictors of quality of work life among nurses were extracted. The results were classified as socio-demographics predictors, job-related predictors, and psychological predictors. Outcome measures that did not correspond to any of the three quality of work life factors were excluded from the results.

Results

The systematic search initially yielded 289 articles. After the meticulous review, only 20 met all inclusion criteria and were ultimately included in the systematic review. For a visual representation of the study selection process, please refer to Figure 1 in the accompanying flow chart. This stringent selection process ensures that the final set of articles aligns closely with the research objectives and inclusion criteria, enhancing the reliability and relevance of the systematic review.

Figure 1 PRISMA flow diagram. Notes: Adapted from Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. The BMJ. 2021;372. Creative Commons.20

The characteristics and results of the included studies are shown in Table 1. The authors grouped the various predictors from the 20 studies into three main domains, (1) socio-demographic predictors, (2) work-related predictors, and (3) psychological predictors.

Table 1 Summary of the 20 Studies

Socio-Demographic Related Predictors

As shown in Figure 1, out of the 20 articles selected for the systematic review, 15 discussed socio-demographic factors. The most prevalent socio-demographic factors that were found to affect the quality of work life for nurses were differences in education level and age. Other influencing factors are marital status, employee status, gender, national origin, job title and family situation.

The quality of work life for nurses is most influenced by their level of education. Studies have shown that nurses with higher levels of education experience better quality of work life.^{3,5,10,21,24,25,31,32} This is because it affects their salary,^5,10,21 job responsibilities,²⁴ workload,¹⁰ promotion opportunities,²⁵ and occupational position.³¹ However, according to Moradi et al,³⁴ nurses with lower levels of education reported a better quality of work life than those with higher levels of education. Nurses with advanced education tend to have greater expectations of their work environment and may experience increased emotional exhaustion when those expectations are not met.³⁴

Age, the second most important socio-demographic factor, also influences the quality of working life. There is a significant difference in QWL between nurses of different age groups.²⁵ Nurses with a higher age group had a better score on the QNWL.^30–32 One possible explanation for this phenomenon is that as individuals age, their skills tend to improve.³¹ Senior nurses may be more valued and better understood by managers, which can lead to an improvement in their quality of work life.³² Additionally,²⁶ found that QWL decreases with age among nurses.

In addition, a nurse’s quality of work life (QWL) is also affected by their work experience. The study found that nurses with more than 10 years of experience had higher QWL scores than those with less experience.^30,31,34 The study found a significant correlation between employee status with nurses’ quality of work life (QWL).^5,25,31 Nurses with higher job titles reported higher levels of QWL satisfaction compared to general nurses.^25,27,31 One possible explanation for this finding is that, compared to staff nurses who work directly with patients and their caregivers, higher level positions may provide a supervisory role, which can often be stressful and may lower the quality of work life (QWL).²⁷

Gender was found to be correlated with nurses’ quality of work life.⁵ Female nurses were found to have the lowest QWL satisfaction,²⁴ whereas³² reported that male nurses had lower QWL compared to female nurses. This systematic literature review also identified additional factors that affect the quality of nurses’ work life, such as marital status,^30–32 nationality,^27,28 family,^22,28 working in different hospital,³³ having a non-nursing job,³³ and working full-time.³⁰

Work-Related Predictors

It is evident that income or salary is a crucial factor in influencing the quality of work life for nurses.^10,22,25,26 Unfair compensation can lead to dissatisfaction and job stress, which can negatively impact the quality of work life for nurses.^5,32 Higher incomes allow individuals to satisfy the needs of their families and enhance their quality of work life.²³ However, Al Mutair et al²⁸ presents interesting findings that suggest a negative relationship between salary and quality of life.

Work unit is another factor that affects nurses’ QWL. Studies have shown that nurses working in intensive care were dissatisfied with their quality of work life (QWL).²¹ However, this contrasts with the findings of,³⁰ who reported that working in specialized and emergency care units resulted in higher QNWL scores. Additionally, the current study found that nurses who worked in outpatient settings were more likely to have a better quality of life.^5,10,31

Shift duration can negatively impact nurses’ quality of work life, as shown by Al Mutair et al,²⁸ Silveira Teixeira et al,²⁴ and Wang et al.²⁶ On the other hand, shift rotation has been identified as a factor that can improve nurses’ quality of work life, as noted by Alharbi et al³⁰ and Lebni et al.³¹ The study found a significant correlation between nurses’ quality of work life (QWL) and the type of hospital they work in. Nurses in tertiary, general, and teaching hospitals had poorer QWL^26,32 compared to those in specialty settings.³⁴ Hospital conditions may contribute to differences in nurses’ quality of work life (QWL) across hospitals. Research has shown that factors such as the size of the hospital, patient demographics, nurse compensation, hospital policies, and the physical environment can have an impact on nurses’ QWL.³⁴

Other factors that significantly affect nurses’ quality of work life (QWL) include poor management treatment of nurses,^5,32 work environment,^10,23,33 and hospital facilities^4,21 The study found that the lack of nursing resources, due to the disproportionate number of nurses and patients, causes high pressure for nurses, leading to sleep disorders and negatively affecting their quality of work life (QWL).^24–26

Psychological Related Predictors

Psychological factors were the last to be identified as contributing to the level of quality of work life of nurses. Job stress experienced by nurses is one of the factors that makes their quality of work life low.^{5,23,24,29,32,35} Job-related factors such as hospital type,^29,32 demands,²⁴ salary, and promotion⁵ were also confirmed to influence work stress resulting from low QWL. Meanwhile, in addition to job stress, there is also burnout, which is an emotional exhaustion syndrome and cynicism that often occurs among individuals who do “people work”,³⁷ which is also associated with low QWL nurses.^26,36

Other than that, social support and having family accompany the nurse have an influence on the QWL.^24,28,32 Nurses who were most dissatisfied with QWL tended to be associated with having low “social support”,²⁴ while nurses who have family members accompanying them have a positive impact on the quality of nurses’ work.²⁸ According to the study,^5,32 job insecurity was another major factor in nurses’ dissatisfaction with QWL. QWL in nurses is also influenced by other factors such as organizational commitment, work saturation, and turnover intention.^23,29

Discussion

The aim of this systematic review was to examine the factors that may influence nurses’ quality of work life. Although there have been several literature reviews on quality of work life, to our knowledge, this is the first systematic review to examine all nurse-specific predictors of quality of work from multiple studies around the world. In the present study, we identified 18 eligible publications that varied in terms of the factors that affect the quality of the work life of nurses. We analyzed each study and found several factors that affect the quality of work life of nurses. Thus, we categorized them into three types of factors, namely, sociodemographic-related factors (eg, educational, age, marital status), work-related factors (eg, salary, work units, work shift) and psychological-related factors (eg, stress, job burnout, family support).

It is important to acknowledge that the quality of work life of nurses is a crucial aspect to consider. Nurses in regular positions frequently encounter death, conflicts with colleagues, patient and family issues, and some professional discrimination.²³ Nurses must make a concerted effort to adapt to all relevant factors in order to maintain the quality of service provided to patients. Nurses commonly face challenges that can reduce their quality of work life and ultimately impact their job performance.^38,39

The decline in nurse quality of work life (QWL) can be attributed to various factors, including stress and burnout.^40–42 The heavy workload and insufficient number of nurses are contributing factors to the stress and burnout experienced by nurses.⁴³ Nursing shortages have a significant impact on their workload, special circumstances such as the COVID-19 pandemic have increased their workload, and inadequate compensation contributes to high levels of work-related stress that affect their quality of work life.²⁹ In addition to the effects of stress, Liu et al⁴⁴ found that the quality of care was negatively affected by the patient-to-nurse ratio. Therefore, nurse managers should be aware of this imbalance and use strategies to help prevent it from occurring.

Lack of social support from family, management, and colleagues is a significant predictor of psychosomatic pressure and has an additional impact on the development of work-related stress in employees.⁴⁵ This finding is consistent with Nowrouzi’s¹⁵ study, which demonstrated that high levels of social support can reduce work-related stress and improve quality of work life (QWL). According to a study by Mutair⁴⁶ non-Saudi healthcare workers who were far from their families reported higher levels of depression and anxiety compared to their counterparts in Saudi Arabia. The study found that the presence of nursing families had a positive impact on the quality of life of nurses, possibly due to better social support and work-life balance when living with family members.⁴⁶ In addition, the support systems provided by family living arrangements, which are often more prevalent among married nurses, may contribute to increased job satisfaction.⁴⁷

Studies have shown that nurse stress and burnout can vary from hospital to hospital and unit to unit, which in turn can have an impact on nurses’ quality of work life.^15,48 For instance, nurses in teaching and tertiary hospitals experience higher levels of stress compared to those in non-teaching hospitals. This could be attributed to longer working hours and heavier workloads in teaching hospitals, which are caused by the demands of student teaching programs and workplace requirements.^49,50 In addition, nurses employed in specialty hospitals, such as ENT hospitals, tend to have a higher quality of work life due to their specific work arrangements, higher salaries, and lower stress levels.^11,51

Nursing is one of the professions that provides 24-hour services in hospitals, which requires nurses to work in shifts. Notably, nurses who work rotating shifts, particularly night shifts, tend to report lower QWL scores than nurses who work other shifts.^41,43 The challenges associated with night shifts, such as the emotional distress of leaving home and children at night, limited family time, and increased fatigue, contribute to these lower QWL scores.^41,48,52 Moreover, shift length emerges as another critical factor influencing nurses’ QWL. Consistent with existing literature,⁵³ nurses working shorter hours per shift may experience increased satisfaction with their QWL. These findings underscore the importance of considering the specificities of shift work and its impact on nurses’ well-being when addressing QWL in healthcare settings.

Work units emerge from the analysis as another significant factor influencing nurses’ quality of work life (QWL). Specifically, QWL is particularly affected by the type of work unit, with specialized units such as emergency/ICUs associated with lower QWL.³⁰ Nurses in specialized units often face challenging conditions, including shift work, direct patient care responsibilities, and time pressures, which collectively contribute to lower QWL⁵⁴

However, variations in findings are observed in studies where nurses in medical wards and outpatient settings express higher satisfaction with their Quality of Nursing Work Life (QNWL) compared to those in intensive care wards.^10,21,31 This could relate to the fact that units other than the outpatient departments usually require engagement in night and weekend shift duty, direct patient care, and work overload which could result in lower quality of life.¹⁰ This is also consistent with research⁵³ where nurses in outpatient clinics and those who do not work night shifts reported better QWL.

Salary is a crucial component of compensation for nurses and plays a significant role in their overall well-being, happiness, and subsequent impact on healthcare quality and organizational productivity.⁵⁵ High-income nurses consistently demonstrate better QWL compared to their low-income counterparts. Studies have highlighted the significance of compensation, including salary and financial incentives, in relation to nurses’ dissatisfaction with their quality of work life (QWL).⁵⁶ This fact is demonstrated by the reality that many nurses in Iran have second jobs due to financial constraints. Kheiri³³ reported that nurses are generally paid insufficient salaries. While having a second job may provide financial relief, it can also have a negative impact on nurses’ quality of work life (QWL), as noted by Hardjanti et al.⁵⁷ Specifically, holding a non-nursing job as a second job can increase stress levels and workload, further reducing QWL.

The salaries earned by nurses may be influenced by the type of hospital they work in. This is supported by a study³² which found that nurses working in public hospitals in Iran were dissatisfied with their compensation. On the other hand, very low salary with high workload may explain their experience of low quality of work life (QWL),¹⁰ so sufficient income with reasonable workload may lead to higher job satisfaction.⁵⁸ A potential explanation for the positive correlation between monthly income and quality of work life (QWL) among nurses is that those with higher incomes, who may be the primary breadwinners, are better able to manage their family needs and therefore have more energy to devote to achieving organizational goals. Accordingly, studies have shown that wages, financial benefits, and pay equality are crucial factors for nurses.^12,56,59 Therefore, in order to reduce the burden on nurses and maintain their quality of life at work, hospital management and other relevant parties should prioritize nurses’ salaries.

Meanwhile, our findings suggest a consistent trend where QWL tends to be lower among nurses with lower levels of education compared to those with higher levels of education. This aligns with previous nursing studies indicating that more educated nurses tend to develop greater job satisfaction, potentially due to increased job opportunities, reduced stress, and enhanced job security.^60,61 Higher education levels may also instill confidence, with more educated nurses feeling more secure about their employability irrespective of their location. Another reason for the educational factors could be wage increases, increased status or acceptance, and improved coping mechanisms for various problems.

However, it’s noteworthy that there are divergent findings in the literature, as some studies indicate that the QWL of nurses with lower levels of education is better than that of nurses with higher levels of education.³⁴ This variance suggests that the relationship between education level and QWL is complex and may be influenced by contextual factors, such as the alignment between expectations and the work environment. Nurses with higher education levels may have higher expectations, and if these expectations are not met, they may experience more emotional exhaustion.⁶² Improving nurses’ education and standards, employment recruitment policies, incentives, and workplace conditions are important factors to consider in enhancing the quality of work life of nurses.

In this literature study, older nurses have also consistently shown higher average scores for QWL than their younger counterparts.^25,30–32 These findings suggest that elderly nurses are adaptable to their work environment and receive recognition and appreciation from managers, potentially leading to greater job satisfaction.⁶³ However, it is important to recognize inconsistencies in the literature. Some studies, such as those by Tajvar et al⁶⁴ and Wang et al,²⁶ report a negative relationship between the age of nurses and QWL. This is because the level of physical and cognitive function decreases with age, which can affect nurse performance.⁴² This inconsistency highlights the need for further exploration of the complex relationship between age and QWL.

Several studies have investigated the relationship between work experience, employee status, and quality of work life (QWL) among nurses. The findings suggest that nurses with 10 or more years of work experience tend to have a better QWL.^30,31,34 This is in line with research indicating that nurses who have job security and more work experience are better equipped to handle work-related stress, which promotes independence, self-confidence, and overall well-being.⁶⁵ However, it is important to acknowledge discrepancies in the literature, as some studies, such as Nabirye et al,⁶² have found that nurses with more work experience may experience higher levels of stress and lower job satisfaction. These findings highlight the complex factors that affect QWL and emphasize the importance of understanding individual experiences and career paths among nurses.

Another interesting finding was that job titles were found to be significant predictors of QWL among nurses.^25,27,31 This suggests that nurses with more advanced professional degrees, such as charge nurse, director of nursing, or supervisor, report higher levels of satisfaction with their QWL than generalist nurses. The likely reason for this finding is that higher positions tend to have more supervisory roles than direct patient care, which is often stressful.

In conclusion, the quality of work and life of nurses has been greatly affected by a number of factors. Hospital management and other related parties can pay more attention to the welfare of nurses based on the factors described above. The pleasant work environment is associated with better QWL for nurses. This is in line with previous studies that showed that nurses working in a supportive work environment experienced a better QWL Islam.⁶⁶ Furthermore, it is necessary to pay more attention to the figure of the leader, as leadership also plays an important role, as shown by Laschinger et al,⁶⁷ which suggests that when the nurse leader creates a supportive work environment, this leads to an increase in work productivity and an increase in the overall well-being of nurses. These findings highlight the importance of organizational and environmental factors in shaping nurses’ experiences and QWL.

Limitation

The results of this study cannot be generalized to all nursing populations because our search was limited to reviewing studies relevant only to registered nurses working in hospitals and did not include nurse educators, and nursing students. In addition, it is possible that additional studies (other than English) may yield different results because the search was limited to studies published in English. It was also challenging to find all relevant studies because of the limited number of studies available on nurses’ quality of work life. However, we included all possible studies to the best of our knowledge. The search was also limited to 2013–2023, so earlier studies may have been missed.

We recommend that future research assess quality of life in a wider range of nurses (eg student nurses). In addition, more extensive follow-up research is needed to identify other factors that influence nurses’ quality of work life. Furthermore, the factors that influence nurses’ quality of work life can be used to guide the development of more effective preventive interventions to improve nurses’ quality of work life, although the findings from our review cannot be generalized to all nurses. It may also help individuals and organizations to pay more attention to quality of work life.

Conclusion

According to our review, improving nurses’ well-being and work productivity requires attention to their QWL. Paying attention to nurses’ quality of work life (QWL) can help organizations create a more supportive and fulfilling work environment in nursing. Our study identified several sociodemographic, organizational, and psychological predictors of nurses’ QWL. The highest sociodemographic factors affecting nurses’ QWL were differences in education level and age. The highest predictors in organizational factors were salary, work-units, and shift rotation. In terms of psychological factors, work stress, burnout, and family and social support are the most significant predictors that affect nurses’ quality of work life (QWL).

Although there has been considerable progress in the discussion of nurses, research on their quality of work life has been lacking, and interventions to address poor quality of work life have not been implemented. Additionally, nurses with a low quality of working life can have a negative impact on productivity in the workplace. This data can be used to plan effective strategies and find appropriate solutions to address factors that reduce QWL by hospital management, policy makers, and others responsible for improving nurses’ overall quality of work life (QWL).