Role of demographic and job-related variables in determining work-related quality of life of hospital employeesK Shukla1, S Shahane2, W D'Souza2
1 Department of MBA (HHM), Symbiosis Institute of Health Sciences (SIU), Pune, Maharashtra, India
2 Department of PGPHS, Sancheti Healthcare Academy, Pune, Maharashtra, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.192794
Source of Support: None, Conflict of Interest: None
Background: Considering a huge working population in health sector faced with stressful work life, limited autonomy in work and declining work contentment calls for an overemphasis on evaluating and monitoring their satisfaction associated with work-related quality of life (WRQoL). This study evaluates WRQoL of hospital employees and validates the bilingual (English and Marathi) version of WRQoL scale. Methods: The study was conducted during March-April'2014 on employees of a corporate hospital of Pune, India after ethical approval and informed consent from employees. The bilingual WRQoL scale has been tested for reliability and validity, and WRQoL scores have been reported. Results: A total of 132 hospital employees (mean age 31 [±8] years, 55% males) who participated in the study reported overall moderate WRQoL scores. The scale showed high internal consistency (Cronbach's alpha = 0.82, P < 0.0001) and moderate to high validity. WRQoL did not significantly vary across marital status, family size, and gender. "Stress at work" score of WRQoL increased with age of employees. Higher work experience, employment at higher positions and those working in clinical and diagnostic departments reported a higher WRQoL. Conclusion: WRQoL scale is a reliable and valid instrument. Better WRQoL in employees placed in higher organizational positions indicates a need for focused measures to enhance WRQoL of employees in lower hierarchical levels, especially in control at work and home life interface domains. WRQoL needs regular monitoring for employees in lower positions and aging employees.
Keywords: Employees, hospital, psychometric, work-related quality of life
By 2030, two hundred and fifty million people will be added to India's workforce.  Considering a huge working population in health sector faced with stressful work life, limited autonomy in work and declining work contentment highlights that evaluating and monitoring their satisfaction associated with quality of work life must be overemphasized. 
Work-related quality of life (WRQoL) evaluation and monitoring is particularly relevant in hospitals as employee satisfaction directly affects the quality of services offered to patients. , In comparison to other quality of work life scales, the WRQoL scale is unique as it measures various factors related to work as well as nonwork factors like general well-being (GWB) in addition to the "homework interface" (HWI). , This study attempts to validate the bilingual (English and Marathi) WRQoL scale and assess the WRQoL perceived by employees of a corporate hospital in Pune City.
Study design and setting
This was a cross-sectional study conducted on the employees of a corporate hospital in Pune, India from March 1, 2014, to April 30, 2014, after obtaining ethical approval from hospital management.
The WRQoL scale  comprises 24 items out of which the last one (item 24) is a global score on overall WRQoL whereas the remaining 23 items are grouped across six psychosocial sub-scales, namely, GWB (6 items), HWI (3 items), job career satisfaction (JCS) (6 items), control at work (CAW) (3 items), working conditions (WCS) (3 items), and stress at work (SAW) (2 items). All questions in the scale are dispersed and not arranged according to domains. Three items in the scale, two in SAW (7, 19) and one item (9) in GWB sub-scale, are negatively scored for which reverse scoring was done as per the guidelines.  All questions are rated on a 5 point-Likert scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. Each sub-scale score is determined by finding the average of the items contributing to that factor. Thus, the score range for items as well as the sub-scale scores was 1-5 with 1 being the minimum and five the maximum possible score.
The standard backward-forward translation method was used to develop Marathi version of the scale which was validated for suitability during the pilot study. Pilot study was a qualitative analysis to examine the suitability of items and scoring scale for the assessment of WRQoL of employees in the local context. The bilingual WRQoL scale with English and Marathi languages was pilot tested on 6% (22) employees of the hospital. The mean age of employees was 33 (±5) years and 55% were males. All the employees responded that the items in the scale are suitable for WRQoL assessment and no changes were suggested. Hence, the combined bilingual version with English and Marathi language [Annexure 1 [Additional file 1]] was used for the final study. However, the pilot study subjects were not included in the final study for analysis purpose.
Data were collected for baseline socio-demographic variables, namely, gender, age, marital status, and family size. Work-related variables were the department of employee, designation, and total work experience (in years).
To detect a mean WRQoL score of 50% for 389 employees of the hospital, at the desired precision of 10% and 95% confidence level, the minimum sample size for the study was computed as 126.
Written Informed consent forms were distributed to the employees and those who consented to participate were included in the study. WRQoL scale and demographic data sheet were interviewer-administered to all respondents for uniformity of mode of administration. The questions were only read out without providing explanations to avoid interviewer-administered bias.
Data were analyzed using Statistical Package for Social Sciences (SPSS) version 17.0 (SPSS, Inc., Chicago, IL, USA). The data were analyzed at 95% confidence level, and all results with the value of P < 0.05 were considered statistically significant. We computed mean and standard deviation for continuous variables, median, and range for ordinal variables and frequency and percentage for discrete variables. Chi-square test and Spearman's correlations were performed to find out any significant difference in sub-scale scores across the baseline variables.
Internal consistency is a measure of the reliability of an instrument  which was evaluated through Cronbach's alpha, "alpha if item deleted" and "corrected item-total correlation" and interpreted using standard guidelines.  The scale was also tested for face validity, content validity, and construct validity. For face validity, we interviewed experts regarding the applicability of the scale and its items in the local context. Content validity can be defined as the extent to which a measurement reflects a specific intended domain of content.  This was assessed by calculating item-domain correlations (correlation between domain scores with the items of that domain) and inter-domain correlations. Construct validity is the extent to which an instrument reflects the intended construct.  We computed cross-domain correlations (correlation between domains scores with items not belonging to that domain) for assessing the construct validity. The accepted norms necessitate that the item-domain correlations should be higher than cross-domain correlations for higher content and construct validity. 
As the global score (item 24) aims at capturing the overall WRQoL, it should predict the WRQoL reported across all the 6 sub-scales. Hence, for assessing the predictive validity, we calculated correlations of the global score with each sub-scale scores. The sub-scales having significant correlations with global score were entered into the linear regression model using enter method. The standard used for interpretation of correlation values were: <0.3 = poor, 0.3-0.5 = fair, 0.6-0.8 = moderate, and >0.8 = very strong. 
Out of a total of 150 employees who were requested to participate in the study, 132 provided consent for participation. The mean age of participants was 31 (±8) years. The baseline characteristics are shown in [Table 1].
[Table 2] shows the frequency of employees reporting different scores for each subscale. It is clear that majority of the employees rated WRQoL as average and above average for all sub-scales.
The scores did not significantly vary across marital status, family size or gender. SAW score increased with the age of employees (χ = 296.92, p < 0.0001). WCS score significantly increased with the mean work experience of employees (χ = 421.53, p < 0.0001). JCS score was positively correlated with employees working in clinical and diagnostic departments (r = 0.5, p < 0.0001). Employment at a higher position namely manager/HOD and in-charges of departments was positively correlated with high scores in JCS (r = 0.5, p < 0.001), CAW (r = 0.31, p < 0.001 and HWI sub-scales (r = 0.36, p < 0.001).
The results of the reliability analysis showed that the scale has a high internal consistency with Cronbach's alpha of 0.82 (p < 0.0001). Dimension-wise Cronbach's alpha, "corrected item-total correlations" and "alpha if item deleted" are shown in [Table 3].
As is evident from [Table 3], except CAW and SAW, the internal consistency of all sub-scales was acceptable. In CAW sub-scale, item 2 was a weak question with a high "alpha if item deleted." The reliability analysis was repeated for CAW after excluding item two which rose the Cronbach's alpha of the sub-scale from 0.45 to 0.69 (p < 0.001). In the case of SAW, both the questions are negative. However, removal of these questions did not improve the reliability neither of the sub-scale nor the overall scale.
The scale was further evaluated for face validity by taking the opinion of 1 expert each from different backgrounds, namely, medical superintendent, chief human resource manager, professor of human resource management, nursing superintendent, and head-housekeeping department. All experts found the questions in the scale appropriate and valid for WRQoL assessment in the Indian context.
Analysis for content validity revealed high item-domain correlations (domain with its respective items) in the range of 0.5-0.9 (p < 0.0001). The range of "item-domain" correlation for each domain was: JCS (0.5-0.76), CAW (0.6-0.8), GWB (0.55-0.76), HWI (0.66-0.86), WCS (0.68-0.79), and SAW (0.5-0.9). The "inter-domain" correlations, for evaluating content validity were 0.38 (GWB-HWI), 0.2 (GWB-CAW), 0.57 (GWB-WCS), 0.46 (GWB-SAW), 0.45 (JCS-GWB), 0.39 (JCS-HWI), 0.3 (JCS-CAW), and 0.48 (JCS-WCS) with all p < 0.001.
Results of construct validity showed that the cross-domain correlations (values not given here) were significantly lower than the item domain correlations with many correlations being statistically insignificant. Thus, the WRQoL illustrated high construct validity as all items had substantially higher correlations with their intended domains rather than with other domains of the scale.
Predictive validity results showed that the global score (item 24) showed significant correlations with all the domains of the scale, JCS (r = 0.36), CAW (r = 0.35), GWB (r = 0.52), HWI (r = 0.23), WCS (r = 0.46), and SAW (r = 0.24) with all p < 0.001. Linear regression was performed to evaluate the predicting effect of domain scores on the global WRQoL out of which GWB and WCS were found to have statistically significant results.
The results in [Table 4] show that GWB and WCS subscales have the highest predicting effect on global WRQoL. Both subscales predict around 27% of the global WRQoL score. Hence, the global sub-scale (item 24) cannot be used solely for evaluating WRQoL across all the six sub-scales.
This study attempted to evaluate the WRQoL of employees of a multi-specialty hospital and to validate the WRQoL scale. The overall WRQoL, as well as sub-scale scores, were in the moderate to a high range similar to a previous study on university staff  whereas a study on health-care workers reported lower scores in WCS, CAW, and HWI.  In this study, employment at a higher position (manager/HOD/in-charges) was correlated with better scores in CAW, JCS and HWI sub-scores.
This is corroborated by findings of previous studies on nurses and other nonclinical staff in hospitals. , The previous studies report that lack of autonomy in work, for nurses and nonclinical staff, is further compounded by the lower social and educational position they occupy as compared to middle-level managers and doctors. WRQoL can prove to be an important tool for monitoring WRQoL of staff at all levels and address the issues wherever needed. Besides, hospital employees at all levels work under stress round the clock and hence, need to be provided with some degree of flexibility to have some more CAW and maintain a balance between their home and work life.
Prior studies have reported high CAW score in university staff,  whereas low CAW has been reported by health-care workers in Uganda,  although without any association to designation or department. In another study, the overall job satisfaction was highest in office and administrative staff while lowest in maintenance staff.  Subjects in our study reported a moderate HWI score contrary to previous studies where HWI was found to be low due to dissatisfaction in the balance between work and home. ,, This may be explained by the assumption that the work-life balance generally means that the individuals have a lot of rather than too little work owing to the long working hours  or carrying forward their work to home leading to disturbed work life balance. There was no significant association observed between the WRQoL and the gender of the employees in our study similar to a previous report.  However, some studies on health-care workers have identified a significant relationship between WRQoL and gender. ,
We observed that higher age of employees reported higher SAW contrary to a previous study that reported higher job satisfaction among older employees  while our study reported that the high age was associated with an increase in SAW. Another study on hospital employees also shows that dissatisfaction increased with age, especially when it comes to stress at job and ability to balance their work and home life. 
Similar to previous studies, WRQoL scale was found to be highly reliable with high content, construct and predictive validity in our study too. ,, We observed that the "item 2" ("I feel able to voice opinions and influence changes in my area of work") in CAW domain was weak due to a high "alpha if item deleted." Removal of this item increased the reliability of the CAW sub-scale. Item two has been suggested for removal by previous studies also, although they used other analytical tools.  Dropping off weak items to improve the reliability of scale has been recommended by previous studies also. , As item 24 (satisfaction with overall WRQoL) is a global score, we assumed that it should capture the essence of the remaining 23 items in the scale that intend to measure WRQoL in different dimensions. This may be particularly useful in situations where only item 24 can be used instead of asking all questions due to time constraints or other reasons. We found that item 24 has high predictive validity only for the GWB and WCS subscales rather than all 23 items. However, further validation in larger samples may be required to support this finding.
The strength of our study is that we validated the WRQoL scale in employees of an Indian hospital and found the same to be suitable, reliable, and valid. The limitation is that the sample size may not be large enough for results to be generalizable on a large scale. Nevertheless, the baseline values for WRQoL scores presented in this study can be utilized by other researches in the Indian context.
WRQoL scale is a suitable instrument for application in the Indian context. However, in all the subscales, scores were in fair to a moderate range that calls for some interventions to improve WRQoL across all domains in hospital employees. Better WRQoL in employees placed on higher organizational positions indicates a need for focused measures to enhance WRQoL of employees in lower hierarchical levels, especially in CAW and home life interface domains. Future research on larger and diverse samples of working populations is further recommended.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3], [Table 4]