Quality of Work Life and Burnout in Healthcare Workers in Turkey

Abstract

Quality of work life (QWL) is important to healthcare organisations that aim to increase patient and employee satisfaction and produce quality healthcare services. The literature lacks research investigating the relationship between QWL and burnout among in healthcare professionals. The purpose of this study is to determine healthcare workers’ QWL and burnout levels and to investigate whether there is a correlation them. The research population consisted of all healthcare workers serving in a public hospital in Ankara. The study did not make a sample selection but tried to access the entire population; a total of 328 usable surveys were obtained. ‘Quality of Work Life Scale’ and ‘Maslach Burnout Inventory’ scales were used for this research. A correlation analysis was performed to determine the correlation between healthcare workers’ QWL and burnout levels. The analysis results showed that healthcare workers had ‘good’ perceived QWL and ‘moderate’ level of burnout. Additionally, there was a statistically significant but weak correlation between healthcare workers’ levels of QWL and burnout (ρ = 0.184; p = 0.0008). Results can be used by healthcare managers to implement appropriate initiatives to improve QWL and reduce burnout of healthcare workers.

Keywords

Quality of work life burnout healthcare workers hospital Turkey

Introduction

Healthcare workers play a major role in promoting individuals’ health through diagnosis, treatment and rehabilitation; however, their welfare is often overlooked (Nayak & Sahoo, 2015, p. 264). Heavy workload, workplace hazards, occupational stress stemming from difficult and crucial tasks that cause physical and psychological pressure, and frequent exposure to illness and death are among critical factors that pose a threat to healthcare workers’ welfare (Mosadeghrad et al., 2011). It is of key importance to deal with these critical factors that may affect service quality and organisational performance in health institutions and to support workers.

The quality of work life (QWL) refers to the process of humanisation of work and work environment. One of the main objectives of this process is to care about workers and emphasise their value as human beings. The other objective is the establishment of a suitable working environment for long-term organisational effectiveness and productivity (Barutçugil, 2004, p. 395). Previous studies have shown that like organisational identity, organisational commitment, job satisfaction and job performance, QWL affects workers’ attitudes and behaviours of employees (Efraty et al., 1991; Huang et al., 2007). Research on QWL in healthcare services reported that QWL are mainly influenced by unsuitable working hours, lack of accommodation facilities for nurses, inability to balance work and family needs, inadequate number of workers, inadequate vacations, management and supervision practices, lack of professional development opportunities, and an inappropriate working environment with respect to the level of security, patient care supplies and equipment, and recreation facilities (Almalki et al., 2012, pp. 2–3). What matters here is the extent to which improvements in organisational factors will contribute. Indeed, although earlier work on burnout focuses on the assumption of burnout resulting from individual characteristics, recent work notes that organisational factors are more effective than individual factors (Taşlıyan et al., 2017, p. 113).

Healthcare Workers’ QWL

QWL is defined as ‘as an extent to which an employee is satisfied with personal and working needs through participating in the workplace while achieving the goals of the organization’ (Swamy et al., 2015, p. 281). QWL is a complex concept that is influenced by and interacted with many aspects of work and personal life (Almalki et al., 2012, p. 2) and has many dimensions such as labour productivity, job stability, job satisfaction and social security (Gómez-Salcedo et al., 2017, p. 911), working conditions, compensation, human relations, management and personnel relations, management support (Phan & Vo, 2016), work environment, health and safety, job stress, work–life balance (Jindal, 2014), human capacity development opportunities, career advancement opportunities (Valarmathi & Balakrishnan, 2013), organisational support, work–family interference, meaningfulness of job, optimism on organisational change, autonomy, access to resources and time control (Chitraa & Mahalakshmi, 2012).

Considering the labour-intensive nature of healthcare services, healthcare workers’ QWL affects not only the quality of personal life but also the quality of healthcare services. Accordingly, Horrigan et al. (2013) reported that nurses’ health levels and QWL were influential on the quality of patient care. Rogers et al. (2004) indicated that nurses with long working hours in hospitals had a significant increase in the risk of making medical errors related to patient care. Additionally, low QWL often reduces the performance of healthcare workers and the quality of care (Grunfeld et al., 2005; Knox & Irving, 1997) and causes high turnover rate (Hayes et al., 2006). Dechawatanapaisal (2017) revealed that perceived QWL, career opportunities, work–life balance and job characteristics were positive and significant predictors of organisational embeddedness. Brooks et al. (2007) reported that work design and work content led to a significant increase in workers’ desire to stay. Several studies have also highlighted that QWL affects turnover intention (Almalki et al., 2012; Faraji et al., 2017; Mosadeghrad, et al., 2011). Furthermore, Lee et al. (2017) mediated the relationship between nurses’ intention to leave the profession and quality of work life. Research on QWL in health services also reported a significant correlation between QWL and job satisfaction of hospital workers (Gayathiri et al., 2013).

Healthcare organisations that wish to increase patient and employee satisfaction and produce quality healthcare services should strive to improve the harmony between employees and working environment and working conditions (Royuele et al., 2009). It is also of major importance to create supportive and quality working environments that enable healthcare workers to optimally use their skills, facilitate autonomy on work, encourage workers, provide workers with decision-making freedom and promote workers’ interaction with colleagues and other health professionals (Abdul Razak et al., 2016).

Burnout in Healthcare Workers

Despite several definitions of burnout in the literature, the definition offered by Maslach who contributed the Maslach Burnout Inventory (MBI) to the literature maintains its validity. Accordingly, ‘burnout is a syndrome of emotional exhaustion and cynicism that occurs frequently among individuals who do “people-work” of some kind’ and is associated with physical exhaustion, despair, helplessness and negative attitudes towards the work, life and others (Maslach & Jackson, 1981). Burnout has three dimensions including emotional exhaustion, cynicism (or depersonalisation) and reduced personal accomplishment (Maslach et al., 2001).

Maslach and Leiter (1997) emphasise that burnout does not stem solely from individual factors, organisational factors contribute to burnout, and individual and organisational factors should be studied together if burnout is examined. They defined work environment as working life composed of six areas including workload, control, reward, belonging, justice and values. They also proposed a model that deals with the match and mismatch between the individual and the job. According to the model, the greater the degree of match is, the greater the degree of job engagement is; conversely, the greater the degree of mismatch is, the greater the degree of burnout is.

Burnout is a damaging experience for both workers and organisations and also a problematic condition especially for healthcare professionals in that it can negatively impact the quality of care services offered (Montgomery et al., 2011). Research on healthcare workers have highlighted that especially nurses (Çınar Tanrıverdi et al., 2017; Vanyperen et al., 1992), physician assistants doctors (Bragard et al., 2012; Thomas, 2004), physicians (Dyrbye & Shanafelt, 2011), health professionals working in mental health services (Morse et al., 2012; Paris & Horge, 2010) and emergency service workers (Kavlu & Pınar, 2009; Potter, 2006) are faced with burnout problems. Burnout levels are reported to be high in healthcare services that are often characterised by a long-term intensive work environment and an exposure to interpersonal pressure (Biksegn et al., 2016; Pavlova et al., 2011; Potter, 2006; Quattrin et al., 2006). Research conducted in Turkey shows that healthcare workers intensely experience burnout (Akpınar & Taş, 2011; Akyüz, 2015; Çınar Tanrıverdi et al., 2017; Günüşen & Üstün, 2008; Kebapçı & Akyolcu, 2011; Kılıç & Seymen, 2011; Metin & Özer, 2007).

Burnout problem stems from such reasons as professionals’ dissatisfaction with work environment, huge workload, limited opportunities for development progress and the lack of management support. Such a perceived work environment leads workers to be engaged in other organisations or seek employment in different fields (Gaesawahong, 2015). Accordingly, the increase in organisational commitment and job satisfaction accounts for the decrease in burnout level (Han et al., 2015; Park & Ahn, 2015). Salyers et al. (2017) reported a negative correlation between burnout, the quality of services and safety in healthcare workers. They argued that high levels of burnout among health service providers mean lower quality healthcare and reduced patient safety.

Creating a working environment that supports multidisciplinary team development is highlighted as an appropriate approach to reduce workers’ burnout (Van Bogaert et al., 2014). Similarly, strengthening team relations at unit levels is also of great importance in preventing burnout (Consiglio et al., 2014). Against this background, this research seeks to address burnout and QWL in healthcare workers in a relational manner.

Methodology

The purpose of this research is to determine healthcare workers’ QWL and burnout levels and to reveal whether there is a correlation between QWL and burnout level.

Population and Sample

Physicians, nurses and other healthcare workers (anaesthesia, laboratory and X-ray technicians) actively working in a public hospital in Ankara composed the population of this research using a quantitative cross-sectional design and conducted between August and October 2015. No sampling was performed since the research aimed to reach the entire population. Thus, within the specified period of research, it reached 78 (39%) of 199 physicians, 183 (44%) of 415 nurses and 67 (42%) of 157 other healthcare workers.

Data Collection

A survey form was used as the data collection tool in the research. It consists of three sections: a personal information form including questions about personal characteristics and working life, the ‘Quality of Work Life Scale’ (QWLS) and the ‘Maslach Burnout Inventory’ (MBI). After gaining permission required to conduct the research from the Ethics Commission of Hacettepe University and from the General Secretariat of Ankara 1st-Region Public Hospitals Association, the research participants were individually asked for their consent and the survey form was applied through one-to-one interviews. The participants were informed that their personal data would be confidential. Each interview took about 10 to 15 minutes.

The research used the QWLS developed by Aydın et al. (2011) to determine healthcare workers’ levels of QWL. The QWLS includes 6 subscales and 27 items: work accidents, risks of occupational diseases, and physical working conditions (6 items); discrimination at work (5 items); continuous development and improvement opportunities (5 items); social integration into the organisation (5 items); work stress and time pressure (3 items); and codes in the organisation (3 items). Positive items in the scale are scored from 1 (strongly disagree) to 5 (strongly agree), while negative items are reverse-scored. The greater the total score is, the higher workers’ QWL is. The validity and reliability study of the scale was carried out by Aydın et al. (2011) in Ankara. Accordingly, the results of the exploratory factor analysis to determine the construct validity showed that factor loadings varied between 0.58 and 0.83. Additionally, the Cronbach’s alpha reliability coefficient for the entire scale was found 0.882. Thus, the scale is reported to be a valid and reliable scale that can be used to determine healthcare workers’ QWL.

The research used the MBI developed by Maslach and Jackson (1981) and adapted to Turkish by Ergin (1992) to determine participants’ burnout levels. The MBI consists of 22 items and evaluates 3 dimensions of burnout including emotional exhaustion (9 items), depersonalisation (5 items) and personal accomplishment (8 items). The MBI is a 5-point Likert scale scored from 0 (never) to 4 (every day). The validity study of the Turkish version of the scale conducted by Ergin (1992) performed a confirmatory factor analysis and showed that the validity of the Turkish version is sufficient (χ2/df = 2.89; standardized root mean square (SRMR)= 0.04; comperative fit index (CFI)= 0.92; non-normed fit index (NNFI) = 0.91). According to the analysis results to evaluate the reliability of the scale, the Cronbach’s alpha coefficients are 0.88, 0.75 and 0.79 for emotional exhaustion, depersonalisation and personal achievement, respectively. Accordingly, the scale is a valid and reliable scale that can be used to determine healthcare workers’ burnout levels. The level of burnout is represented by high scores on the emotional exhaustion and depersonalisation subscales and a low score on the personal achievement subscale. While a moderate level of burnout reflects moderate scores in all three subscales, a low level of burnout reflects low scores in the emotional exhaustion and depersonalisation subscales and a high score in the personal achievement subscale.

Data Analysis

The research data were analysed using Statistical Package for the Social Science v. 20.0 package software for the purpose of the study (SPSS; http://spss.com). The Pearson correlation coefficient was used to analyse the correlation between the scores of the QWLS and MBI.

Results

The research results are explained in tables in this section. Table 1 shows the distribution of the participants according to a set of individual characteristics.

Table 1.

Characteristics of Participants (N = 328)

Characteristics	Frequency	Percentage (%)
Gender Female Male	247 81	75.30 24.70
Marital Status Single Married	113 211	34.50 64.30
Age Ranges 20–29 years 30–39 years 40 years and over	97 174 56	29.60 53.00 17.10
Educational Status High school Associate’s degree Bachelor’s degree Postgraduate degree	53 107 93 73	16.20 32.60 28.40 22.30
Profession Physician Nurse Other	78 183 67	23.80 55.80 20.40
Having Watch Duties Yes No	207 119	63.10 36.30
Working Hours Per Week (Hours) 45 hours and less 46 hours and over Irregular	228 78 22	69.50 23.80 6.70
Professional Length of Service (Years) 1–10 years 11–20 Years 21 years and over	130 139 57	39.60 42.40 17.40
Length of Service in the Organization (Years) 1–10 years 11–20 Years 21 years and over	175 109 34	53.40 33.20 10.40

Source: The authors.

As seen in Table 1, the majority of the participants are female (75.3%) and married (64.3%). Considering the age-related distribution of the participants, most (53%) are within the age range of 30–39 years. Considering the educational status of the participants, 32.6 per cent have an associate’s degree, 28.4 per cent have a bachelor’s degree, 22.3 per cent have a postgraduate degree and 16.2 per cent are high school graduates. Nurses (55.8%) constitute the majority of the healthcare workers participating in the survey. Most of the participants (63.1%) are engaged in watch duties and most (69.5%) work 45 hours or less per week. The participants mostly reported their professional length of service between 11 and 20 years (42.4%) and between 1 and 10 years, and their length of service in the organisation between 1 and 10 years (53.4%) and between 11 and 20 years (33.20%).

Table 2 shows the mean scores of the QWLS and MBI subscales. The total scores in the subscales were standardised since the number of items in each dimension is not equal. In other words, the total scores of the responses given to the dimensions were divided into the number of items in the relevant dimension and thus standardised based on 5 since a 5-point Likert scale scoring was used. According to the analysis results, the participants had the highest mean score (4.29) in the QWLS dimension ‘work accidents, risks of occupational diseases and physical working conditions’ and the lowest mean score (2.87) in the QWLS dimension ‘social integration into the organisation’. Considering the participants’ total score in the QWLS, the mean score was 71.07. According to these results, it seems that the healthcare workers’ QWL is at a ‘good’ level. Considering the participants’ scores in the MBI, their mean score in the emotional exhaustion dimension (2.87) is at a ‘moderate’ level, their mean score in the depersonalisation dimension (1.85) is at a ‘low’ level, and their mean score in the personal achievement dimension (3.11) is also a ‘moderate’ level. Thus, it seems that the healthcare workers participating in the research have a ‘moderate’ level of burnout.

Table 2.

Descriptive Statistics on the QWLS and the MBI

Quality of Work Life Scale		Min.	Max.	Mean	STD
Dimension 1	Work accidents, risks of occupational diseases and physical working conditions	6	30	25.74(4.29)*	4.18
Dimension 2	Discrimination at work	5	25	17.12(3.42)*	4.60
Dimension 3	Continuous development and improvement opportunities	5	25	16.15(3.23)*	3.88
Dimension 4	Social integration into the organization	5	25	14.34(2.87)*	4.13
Dimension 5	Work stress and time pressure	3	15	11.60(3.87)*	2.73
Dimension 6	Codes in the organization	3	15	8.76(2.92)*	2.33
Total Score		43.33	99.50	71.07	8.03
Maslach Burnout Inventory		Min.	Max.	Mean	STD
Dimension 1	Emotional exhaustion	12	28	20.69(2.87)*	3.02
Dimension 2	Depersonalization	0	20	7.40(1.85)*	4.03
Dimension 3	Personal achievement	4	32	19.93(3.11)	4.06

Source: The authors.

Note: * signifies the mean scores of the dimensions were converted to a standard based on 5 (25.74 * 5)/30 = 4.29.

Table 3.

The Correlation Between QWL and Burnout

Dimensions	Emotional Exhaustion	Depersonalization	Personal Achievement
Work accidents, risks of occupational diseases and physical working conditions	0.077	0.050	0.088
Discrimination at work	0.051	0.069	0.021
Continuous development and improvement opportunities	–0.242*	–0.230*	0.213*
Social integration into the organization	–0.070	–0.058	0.183*
Work stress and time pressure	0.322*	0.340*	–0.071
Codes in the organization	–0.045	–0.043	0.092
QWLS total score	0.041	0.056	0.184*

Source: The authors.

Note: * signifies correlation is significant at the level of 0.01(two-tailed).

Table 3 shows the correlation values of the relationship between the QWLS total score, the QWLS subscales and the MBI subscales. According to the analysis results, the correlations between the subscales of the scales are low. The QWLS subscale continuous development and improvement opportunities has a negative correlation with the MBI subscales emotional exhaustion and depersonalisation, but a positive correlation with the subscale personal achievement. The subscale work stress and time pressure has also a positive correlation with the subscales emotional exhaustion and depersonalisation. There is a positive correlation between the subscale social integration into the organisation and the subscale personal achievement. Separately considering the correlations between the MBI subscales and the QWLS total score, the QWLS total score has the highest level of correlation with the MBI subscale personal achievement. However, although this correlation is statistically significant, it is quite low (ρ = 0.184; p = 0.0008).

Discussion

This research investigating healthcare workers’ perceived QWL and burnout and their correlation surveyed 78 (23.80%) physicians, 183 (55.80%) nurses and 67 (20.40%) other healthcare workers (laboratory and anaesthesia technician, and administrative healthcare workers). According to the research results, the healthcare workers have a ‘good’ perception of QWL (mean 71.07) and a ‘moderate’ level of burnout. The study found that the healthcare workers participating the study had the highest score in the QWLS dimension ‘work accidents, risks of occupational diseases, and physical working conditions’ (mean 4.29 ± 4.18). To put it differently, their QWL was highest in this dimension. However, the participants had low scores in the QWLS subscales ‘social integration into the organisation’ (mean 2.87 ± 4.13) and ‘codes (rules) in the organisation’ (mean 2.92 ± 2.33). It seems that these two dimensions reduce the healthcare workers’ QWL.

Running parallel to the results of this research, previous research conducted with healthcare workers reported that nurses perceive their QWL as good (Khaghanizadeh et al., 2008; Mogharab et al., 2013). Çatak and Bahçecik (2015) investigated the factors affecting the QWL of nurses working private and university hospitals and reported that the perceived QWL of nurses working in private hospitals was generally good and that of the nurses working in education and research hospitals was moderate. Bragard et al. (2012) surveyed 431 physician assistants working with cancer patients in Belgium and found that the participants’ QWL was moderate; however, their perception was very low in the quality of work life subscales work schedule, support offered to employee and working relationship with superiors. Bragard et al. (2015) also investigated the QWL of emergency physicians and nurses working in rural areas and reported that their QWL was generally moderate, but low only in the subscale ‘support offered to employee’.

The literature includes studies reporting low levels of QWL in healthcare workers, contrary to the results of the present study. Faraji et al. (2017) surveyed nurses working in a university hospital in Iran and reported that 61 per cent of the nurses had a low level of perceived QWL and 39 per cent had turnover intention. Dargahi et al. (2007) also found that nurses perceived their level of QWL as low. In their research conducted with emergency physicians and nurses in rural Quebec, Fleet et al. (2017) reported that the total QWL score was low and the QWL was statistically significantly lower in nurses than in physicians. Fleet et al. (2017) further noted that the health professionals scored very low especially in the subscales ‘sharing workload during absence of an employee’, ‘working equipment’, ‘flexibility of work schedule’, ‘impact of working hours on health’, ‘possibility of being absent for familial reasons’ and ‘relations with employees’. Saraji and Dargahi (2006) showed that most hospital workers had low levels of QWL and considered their works unattractive and dissatisfying in terms of income levels, occupational health, work safety, relationships with managers and work–family balance. Dargahi et al. (2012) surveyed employees of the radiology department in a university hospital and reported that their perceived QWL was low or very low. Horrigan et al. (2013) addressed the relationship between nurses’ health level and QWL and suggested that nurses were within the group with the worst health level among healthcare professionals and their work environments led to an increase in their diseases, disability and absenteeism.

According to the research results, the participants’ burnout mean scores were 20.69 ± 3.02 in the emotional exhaustion dimension, 7.40 ± 4.03 in the depersonalisation dimension and 19.93 ± 4.06 in the personal achievement dimension. This result indicated that the healthcare workers had a moderate level of burnout. Research conducted with healthcare workers in Turkey reported similar results. Kavlu and Pınar (2009) reported that nearly half of the ED nurses felt burnout. They found that 54.3 per cent of the nurses had emotional exhaustion, 54.7 per cent were depersonalised and 46 per cent lacked personal achievement. They also indicated that 76.6 per cent of those feeling emotional exhaustion, 72.7 per cent of those feeling depersonalisation and 60.8 per cent of those feeling the lack of personal achievement had a moderate to high level of burnout. Armutçuk et al. (2011) investigated burnout levels of health professionals other than physicians and found the MBI mean scores 15.0 ± 6.1 in the emotional exhaustion subscale, 4.2 ± 3.0 in the depersonalisation subscale and 22.1 ± 4.3 in the personal achievement subscale. Çankaya (2017) surveyed 274 health professional working in private hospitals and found the mean emotional exhaustion score 21.52 ± 6.41, the mean depersonalisation score 11.20 ± 3.95 and the mean personal achievement score 12.01 ± 4.54. Yıldırım and Hacıhasanoğlu (2011) found the healthcare workers’ mean emotional exhaustion score 13.86 ± 6.96, the mean depersonalisation score 4.31 ± 3.25 and the mean personal achievement score 10.09 ± 4.72. Orsal et al. (2017) surveyed 446 nurses and reported their mean MBI scores as follows: 17 ± 7 in the emotional exhaustion subscale, 5 ± 3 in the depersonalisation subscale and 21 ± 4 the personal achievement subscale. They further noted that job dissatisfaction had a strong influence on emotional exhaustion and depersonalisation and led to a decrease in personal achievement scores.

The literature also includes studies reporting high levels of burnout in healthcare workers. Çınar Tanrıverdi et al. (2017) investigated the occupational burnout of health professionals working in a maternity hospital and reported that the participants had a high level of emotional exhaustion and a moderate level of job satisfaction. They also found a statistically significant correlation between burnout and the professional length of service, having watching duties, the belief in the society’s appreciation of profession as it deserves, the belief in the right choice of profession, receiving in-service training in the last years, the participation in and monitoring of academic work, and smoking status. Potter (2006) found that emergency department (ED) nurses and physicians had a high level of emotional exhaustion and depersonalisation and reported that the work environment-related factors contributing to burnout in the ED included stressful situations such as workload, inadequate number of employees, uncontrollable environment, violence, trauma and death of patients. Considering the personal factors contributing to burnout, Potter (2006) suggested that young and inexperienced nurses suffered more emotional exhaustion and depersonalisation. Bragard et al. (2012) surveyed 431 physician assistants working with cancer patients in Belgium and found that almost half of the participants had a high level of burnout.

The results of the correlations analysis yielded a statistically significant positive, but relatively weak correlation between the QWLS and the MBI subscale personal achievement (ρ = 0.184; p = 0.0008). There was no statistically significant correlation between the perceived QWL and the MBI subscales emotional exhaustion and depersonalisation. This result may stem from the fact that the participant healthcare workers perceive their QWL as ‘good’ and their burnout levels are not very high. However, according to the analysis results, while continuous development and improvement opportunities increase, emotional exhaustion and depersonalisation decrease, but personal achievement increases. Additionally, as work stress and time pressure increase, so do emotional exhaustion and depersonalisation. The analysis results also indicate that the more the social integration into the organisation is, the greater the personal achievement is. Bragard et al. (2012) argued that QWL is associated with high level of emotional exhaustion and work stress. The literature includes no other studies that address healthcare workers’ QWL and burnout and analyse their correlation.

Conclusion

In a globalised and increasingly competitive age, health facilities should recognise that healthcare workers are valuable resources for ensuring competitive advantage. For health facilities, success requires the quality of services offered to patients and their relatives; therefore, health facilities should address the issue of QWL of health professionals. For health facilities, the provision of quality service is influential on value creation, customer satisfaction and customer retention, while QWL is the basis of employee well-being and is a must for better performance.

Today, improved qualifications of healthcare workers today and accordingly increased expectations about work and workplace have led healthcare organisations to be engaged in decisions and practices that prevent burnout and help to achieve the best QWL. In order to achieve corporate goals, it is suggested that healthcare managers should develop appropriate policies to ensure QWL and take efforts to create a peaceful, happy and healthy work environment.

Burnout in health professionals is among the hot topics in the literature. However, the literature lacks research investigating the relationship between burnout and QWL. Thus, the present study filling this gap is believed to contribute to the literature.

Footnotes

Acknowledgements

The authors would like to thank all the participants for their valuable contributions to this study.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

References

Abdul Razak

Ma’amor

Hassan

(2016). Measuring reliability and validity ınstruments of work environment towards quality work life. Procedia Economics and Finance , 37(1), 520–528.

Akpınar

A. T.

Taş

(2011). A study to determine the relationship between burnout and job satisfaction levels of emergency workers. Turkey Emergency Medicine Journal , 11(4), 161–165.

Akyüz

İ.

(2015). Examination of burnout and depression levels of nurses in terms of working conditions and demographics. Journal of Business and Economics Studies , 3(1), 21–34.

Almalki

M. J.

FitzGerald

Clark

(2012). Quality of work life among primary health care nurses in the Jazan Region, Saudi Arabia: A cross-sectional study. Human Resources for Health , 10(30), 1–13.

Armutçuk

A. K.

Sevinç

Ö.

Bozkurt

A. İ.

Bostancı

Zencir

(2011). Burnout level and related factors in non-physician health personnel working at Denizli State Hospital. Pamukkale Medical Journal , 4(1), 15–20.

Aydın

İ.

Çelik

Uğurluoğlu

Ö.

(2011). Health staff work quality of life scale: Development, validity and reliability. Society and Social Work , 22(2), 79–100.

Barutçugil

. (2004). Strategic human resources management . Kariyer Publications.

Biksegn

Kenfe

Matiwos

Eshetu

(2016). Burnout status at work among health care professionals in atertiary hospital. Ethiopian Journal of Health Sciences , 26(2), 101–108.

Bragard

Dupuis

Razavi

Reynaert

Etienne

A. M.

(2012). Quality of work life in doctors working with cancer patients. Occupational Medicine , 62(1), 34–40.

10.

Bragard

Fleet

Etienne

A. M.

Archambault

Legare

Chauny

J. M.

Lévesque

J.-F.

Ouimet

Poitras

Dupuis

(2015). Quality of work life of rural emergency department nurses and physicians: A pilot study. BMC Research Notes , 8(116), 1–9.

11.

Brooks

B. A.

Storfjell

Omoike

Ohlson

Stemler

Shaver

Brown

(2007). Assessing the quality of nursing work life. Nursing Administration Quarterly , 31(2) 152–157.

12.

Çankaya

(2017). Burnout levels of private hospital employees and a field study. International Journal of Academic Value Studies , 3(9), 1–15.

13.

Çatak

Bahçecik

(2015). Determination of nurses’ quality of work life and influencing factors. Journal of Marmara University Institute of Health Sciences , 5(2), 85–95.

14.

Chitraa

Mahalakshmi

(2012). A study on employees’ perception on quality of work life and job satisfaction in manufacturing organization: An empirical study. Trade & Commerce , 1(2), 175–184.

15.

Çınar Tanrıverdi

Dikbaş

. Okşan Çalıkoğlu

Koca

Ö.

Göktuğ Kadıoğlu

(2017). The relation between the levels of burnout and job satisfaction of health personnel working in a maternity hospital and sociodemographic factors. Medical Journal of Bakırköy , 13(1), 32–39.

16.

Consiglio

Borgogni

Vecchione

Maslach

(2014). Self-efficacy, perceptions of context, and burnout: A multilevel study on nurses. La Medicina del lavoro , 105(4), 255–268.

17.

Dargahi

Changizi

Gharabagh

E. J.

(2012). Radiology employees’ quality of work life. Acta Medica Iranica , 50(4), 250–256.

18.

Dargahi

Gharib

Goodarzi

(2007). Quality of work life in nursing employees of Tehran University of Medical Sciences Hospitals. Journal of Hayat , 13(2), 13–21.

19.

Dechawatanapaisal

(2017). The mediating role of organizational embeddedness on the relationship between quality of work life and turnover: Perspectives from healthcare professionals. International Journal of Manpower , 38(5), 696–711.

20.

Dyrbye

L. N.

Shanafelt

T. D.

(2011). Physician burnout: A potential threat to successful health care reform. JAMA , 305(19), 2009–2010.

21.

Efraty

Sirgy

M. J.

Claiborne

C. B.

(1991). The effects of personal alienation on organizational identification: A quality of work life model. Journal of Business Psychology , 6(1), 57–78.

22.

Ergin

(1992, September). Adapting burnout and Maslach burnout scale in doctors and nurses. In Bayraktar

Dağ

İ.

(Eds.), National Congress of psychology scientific study handbook (Vol. 7, pp. 143–154). The Turkish Psychological Association.

23.

Faraji

Salehnejad

Gahramani

Valiee

(2017). The relation between nurses’ quality of work life with intention to leave their job. Nursing Practice Today , 4(2), 103–111.

24.

Fleet

Dupuis

Mbakop-Nguebou

Archambault

Plant

Chauny

Levesque

Ouimet

Poitras

Haggerty

Legare

(2017). Quality of work life among nurses and physicians in Québec rural emergency departments. Canadian Journal of Emergency Medicine , 19(1), 70. https://doi.org/10.1017/cem.2017.182

25.

Gaesawahong

(2015). A review of nurses’ turnover rate: Does increased income solve the problem of nurses leaving regular jobs. Bangkok Medical Journal , 9(1), 76–82.

26.

Gayathiri

Ramakrishnan

Babatunde

S. A.

Banerjee

Islam

M. Z.

(2013). Quality of work life: Linkage with job satisfaction and performance. International Journal of Business and Management Invention , 2(1), 1–8.

27.

Gómez-Salcedo

M. S.

Galvis-Aponte

L. A.

Royuele

(2017). Quality of work life in Colombia: A multidimensional fuzzy indicator. Social Indicators Research , 130(3), 911–936.

28.

Grunfeld

Zitzelsberger

Coristine

Whelan

T. J.

Aspelund

Evans

W. K.

(2005). Job stress and job satisfaction of cancer care workers. Psycho-Oncology , 14(1), 61–69.

29.

Günüşen

Üstün

(2008). Determining the level of burnout in nurses working at a university hospital and affecting factors. Journal of Anatolia Nursing and Health Sciences , 11(4), 48–59.

30.

Han

S. S.

Han

J. W.

Y. S.

Lim

S. H.

(2015). Effects of role stress on nurses’ turnover intentions: The mediating effects of organizational commitment and burnout. Japan Journal of Nursing Science , 12(4), 287–296.

31.

Hayes

L. J.

O’Brien-Pallas

Duffield

Shamian

Buchan

Hughes

Spence Laschinger

H. K.

North

Stone

P. W.

(2006). Nurse turnover: A literature review. International Journal of Nursing Studies , 43(2), 237–263.

32.

Horrigan

Lightfoot

N. E.

Larivière

M. A. S.

Jacklin

(2013). Evaluating and improving nurses’ health and quality of work life. Workplace Health & Safety , 61(1), 173–181.

33.

Huang

Lawler

Lei

(2007). The effects of quality of work life on commitment and turnover intention. Social Behavior and Personality , 35(6), 735–750.

34.

Jindal

(2014). Factors affecting quality of worklife. Academicia: An International Multidisciplinary Research Journal , 4(2), 216–221.

35.

Kavlu

İ.

Pınar

(2009). Effects of job satisfaction and burnout on quality of life in nurses who work in emergency services. Turkey Clinics Journal of Medical Sciences , 29(1), 1543–1555.

36.

Kebapçı

Akyolcu

(2011). The effects of the work environment on nurse burnout in emergency department. Turkish Journal of Emergency Medicine , 11(2), 59–67.

37.

Khaghanizadeh

Ebadi

Sertiner

Rahmani

(2008). Investigation relationship between job stress and quality of work life of nurses in armed forces hospitals. Military Medicine , 10(3), 175–184.

38.

Kılıç

Seymen

(2011). Analysis of factors affecting burnout syndrome in health sector and a research. Journal of Management and Economics Research , 16(1), 47–67.

39.

Knox

Irving

J. A.

(1997). An interactive quality of work life model applied to organizational transition. Journal of Nursing Administration , 27(1), 39–47.

40.

Lee

Y. W.

Dai

Y. T.

Chang

M. Y.

Chang

Y. C.

Yao

K. G.

Liu

M. C.

(2017). Quality of work life, nurses’ ıntention to leave the profession, and nurses leaving the profession: A one-year prospective survey. Journal of Nursing Scholarship , 49(4), 438–444.

41.

Maslach

Jackson

S. E.

(1981). The measurement of experienced burnout. Journal of Occupational Behavior , 2(1), 99–113.

42.

Maslach

Leiter

P. M.

(1997). The truth about burnout . Jossey-Bass.

43.

Maslach

Schaufeli

Leiter

M. P.

(2001). Job burnout. Annual Review of Psychology , 52(1), 397–422.

44.

Metin

Ö.

Özer

F. G.

(2007). Determination of burnout level of nurses. Ataturk University Journal of Nursing School , 10(1), 58–66.

45.

Mogharab

Riyasi

Hedayati

Mogharab

(2013). Work life quality of nurses working in educational hospitals affiliated to Birjand University of Medical Sciences. Modern Care Journal , 10(1), 84–90.

46.

Montgomery

Panagopoulou

Kehoe

Valkanos

(2011). Connecting organisational culture and quality of care in the hospital: Is job burnout the missing link? Journal of Health Organization and Management , 25(1), 108–123.

47.

Morse

Salyers

Rollins

Monroe-DeVita

Pfahler

(2012). Burnout in mental health services: A review of the problem and its remediation. Administration and Policy in Mental Health and Mental Health , 39(5), 341–352.

48.

Mosadeghrad

A. M.

Ferlie

Rosenberg

(2011). A study of relationship between job stress, quality of working life and turnover intention among hospital employees. Health Services Management Research , 24(4), 170–181. https://doi.org/10.1258/hsmr.2011.011009

49.

Nayak

Sahoo

C. K.

(2015). Quality of work life and organizational performance the mediating role of employee commitment. Journal of Health Management , 17(3), 263–273.

50.

Orsal

Duru

Ünsal

Barlas

(2017). Evaluation of the factors associated with burnout of nurses working at a state hospital in Turkey. Nursing Practice Today , 4(1), 21–34.

51.

Paris

Hoge

M. A.

(2010). Burnout in the mental health workforce: A review. The Journal of Behavioral Health Services & Research , 37(4) 519–528.

52.

Park

S. A.

Ahn

S. H.

(2015). Relation of compassionate competence to burnout, job stress, turnover ıntention, job satisfaction and organizational commitment for oncology nurses in Korea. Asian Pacific Journal of Cancer Prevention , 16(13), 5463–5469.

53.

Pavlova

Afanasieva

Deliyska

(2011). Economic dimensions of burnout among medical professionals in Bulgaria. Journal of Management & Marketing in Healthcare , 4(4), 247–253.

54.

Phan

G. T.

T. Q.

(2016). A literature review on quality of working life: A case of healthcare workers. Journal of Pharmaceutical Science , 6(7), 193–200.

55.

Potter

(2006). To what extent do nurses and physicians working within the emergency department experience burnout: A review of the literatüre. Australasian Emergency Nursing Journal , 9(1), 57–64.

56.

Quattrin

Zanini

Nascig

Annunziata

M. A.

Calligaris

Brusaferro

(2006). Level of burnout among nurses working in oncology in an Italian Region. Oncology Nursing Forum , 33(4), 815–820.

57.

Rogers

A. E.

Hwang

W. T.

Scott

L. D.

Aiken

L. H.

Dinges

D. F.

(2004). The working hours of hospital staff nurses and patient safety. Health Affairs , 23(4), 202–212.

58.

Royuele

Lopez-Tamayo

Surinach

(2009). Results of quality of work life index in Spain: A comparison of survey results and aggregate social indicators. Social Indicators Research , 90(1), 225–241.

59.

Salyers

M. P.

Bonfils

K. A.

Luther

Firmin

R. L.

White

D. A.

Adams

E. L.

Rollins

A. L.

(2017). The relationship between professional burnout and quality and safety in healthcare: A meta-analysis. Journal of General Internal Medicine , 32(4), 475–482.

60.

Saraji

G. N.

Dargahi

(2006). Study of quality of work life (QWL). Iranian Journal of Public Health , 35(4), 8–14.

61.

Swamy

D. R.

Nanjundeswaraswamy

T.S.

Rashmi

(2015). Quality of work life: Scale development and validation. International Journal of Caring Sciences , 8(2), 281–300.

62.

Taşlıyan

Engizek

Gül

(2017). Burnout, job satisfaction and flexible working hours: A study of working women. TÜBAV Science , 10(2), 111–125.

63.

Thomas

N. K.

(2004). Resident burnout. JAMA , 292(23), 2880–2889.

64.

Valarmathi

Bhalakarishnan

(2013). Quality of work life: A study among nurses in Coimbatore. Global Research Analysis , 2(1), 159–160.

65.

Van Bogaert

Timmermans

Weeks

S. M.

Van Heusden

Wouters

Franck

(2014). Nursing unit teams matter: Impact of unit-level nurse practice environment, nurse work characteristics, and burnout on nurse reported job outcomes, and quality of care, and patient adverse events—A cross-sectional survey. International Journal of Nursing Studies , 51(8), 1123–1134.

66.

Yıldırım

Hacıhasanoğlu

(2011). Quality of life and influencing variables in healthcare workers. Journal of Psychiatric and Mental Health Nursing , 2(2), 61–68.