Modeling the Relationship Between Job Demands, Work Attitudes and Performance Among Nurses

Modeling the Relationship between Job Demands, Work Attitudes and Performance among Nurses in a Transition Economy

Abstract Nurses are critical human resource input in the hospitals’ functions of health promotion, curative and preventive care and; effective performance of their roles have implications for patients’ health outcomes. This study based on data obtained from 228 nurses in general and specialist hospitals explores the link between various dimensions of nurses’ job demand, job security and work attitude. Structural equation model analysis results indicate that work- family conflict and work pressures have implications for absenteeism; and that absenteeism is strongly linked with turnover while being a symptom of low job satisfaction. In addition, while job security negatively impact on absenteeism it has direct positive effect on both job satisfaction and commitment. This underlies the need for specific managerial countermeasures to balance work-family responsibilities as well as balance work load as measures to limit work pressures on nurses and hedge against absenteeism and turnover among nurses . Keywords: Job Demand, Work Attitude, Job Security, Turnover, Absenteeism.

BACKGROUND An issue of concern in the Nigerian health system is the cost of health care. In addition, the ineffectiveness and inefficiency in health care delivery in most health facility at all tiers of the health system: primary, secondary and tertiary levels are common knowledge. Often these shortcomings are attributed to inadequate resources especially health care personnel and poor remunerations (Lambo, 1983, Peters, Chakraborty, Mahapatra & Steinhardt, 2010). Health workers remunerations, however, seem to be reflective of the difficult economic conditions obtained in the country and in most countries in the African continent. Consequently, the health sector has been characterized by incessant strikes over remunerations, and unsympathetic care procedure, demand for payment before care (Khemani, 2004; Abiodun, 2010). Besides, the health system is characterized by negligence in the public sub-sector of the system: health worker expect to be paid irrespective of contributions. According to Peters, et al, 2010, lack of adequate remunerations is the main grievance of health worker in low income countries

There is an additional dimension to the problem with reference to organizational structure of the Nigerian health system. The organizational structure shared responsibilities for health among tiers of government: federal, states and local governments. These transfers of responsibilities have significantly affected medical inputs, service provision, managerial decisions, financing and incentive structure within the health system. Consequently, the hospital system has become political clout in terms of management and resource allocation. The managerial problem is manifested in the inequalities in the administrations of remunerations across different category of health workers. The inequality and comparatively low remuneration structure has often resulted to industrial actions and dis-affection among cadres of health workers. The dominating arguments have been that health care requires a multi-disciplinary approach, thus, fair and equitable reward for all health workers is a necessary condition for optimal contributions and job satisfaction of all health workers. In addition, the output of the health system is a critical resource in the process of economic development and that the nature and job demand for health workers is unique with implications for role performances of individual and national economic health. The unique nature of their job demand is magnified when set against the social and economic pressure categories of health workers face in most transition economy. The foregoing argument to support demand for higher and equitable remunerations is not without merit given the fact that the performance and benefits health system offer is dependent on the knowledge, skill and motivations of health workers responsible for health care delivery (Kabene, Orchard, Howard, Soriano & Leduc, 2006). In addition, the quality (skills and knowledge) and quantity (numbers) of health workers may serve as an indicator of health system’s capacity to provide delivery and health care interventions.

Consequently, understanding the relationship between job demands, job security and work attitudes of nurses seem to be a promising and worthwhile research endeavour. Nurses constitute a key health human resource with vital roles in health promotion, curative and preventive care. Indeed, effective performance of their roles may have implication for patients’ health outcomes. Thus, given the pivotal roles of nurses in determining the efficiency, effectiveness and sustainability of healthcare system a study of nurse job demands and implications for work attitude seems worthy of research effort.

Therefore, the current study seeks to provide a link between nurses job demands, job security and nurses response to cope with seemingly increased demands of their job. The focus is to shed lights on the effect of job demands in environment plagued with high unemployment rates which makes job security an issue of concern on the nurses’ work attitude such as voluntary absenteeism, turnover intention; and outcomes (commitment and performance). It seems intuitively plausible that research effort should seek to gain insight into the interconnections of these variables among critical health personnel as nurses. This effort has both practical and theoretical values given the dearth of literatures investigating this phenomenon in context of transition economies, and among health care personnel. Besides, the assertion of Yildrim & Aycan (2008) that working conditions of nurses are difficult in transition economies and that nursing is a female-dominated profession practiced under demanding cultural, social and economic conditions in these economies is a potent motivation for the study.

CONCEPTUAL FRAMEWORK Nurses Job demand Job demands, according to Bakker, Demerouti, Boer and Schaufeli (2003) encompass psychological, social as well as organizational aspects of job such as work pressure, role overload, environmental conditions that require sustained emotional and cognitive efforts. Nurses’ job demands are somewhat unique with implications on individuals, organizational and better health and social outcomes. Their job roles involve oversight of life-saving treatments and provision of emotional support to patients which often involves significant exertion of physical labour, long and irregular work hours and inter personal relationship which may conflict with family and other social responsibilities.

The nature and characteristics of nurses’ job and the work environment they confront exert significant influence and define the role performances for nurses. According to Bakker, et al (2003) the characteristics of this environment can be segregated into job demands and job resources. Job demands encompass the physical, social and organizational aspect of job requiring both physical and physiological efforts while job resources will include variables with which nurses cope with job demands. Nurses, by the nature of their assignments, are associated with emotional, cognitive and physical strains (Bakker, et al, 2000; Aikens, et al, 2001). The task

2 structure and roles demand within and outside the organization requires coping strategies which might take the extreme form of organizational withdrawal (turnover) or job withdrawal (absenteeism). The coping strategies may be individualized due to variations in depth of work- family interface.

Nurses, however, are involved in ‘life saving’ care (Beatrice, et al, 2008). This often demand working long hours, in awkward positions, intense work load, shift work, overtime and work overload (Bakker et al,2003, Yildrim, et al 2008) The challenging conditions of nurses job not only predisposed them to physical exhaustion but make them more prone to experience work- family conflict. Indeed, work and family life are not mutually exclusive such that combining the multiple roles on both domains may become a breeding ground for conflict. These become most pronounced in nursing which is somewhat a female dominated profession thus the need to combine the responsibilities of work and marriage engender family-work conflict. Therefore, it could be proposed that various dimensions of nurses job demand covaries with work attitude.

Job demands, Absenteeism and Turnover Nurses spend a significant portion of time in the work domain, however, their life as individuals are not completely defined by the job; consequently, it is also require that they function in other domains in life. Job demands that are incompatible with roles fulfillment in other domains, for example, family will strain behavior either at work or in other domains or in the two domains. Incompatibility in the domain may arise due to time involvement, strain or behavioural difficulties in switching between different roles (Greenhause & Bentell, 1985). Work demands such as work hours, workload, shift work which, by nature, reduce time available for family activities is associated with work-family conflict(Burke,2002, Higgin, et al 2000; Saltzstein et al, 2001) Nurses’ work involve direct interactions with patients, patients relations, colleagues, extended work hours, excessive work load which may be instrumental to the design of individual coping strategies. Coping strategies may involve elements designed to reduce the negative consequences of the job domain on other domains. For example, nurses with problems coping with work- family conflict might be absent from work (Job withdrawal) or be more prone to seek job in other environment that accommodate more time in other domains (organizational withdrawal). Higher work demands especially with reference to time involvement (shiftwork, overtime, long working hours, and excessive workloads, among others) reduce time available for accommodation of other domain activities. Research evidence indicates, for example that work- family conflicts are associated with negative organizational outcomes such as increase tendency to quit (Eby, et al, 2002). Generally, literature evidences are that some features of nurse job such as long work hours, excessive workloads have depicted negative effect on employees (Brett & Stroh, 2003, Jamal & Baba, 2003).

Job Security, Job Satisfaction and Commitment The concept of job security describes employees’ degree of assurance of the future existence of their jobs. Expectedly, such feelings of security or insecurity about jobs will evoke behavioural responses from employees. According to Staufenbiel and Konig (2010) research evidences indicate negative relationship between job insecurity and attitude towards the job and organization such as job satisfaction and organizational commitment. However, job satisfaction studies among health workers seem more focused on job-related factors than job security of

3 health workers. For example, studies have examined the effect of autonomy and pay of health workers job satisfaction (Fung-Kam,1998), the contributory role of pay to job satisfaction (Curtis, 2007), and job characteristics have been linked to job satisfaction among health workers (Kirimaki, Voutilainen andKoskinen,1995; Tzeng, 2002). Consequently, research evidences on the effect of job security on attitude towards jobs and organizational commitment among health workers is scanty.

It may make compelling viewpoint to advance the argument that if relative scarcity factor of health workers are brought to bear there will exist the tendency for organizational withdrawal behaviours in form of absenteeism as coping mechanism for work pressure. Health workers who have less likelihood of involuntary separation from organizations may show more inclinations towards individual actions to cope with work pressure and family-work interface. On the contrary, however, job security may indeed gender organizational commitment and improved work performance specially if such effort lead to positive outcome on performance of the organization and improve security of employees in the organization. Job insecurity has been shown to relate to long work hours (Fischer, et al, 2005; De Cuyper et al, 2008), and productivity (Probst, Stewart, Gruys &Tierney, 2007). However, given the scarcity factor, job insecurity among health workers might show results inconsistent with research findings in other industries.

Deriving from preceding discussions it seems worthwhile to explore the hypotheses that job security has causative link with nurses’ job satisfaction, absenteeism as well as commitment; and that interrelationship at work among nurses and work roles covary with job satisfaction and commitment

MATERIALS AND METHODS Data for this research were collected from practicing nurses from public hospitals in Lagos, Nigeria: two general hospitals and two specialists’ hospitals. Based on national administrative structure, general hospitals are located at the secondary health care level while specialists’ hospitals which provide care for specific disease and are usually referral institutions for secondary health care facilities and are positioned at the tertiary level. Functionally, both types of facilities provide curative services both clinical and diagnostic services. However, due to poor resource endowment at the primary level there is evident ‘lack of faith’ in the primary level facilities; consequently secondary care level facilities are often overcrowded with attendant roles and social pressure on both facilities and health workers.

In addition to logistic and cost considerations, the choice of Lagos, the commercial and economic nerve centre of Nigeria, as the setting for the study was motivated by the high concentration of economic activities, availability of diverse and sophisticated health facilities, difficult traffic conditions, and numbers of skilled married women in employment. In addition, the large population is indicative of potentials for high demand for health care services; a unique feature of the study context is the cultural environment which placed high premium on closely knit nuclear and extended family concepts with extensive roles for females to fill within the nuclear and extended family. This provides a somewhat ideal setting for weighing the effect of jobs and environmental demands on interpersonal and social roles performance.

4 Sample for the study comprised of 267 nurses with 228 responding to the research instruments with 206 or 90.4% of the respondents being females. Anonymity was ensured in the data gathering process with assurance through the rubrics on the copies of the research instrument explaining the purpose of the study and indicating to respondents that the data will be used for scientific purpose. The purpose was to secure responses that are honest and less fear induced or responses that are not tainted by possible negative reactions from hospital management Therefore, data for the study was obtained using structured questionnaire. Most items in the research instrument were adapted with some modifications to suit the research context from the works of Staufenbiel & Konig, 2010; Sackey & Sanda, 2009, Yildrim &Aycan, 2008. Respondents responded to the survey research instrument which include both likert scale and demographic research items.

The research instrument sought to isolate, among others, issues of work-family conflict, pressure or stress experienced from work situations as consequence of work overload, job security, inter- relationship with colleagues (job climate) and work roles. Work attitude was operationalized along the dimensions of organizational withdrawal (absenteeism), job withdrawal (turnover), job satisfaction and organizational commitment; and self-rated performance. Generally, for these variables multi-item indices were used to measure each of the key variables in the study. In addition, for each of the key variables the mean response to scale items for each variable was considered as the respondents’ score on that measure. Therefore, the scores for each key variable is a sum of the responses for the scale items divided by the number of items in the scale. These scores were further used as observed variables in the structural equation model. Consequently, data analysis procedure was done using both the SPSS 19.0 and AMOS 19.0. Typically, the responses were recorded in SPSS data format in the defined 7-point likert scale from the research instrument while structural equation modeling (SEM) was used to determine the causal relationships between variables. In determining the causal relationships between variables in a single model the analysis of moment structures software was utilized. The fit indices available on AMOS were used to examine the overall fit of the research model.

RESULTS AND DISCUSSION A total of 228 nurses completed the questionnaire: 120 of the respondents are from general hospitals and 108 from specialist hospitals. 206 or 90.4% of the respondents are females and 22(9.6%) were males. This gender make-up agrees with empirical evidences in other clime that nursing is a female dominated occupation (Yildirim et al, 2008). 116 or 50.9% of the respondents are married; 31 or (13.6%) of the respondents had at a time been in marriage relationship but are currently divorced and 81 or 35.5% are single or have not been in marriage relationship. The economic conditions across nations of the world, particularly in the transition economies in the African continent with their peculiar cultural requirements; women are involved in multiple roles: work related, nuclear and extended family care and other social roles. Besides, due to the difficult economic condition that persists in some nations in Africa continent it is not out of place to find women as bread winner for the family or having some other major responsibility. With reference to current work responsibility 38 respondents (16.7%), 54 (23.7%) and 53 (23.2%) of the respondents are engaged in critical care, surgery and internal medicine sections. In addition, 43 respondents (18.9%) and 40 (17.5%) respondents work in the outpatient and emergency sections respectively. Therefore, subject to usual limitations associated with the approach

5 adopted in the study, the data which form the basis of analysis in the study may be considered as representing a rich data set.

TABLE 1. Demographic Characteristics of the Sample Category Frequency Percentage Gender Male 22 9.6% Female 206 90.4% Marital Status Single 81 35.5% Married 116 50.9% Divorce 31 13.6% Hospital Type General 120 52.6% Specialist 108 47.4% Department Critical care 38 16.7% Surgery 54 23.7% Internal Medicine 53 23.2% Emergency 40 17.5% Outpatient 43 18.9% Source: Survey, 2013 Table 2 presents the descriptive statistics and inter-correlations among the key variables included in the structural equation model analysis (SEM-analysis). Generally, the correlations between these variables ranged from low to medium, however, job withdrawal measure or turnover among nurses positively covaries with two dimensions of nurses’ job demands: work-family conflict (r= 0.21, p< 0.001) and pressure emanating from workload (r= 0.33 p<0.05) and organizational withdrawal measure or absenteeism (r=0.32, p<0.001). Expectedly, turnover negatively covaries with work attitude variables: job satisfaction (r=-0.18) and organizational commitment (r = -0.21, p<0.05), performance (r = -0.08) and job security (r = -0.38). Similarly, a negative association exists between absenteeism and job security; these result provide insight to variables that may have useful potentials in hedging negative work attitudes among nurses.

TABLE2. Means, Standard deviations and Inter-correlations of key variables Variables Mean Std. 1 2 3 4 5 6 7 8 9 10 Dev Commitment 5.41 1.09 1 -.20** -.24** .50** .32** . -02 . . .43** 51** 52** 21** Turnover 3.43 1.34 1 -.32** -.38* -.08 -.18* . -.16* . -.07 * * 21** 33** Absenteeism 2.86 1.40 1 -.32* -.30* -.36* . -.13 . -.18* * * * 34** 26** * Job security 5.07 1.04 1 .42** . -.09 . -.04 .42** 50** 40** Performance 2.36 0.99 1 . -.05 . .10 .38** 43** 34** Job satisfaction 5.53 1.15 1 -.05 . .002 .52** 38** Work-family conflict 3.90 1.28 1 .06 . .02 42** Work roles 5.20 0.82 1 . .50** 31** Pressure 4.49 0.89 1 .23** Interrelationship 4.94 0.93 1 **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed Source: Survey, 2013

6 Model Testing The test of the hypothesized relationship was done with structural equation model analysis (SEM). Results indicate the proposed measurement model which form the framework for testing of relationship in the model reasonably fit the data. Examination of the fit indices such as the CFI, NFI, IFI, CMIN and RMSEA showed an acceptable fit. All the fit indices are above the minimum threshold of 0.9 (Hu &Bentler, 1999; Tabachnick & Fidell, 2007) and an RMSEA value of 0.07. However, the Chi-square value was significant (X2 =35.252, p =0.002) as against what is normally the acceptance norm for a structural equation model. This may not be a liability as such given that models with large sample are apt to have a significant Chi-square (Kremelberg, 2010). However, with the CMIN/df being 2.35 one can reasonably conclude the model as a good fit.

The model results show the causal relationship between work-family conflict, work load pressure and organizational withdrawal measures (absenteeism). Both work- family conflict with path coefficients of 0.17, p= .006 and pressure arising from workload (0.18, p <0.002) have positive path coefficients as causative of absenteeism. The implication is that conflict between and work responsibilities and the pressure nurses experienced at work predisposed nurses to absenteeism. This result does not seem to be contrary to expectations given the cultural context of the study where nuclear and extended family concept is of much value with the care and concern of family members extending far beyond the nuclear settings. Consistent with Bakker, et al suggestions nurses absenteeism might serve nurses’ personal purposes if it became instrumental for recuperating from pressures or stress experienced at work, therefore, the causative relationship of work pressure to absenteeism might be expected. Perhaps, if managed may serve useful organizational ends, specifically, if such absenteeism assist nurses to fulfill some family roles which could constitute much personal concern as to negatively affect role performances at work. This could be so if the family roles which have been sacrificed for work roles due to job demands improve nurses’ health concern which had been consequence of work related pressures or stress. The effect of job security on absenteeism is negative (path coefficient: -0.33, p<.001). One would have considered that job security which increase nurses’ self-confidence and sense of importance in the organization may encourage absenteeism due to reduced likelihood of involuntary separation from work, on the contrary evidence indicate that job security reduces absenteeism. Thus, the higher the likelihood of involuntary separation from work (insecurity) the lower is the tendency or intention for absenteeism among nurses.

Pressure arising from nurses work role overload and absenteeism are positively associated with turnover intention. However, work role pressures with work-family interference showed more strength as causative factors for turnover intention or job withdrawal among nurses, that is , when the relationship in moderated by absenteeism there is greater predisposition to job withdrawal or turnover. Nurses who showed higher absenteeism intention are more predisposed to job withdrawal as indicated by the path coefficient (0.82). Work role pressures alone are less likely to lead turnover than when role pressure from work and family domains act together.

Expectedly, organizational commitment is negatively associated with turnover among nurses. Further results of the SEM analysis show that interrelationship at work between nurses is stronger causative factor (0.33) of job satisfaction than work roles (path coefficient: 0.23). The

7 implications may be that nurses’ technical competence, especially those who add administrative responsibilities to their schedules, may not suffice to secure job satisfaction among nurses rather management skills that equip nurses managers and administrators to support and foster beneficial inter-relationship among nurses may do. Problematic relationship at work or poor managerial skills of nurses’ managers and administrator that impedes relationship may exact penalty on nurses job satisfaction

FIGURE 1: Structural Model with Standardized Parameter Estimates X2=35.252, P =0.002 CMIN/df= 2.32 GFI= 0.97 Comparative Fit Index (CFI) = 0.968 Normed Fit Index (NFI) = 0.948 Root Mean Square Error of Approximation (RMSEA) = 0.07 Incremental Fit Index (IFI) = 0.969

Source: Survey, 2013

Work roles have stronger explanatory power for nurses’ commitment (0.32) than do job satisfaction (0.25). The ‘life-saving’ nature of nurses’ work, personal characteristics, the demand for interpersonal relationship in their work role performances may have accounted for overlooking disagreeable issues that gender dissatisfaction with their job. In addition, job security has direct effect on both job satisfaction (0.27) and commitment (0.23) while the mediating power of commitment between job satisfaction, job security, work roles, inter- relationship and performance indicate stronger positive link to performance while being negatively connected to turnover. Absenteeism is negatively related with job satisfaction among

8 nurses. This aligns with research evidence that suggests that low job satisfaction will lead to absenteeism and high turnover (Furham, 2005). The causative effects of absenteeism on job satisfaction among nurses, which in negative, suggest that absenteeism is a symptom of low job satisfaction. Consequently, devoting attention to those variables that are causative of job satisfaction might serves a double edge purpose of improving job satisfaction and reducing absenteeism.

MANAGERIAL IMPLICATIONS AND CONCLUSION

The present study should assist health policy administrators and nurses manager better understand the inter-relationship between nurses job demand dimensions, job security, job satisfaction, absenteeism, commitment, turnover and performance. In addition, it provides insight to mechanism for managing negative work attitude among nurses. The results from the study show that work-family conflict and work pressures have implications for absenteeism; and that absenteeism is strongly linked with turnover while being a symptom of low job satisfaction. This underlies the need for specific managerial countermeasures to balance work-family responsibilities and balance work load as measures to limit work pressures on health nurses. It seems such managerial measure have potentials for reducing negative work attitudes as absenteeism, voluntary turnover, and low job satisfaction among nurses. In addition, provision of job security i.e less likelihood of involuntary separation from job, and inter-relationship at work which creative a supportive social environment at work should be considered as potent variables foe achieving improved work attitude in form of job satisfaction, commitment and performance. It might prove of benefit to specify for nurse managers and administrators skills for creation of managerial environment that is social supportive and that facilitates inter-relationship at work. Management of relationship or creation of conducive organizational climate might have implication for nurses’ effective performance and commitment.

Key to variables included in structural equation model analysis in figure 1 Family (family-work conflict) Pressure (work overload) Security (Job security) Climate (Relationship among nurses at work) Wroles (work roles) Absentism (Absenteeism) Satisfaction (Job satisfaction) Commitment (organizational commitment) Perform (Performance) Turnover (Turnover)

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