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Nursing and Health Sciences (2014), 16, 298–306
Research Article
Psychometric properties of the Chinese-version Quality of Nursing Work Life Scale Ya-Wen Lee, RN, PhD,1,3 Yu-Tzu Dai, RN, PhD,1 Linda L. McCreary, RN, PhD,4 Grace Yao, PhD2 and Beth A. Brooks, RN, PhD5 1 Department of Nursing, 2Department of Psychology, National Taiwan University, Taipei, 3Department of Nursing, Changhua Christian Hospital, Changhua, Taiwan, 4Department of Health Systems Science, University of Illinois at Chicago and 5Resurrection University & Fellow of the American College of Healthcare Executives, Chicago, Illinois, USA
Abstract
In this study, we developed and tested the psychometric properties of the Chinese-version Quality of Nursing Work Life Scale along seven subscales: supportive milieu with security and professional recognition, work arrangement and workload, work/home life balance, head nurse’s/supervisor’s management style, teamwork and communication, nursing staffing and patient care, and milieu of respect and autonomy. An instrumentdevelopment procedure with three phases was conducted in seven hospitals in 2010–2011. Phase I comprised translation and the cultural-adaptation process, phase II comprised a pilot study, and phase III comprised a field-testing process. Purposive sampling was used in the pilot study (n = 150) and the large field study (n = 1254). Five new items were added, and 85.7% of the original items were retained in the 41 item Chinese version. Principal component analysis revealed that a model accounted for 56.6% of the variance with acceptable internal consistency, concurrent validity, and discriminant validity. This study gave evidence of reliability and validity of the 41 item Chinese-version Quality of Nursing Work Life Scale.
Key words
exploratory factor analysis, instrument development, nursing work environment, psychometric testing, quality of work life, reliability and validity, Taiwan.
INTRODUCTION Quality of work life (QWL) is the perception of an organization’s staff about the physical and psychological desirability of their work environment and working conditions (Sarah et al., 2012). It is an umbrella concept that covers salary, working hours, work environment, career prospects, and interpersonal relationships among the workplace, the organization, and society (Martel & Dupuis, 2006; Vagharseyyedin et al., 2011). Past research has indicated that QWL is negatively associated with job stress (Mosadeghrad et al., 2011; Bragard et al., 2012), turnover intention (Mosadeghrad et al., 2011; Almalki et al., 2012), and depression symptoms (Wang, 2009), and positively with productivity (Nayeri et al., 2011) and patient safety (Mitchell, 2012). In a 2009 study by the International Council of Nurses that that examined nurses’ expectations and needs globally, the proportion of nurses in Taiwan who believed that nursing was “better today than five years ago” ranked ninth in the 11 countries surveyed (International Council of Nurses, 2011). Only 53% of Taiwanese nurses said they were “very likely” to remain in the nursing profession in five years’ time, a lower Correspondence address: Yu-Tzu Dai, Department of Nursing, College of Medicine, National Taiwan University, No. 1, Section 1, Jen-Ai Road, Taipei 10051, Taiwan. Email: [email protected] Received 4 February 2013; revision received 12 September 2013; accepted 13 September 2013.
© 2014 Wiley Publishing Asia Pty Ltd.
percentage than in Portugal (77%), Brazil (75%), Canada (71%), and the USA (68%). Inordinate workloads, low pay, benefits and incentives, and lack of recognition were among the particular issues cited as contributing factors (International Council of Nurses, 2011). In Taiwan, although nurses are protected by laws governing maximum working hours and mandated time off (Council of Labor Affairs, Executive Yuan Taiwan, 2008), they are nonetheless commonly asked to work overtime and are assigned excessive workloads (Council of Labor Affairs, Executive Yuan Taiwan, 2011). In 2008, the average turnover rate of Taiwanese nurses was 19.9%, and the average vacancy rate reached nearly 7% in 515 hospitals nationwide (Chang & Yu, 2010), higher values than the ideal standards of 10% and 5%, respectively (National Audit Office & Taiwan, 2013). A psychometrically-sound tool to measure our nurses’ QWL is needed to further explore the relationship between QWL and high turnover rate. We found an existing tool, the Chinese version of the Nursing Practice Environment Scale (C-NPES; Chiang & Lin, 2008), which was translated and revised from the Practice Environment Scale of the Nursing Work Index (PES-NWI; Lake, 2002). The C-NPES is a Chinese language instrument and consists of 30 items that fall under five subscales: management and leadership, nursing professional development, nursing quality, staffing and resource adequacy, and participation in hospital affairs. However, the C-NPES does not include the items of working doi: 10.1111/nhs.12099
Quality of Nursing Work Life Scale
conditions and work/home life balance, rendering the instrument less than ideal for use with Taiwanese nurses in light of their specific complaints of overtime and excessive workloads (Council of Labor Affairs, Executive Yuan Taiwan, 2011). This means there is a gap in the existing Chinese version of the instrument: it fails to measure these working conditions and work/home life balance issues in Taiwan. To address the lack of a culturally-sensitive questionnaire, we searched the MEDLINE, CINAHL, and PsycINFO electronic databases for relevant articles published from 2005 to 2011. Three tools related to QWL were identified: the Brooks Quality of Nursing Work Life Survey (BQNW; Brooks & Anderson, 2005), the Work-Related Quality of Life Scale (WRQoL; Van Laar et al., 2007), and the Self-Evaluation of Working Life Quality questionnaire (SEQWL; Ventegodt et al., 2008). The BQNW assesses QWL for nurses, and is a self-report questionnaire containing 42 Likert-type items scored from 1 to 6 (1 = strongly disagree, 6 = strongly agree) along four subscales: work life/home life (i.e. work/home life balance), work design (i.e. responsibilities and duties), work context (i.e. practice environment), and work world (i.e. sociocultural influences) (Brooks & Anderson, 2004). Cronbach’s alpha for the subscales ranges from 0.56 to 0.88, and the BQNW shows high test–retest reliability (r = 0.90) (Brooks & Anderson, 2004). The WRQoL is also a self-report questionnaire, but it assesses QWL for healthcare workers in general. It contains 23 Likert-type items scored from 1 to 5 (1 = strongly agree, 5 = strongly disagree) along five subscales: job and career satisfaction, general well-being, home–work interface, stress at work, control at work, and working conditions (Van Laar et al., 2007). Cronbach’s alpha for the overall scale is 0.91, and those for the subscales range from 0.76 to 0.91 (Van Laar et al., 2007). The SEQWL assesses QWL for the public: it is a self-report questionnaire containing 108 Likert-type items scored from 1 to 5 (1 = very good, 5 = very bad) along four subscales – quality of life, mastery, fellowship, and creation of real value – and has high criterion-related validity (r = 0.69, P = 0.0001) (Ventegodt et al., 2008). We decided to select the nursing-specific BQNW for evaluating nurse QWL in this study. The BQNW was published in 2005 (Brooks & Anderson, 2005), and has been employed in four studies to date (Brooks & Anderson, 2004; Brooks et al., 2007; Almalki et al., 2012; Lee et al., 2013). The BQNW situates QWL within the context of O’Brien-Pallas and Baumann’s (1992) model of influences on the quality of nurses’ work life, and measures working conditions and work/home life balance. In this study, we developed and tested the psychometric properties of the Chinese-version Quality of Nursing Work Life Scale (C-QNWL).
METHODS Study design Psychometric properties of the C-QNWL were estimated using a descriptive and correlational design.
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Setting and participants Data were collected over seven acute care private hospitals, including a medical teaching center (1455 beds), two regional teaching hospitals (202 & 262 beds), and four district nonteaching hospitals (93, 136, 157, & 190 beds) in central Taiwan. A total of 1254 nurses were recruited for the field study using purposive sampling. Inclusion criteria were nurses who provided bedside care and worked rotating shifts; exclusion criteria were nurses still in the probation period, those working in management, and those who had already participated in our pilot study. A majority of the sample was female (98.4%), single (70.4%), and childless (77.3%). Nurses ranged in age from 21 to 49 years (mean: 28.7 ± 4.5), and reported an average seniority of 5.9 ± 4.6 years. Most had baccalaureate degrees as their highest level of education (63.4%) and were nonreligious (60.6%). Nurses were also asked to report their nursing career ladder level, referring to a system guiding the responsibilities and capacities of Taiwanese nurses, which is overseen by the Taiwan Nurses Association. Level N designates novice nurses; N1, performing general patient care; N2, participating in critical patient care; N3, being responsible for clinical educational activities and executing integrated nursing care; and N4, nursing administration and conducting nursing research. The most represented nursing career ladder level was N2 (43.1%) (Table 1).
Ethical considerations This study, including the pilot study and the field test, was approved by the institutional review boards of Changhua Christian Hospital, and authorization for use of all instruments was obtained from their authors or publishing company.
Procedure and data collection The C-QNWL was developed in three phases over 11 months in 2010–2011 (Fig. 1).
Phase I: translation and cultural-adaptation process The translation and cultural-adaptation process followed typical four step guidelines for the cross-cultural adaption of self-report measures (Beaton et al., 2000; Kutlu et al., 2012). First, two bilingual translators, whose first language was Chinese, completed independent forward translations of the BQNW from English to Chinese. One translator was the first author, and was familiar with the concept of QWL; the other was a Taiwanese physician and certified translator who was not familiar with the concept of QWL. We focused on translating the conceptual meaning of the items, rather than the word-for-word literal translations. Second, back translations were performed by two bilingual translators – a Hong Kong physician and a Filipino research associate – whose first language was English. They created independent translations of the Chinese instrument into English. © 2014 Wiley Publishing Asia Pty Ltd.
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Table 1.
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Participants’ demographic characteristics (n = 1254)
Variables Age Seniority Sex Female Male Marital status Single Married Divorced Others Have children Yes No Education level Diploma Bachelor Graduate Others Religion None Tao Buddhist Christian Other Nurses’ career ladder level N N1 N2 N3 N4
Mean (SD)
Range
28.7 ± 4.5 5.9 ± 4.6
21–49
%
98.4 1.6 70.4 28.5 1.0 0.1 22.7 77.3 32.5 63.4 0.6 3.5 60.6 21.4 10.5 5.1 2.4 16.0 32.0 43.1 8.7 0.2
N, novice; N1, the first ladder level; N2, the second ladder level; N3, the third ladder level; N4, the fourth ladder level; SD, standard deviation.
Third, one language expert and the four translators discussed conceptual, semantic, and experiential equivalences between the English and the Chinese instruments until they arrived at consensus. Items 5 (leave for family), 8 (unlicensed support personnel), and 17 (unlicensed support personnel) were deleted, because Taiwan hospital regulations do not specifically identify family-related leave within leave guidelines, and nurse aides are seldom employed. The process resulted in the first version of the C-QNWL, which contained 39 items. Fourth, individual 30–60 min content-validation interviews were conducted with six nurses. They had a mean of 7.6 years of work experience, and their specialties covered internal medicine care, intensive care, pediatric care, respiratory care, and emergency care. These interviews were conducted to assess how clear the items in the C-QNWL were, and to identify additional areas within the domain of nursing work life for which new items were needed. Adding items demands careful consideration of the trade-off between maintaining conceptual equivalence between the source and target languages and enhancing the measure’s cultural validity (Leplège & Verdier, 1995). Significant revisions were made for items 13 © 2014 Wiley Publishing Asia Pty Ltd.
(answer the phone) and 34 (standard operation procedure) based on these interviews. Issues mentioned by at least three nurses during the interviews were considered significant: eight such issues were observed. After the research team discussed how relevant the content of these eight items were to the scale, two were removed, and six new items, for which there were no equivalents on the BQNW (items 43–48), were developed and added at the end of the scale. These modifications produced the 45 item C-QNWL (second version). We continued the instrument development by reviewing the characteristics of the 45 items and inter-item associations. Item 21 (friendship) had the highest mean (5.09) and relatively low variance (0.59), but we retained the item because of its importance to the QWL concept. Three items – items 4 (rotating schedules), 40 (find the same job), and 42 (impacts patients/families) – had low inter-item (< 0.30) and item-total correlations (< 0.20), indicating minimal contribution to the QWL concept, and so we deleted these three items. Items 45 (take leave) and 46 (arrange holidays) had high inter-item correlation (0.83); the former was deleted to avoid redundancy. Four items were removed overall, and the resultant 41-item C-QNWL, the final version, was employed in the remaining analyses.
Phase II: pilot study We conducted a pilot study using the 41-item C-QNWL, with data collected using purposive sampling at seven acute care hospitals in central Taiwan. Nurses who provided bedside care in rotating shifts and acted as opinion leaders within their nursing units were invited to evaluate the clarity of each item of the C-QNWL. The sample size, 150 nurses, provided approximately one-tenth of the proposed field-testing study size, as per the recommendations of Pett et al. (2003). A 94% response rate (141/150) was achieved. The respondents rated item clarity using a 10-point rating scale, ranging from 1 (not at all clear) to 10 (very clear). Nurses were further invited to offer written suggestions to improve item clarity for any item rated < 7. An assessment of 2 week test–retest reliability yielded a reliability r value of 0.79 (P < 0.01).
Phase III: field-testing process A sample size of 450–675 was calculated as sufficient to meet the criteria for a robust factor analysis, requiring at least 10–15 participants per item (Pett et al., 2003). To prevent problems arising from a low response rate, the population was oversampled to ensure an adequate sample size. Three instruments – the developed C-QNWL, the Chinese version of the second edition of the Beck Depression Inventory (C-BDI-II), and the C-NPES – and two copies of the informed consent document were put in an envelope and delivered to nurses’ workplaces. Nurses were invited to sign the informed consent and complete the questionnaires; participants were only identified by a study identification number. Weekly follow-up reminders and an institutional review board-approved incentive payment of NT$100 (approximately US$3.33) were provided to encourage a higher response rate.
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Source scale (BNQW, 42 items, English)
1. Forward translation: two independent translators
Integrated translations
Phase I
2. Back translation: two independent translators
3. Consensus discussion: one language expert and the four translators
4. Content validation interview: six nursing professionals
First version of the C-QNWL (39 items)
Second version of the C-QNWL (45 items)
The final version of the C-QNWL (41 items)
Phase II
Figure 1. Chinese-version Quality of Nursing Work Life Scale (C-QNWL) translation, cultural adaptation, and field-testing process.
Phase III
Instruments C-QNWL The final version of the C-QNWL is a self-report questionnaire consisting of 41 items answered on a six-point Likerttype scale (1 = strongly disagree, 6 = strongly agree) adapted from the 42-item BQNW (Brooks & Anderson, 2005) via the translation process and 39- and 45-item intermediate versions outlined above.
C-BDI-II Work/home life imbalance is a risk factor for the onset of depression (Couser, 2008). Research has indicated that the QWL of workers is significantly impaired by depressive symptoms (Wang, 2009). Hospital nurses are known to work in psychologically- and physically-demanding work environments, which could lead to depressive symptoms (Gao et al., 2012). We believed an instrument targeting such symptoms would provide a strong measure of concurrent validity. We chose the C-BDI-II (Chen, 2000) for this purpose, which is used to assess Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, depressive symptomatology in adolescents and adults. The C-BDI-II was previously translated into Chinese by the Chinese Behavioral Science Cor-
Pilot study (n =150)
10-point item clarity, test-retest reliability
Field test (n = 1,254)
Internal consistency reliability, concurrent validity, exploratory factor analysis, discriminant validity.
poration (Chen, 2000). The C-BDI-II is a 21-item, self-report questionnaire, with each item scored from 0 to 3, and higher values indicating increasing severity of depression over the most recent 2 weeks (Beck & Steer, 1996). Its reported internal consistency is 0.92, and its construct validity has been demonstrated to be satisfactory using the Rasch measurement model (Pan & Hsu, 2008).
C-NPES The C-NPES (Chiang & Lin, 2008), a measure of the nursing work practice environment, was chosen to measure the discriminant validity of the C-QNWL. The C-NPES is a selfreport, four-point Likert-type scale (1 = strongly disagree, 4 = strongly agree) consisting of 30 items over five subscales: management and leadership, nursing professional development, nursing quality, staffing and resource adequacy, and participation in hospital affairs. Cronbach’s alpha for the subscales ranges from 0.65 to 0.87, and the validity was obtained using a content validity index and principal component analysis (PCA) of a five-factor structure, which explained 47.89% of the variance (Chiang & Lin, 2008).
Data analysis Data were analyzed using SPSS 17.0 software (SPSS, Chicago, IL, USA). Missing items were treated by item mean © 2014 Wiley Publishing Asia Pty Ltd.
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Table 2.
Inter-item correlations and corrected item-total correlations grouped into seven factors
Factor 1. 2. 3. 4. 5. 6. 7.
Supportive milieu with job security and professional recognition Work arrangement and workload Work/home life balance Head nurse’s/supervisor’s management style Teamwork and communication Nursing staffing and patient care Milieu of respect and autonomy
Item
Inter-item correlation† (mean)
Item-total correlation† (mean)
19, 30, 31, 34, 35, 36, 37, 38, 39, 41
0.25–0.57 (0.39)
0.51–0.67 (0.58)
12, 10, 13, 43‡, 44‡, 46‡ 1, 2, 3, 6, 7 18, 20, 22, 26, 27, 33, 48‡ 21, 23, 24, 25 9, 14, 15, 16, 47‡ 11, 28, 29, 32
0.22–0.53 (0.32) 0.43–0.77 (0.54) 0.40–0.71 (0.54) 0.31–0.70 (0.50) 0.35–0.49 (0.44) 0.27–0.70 (0.40)
0.42–0.52 (0.48) 0.58–0.77 (0.67) 0.57–0.80 (0.68) 0.58–0.76 (0.62) 0.49–0.66 (0.58) 0.40–0.65 (0.52)
Item 45 was deleted due to redundancy; original item numbers have been retained. †Pearson’s correlation; ‡items developed post-pilot study.
substitution; this procedure does not distort the data when the number of missing items is less than 5% of the total (Streiner & Norman, 2008); there was less than 4% in the present study.
Descriptive statistics and item analysis Demographic characteristics were described in terms of percentage and mean. Item analysis was conducted in terms of means, variances, inter-item correlations, corrected item-total correlations, and the change in the Cronbach’s alpha if the item was deleted. A mean close to the center of the range of possible scores with a relatively high variance was desirable (DeVellis, 2012), and inter-item correlations of 0.30–0.80 (Pett et al., 2003) and corrected item-total correlations of 0.20–0.80 (Streiner & Norman, 2008) were considered satisfactory. Inter-item correlations of less than 0.3 indicated an item that had little in common with other items, whereas correlations higher than 0.80 could signify redundant items (Pett et al., 2003).
rotation at delta = 0 was chosen instead of orthogonal rotation, because we anticipated the concepts within QWL to be highly correlated (O’Brien-Pallas & Baumann, 1992). Factors were extracted based on eigenvalues being > 1, results of a scree plot, and their conceptual meanings. Factor loadings of > 0.3 were used (Kline, 1994; Pett et al., 2003). Discriminant validity was examined by calculating Pearson’s correlation coefficient of the C-QNWL with the C-NPES.
RESULTS A very good response rate was achieved for the C-QNWL (90.9%), the C-BDI-II (89.4%), and the C-NPES (84.9%), with 75.2% of scales employed for concurrent validity and discriminant validity analysis after the removal of unusable ones. The results provide strong evidence for the reliability and validity of the C-QNWL, thus supporting the study aim.
Correlations between items and groups of items
Concurrent validity
Inter-item correlations ranged from 0.22 to 0.77 (P < 0.01), and item-total correlations grouped over seven factors ranged from 0.40 to 0.80 (P < 0.01) (Table 2). Inter-correlations among the factor-based scales were significant (P < 0.01), with only one exception; correlations ranged from 0.19 to 0.68. These seven factors also significantly correlated with the total C-QNWL (P < 0.01) (Table 3).
Concurrent validity was examined by calculating Pearson’s correlation coefficient for the C-QNWL and the C-BDI-II.
Internal consistency reliability analysis
Internal consistency reliability The internal consistency reliability of the C-QNWL was assessed using Cronbach’s alpha; a value greater than 0.7 was taken as satisfactory (Streiner & Norman, 2008; DeVellis, 2012).
Construct validity Construct validity was evaluated using exploratory factor analysis, together with tests of discriminant validity. The Kaiser–Meyer–Olkin (KMO) test of sampling adequacy and Bartlett’s test of sphericity for evaluating the correlation matrix were examined prior to conducting factor analysis. A KMO value above 0.9 was considered excellent for factor analysis (Pett et al., 2003). PCA with oblique direct oblimin © 2014 Wiley Publishing Asia Pty Ltd.
Overall scale internal consistency reliability was high (α = 0.93), with good subscale reliability (α = 0.72–0.89) (Table 4).
Concurrent validity We observed a significant and weakly-negative Pearson’s correlation coefficient between the C-QNWL and the C-BDI-II (r = −0.22, P < 0.01).
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Table 3. Inter-correlations among the factor-based scales in the Chinese-version Quality of Nursing Work Life Scale
Factor 1. Supportive milieu with job security and professional recognition 2. Work arrangement and workload 3. Work/home life balance 4. Head nurse’s/supervisor’s management style 5. Teamwork and communication 6. Nursing staffing and patient care 7. Milieu of respect and autonomy Full scale
Factor 4
1
2
3
1.00 0.25** 0.48** 0.66** 0.48** 0.63** 0.68** 0.88**
1.00 0.28** 0.19** −0.02 0.39** 0.19** 0.47**
1.00 0.41** 0.25** 0.55** 0.45** 0.69**
1.00 0.54** 0.47** 0.56** 0.79**
5
6
7
1.00 0.30** 0.43** 0.55**
1.00 0.53** 0.79**
1.00 0.76**
**P < 0.01.
Construct validity Exploratory factor analysis The KMO value was found to be 0.94 and Bartlett’s test of sphericity was significant (χ2 = 23614.59, d.f. = 820, P < 0.001). The PCA generated nine components, but it was difficult to assign meaning to some of them. Close inspection of the scree plot and eigenvalues of > 1 showed mild discontinuity at values five, seven, and eight, and so we targeted our analysis for five-, seven-, and eight-factor solutions. Meaning was most clearly interpretable for the solution of seven factors, which explained 56.6% of the variance in the QWL of Taiwanese nurses (Table 4). Factor 1 (10 items) was labeled “supportive milieu with security and professional recognition”, factor 2 (6 items) was labeled “work arrangement and workload”, factor 3 (5 items) was labeled “work/home life balance”, factor 4 (7 items) was labeled “head nurse’s/supervisor’s management style”, factor 5 (4 items) was labeled “teamwork and communication”, factor 6 (5 items) was labeled “nursing staffing and patient care”, and factor 7 (4 items) was labeled “milieu of respect and autonomy”.
Discriminant validity analysis A significant positive Pearson’s correlation between the C-QNWL and the C-NPES (r = 0.72, P < 0.01) provided evidence of discriminant validity.
DISCUSSION The factor structure determined in this study shared some similarities, but many differences, with that of Brooks and Anderson’s study (2005); 85.7% of Brooks and Anderson’s BQNW items were retained in the final version of the C-QNWL. Exploratory factor analysis revealed a sevenfactor structure for the C-QNWL, in which the scale items were recategorized, and all of Brooks and Anderson’s factors were renamed, with the exception of work life/home life. In this study, the items comprising Brooks and Anderson’s BQNW “work design” dimension were split into three factors: work arrangement and workload, nursing staffing and
patient care, and milieu of respect and autonomy. The BQNW “work context” dimension was also split into three factors: supportive milieu with security and professional recognition, head nurse’s/supervisor’s management style, and teamwork and communication. The BQNW “work world” dimension disappeared entirely, with the two items that had fallen under “work world” loading with supportive milieu with security and professional recognition in the C-QNWL. The findings of our study reflect several ways in which nursing in Taiwan differs from the West. For example, in Taiwan, nurse aides are not employed in most hospitals; family-related leave is not available; national nursing shortages make it easy to find and transfer to a job in another hospital; and Taiwanese nurses are more concerned about the work conditions, management style, and issues of respect, recognition, and support in their work environment. The seven factors found in our investigation exhibited some similarities with the results of past research. Previous authors have independently identified our work life/home life (O’Brien-Pallas & Baumann, 1992; Brooks & Anderson, 2004; Van Laar et al., 2007) and work arrangement and workload (O’Brien-Pallas & Baumann, 1992; Hsu & Kernohan, 2006; Van Laar et al., 2007) dimensions as essential components of the QWL concept. The extracted factor, milieu of respect and autonomy, has not been previously described in the QWL-related literature; however, autonomy is known to be an important component of nurses’ job satisfaction and professional status (Varjus et al., 2011; Papathanassoglou et al., 2012). Conflicts regarding hierarchy and power (Reeves et al., 2008; Holyoake, 2011) still exist between Taiwanese doctors and nurses, and nurses work in a profession that traditionally carries less respect and autonomy. The C-QNWL had acceptable internal consistency, with a Cronbach’s alpha of 0.93 for the total scale, and those for the seven factors ranging from 0.74 to 0.89; this is even slightly higher than the alpha reported for the original BQNW. We suspect the improved consistency was directly attributable to our tailoring of the C-QNWL to be culturally appropriate through careful translation and creation of new items. The test–retest reliability analysis of the C-QNWL confirmed adequate stability for the overall scale. © 2014 Wiley Publishing Asia Pty Ltd.
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Table 4.
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Exploratory factor analysis results (n = 1254)
Factor Factor 1: Supportive milieu with job security and professional recognition (10 items) 35. The security department provides a secure environment 38. Society has the correct image of nurses 41. Job is secure 37. Upper-level management has respect for nursing 39. Salary is adequate for my job, given the current job market conditions 36. Safe from personal harm 34. Nursing policies and procedure facilitate my work 31. Support to attend in-service and continuing education programs 19. Adequate patient care supplies and equipment 30. Access to degree-completion programs Factor 2: Work arrangement and workload (6 items) 43. Difficulty to take sick leave† 44. Difficulty to arrange holidays† 46. To participate in many lectures that occupy my after work time† 12. Many non-nursing tasks† 10. Workload is too heavy† 13. Many interruptions in work routine† Factor 3: Work/home life balance (5 items) 2. Able to arrange for family care 1. Able to balance work with family needs 6. Able to arrange day care for family 7. Able to arrange sick leave when a family member is unwell 3. Energy left after work Factor 4: Head nurse’s/supervisor’s management style (7 items) 48. Head nurse’s/supervisor’s mood is adequate 26. Receiver feedback on my performance from my head nurse/supervisor 18. Good communication with head nurse/supervisor 33. Recognized for my accomplishments 27. Participation in decision-making process 20. Adequate supervision 22. Access to career-advancement opportunities Factor 5: Teamwork and communication (4 items) 24. I belong in the work team 23. Teamwork in my work setting 21. Friendships are important 25. Communication with other therapists Factor 6: Nursing staffing and patient care (5 items) 14. Enough time to do my job well 15. Enough nursing staff 16. Good quality of patient care 47. Adequate mealtimes 9. Satisfied with my job Factor 7: Milieu of respect and autonomy (4 items) 28. Respect by physicians 32. Good communication with physicians 29. High quality of lounge/break area/locker room 11. Autonomy to make patient care decisions Eigenvalue Explained variance (%) Alpha reliability coefficient Subscale Full scale
Factor loadings F3 F4 F5
F1
F2
F6
F7
0.69 0.67 0.64 0.62 0.53 0.51 0.38 0.36 0.33 0.33
– – – – – – – – – –
– – – – – – – – – –
– – – – – – – – – –
– – – – – – – – – –
– – – – – – – – – –
– – – – – – – – – –
– – – – – –
0.74 0.70 0.70 0.45 0.42 0.44
– – – – – –
– – – – – –
– – – – – –
– – – −0.43 −0.40 −0.48
– – – – – –
– – – – –
– – – – –
−0.87 −0.82 −0.78 −0.70 −0.69
– – – – –
– – – – –
– – – – –
– – – – –
– – – – – – –
– – – – – – –
– – – – – – –
0.85 0.81 0.81 0.71 0.64 0.59 0.45
– – – – – – –
– – – – – – –
– – – – – – –
– – – –
– – – –
– – – –
– – – –
0.81 0.72 0.72 0.63
– – – –
– – – −0.31
– – – – –
– – – – –
– – – – –
– – – – –
– – – – –
−0.62 −0.57 −0.56 −0.53 −0.37
– – – – –
– – – – 12.23 29.85
– – – – 3.38 8.24
– – – – 2.04 4.99
– – – – 1.73 4.23
– – – – 1.46 3.55
– – – – 1.24 3.01
−0.78 −0.73 −0.41 −0.31 1.11 2.71
0.86 0.93
0.74
0.86
0.89
0.80
0.79
0.72
†Reverse-scored item. Component loadings of < 0.30 have been suppressed. Original item numbers have been retained. F1–7, factors 1–7.
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Quality of Nursing Work Life Scale
The discriminant validity of the C-QNWL and the C-NPES was satisfactory. The C-QNWL had five additional factors (supportive milieu with job security and professional recognition, work arrangement and workload, work/home life balance, teamwork and communication, and milieu of respect and autonomy) that were not found in the C-NPES. The nurse–physician relationship is an important issue to consider in QWL studies, and it was addressed in the C-QNWL (milieu of respect and autonomy factor) and the PES-NWI (i.e. the C-NPES source instrument, collegial nurse–physician relations factor), but not in the C-NPES.
Limitation of the study We note that the adaptation and developments of this instrument were conducted in Taiwan; the findings might not be generalizable to all areas of the world.
Conclusions Findings from this study give a starting point for evidence for the acceptable reliability and validity of the 41-item C-QNWL, which was translated and culturally adapted to accurately measure the perspectives of nurses in Taiwan on their QWL. One application for which it is very suitable would be evaluations of the effectiveness of interventions in improving nurses’ QWL.The C-QNWL was developed based on a sample of Taiwanese hospital nurses, and should be tested for suitability in other Asian countries with similar healthcare systems. Further study is necessary to continue to validate our results using confirmatory factor analysis. This study provides a useful model of steps to take when adapting an existing research instrument for the target culture. In addition, the revised instrument will be of interest to nurse administrators and researchers in the area of QWL, particularly in countries with a nursing culture similar to that of Taiwan.
ACKNOWLEDGMENTS We gratefully acknowledge the support of the multiple members and the directors of the nursing department from the seven hospitals: Shu-Chen Chang, Shu-Hui Chiu, Mei-Yu Kang, Tsui-Fen Chang, Huei-Shan Chen, Shu-Chuan Lin, and Mei-Mei Hsieh.
CONTRIBUTIONS Study Design: YTD, YWL. Data Collection and Analysis: YWL, LLM, YTD, GY, BAB. Manuscript Writing: YWL, LLM, YTD.
REFERENCES Almalki MJ, FitzGerald G, Clark C. The relationship between quality of work life and turnover intention of primary health care nurses in Saudi Arabia. BMC Health Serv. Res. 2012; 12: 314–324.
305
Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000; 25: 3186–3191. Beck AT, Steer RA. Beck depression inventory – II. Behav. Meas. Lett. 1996; 3: 3–5. Bragard I, Dupuis G, Razavi D, Reynaert C, Etienne AM. Quality of work life in doctors working with cancer patients. Occup. Med. (Lond) 2012; 62: 34–40. Brooks BA, Anderson MA. Nursing work life in acute care. J. Nurs. Care Qual. 2004; 19: 269–275. Brooks BA, Anderson MA. Defining quality of nursing work life. Nurs. Econ. 2005; 23: 319–326. Brooks BA, Storfjell J, Omoike O et al. Assessing the quality of nursing work life. Nurs. Adm. Q. 2007; 31: 152–157. Chang M, Yu YM. Nurse Workforce & Nurse Practitioner System: Vision and Challenges. Miaoli: National Health Research Institute, 2010. Chen SY. Chinese Version Beck Depression Inventory? Taipei: Chinese Behavioral Science Cooperation, 2000. Chiang H, Lin S. Psychometric testing of the Chinese version of Nursing Practice Environment Scale. J. Clin. Nurs. 2008; 18: 919– 929. Council of Labor Affairs, Executive Yuan Taiwan. Labor standards. 2008. [Cited 21 Jan 2014.] Available from URL: http://www .cla.gov.tw/cgi-bin/siteMaker/SM_theme?page=48eaf454. Council of Labor Affairs, Executive Yuan Taiwan. Call for improvement nurses’ working condition. 2011. [Cited 17 Jun 2013.] Available from URL: http://www.cla.gov.tw/cgi-bin/Message/MM_msg _control?mode=viewnews&ts=4dc90f21:5771. Couser GP. Challenges and opportunities for preventing depression in the workplace: a review of the evidence supporting workplace factors and interventions. J. Occup. Environ. Med. 2008; 50: 411– 427. DeVellis RF. Scale Development: Theory and Applications (3th edn). Thousand Oaks, CA: Sage, 2012. Gao YQ, Pan BC, Sun W, Wu H, Wang JN, Wang L. Depressive symptoms among Chinese nurses: prevalence and the associated factors. J. Adv. Nurs. 2012; 68: 1166–1175. Holyoake DD. Is the doctor–nurse game still being played? Nurs. Times 2011; 107: 12–14. Hsu M, Kernohan G. Dimensions of hospital nurses’ quality of working life. J. Adv. Nurs. 2006; 54: 120–131. International Council of Nurses. Nurses in the workplace: expectations and needs. 2011. [Cited 21 Jun 2013.] Available from URL: http://www.icn.ch/news/nurses-in-the-workplace-expectations-and -needs/a-global-survey-of-nurses-may-2009-1335.html. Kline P. An Easy Guide to Factor Analysis. New York: Routledge, 1994. Kutlu Y, Kucuk L, Findik UY. Psychometric properties of the Turkish version of the Fraboni Scale of Ageism. Nurs. Health Sci. 2012; 14: 464–471. Lake ET. Development of the Practice Environment Scale of the Nursing Work Index. Res. Nurs. Health 2002; 25: 176–188. Lee YW, Dai YT, Park CG, McCreary LL. Predicting quality of work life on nurses’ intention to leave. J. Nurs. Scholarsh. 2013; 45: 160–168. Leplège A, Verdier A. The adaptation of health status measurement: methodological aspects of the translation procedure. In: Shumaker SA, Berzon RA (eds). The International Assessment of the Healthrelated Quality of Life: Theory, Translation, Measurement and Analysis. Oxford: Rapid Communications, 1995; 93–101. Martel JP, Dupuis G. Quality of work life: theoretical and methodological problems, and presentation of a new model and measuring instrument. Soc. Indic. Res. 2006; 77: 333–368.
© 2014 Wiley Publishing Asia Pty Ltd.
306
Mitchell JI. Work life and patient safety culture in Canadian healthcare: connecting the quality dots using national accreditation results. Healthc. Q. 2012; 15: 51–58. Mosadeghrad AM, Ferlie E, Rosenberg D. A study of relationship between job stress, quality of working life and turnover intention among hospital employees. Health Serv. Manage. Res. 2011; 24: 170–181. National Audit Office, Taiwan. The report of the clinical nursing workforce in Taiwan. 2013. [Cited 12 Jun 2013.] Available from URL: http://www.audit.gov.tw/ezfiles/0/1000/attach/34/pta _862_4339352_87973.pdf. Nayeri ND, Salehi T, Noghabi AAA. Quality of work life and productivity among Iranian nurses. Contemp. Nurse 2011; 39: 106–118. O’Brien-Pallas L, Baumann A. Quality of nursing worklife issues – a unifying framework. Can. J. Nurs. Adm. 1992; 5: 12–16. Pan AW, Hsu WL. Application of Rasch measurement model in the construct validity of the Beck depression inventory-II. Formos. J. Med. 2008; 12: 284–291. Papathanassoglou EDE, Karanicola MNK, Kalafati M, Giannakopoulou M, Lemonidou C, Albarran JW. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. Am. J. Crit. Care 2012; 21: e41–e52. Pett MA, Lackey NR, Sullivan JJ. Making Sense of Factor Analysis: The Use of Factor Analysis for Instrument Development in Health Care Research. Thousand Oaks, CA: Sage, 2003.
© 2014 Wiley Publishing Asia Pty Ltd.
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Reeves S, Nelson S, Zwarenstein M. The doctor-nurse game in the age of interprofessional care: a view from Canada. Nurs. Inq. 2008; 15: 1–2. Sarah B, Masoud J, Zeinab Masoumi J, Bahman T. Assessing the quality of working life and levels of depression in athletes and non-athlete staff in National Olympic and Paralympics Academy of Iran. Int. J. Acad. Res. Bus. Soc. Sci. 2012; 2: 508–513. Streiner DL, Norman GR. Health Measurement Scales: A Practical Guide to Their Development and Use. Oxford: Oxford Medical Publications, 2008. Vagharseyyedin SA, Vanaki Z, Mohammadi E. The nature nursing quality of work life: an integrative review of literature. West. J. Nurs. Res. 2011; 33: 786–804. Van Laar D, Edwards JA, Easton S. The work-related quality of life scale for healthcare workers. J. Adv. Nurs. 2007; 60: 325–333. Varjus SL, Leino-Kilpi H, Suominen T. Professional autonomy of nurses in hospital settings – a review of the literature. Scand. J. Caring Sci. 2011; 25: 201–207. Ventegodt S, Andersen NJ, Kandel I, Enevoldsen L, Merrick J. Scientific research in the quality of working-life (QWL): generic measuring of the global working life quality with the SEQWL questionnaire. Int. J. Disabil. Hum. Dev. 2008; 7: 201–217. Wang XL. P01-300 impact of depressive symptoms on the work-life quality of financial workers in China. Eur. Psychiatry 2009; 24 (Suppl. 1): S688.
Nursing and Health Sciences (2014), 16, 298–306
Research Article
Psychometric properties of the Chinese-version Quality of Nursing Work Life Scale Ya-Wen Lee, RN, PhD,1,3 Yu-Tzu Dai, RN, PhD,1 Linda L. McCreary, RN, PhD,4 Grace Yao, PhD2 and Beth A. Brooks, RN, PhD5 1 Department of Nursing, 2Department of Psychology, National Taiwan University, Taipei, 3Department of Nursing, Changhua Christian Hospital, Changhua, Taiwan, 4Department of Health Systems Science, University of Illinois at Chicago and 5Resurrection University & Fellow of the American College of Healthcare Executives, Chicago, Illinois, USA
Abstract
In this study, we developed and tested the psychometric properties of the Chinese-version Quality of Nursing Work Life Scale along seven subscales: supportive milieu with security and professional recognition, work arrangement and workload, work/home life balance, head nurse’s/supervisor’s management style, teamwork and communication, nursing staffing and patient care, and milieu of respect and autonomy. An instrumentdevelopment procedure with three phases was conducted in seven hospitals in 2010–2011. Phase I comprised translation and the cultural-adaptation process, phase II comprised a pilot study, and phase III comprised a field-testing process. Purposive sampling was used in the pilot study (n = 150) and the large field study (n = 1254). Five new items were added, and 85.7% of the original items were retained in the 41 item Chinese version. Principal component analysis revealed that a model accounted for 56.6% of the variance with acceptable internal consistency, concurrent validity, and discriminant validity. This study gave evidence of reliability and validity of the 41 item Chinese-version Quality of Nursing Work Life Scale.
Key words
exploratory factor analysis, instrument development, nursing work environment, psychometric testing, quality of work life, reliability and validity, Taiwan.
INTRODUCTION Quality of work life (QWL) is the perception of an organization’s staff about the physical and psychological desirability of their work environment and working conditions (Sarah et al., 2012). It is an umbrella concept that covers salary, working hours, work environment, career prospects, and interpersonal relationships among the workplace, the organization, and society (Martel & Dupuis, 2006; Vagharseyyedin et al., 2011). Past research has indicated that QWL is negatively associated with job stress (Mosadeghrad et al., 2011; Bragard et al., 2012), turnover intention (Mosadeghrad et al., 2011; Almalki et al., 2012), and depression symptoms (Wang, 2009), and positively with productivity (Nayeri et al., 2011) and patient safety (Mitchell, 2012). In a 2009 study by the International Council of Nurses that that examined nurses’ expectations and needs globally, the proportion of nurses in Taiwan who believed that nursing was “better today than five years ago” ranked ninth in the 11 countries surveyed (International Council of Nurses, 2011). Only 53% of Taiwanese nurses said they were “very likely” to remain in the nursing profession in five years’ time, a lower Correspondence address: Yu-Tzu Dai, Department of Nursing, College of Medicine, National Taiwan University, No. 1, Section 1, Jen-Ai Road, Taipei 10051, Taiwan. Email: [email protected] Received 4 February 2013; revision received 12 September 2013; accepted 13 September 2013.
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percentage than in Portugal (77%), Brazil (75%), Canada (71%), and the USA (68%). Inordinate workloads, low pay, benefits and incentives, and lack of recognition were among the particular issues cited as contributing factors (International Council of Nurses, 2011). In Taiwan, although nurses are protected by laws governing maximum working hours and mandated time off (Council of Labor Affairs, Executive Yuan Taiwan, 2008), they are nonetheless commonly asked to work overtime and are assigned excessive workloads (Council of Labor Affairs, Executive Yuan Taiwan, 2011). In 2008, the average turnover rate of Taiwanese nurses was 19.9%, and the average vacancy rate reached nearly 7% in 515 hospitals nationwide (Chang & Yu, 2010), higher values than the ideal standards of 10% and 5%, respectively (National Audit Office & Taiwan, 2013). A psychometrically-sound tool to measure our nurses’ QWL is needed to further explore the relationship between QWL and high turnover rate. We found an existing tool, the Chinese version of the Nursing Practice Environment Scale (C-NPES; Chiang & Lin, 2008), which was translated and revised from the Practice Environment Scale of the Nursing Work Index (PES-NWI; Lake, 2002). The C-NPES is a Chinese language instrument and consists of 30 items that fall under five subscales: management and leadership, nursing professional development, nursing quality, staffing and resource adequacy, and participation in hospital affairs. However, the C-NPES does not include the items of working doi: 10.1111/nhs.12099
Quality of Nursing Work Life Scale
conditions and work/home life balance, rendering the instrument less than ideal for use with Taiwanese nurses in light of their specific complaints of overtime and excessive workloads (Council of Labor Affairs, Executive Yuan Taiwan, 2011). This means there is a gap in the existing Chinese version of the instrument: it fails to measure these working conditions and work/home life balance issues in Taiwan. To address the lack of a culturally-sensitive questionnaire, we searched the MEDLINE, CINAHL, and PsycINFO electronic databases for relevant articles published from 2005 to 2011. Three tools related to QWL were identified: the Brooks Quality of Nursing Work Life Survey (BQNW; Brooks & Anderson, 2005), the Work-Related Quality of Life Scale (WRQoL; Van Laar et al., 2007), and the Self-Evaluation of Working Life Quality questionnaire (SEQWL; Ventegodt et al., 2008). The BQNW assesses QWL for nurses, and is a self-report questionnaire containing 42 Likert-type items scored from 1 to 6 (1 = strongly disagree, 6 = strongly agree) along four subscales: work life/home life (i.e. work/home life balance), work design (i.e. responsibilities and duties), work context (i.e. practice environment), and work world (i.e. sociocultural influences) (Brooks & Anderson, 2004). Cronbach’s alpha for the subscales ranges from 0.56 to 0.88, and the BQNW shows high test–retest reliability (r = 0.90) (Brooks & Anderson, 2004). The WRQoL is also a self-report questionnaire, but it assesses QWL for healthcare workers in general. It contains 23 Likert-type items scored from 1 to 5 (1 = strongly agree, 5 = strongly disagree) along five subscales: job and career satisfaction, general well-being, home–work interface, stress at work, control at work, and working conditions (Van Laar et al., 2007). Cronbach’s alpha for the overall scale is 0.91, and those for the subscales range from 0.76 to 0.91 (Van Laar et al., 2007). The SEQWL assesses QWL for the public: it is a self-report questionnaire containing 108 Likert-type items scored from 1 to 5 (1 = very good, 5 = very bad) along four subscales – quality of life, mastery, fellowship, and creation of real value – and has high criterion-related validity (r = 0.69, P = 0.0001) (Ventegodt et al., 2008). We decided to select the nursing-specific BQNW for evaluating nurse QWL in this study. The BQNW was published in 2005 (Brooks & Anderson, 2005), and has been employed in four studies to date (Brooks & Anderson, 2004; Brooks et al., 2007; Almalki et al., 2012; Lee et al., 2013). The BQNW situates QWL within the context of O’Brien-Pallas and Baumann’s (1992) model of influences on the quality of nurses’ work life, and measures working conditions and work/home life balance. In this study, we developed and tested the psychometric properties of the Chinese-version Quality of Nursing Work Life Scale (C-QNWL).
METHODS Study design Psychometric properties of the C-QNWL were estimated using a descriptive and correlational design.
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Setting and participants Data were collected over seven acute care private hospitals, including a medical teaching center (1455 beds), two regional teaching hospitals (202 & 262 beds), and four district nonteaching hospitals (93, 136, 157, & 190 beds) in central Taiwan. A total of 1254 nurses were recruited for the field study using purposive sampling. Inclusion criteria were nurses who provided bedside care and worked rotating shifts; exclusion criteria were nurses still in the probation period, those working in management, and those who had already participated in our pilot study. A majority of the sample was female (98.4%), single (70.4%), and childless (77.3%). Nurses ranged in age from 21 to 49 years (mean: 28.7 ± 4.5), and reported an average seniority of 5.9 ± 4.6 years. Most had baccalaureate degrees as their highest level of education (63.4%) and were nonreligious (60.6%). Nurses were also asked to report their nursing career ladder level, referring to a system guiding the responsibilities and capacities of Taiwanese nurses, which is overseen by the Taiwan Nurses Association. Level N designates novice nurses; N1, performing general patient care; N2, participating in critical patient care; N3, being responsible for clinical educational activities and executing integrated nursing care; and N4, nursing administration and conducting nursing research. The most represented nursing career ladder level was N2 (43.1%) (Table 1).
Ethical considerations This study, including the pilot study and the field test, was approved by the institutional review boards of Changhua Christian Hospital, and authorization for use of all instruments was obtained from their authors or publishing company.
Procedure and data collection The C-QNWL was developed in three phases over 11 months in 2010–2011 (Fig. 1).
Phase I: translation and cultural-adaptation process The translation and cultural-adaptation process followed typical four step guidelines for the cross-cultural adaption of self-report measures (Beaton et al., 2000; Kutlu et al., 2012). First, two bilingual translators, whose first language was Chinese, completed independent forward translations of the BQNW from English to Chinese. One translator was the first author, and was familiar with the concept of QWL; the other was a Taiwanese physician and certified translator who was not familiar with the concept of QWL. We focused on translating the conceptual meaning of the items, rather than the word-for-word literal translations. Second, back translations were performed by two bilingual translators – a Hong Kong physician and a Filipino research associate – whose first language was English. They created independent translations of the Chinese instrument into English. © 2014 Wiley Publishing Asia Pty Ltd.
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Table 1.
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Participants’ demographic characteristics (n = 1254)
Variables Age Seniority Sex Female Male Marital status Single Married Divorced Others Have children Yes No Education level Diploma Bachelor Graduate Others Religion None Tao Buddhist Christian Other Nurses’ career ladder level N N1 N2 N3 N4
Mean (SD)
Range
28.7 ± 4.5 5.9 ± 4.6
21–49
%
98.4 1.6 70.4 28.5 1.0 0.1 22.7 77.3 32.5 63.4 0.6 3.5 60.6 21.4 10.5 5.1 2.4 16.0 32.0 43.1 8.7 0.2
N, novice; N1, the first ladder level; N2, the second ladder level; N3, the third ladder level; N4, the fourth ladder level; SD, standard deviation.
Third, one language expert and the four translators discussed conceptual, semantic, and experiential equivalences between the English and the Chinese instruments until they arrived at consensus. Items 5 (leave for family), 8 (unlicensed support personnel), and 17 (unlicensed support personnel) were deleted, because Taiwan hospital regulations do not specifically identify family-related leave within leave guidelines, and nurse aides are seldom employed. The process resulted in the first version of the C-QNWL, which contained 39 items. Fourth, individual 30–60 min content-validation interviews were conducted with six nurses. They had a mean of 7.6 years of work experience, and their specialties covered internal medicine care, intensive care, pediatric care, respiratory care, and emergency care. These interviews were conducted to assess how clear the items in the C-QNWL were, and to identify additional areas within the domain of nursing work life for which new items were needed. Adding items demands careful consideration of the trade-off between maintaining conceptual equivalence between the source and target languages and enhancing the measure’s cultural validity (Leplège & Verdier, 1995). Significant revisions were made for items 13 © 2014 Wiley Publishing Asia Pty Ltd.
(answer the phone) and 34 (standard operation procedure) based on these interviews. Issues mentioned by at least three nurses during the interviews were considered significant: eight such issues were observed. After the research team discussed how relevant the content of these eight items were to the scale, two were removed, and six new items, for which there were no equivalents on the BQNW (items 43–48), were developed and added at the end of the scale. These modifications produced the 45 item C-QNWL (second version). We continued the instrument development by reviewing the characteristics of the 45 items and inter-item associations. Item 21 (friendship) had the highest mean (5.09) and relatively low variance (0.59), but we retained the item because of its importance to the QWL concept. Three items – items 4 (rotating schedules), 40 (find the same job), and 42 (impacts patients/families) – had low inter-item (< 0.30) and item-total correlations (< 0.20), indicating minimal contribution to the QWL concept, and so we deleted these three items. Items 45 (take leave) and 46 (arrange holidays) had high inter-item correlation (0.83); the former was deleted to avoid redundancy. Four items were removed overall, and the resultant 41-item C-QNWL, the final version, was employed in the remaining analyses.
Phase II: pilot study We conducted a pilot study using the 41-item C-QNWL, with data collected using purposive sampling at seven acute care hospitals in central Taiwan. Nurses who provided bedside care in rotating shifts and acted as opinion leaders within their nursing units were invited to evaluate the clarity of each item of the C-QNWL. The sample size, 150 nurses, provided approximately one-tenth of the proposed field-testing study size, as per the recommendations of Pett et al. (2003). A 94% response rate (141/150) was achieved. The respondents rated item clarity using a 10-point rating scale, ranging from 1 (not at all clear) to 10 (very clear). Nurses were further invited to offer written suggestions to improve item clarity for any item rated < 7. An assessment of 2 week test–retest reliability yielded a reliability r value of 0.79 (P < 0.01).
Phase III: field-testing process A sample size of 450–675 was calculated as sufficient to meet the criteria for a robust factor analysis, requiring at least 10–15 participants per item (Pett et al., 2003). To prevent problems arising from a low response rate, the population was oversampled to ensure an adequate sample size. Three instruments – the developed C-QNWL, the Chinese version of the second edition of the Beck Depression Inventory (C-BDI-II), and the C-NPES – and two copies of the informed consent document were put in an envelope and delivered to nurses’ workplaces. Nurses were invited to sign the informed consent and complete the questionnaires; participants were only identified by a study identification number. Weekly follow-up reminders and an institutional review board-approved incentive payment of NT$100 (approximately US$3.33) were provided to encourage a higher response rate.
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Source scale (BNQW, 42 items, English)
1. Forward translation: two independent translators
Integrated translations
Phase I
2. Back translation: two independent translators
3. Consensus discussion: one language expert and the four translators
4. Content validation interview: six nursing professionals
First version of the C-QNWL (39 items)
Second version of the C-QNWL (45 items)
The final version of the C-QNWL (41 items)
Phase II
Figure 1. Chinese-version Quality of Nursing Work Life Scale (C-QNWL) translation, cultural adaptation, and field-testing process.
Phase III
Instruments C-QNWL The final version of the C-QNWL is a self-report questionnaire consisting of 41 items answered on a six-point Likerttype scale (1 = strongly disagree, 6 = strongly agree) adapted from the 42-item BQNW (Brooks & Anderson, 2005) via the translation process and 39- and 45-item intermediate versions outlined above.
C-BDI-II Work/home life imbalance is a risk factor for the onset of depression (Couser, 2008). Research has indicated that the QWL of workers is significantly impaired by depressive symptoms (Wang, 2009). Hospital nurses are known to work in psychologically- and physically-demanding work environments, which could lead to depressive symptoms (Gao et al., 2012). We believed an instrument targeting such symptoms would provide a strong measure of concurrent validity. We chose the C-BDI-II (Chen, 2000) for this purpose, which is used to assess Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, depressive symptomatology in adolescents and adults. The C-BDI-II was previously translated into Chinese by the Chinese Behavioral Science Cor-
Pilot study (n =150)
10-point item clarity, test-retest reliability
Field test (n = 1,254)
Internal consistency reliability, concurrent validity, exploratory factor analysis, discriminant validity.
poration (Chen, 2000). The C-BDI-II is a 21-item, self-report questionnaire, with each item scored from 0 to 3, and higher values indicating increasing severity of depression over the most recent 2 weeks (Beck & Steer, 1996). Its reported internal consistency is 0.92, and its construct validity has been demonstrated to be satisfactory using the Rasch measurement model (Pan & Hsu, 2008).
C-NPES The C-NPES (Chiang & Lin, 2008), a measure of the nursing work practice environment, was chosen to measure the discriminant validity of the C-QNWL. The C-NPES is a selfreport, four-point Likert-type scale (1 = strongly disagree, 4 = strongly agree) consisting of 30 items over five subscales: management and leadership, nursing professional development, nursing quality, staffing and resource adequacy, and participation in hospital affairs. Cronbach’s alpha for the subscales ranges from 0.65 to 0.87, and the validity was obtained using a content validity index and principal component analysis (PCA) of a five-factor structure, which explained 47.89% of the variance (Chiang & Lin, 2008).
Data analysis Data were analyzed using SPSS 17.0 software (SPSS, Chicago, IL, USA). Missing items were treated by item mean © 2014 Wiley Publishing Asia Pty Ltd.
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Table 2.
Inter-item correlations and corrected item-total correlations grouped into seven factors
Factor 1. 2. 3. 4. 5. 6. 7.
Supportive milieu with job security and professional recognition Work arrangement and workload Work/home life balance Head nurse’s/supervisor’s management style Teamwork and communication Nursing staffing and patient care Milieu of respect and autonomy
Item
Inter-item correlation† (mean)
Item-total correlation† (mean)
19, 30, 31, 34, 35, 36, 37, 38, 39, 41
0.25–0.57 (0.39)
0.51–0.67 (0.58)
12, 10, 13, 43‡, 44‡, 46‡ 1, 2, 3, 6, 7 18, 20, 22, 26, 27, 33, 48‡ 21, 23, 24, 25 9, 14, 15, 16, 47‡ 11, 28, 29, 32
0.22–0.53 (0.32) 0.43–0.77 (0.54) 0.40–0.71 (0.54) 0.31–0.70 (0.50) 0.35–0.49 (0.44) 0.27–0.70 (0.40)
0.42–0.52 (0.48) 0.58–0.77 (0.67) 0.57–0.80 (0.68) 0.58–0.76 (0.62) 0.49–0.66 (0.58) 0.40–0.65 (0.52)
Item 45 was deleted due to redundancy; original item numbers have been retained. †Pearson’s correlation; ‡items developed post-pilot study.
substitution; this procedure does not distort the data when the number of missing items is less than 5% of the total (Streiner & Norman, 2008); there was less than 4% in the present study.
Descriptive statistics and item analysis Demographic characteristics were described in terms of percentage and mean. Item analysis was conducted in terms of means, variances, inter-item correlations, corrected item-total correlations, and the change in the Cronbach’s alpha if the item was deleted. A mean close to the center of the range of possible scores with a relatively high variance was desirable (DeVellis, 2012), and inter-item correlations of 0.30–0.80 (Pett et al., 2003) and corrected item-total correlations of 0.20–0.80 (Streiner & Norman, 2008) were considered satisfactory. Inter-item correlations of less than 0.3 indicated an item that had little in common with other items, whereas correlations higher than 0.80 could signify redundant items (Pett et al., 2003).
rotation at delta = 0 was chosen instead of orthogonal rotation, because we anticipated the concepts within QWL to be highly correlated (O’Brien-Pallas & Baumann, 1992). Factors were extracted based on eigenvalues being > 1, results of a scree plot, and their conceptual meanings. Factor loadings of > 0.3 were used (Kline, 1994; Pett et al., 2003). Discriminant validity was examined by calculating Pearson’s correlation coefficient of the C-QNWL with the C-NPES.
RESULTS A very good response rate was achieved for the C-QNWL (90.9%), the C-BDI-II (89.4%), and the C-NPES (84.9%), with 75.2% of scales employed for concurrent validity and discriminant validity analysis after the removal of unusable ones. The results provide strong evidence for the reliability and validity of the C-QNWL, thus supporting the study aim.
Correlations between items and groups of items
Concurrent validity
Inter-item correlations ranged from 0.22 to 0.77 (P < 0.01), and item-total correlations grouped over seven factors ranged from 0.40 to 0.80 (P < 0.01) (Table 2). Inter-correlations among the factor-based scales were significant (P < 0.01), with only one exception; correlations ranged from 0.19 to 0.68. These seven factors also significantly correlated with the total C-QNWL (P < 0.01) (Table 3).
Concurrent validity was examined by calculating Pearson’s correlation coefficient for the C-QNWL and the C-BDI-II.
Internal consistency reliability analysis
Internal consistency reliability The internal consistency reliability of the C-QNWL was assessed using Cronbach’s alpha; a value greater than 0.7 was taken as satisfactory (Streiner & Norman, 2008; DeVellis, 2012).
Construct validity Construct validity was evaluated using exploratory factor analysis, together with tests of discriminant validity. The Kaiser–Meyer–Olkin (KMO) test of sampling adequacy and Bartlett’s test of sphericity for evaluating the correlation matrix were examined prior to conducting factor analysis. A KMO value above 0.9 was considered excellent for factor analysis (Pett et al., 2003). PCA with oblique direct oblimin © 2014 Wiley Publishing Asia Pty Ltd.
Overall scale internal consistency reliability was high (α = 0.93), with good subscale reliability (α = 0.72–0.89) (Table 4).
Concurrent validity We observed a significant and weakly-negative Pearson’s correlation coefficient between the C-QNWL and the C-BDI-II (r = −0.22, P < 0.01).
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Table 3. Inter-correlations among the factor-based scales in the Chinese-version Quality of Nursing Work Life Scale
Factor 1. Supportive milieu with job security and professional recognition 2. Work arrangement and workload 3. Work/home life balance 4. Head nurse’s/supervisor’s management style 5. Teamwork and communication 6. Nursing staffing and patient care 7. Milieu of respect and autonomy Full scale
Factor 4
1
2
3
1.00 0.25** 0.48** 0.66** 0.48** 0.63** 0.68** 0.88**
1.00 0.28** 0.19** −0.02 0.39** 0.19** 0.47**
1.00 0.41** 0.25** 0.55** 0.45** 0.69**
1.00 0.54** 0.47** 0.56** 0.79**
5
6
7
1.00 0.30** 0.43** 0.55**
1.00 0.53** 0.79**
1.00 0.76**
**P < 0.01.
Construct validity Exploratory factor analysis The KMO value was found to be 0.94 and Bartlett’s test of sphericity was significant (χ2 = 23614.59, d.f. = 820, P < 0.001). The PCA generated nine components, but it was difficult to assign meaning to some of them. Close inspection of the scree plot and eigenvalues of > 1 showed mild discontinuity at values five, seven, and eight, and so we targeted our analysis for five-, seven-, and eight-factor solutions. Meaning was most clearly interpretable for the solution of seven factors, which explained 56.6% of the variance in the QWL of Taiwanese nurses (Table 4). Factor 1 (10 items) was labeled “supportive milieu with security and professional recognition”, factor 2 (6 items) was labeled “work arrangement and workload”, factor 3 (5 items) was labeled “work/home life balance”, factor 4 (7 items) was labeled “head nurse’s/supervisor’s management style”, factor 5 (4 items) was labeled “teamwork and communication”, factor 6 (5 items) was labeled “nursing staffing and patient care”, and factor 7 (4 items) was labeled “milieu of respect and autonomy”.
Discriminant validity analysis A significant positive Pearson’s correlation between the C-QNWL and the C-NPES (r = 0.72, P < 0.01) provided evidence of discriminant validity.
DISCUSSION The factor structure determined in this study shared some similarities, but many differences, with that of Brooks and Anderson’s study (2005); 85.7% of Brooks and Anderson’s BQNW items were retained in the final version of the C-QNWL. Exploratory factor analysis revealed a sevenfactor structure for the C-QNWL, in which the scale items were recategorized, and all of Brooks and Anderson’s factors were renamed, with the exception of work life/home life. In this study, the items comprising Brooks and Anderson’s BQNW “work design” dimension were split into three factors: work arrangement and workload, nursing staffing and
patient care, and milieu of respect and autonomy. The BQNW “work context” dimension was also split into three factors: supportive milieu with security and professional recognition, head nurse’s/supervisor’s management style, and teamwork and communication. The BQNW “work world” dimension disappeared entirely, with the two items that had fallen under “work world” loading with supportive milieu with security and professional recognition in the C-QNWL. The findings of our study reflect several ways in which nursing in Taiwan differs from the West. For example, in Taiwan, nurse aides are not employed in most hospitals; family-related leave is not available; national nursing shortages make it easy to find and transfer to a job in another hospital; and Taiwanese nurses are more concerned about the work conditions, management style, and issues of respect, recognition, and support in their work environment. The seven factors found in our investigation exhibited some similarities with the results of past research. Previous authors have independently identified our work life/home life (O’Brien-Pallas & Baumann, 1992; Brooks & Anderson, 2004; Van Laar et al., 2007) and work arrangement and workload (O’Brien-Pallas & Baumann, 1992; Hsu & Kernohan, 2006; Van Laar et al., 2007) dimensions as essential components of the QWL concept. The extracted factor, milieu of respect and autonomy, has not been previously described in the QWL-related literature; however, autonomy is known to be an important component of nurses’ job satisfaction and professional status (Varjus et al., 2011; Papathanassoglou et al., 2012). Conflicts regarding hierarchy and power (Reeves et al., 2008; Holyoake, 2011) still exist between Taiwanese doctors and nurses, and nurses work in a profession that traditionally carries less respect and autonomy. The C-QNWL had acceptable internal consistency, with a Cronbach’s alpha of 0.93 for the total scale, and those for the seven factors ranging from 0.74 to 0.89; this is even slightly higher than the alpha reported for the original BQNW. We suspect the improved consistency was directly attributable to our tailoring of the C-QNWL to be culturally appropriate through careful translation and creation of new items. The test–retest reliability analysis of the C-QNWL confirmed adequate stability for the overall scale. © 2014 Wiley Publishing Asia Pty Ltd.
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Table 4.
Y-W. Lee et al.
Exploratory factor analysis results (n = 1254)
Factor Factor 1: Supportive milieu with job security and professional recognition (10 items) 35. The security department provides a secure environment 38. Society has the correct image of nurses 41. Job is secure 37. Upper-level management has respect for nursing 39. Salary is adequate for my job, given the current job market conditions 36. Safe from personal harm 34. Nursing policies and procedure facilitate my work 31. Support to attend in-service and continuing education programs 19. Adequate patient care supplies and equipment 30. Access to degree-completion programs Factor 2: Work arrangement and workload (6 items) 43. Difficulty to take sick leave† 44. Difficulty to arrange holidays† 46. To participate in many lectures that occupy my after work time† 12. Many non-nursing tasks† 10. Workload is too heavy† 13. Many interruptions in work routine† Factor 3: Work/home life balance (5 items) 2. Able to arrange for family care 1. Able to balance work with family needs 6. Able to arrange day care for family 7. Able to arrange sick leave when a family member is unwell 3. Energy left after work Factor 4: Head nurse’s/supervisor’s management style (7 items) 48. Head nurse’s/supervisor’s mood is adequate 26. Receiver feedback on my performance from my head nurse/supervisor 18. Good communication with head nurse/supervisor 33. Recognized for my accomplishments 27. Participation in decision-making process 20. Adequate supervision 22. Access to career-advancement opportunities Factor 5: Teamwork and communication (4 items) 24. I belong in the work team 23. Teamwork in my work setting 21. Friendships are important 25. Communication with other therapists Factor 6: Nursing staffing and patient care (5 items) 14. Enough time to do my job well 15. Enough nursing staff 16. Good quality of patient care 47. Adequate mealtimes 9. Satisfied with my job Factor 7: Milieu of respect and autonomy (4 items) 28. Respect by physicians 32. Good communication with physicians 29. High quality of lounge/break area/locker room 11. Autonomy to make patient care decisions Eigenvalue Explained variance (%) Alpha reliability coefficient Subscale Full scale
Factor loadings F3 F4 F5
F1
F2
F6
F7
0.69 0.67 0.64 0.62 0.53 0.51 0.38 0.36 0.33 0.33
– – – – – – – – – –
– – – – – – – – – –
– – – – – – – – – –
– – – – – – – – – –
– – – – – – – – – –
– – – – – – – – – –
– – – – – –
0.74 0.70 0.70 0.45 0.42 0.44
– – – – – –
– – – – – –
– – – – – –
– – – −0.43 −0.40 −0.48
– – – – – –
– – – – –
– – – – –
−0.87 −0.82 −0.78 −0.70 −0.69
– – – – –
– – – – –
– – – – –
– – – – –
– – – – – – –
– – – – – – –
– – – – – – –
0.85 0.81 0.81 0.71 0.64 0.59 0.45
– – – – – – –
– – – – – – –
– – – – – – –
– – – –
– – – –
– – – –
– – – –
0.81 0.72 0.72 0.63
– – – –
– – – −0.31
– – – – –
– – – – –
– – – – –
– – – – –
– – – – –
−0.62 −0.57 −0.56 −0.53 −0.37
– – – – –
– – – – 12.23 29.85
– – – – 3.38 8.24
– – – – 2.04 4.99
– – – – 1.73 4.23
– – – – 1.46 3.55
– – – – 1.24 3.01
−0.78 −0.73 −0.41 −0.31 1.11 2.71
0.86 0.93
0.74
0.86
0.89
0.80
0.79
0.72
†Reverse-scored item. Component loadings of < 0.30 have been suppressed. Original item numbers have been retained. F1–7, factors 1–7.
© 2014 Wiley Publishing Asia Pty Ltd.
Quality of Nursing Work Life Scale
The discriminant validity of the C-QNWL and the C-NPES was satisfactory. The C-QNWL had five additional factors (supportive milieu with job security and professional recognition, work arrangement and workload, work/home life balance, teamwork and communication, and milieu of respect and autonomy) that were not found in the C-NPES. The nurse–physician relationship is an important issue to consider in QWL studies, and it was addressed in the C-QNWL (milieu of respect and autonomy factor) and the PES-NWI (i.e. the C-NPES source instrument, collegial nurse–physician relations factor), but not in the C-NPES.
Limitation of the study We note that the adaptation and developments of this instrument were conducted in Taiwan; the findings might not be generalizable to all areas of the world.
Conclusions Findings from this study give a starting point for evidence for the acceptable reliability and validity of the 41-item C-QNWL, which was translated and culturally adapted to accurately measure the perspectives of nurses in Taiwan on their QWL. One application for which it is very suitable would be evaluations of the effectiveness of interventions in improving nurses’ QWL.The C-QNWL was developed based on a sample of Taiwanese hospital nurses, and should be tested for suitability in other Asian countries with similar healthcare systems. Further study is necessary to continue to validate our results using confirmatory factor analysis. This study provides a useful model of steps to take when adapting an existing research instrument for the target culture. In addition, the revised instrument will be of interest to nurse administrators and researchers in the area of QWL, particularly in countries with a nursing culture similar to that of Taiwan.
ACKNOWLEDGMENTS We gratefully acknowledge the support of the multiple members and the directors of the nursing department from the seven hospitals: Shu-Chen Chang, Shu-Hui Chiu, Mei-Yu Kang, Tsui-Fen Chang, Huei-Shan Chen, Shu-Chuan Lin, and Mei-Mei Hsieh.
CONTRIBUTIONS Study Design: YTD, YWL. Data Collection and Analysis: YWL, LLM, YTD, GY, BAB. Manuscript Writing: YWL, LLM, YTD.
REFERENCES Almalki MJ, FitzGerald G, Clark C. The relationship between quality of work life and turnover intention of primary health care nurses in Saudi Arabia. BMC Health Serv. Res. 2012; 12: 314–324.
305
Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000; 25: 3186–3191. Beck AT, Steer RA. Beck depression inventory – II. Behav. Meas. Lett. 1996; 3: 3–5. Bragard I, Dupuis G, Razavi D, Reynaert C, Etienne AM. Quality of work life in doctors working with cancer patients. Occup. Med. (Lond) 2012; 62: 34–40. Brooks BA, Anderson MA. Nursing work life in acute care. J. Nurs. Care Qual. 2004; 19: 269–275. Brooks BA, Anderson MA. Defining quality of nursing work life. Nurs. Econ. 2005; 23: 319–326. Brooks BA, Storfjell J, Omoike O et al. Assessing the quality of nursing work life. Nurs. Adm. Q. 2007; 31: 152–157. Chang M, Yu YM. Nurse Workforce & Nurse Practitioner System: Vision and Challenges. Miaoli: National Health Research Institute, 2010. Chen SY. Chinese Version Beck Depression Inventory? Taipei: Chinese Behavioral Science Cooperation, 2000. Chiang H, Lin S. Psychometric testing of the Chinese version of Nursing Practice Environment Scale. J. Clin. Nurs. 2008; 18: 919– 929. Council of Labor Affairs, Executive Yuan Taiwan. Labor standards. 2008. [Cited 21 Jan 2014.] Available from URL: http://www .cla.gov.tw/cgi-bin/siteMaker/SM_theme?page=48eaf454. Council of Labor Affairs, Executive Yuan Taiwan. Call for improvement nurses’ working condition. 2011. [Cited 17 Jun 2013.] Available from URL: http://www.cla.gov.tw/cgi-bin/Message/MM_msg _control?mode=viewnews&ts=4dc90f21:5771. Couser GP. Challenges and opportunities for preventing depression in the workplace: a review of the evidence supporting workplace factors and interventions. J. Occup. Environ. Med. 2008; 50: 411– 427. DeVellis RF. Scale Development: Theory and Applications (3th edn). Thousand Oaks, CA: Sage, 2012. Gao YQ, Pan BC, Sun W, Wu H, Wang JN, Wang L. Depressive symptoms among Chinese nurses: prevalence and the associated factors. J. Adv. Nurs. 2012; 68: 1166–1175. Holyoake DD. Is the doctor–nurse game still being played? Nurs. Times 2011; 107: 12–14. Hsu M, Kernohan G. Dimensions of hospital nurses’ quality of working life. J. Adv. Nurs. 2006; 54: 120–131. International Council of Nurses. Nurses in the workplace: expectations and needs. 2011. [Cited 21 Jun 2013.] Available from URL: http://www.icn.ch/news/nurses-in-the-workplace-expectations-and -needs/a-global-survey-of-nurses-may-2009-1335.html. Kline P. An Easy Guide to Factor Analysis. New York: Routledge, 1994. Kutlu Y, Kucuk L, Findik UY. Psychometric properties of the Turkish version of the Fraboni Scale of Ageism. Nurs. Health Sci. 2012; 14: 464–471. Lake ET. Development of the Practice Environment Scale of the Nursing Work Index. Res. Nurs. Health 2002; 25: 176–188. Lee YW, Dai YT, Park CG, McCreary LL. Predicting quality of work life on nurses’ intention to leave. J. Nurs. Scholarsh. 2013; 45: 160–168. Leplège A, Verdier A. The adaptation of health status measurement: methodological aspects of the translation procedure. In: Shumaker SA, Berzon RA (eds). The International Assessment of the Healthrelated Quality of Life: Theory, Translation, Measurement and Analysis. Oxford: Rapid Communications, 1995; 93–101. Martel JP, Dupuis G. Quality of work life: theoretical and methodological problems, and presentation of a new model and measuring instrument. Soc. Indic. Res. 2006; 77: 333–368.
© 2014 Wiley Publishing Asia Pty Ltd.
306
Mitchell JI. Work life and patient safety culture in Canadian healthcare: connecting the quality dots using national accreditation results. Healthc. Q. 2012; 15: 51–58. Mosadeghrad AM, Ferlie E, Rosenberg D. A study of relationship between job stress, quality of working life and turnover intention among hospital employees. Health Serv. Manage. Res. 2011; 24: 170–181. National Audit Office, Taiwan. The report of the clinical nursing workforce in Taiwan. 2013. [Cited 12 Jun 2013.] Available from URL: http://www.audit.gov.tw/ezfiles/0/1000/attach/34/pta _862_4339352_87973.pdf. Nayeri ND, Salehi T, Noghabi AAA. Quality of work life and productivity among Iranian nurses. Contemp. Nurse 2011; 39: 106–118. O’Brien-Pallas L, Baumann A. Quality of nursing worklife issues – a unifying framework. Can. J. Nurs. Adm. 1992; 5: 12–16. Pan AW, Hsu WL. Application of Rasch measurement model in the construct validity of the Beck depression inventory-II. Formos. J. Med. 2008; 12: 284–291. Papathanassoglou EDE, Karanicola MNK, Kalafati M, Giannakopoulou M, Lemonidou C, Albarran JW. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. Am. J. Crit. Care 2012; 21: e41–e52. Pett MA, Lackey NR, Sullivan JJ. Making Sense of Factor Analysis: The Use of Factor Analysis for Instrument Development in Health Care Research. Thousand Oaks, CA: Sage, 2003.
© 2014 Wiley Publishing Asia Pty Ltd.
Y-W. Lee et al.
Reeves S, Nelson S, Zwarenstein M. The doctor-nurse game in the age of interprofessional care: a view from Canada. Nurs. Inq. 2008; 15: 1–2. Sarah B, Masoud J, Zeinab Masoumi J, Bahman T. Assessing the quality of working life and levels of depression in athletes and non-athlete staff in National Olympic and Paralympics Academy of Iran. Int. J. Acad. Res. Bus. Soc. Sci. 2012; 2: 508–513. Streiner DL, Norman GR. Health Measurement Scales: A Practical Guide to Their Development and Use. Oxford: Oxford Medical Publications, 2008. Vagharseyyedin SA, Vanaki Z, Mohammadi E. The nature nursing quality of work life: an integrative review of literature. West. J. Nurs. Res. 2011; 33: 786–804. Van Laar D, Edwards JA, Easton S. The work-related quality of life scale for healthcare workers. J. Adv. Nurs. 2007; 60: 325–333. Varjus SL, Leino-Kilpi H, Suominen T. Professional autonomy of nurses in hospital settings – a review of the literature. Scand. J. Caring Sci. 2011; 25: 201–207. Ventegodt S, Andersen NJ, Kandel I, Enevoldsen L, Merrick J. Scientific research in the quality of working-life (QWL): generic measuring of the global working life quality with the SEQWL questionnaire. Int. J. Disabil. Hum. Dev. 2008; 7: 201–217. Wang XL. P01-300 impact of depressive symptoms on the work-life quality of financial workers in China. Eur. Psychiatry 2009; 24 (Suppl. 1): S688.
