Reward frustration at work and intention to leave the nursing profession—Prospective results from the European longitudinal NEXT study

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Abstract

Background

Many countries are facing a serious situation of nursing shortage, and retention of nurses is a challenge.

Objectives

To examine whether reward frustration at work, as measured by the effort–reward imbalance model, predicts intention to leave the nursing profession, using data from the European longitudinal nurses’ early exit study.

Design

A prospective study with one-year follow-up.

Methods

6469 registered female nurses working in hospitals in seven European countries who did not have intention to leave the nursing profession at baseline were included in our analyses by multivariate Poisson regression.

Results

8.24% nurses newly developed intention to leave during follow-up. High effort–reward imbalance at baseline predicted an elevated risk of intention to leave the profession (relative risk 1.33, 95% confidence interval 1.22–1.45), and reward frustration (poor salary and promotion prospects, lack of esteem) showed the strongest explanatory power. Findings were similar in a majority of the countries.

Conclusions

Results suggest that improving the psychosocial work environment, and specifically occupational rewards, may be helpful in retaining nurses and consequently reducing nursing shortage in Europe.

Introduction

Nursing shortage and understaffing is a problem of growing concern in many countries, in particular in rapidly aging societies (West et al., 2007). In a recent international survey in 69 countries, 90 out of 105 (86%) nursing unions and organizations reported shortage of nursing personnel and its impact on health care delivery (Clark and Clark, 2003, Lynn and Redman, 2005). While improved strategies of recruiting health professionals, in part from foreign countries, are needed, major efforts should be directed towards maintaining employed nurses in their jobs as long as possible (Westendorf, 2007). To this end, quality of work and employment needs to be critically improved. In order to promote these aims, the availability of detailed research findings from organizational and occupational sciences seems crucial as they can guide targeted interventions and the development of strategies of organizational change. A number of studies have been performed in recent years to tackle this problem by identifying work- and employment-related determinants of nursing turnover, intention to leave the nursing profession, and early exit from the labour market (Hayes et al., 2006). One such investigation, the Nurses’ early exit (NEXT) study, explicitly addressed the role of adverse work conditions in explaining professional turnover and intention to leave the job in a comparative perspective, by recruiting nursing staff from 10 European countries (Hasselhorn et al., 2005). Previous findings report strong associations of a stressful psychosocial work environment with intention to leave one's profession, specifically if measured in terms of two leading models of work-related stress, the combination of high demand and low control (Hasselhorn et al., 2008) and the imbalance between high efforts spent and low rewards received in turn (Hasselhorn et al., 2004). However, with the exception of one report focusing on the former model, available evidence from this comparative study is restricted to cross-sectional study designs, thus preventing any interpretation of results in terms of a possible causal direction.

To our knowledge, the current study is the first to analyze associations of a stressful psychosocial work environment, as measured by the effort–reward imbalance model, with intention to leave nursing profession in a prospective design, using a broad data base with samples from seven different European countries. This model of an adverse psychosocial work environment is based on the fundamental principle of reciprocity in contractual social exchange, such as the work contract. It posits that failed reciprocity in terms of high effort and low reward elicits strong negative emotions and stress reactions with adverse long-term effects on health and job satisfaction. The model claims that in addition to the imbalance caused by these two extrinsic factors (effort, reward) an intrinsic factor, a distinct motivational pattern of people's coping with work demands (overcommitment) may modify the effects of effort–reward imbalance at work on health and job satisfaction (Siegrist et al., 2004). Our focus on occupational reward frustration is justified by the fact that this model distinguishes three dimensions of occupational rewards, money, career-related rewards (promotion prospects, job security) and non-material rewards (esteem, recognition) which all seem to matter for nurses’ well-being and organizational commitment (van Vegchel et al., 2002).

Section snippets

Aims

We therefore set out to test whether, and to what extent, the single dimensions of this model (effort, reward, overcommitment) increase the risk of developing intention to leave nursing over a one-year observation period, and to analyse the contribution of a combined measure of effort–reward imbalance towards estimating this risk. Furthermore, we are interested in exploring the consistency of associations across countries and to explain potential deviations from this pattern by referring to

Study design and population

The details of the NEXT study were described elsewhere (Hasselhorn et al., 2005). In summary, this is a one-year longitudinal study which was approved by the Ethical Committee of the University of Wuppertal. 30,613 nurses in 7 countries (Belgium, Germany, France, Italy, The Netherlands, Poland, and Slovakia) filled in the effort–reward imbalance (ERI) questionnaire at baseline (Hasselhorn et al., 2004). Our present investigation was restricted to 19,290 registered female nurses working in

Characteristics of study subjects at baseline

Table 1 gives information on the sample composition (means and percentages of socio-demographic and occupational characteristics) at baseline. Of the 6469 female respondents in this study, the overall mean age was 38.04 years, while the Dutch nurse were youngest (37.51 years) and the Slovakian nurses were oldest (39.17 years). Generally, 81.73% nurses lived with partners, ranging from 71.44% in Germany to 88.45% in Poland. The distribution of shift work in the 7 European countries was uneven,

Discussion

The aim of this paper was to analyze whether reward frustration at work, as measured by the scales of the effort–reward imbalance model, influenced nurses’ intention to leave their profession, using a one-year prospective comparative study design covering samples of nurses from seven European countries. Whereas pooled results confirmed these associations two national samples (The Netherlands and Slovakia) deviated from the general pattern of findings. When comparing the single scales of the

Conclusions

The findings of this comparative longitudinal study of nurses’ self-report level of reward frustration at work indicate that the risk of their intention to leave nursing is critically increased as a function of the amount of non-reciprocity experienced between efforts spent and rewards received in turn. Measures aiming at reducing this imbalance may define a promising approach towards retention of nurses and tackling nursing shortage across European countries.

Acknowledgement

The authors would like to thank the members of the NEXT Study for their continuing participation and support.

Conflict of interest: None declared.

Funding: The NEXT Study has been funded by the European Commission (QLK6-CT-2001-00475 /PIIF-GA-2008-220641); the current analyses have been also supported by the Belgian Science Policy (WOQUAL study TA/00/033), and by the Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (BGW, Germany).

Ethical approval: This study was approved by the

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