14 Effort, reward and effort-reward-imbalance in the nursing profession in Europe

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1 14 Effort, reward and effort-reward-imbalance in the nursing profession in Europe Hans-Martin Hasselhorn, Maria Widerszal-Bazyl, Pjotr Radkiewicz and the NEXT-Study Group Introduction There is evidence that psychosocial work characteristics are associated with adverse health outcomes such as cardiovascular (Schnall et al., 00; Kristensen, 1999; Kuper et al., 02) and musculoskeletal diseases (Bongers et al., 1993, Leino & Hänninen, 1995). Taking the variety and complexity of psychosocial work environment into consideration, it is necessary for such potential stressors to be identified and then operationalised. The first widely recognised attempt has been made by Karasek who in his job strain model postulated that high psychological demands and low decision latitude at work are associated with ill health (Karasek, 1979) (see previous chapter). Within the last decade, another operationalisation has found international attention which not only takes the quantity of exposure to working conditions into account, but also its relation to other exposures and its perception by the employees: Siegrist s model of effortreward imbalance (ERI) (Siegrist, 1996a, 1996b). It is based on the postulate that digression from reciprocity in transaction results in a stressful experience. Applied to the workplace, this would mean that there should be a balance between what the employee gives ( effort ) and what he or she receives ( reward ). Here, reward not only implicates financial reward, but also esteem and career opportunities including job security. In case an imbalance occurs in this social contract, adverse health effects might develop, e.g. as a result of an activated autonomic nervous system (Siegrist, 1996b). In a number of studies, imbalance has been found to be related to cardiovascular diseases (Kuper et al., 02; Schnall et al., 00). A second assumption made by Siegrist is that people characterised by a high work related commitment and high need for approval ( overcommitment ) would be experiencing the imbalance even more and might be at increased risk for adverse health outcomes (Siegrist, 1996b). Siegrist postulates that the condition of imbalance is more prevalent in unstable societies, e.g. in societies which are in transition such as the eastern European countries (Siegrist, 1996b). However, economic sectors may also be in transition: such as the health care system in some European countries. Consequently, the ERI model seems especially appropriate to investigate the nursing force in Europe. In this contribution, national differences with respect to the three components of the ERI model are being presented. 8

2 Methods The ERI instrument The 23 item shortened version of the effort-reward questionnaire was used (Siegrist et al., in press). Here, effort is assessed with six items mainly measuring quantitative work load. High scores indicate high distress experienced by the respondent due to his or her efforts at work. Reward is measured by eleven items covering the three central aspects of reward: financial reward, esteem reward and promotion prospects including job security. Again, the degree of distress was measured. High scores indicate high reward (or low distress). Six items for overcommitment investigate the individual s inability to withdraw from work obligations. The effort-reward ratio measuring the actual imbalance was calculated: effort/reward x correction factor (factor correcting for the different number of items of the two scales). Data collection Data collection and participation is described in the respective chapters in this book. For technical reasons no data for the Finnish reward scale was available. The Norwegian data for reward had many missings, a systematic error (possibly layout) cannot be excluded, the data was not used in this analysis. Consequently, no effort-reward ratio could be calculated. Data analysis Data analysis was conducted with SPSS.0 and Differences of means were calculated by ANOVA and T-Test. Differences in prevalence were measured by Chi 2 test. Due to the large size of the sample, the limit for significance was set by alpha <.01 Psychometric properties of the scales are presented in chapter Effort, reward and effort-reward-imbalance in the nursing profession in Europe 9

3 Table 1. Overview of participants by country and ERI scale. No data was available for the Finnish reward scale. (*excluded from analysis) country abbrev. total n n effort n reward n overcommitment n effort / reward ratio Belgium BE 4,7 4,172 4,4 4,166 4,063 Germany D 3,565 3,5 3,484 3,526 3,453 Finland FIN 3,970 3,862-3,929 - France FR 5,376 5,346 5,344 5,298 5,338 Italy IT 5,645 5,394 5,354 5,350 5,249 Norway N 2,733 1, * 2,665 - Netherlands NL 4,019 3,991 3,980 3,993 3,968 Poland PL 3,263 3,141 3,8 3,179 3,067 Slovakia SLK 3,396 3,283 3,191 3,189 3,160 all 36,224 34,228 29,038 35,295 28,726 Results Effort Effort scores were highest in the German sample (17.7) and lowest in the Dutch (11.3) (Figure 1). Differences between countries were significant except between Finland, Poland and Italy. Women in all countries except Italy had higher scores than men. This was significant in Finland, France, Poland and Slovakia. In most countries, the mean effort scores increased with age by in total 1 to 2 points. The main increase was between the youngest age group (-24 years) and those to 29 years of age. In Italy and the Netherlands, a constant decrease was found with age. Figure 1. Mean scores for ERI effort scale in the nursing population by country. Possible score range from 6 to 30, n total =34,228. High values indicate high effort. effort BE D FIN FR IT N NL PL SLK 1 14 Effort, reward and effort-reward-imbalance in the nursing profession in Europe

4 Reward The scores for reward were highest in the Netherlands and lowest in Italy, Slovakia and Germany (Figure 2). This means that nurses in these countries felt most distressed by lack of reward. All differences between the countries were significant except between Slovakia and Italy and Germany, respectively. In the total sample, women experienced somewhat higher reward scores (45.0) than men (43.9, p<.001). There was a u-shaped association between reward and age: The youngest age groups reported almost the same levels of reward as the oldest age groups in their country and higher scores than the age groups in-between. This was most pronounced in countries with low reward scores (Germany, Italy and Slovakia, but contrary in Poland). Figure 2. Mean scores for ERI reward scale in the nursing population by country. Possible score range from 11 to 55, no data for Finland and Norway, n total =29,038. High values indicate high reward. reward BE D FIN FR IT N NL PL SLK Overcommitment Scores for overcommitment were lowest in the Netherlands and highest in the Slovakian and the German samples, indicating an on average increased inability of respondents in these countries to psychologically withdraw from work obligations. The mean differences between all countries were significant except between Belgium, France, Italy, and between Germany and Poland. In all countries except Norway and Poland, female nursing staff reported significantly higher mean overcommitment scores than men. In most countries, the association of overcommitment with age was j -shaped: nurses between 30 and 40 years expressed lowest overcommitment and older age groups highest. 14 Effort, reward and effort-reward-imbalance in the nursing profession in Europe 111

5 Figure 3. Mean scores for the ERI overcommitment scale in the nursing population by country. High values indicate high overcommitment and thereby an adverse situation. Possible score range from 6 to 24, n total =35,295. High values indicate high overcommitment. overcommittment BE D FIN FR IT N NL PL SLK Effort-reward ratio Effort-reward ratio values close to 0 are hypothesised to indicate a favourable relation between the respondent s effort made and the reward received (Siegrist 1996a, 1996b). Ratios above 1.0 indicate that the efforts made are not counterbalanced by sufficient reward and that an increased risk for adverse health effects may exist. In the countries Poland, Germany, Italy and Slovakia, the proportion of respondents with an adverse ratio above 1 was compared to other investigations extremely high (Figure 4). The proportion was exceptionally low in the Dutch sample. There were no clear gender differences with respect to the ratio apart from in the German sample, where male nurses were more often among those exposed to a ratio > 1 (p<.001). In all countries apart from the Netherlands, the effort-reward ratio increased with age from the youngest age groups until around 35 years of age. In three countries with a high prevalence of adverse ratios, Germany, Italy and Slovakia, it was mainly the age groups from () 30 to 40 years where the highest prevalence of people with adverse ratios was registered. In Poland, the proportion of those exposed remained very high (>22%) even among older age groups and was highest (30%) among those of 55 years of age and above. The effort-reward ratio was clearly associated with intent to leave the nursing profession (Figure 5). This was identical in all countries where the data was available. Almost one out of three of the participants with an adverse ratio >1 considered leaving the profession several times per month or frequently still Effort, reward and effort-reward-imbalance in the nursing profession in Europe

6 Figure 4. Percentage of participants in each country with an effort/reward ratio above 1 indicating an (adverse) effort/reward imbalance. No data for Finland and Norway. (n total =28,726) % with ratio above '1' BE D FR IT NL PL SLK Figure 5. Distribution of responses to the question How often did you consider leaving the nursing profession? in relation to the effort-reward ratio. A ratio above 1 indicates an (adverse) effort-reward imbalance. No data for Finland and Norway. (n total =,853) 0% 80% 60% 40% % 0% effort-reward ratio considering leaving nursing never sometimes/year sometimes/month sometimes/week every day Discussion The analysis of effort, reward and overcommitment as defined by the ERI imbalance model by Siegrist (Siegrist 1996a, 1996b) has shown substantial differences for all scales between the different national samples. The data from the countries Poland, Germany, Italy and Slovakia indicate particularly adverse situations. For Poland and Slovakia, the fundamental political and economic change may account for the high proportion of nurses exposed to adverse conditions. In Germany and Italy, nursing staff have often rated both exposure and health outcomes more negatively than their colleagues from other countries (see other chapters in this book) and the wish to leave the profession was most pronounced in these countries. Already in 1999, Killmer reported that in the German nursing profession the gap between demands and rewards was widening. There is nothing to indicate a recent change in this trend. Also in Italy, there 14 Effort, reward and effort-reward-imbalance in the nursing profession in Europe 113

7 seems to be substantial dissatisfaction with the working conditions among the nursing staff. A detailed analysis of the differences between the countries is beyond the scope of this report. In the future, three potential causes for the differences between the countries must be evaluated: a) different response habits (there was a rather low response rate in the Dutch sample where best conditions were registered with respect to the ERI scales), b) different attitudes of the national nursing populations, and c) different working conditions. The consistently strong association of reward with intent to leave the profession seems to be of relevance for health care institutions in all participating countries. Assuming that the ERI model assesses aspects which can be subject to organisational intervention, the NEXT-Study data may present valuable data for such measures. This, however, requires more detailed analysis which includes associations between the ERI components and work exposure, private conditions and organisational style. Finally, the ERI components shall be related to outcomes such as health and work ability. References Bongers PM, de Winter CR, Kompier MAJ & Hildebrandt VH. (1993) Psychosocial factors at work and musculoskeletal disease. Scand J Work Environ Health 19: Karasek RA (1979). Job demands, job decision latitude, and mental strain: implications for job redesign. Adm Sci Q 24: Killmer C (1999) Burnout bei Krankenschwestern. Dissertation. Münster: Lit Verlag Kristensen TS (1999). Challenges for research and prevention in relation to work and cardiovascular diseases. Scand J Work Environ Health (6, special issue): Kuper H, Singh-Manoux, Siegrist J & Marmot M. (02) When reciprocity fails: effortreward imbalance in relation to coronary heart disease and health functioning within the Whitehall II study. Occup Environ Med 59: Leino PI & Hänninen V (1995) Psychosocial factors at work in relation to back and limb disorders. Scand J Work Environ Health 21: Schnall PL, Belkic K, Landsbergis P & Baker D (02) The workplace and cardiovascular disease. Occup Med State of the Art Reviews : Siegrist J, Starke D, Chandola T, Godin I, Marmot M, Niedhammer I & Peter R (in press) The measurement of effort-reward imbalance at work. European Comparison. Special Issue Social Science & Medicine. Siegrist J (1996a) Adverse health effects of high effort low reward conditions at work. J Occup Health Psychol 1: Siegrist J (1996b) Soziale Krisen und Gesundheit. Göttingen Effort, reward and effort-reward-imbalance in the nursing profession in Europe