Quality of Working Life : An Antecedent to Employee Turnover Intention

BACKGROUND
The purpose of this study was to measure the level of quality of work life (QWL) among hospital employees in Iran. Additionally, it aimed to identify the factors that are critical to employees' QWL. It also aimed to test a theoretical model of the relationship between employees' QWL and their intention to leave the organization.


METHODS
A survey study was conducted based on a sample of 608 hospital employees using a validated questionnaire. Face, content and construct validity were conducted on the survey instrument.


RESULTS
Hospital employees reported low QWL. Employees were least satisfied with pay, benefits, job promotion, and management support. The most important predictor of QWL was management support, followed by job proud, job security and job stress. An inverse relationship was found between employees QWL and their turnover intention.


CONCLUSION
This study empirically examined the relationships between employees' QWL and their turnover intention. Managers can take appropriate actions to improve employees' QWL and subsequently reduce employees' turnover.

decisions.People in such a culture emphasise individual initiative and achievement.Iranians are more "feminine" (16).They do care about people surrounding them.People in such a society are more emotional and less tolerant of opinions different from what they are used to.Relationships with co-workers, employment security and a friendly atmosphere are relatively more important than recognition, advancement and challenge in such a society.Iranians are more short-term thinkers.They emphasise more on quick results and benefits (20).
The results of this research will allow a better understanding of the impact of employees' QWL on their turnover intention.The results also, will enhance our understanding of the determinants of QWL in an Islamic and developing country.It is anticipated that a better understanding of these issues and their relationships can aid further research, pinpoint better strategies for recruiting, promotion, and training of future hospital employees, particularly in Iran but perhaps in other societies as well.

Literature review
Employee turnover is an employee's voluntary withdrawal from the organization (21).Turnover of skilled and professional healthcare staff can incur substantial costs for organizations.Recruiting and training new employees are very costly for organizations.High staff turnover can also influence negatively an organization's capacity to meet patient needs and provide quality healthcare services (22,23).Employees' behavioural intention to turnover is a predictor of their actual turnover (24).Turnover intention may be an indicator of low QWL.Some studies found a positive relationship between employees' QWL and their job satisfaction (1,25).Low employees' job satisfaction is a significant predictor of their turnover intention (26)(27)(28).Other empirical studies confirm the important role of organizational commitment in the turnover process (27,29).Demographic variables such as age and tenure were also reported as employees' turnover predictors (30).
Nevertheless, the role of QWL in employee turnover has not been well investigated.The proposed framework presented at Figure 1 aims to explain the relationship between employees' QWL and their turnover intention.It is anticipated that improving employees' QWL, increases their job satisfaction and subsequently their organizational commitment.As a result, employees' intention to leave the organization will be decreased.
This survey investigates possible relationships between QWL and employees' turnover intention.This study also focuses on revealing demographic variables that influences employees' QWL and turnover intention.Examining the impact of other variables shown in Figure 1 on employees' turnover intention is beyond the focus of this study.

Purpose and objectives
The main purpose of this study was to determine the level of QWL among hospital employees in Isfahan, Iran.It also aimed to explore the relationship between QWL and turnover intention among hospital employees.Doing so has practical relevance for designing and implementing strategies and interventions to improve QWL among hospital employees.

Design
The study utilised cross-sectional, descriptive and corelational design and survey methodology.

Setting
Hospital care in Iran is provided by a network of regional hospitals located in the main cities.This includes government financed Ministry of Health hospitals (MOH), the Social Security Organization (SSO) affiliated hospitals and private hospitals.The study was carried out at six hospitals, three MOH (two educational and one non educational), one SSO and two private hospitals.The six hospitals of the study were selected to represent the three dominant hospital care systems in Iran.

Population and sample
Seven hundred and forty employees were selected for this research after a pilot study by using the following formula (n=2411, d=0.03, z=1.96 and s=0.50).Employees who had less than 6 months working experience were excluded from this study.

Instrument
The items of QWL questionnaire were gathered by means of a literature review (31)(32)(33)(34) and a Delphi method.In total, nine dimensions of QWL were defined (Table 1).This questionnaire has 36 items (four items in each dimension).Ratings were completed on a five-point scale (from very low=1 to very high=5).Turnover intention was measured using a single item: "To what extent do you want to leave this organization, if you find another job opportunity?"

Dependent and independent variables
Employee's turnover intention was the dependent variable in this study.Independent variables included nine dimensions of QWL (i.e., Participation and involvement, job promotion, disturbance handling, communication, motivation for work, job security, wages and salaries, job proud, and job stress).

Pilot study
A pilot study was undertaken to test the relevance and clarity of the questions and to refine them as needed to avoid misunderstanding.A small sample of forty of randomly selected hospital employees who were not included in the sample was received the questionnaires.The questionnaires were found to be understandable and acceptable.

Validity of the research instruments
In this research, nine QWL constructs have content validity since they were derived from an extensive review of the literature, and evaluations by academics and practitioners.

Reliability of the research instrument
Cronbach's alpha was computed for each scale using the SPSS 11 (SPSS Inc., Chicago, IL, USA).The reliability coefficient was 0.91 for QWL questionnaire (Table 1).

Data collection
A stratified random sampling method was employed in this study.Data collection was undertaken in September 2008.Informed consent was obtained from all subjects following receipt of information on the purpose of the study, assurances of anonymity and confidentiality.

Data analysis
All data were analysed using the SPSS 11 (SPSS Inc., Chicago, IL, USA).In order to normalize the Likert scale on 1-5 scales for each domain of QWL questionnaire, the sum of raw scores of items in each domain was divided by the numbers of items in each domain (4 items) and for overall QWL, sum of raw scores of items were divided by 36 respectively.The possible justified scores were varied between 1 and 5 The differences between groups were tested with the chi-squared test, in-dependent t-Test, Mann-Whitney and Kruskal Wallis tests.Then, the relationship between QWL and turnover intention was investigated by calculating Pearson's correlation coefficients.Regression analysis was used to identify the most important predictor domains in QWL.The significance level was set at P<0.05.

Results
Six hundred and eight employees completed the questionnaires (82.20%).The characteristics of the sample are summarized in Table 2.More than half of the respondents were females and over three fourths were married.They had mostly at least a college degree.More than half of the employees had incomes of less than 3,000,000 Rials (poverty line in Iran in 2008).48.70% of employees had permanent employment.The age of these hospital employees ranged from 21 to 60, with an average age of 34.53 ± 8.28 (Mean ± SD).Over half (67%) is less than 40 years old.Employees on the average had 10.80 years of working experiences respectively.
The mean score of employees QWL was 2.53 on a five scale implying that overall the level of QWL was low.The overall scores ranged from 1.47 to 4.45 (possible range 1-5).QWL was very low, low, medium, high and very high in 16.10, 53.90, 25.20, 4.60 and 0.20% of hospital employees.
In correlation analysis between QWL and its nine dimensions, disturbance handling (management support), job proud, job security, job stress and participation and involvement respectively had the highest effect on employees' QWL.The results of the stepwise regression model indicate that 89% of the variance in overall QWL is explained by disturbance handling (management support), job proud, and job security.The variables-resolving organizational and job related problems of employees, using employees' suggestion and ideas in resolving organizational problems, good relations between employees and managers, employees' proud about working in the organization, fair job promotion, job security, fringe benefits and job stress were the most influential factor in QWL.
Organizational factors explained the largest amount of the variance in employees' QWL (26.20%), followed by individual factors such as education and marital status.There was strong correlation between QWL of employees and their gender, marital status, organizational position, and education level (P<0.05).Those who were married had a higher level of QWL as compared to the singles.A statistical significant association was not found between employees' QWL and their area of work (P=0.76).
The Kruskal Wallis test revealed that the total QWL scores was differed among six hospitals (Chi squared =30.29, df=5, P<0.001).Employees' QWL in private hospitals was less than public and semi public hospitals (see Table 3).However, the differences between values of employees QWL in these hospitals were not statistically significant (P>0.05).
Managers registered a statistically significant higher level of quality of working life than employees (t=-1.99 and P=0.04).They experienced more job proud, job promotion, and job security, felt more supported by top management and were involved more in the management of their organizations (see Table 4).As a result, they were more motivated than their staff.Employees were more likely than managers to be dissatisfied with their promotion, wages and salaries.
Employees' QWL in administrative (2.44)When asked whether they would leave their organization, if they find another job opportunity, 40.40% of hospital employees responded that they would leave their organization if they find another job opportunity.QWL was negatively (r=-0.44 and P<0.001) associated with turnover intentions (see Table 5).QWL was positively (r=-0.54 and P<0.001) associated with recommending the organization to others for work.QWL was a major contributor to employee turnover intention.Regression analysis of data indicated that predictors of intent to leave were low motivation, organizational policies, job stress, poor communication, and lack of job security.
Significant relationships were found between employees' turnover intention and their age (P<0.001),tenure (P<0.001) and marital status (P=0.03) and type of employment (P=0.05).An inverse relationship between employees' education level and turnover intention was found in this study.Employees in lower educational background were less satisfied with pay and more likely to leave.Temporary and casual employees were more likely to leave their hospitals than fulltime permanent staff.

Discussion
This study set out to assess the degree of QWL among Iranian hospital employees.Hospital employees reported low levels of QWL.Management support and security of employment exhibited the most direct effects on employees' QWL.These findings are consistent with other similar studies in Iranian healthcare context (35).They also found that employees were more dissatisfied with management support, poor communication, payment and working conditions.Similarly, Lewis and colleagues in a study of the health-care settings in the south central region of Ontario, Canada found that pay, benefits and supervisor style play the major role in determining employees' QWL satisfaction (6).
This study showed that employees who worked in private hospitals had lower QWL.They were more dissatisfied with their career prospects, pay, benefit, workload and job security.Job insecurity negatively influenced QWL of hospital employees.Job security is an important determinant of employees' job satisfaction (27).Increased workloads and financial restraint has left employees feeling increased pressure in their jobs.Hospital managers should enhance employees' QWL through improving their working conditions and providing fair promotion and benefits.
Employees' QWL is also related to the quality of management and leadership of the organization.Management support and employees' experience of fair treatment by management is positively related to employees' job satisfaction (36)(37)(38) and quality of work life (8,39)  promotion opportunities, involve employees in decisionmakings and pay them fairly and adequately.The current study showed that promotion opportunities were another significant predictor of QWL.Unfair promotion policies perceived by employees may negatively affect their QWL.Dissatisfaction with promotion opportunities has been shown to have a stronger impact on employees' turnover.These finding is consistent with the findings of other researchers (23,40).Employees should be considered as developing human assets.Life-long learning, professional growth and advancement promote employees' job satisfaction, and enable continued provision of high-quality healthcare services (41,42).Managers must be supportive and give employees opportunities for advancement.
Salary and fringe benefits are also correlated with employees' QWL and turnover intention.Employees may leave their organizations for higher salary.Besides, the fairness of an organization's compensation system is important for employees.Employees who feel a fair compensation system that rightfully rewards their efforts have less intention to leave their organization (11).
The results show that occupational stress is negatively associated with employees' QWL.Employees who were least satisfied with pay, promotion, job security, participation in decision making tended to experience higher levels of occupational stress.Occupational stressors may have harmful effects on an individual's physical (43,44) as well as mental and emotional health (45,46).High levels of occupational stress have been linked to high staff absenteeism and low levels of productivity (47).Occupational stress is also negatively related to quality of care (48).A strong inverse relationship was found between employees' occupational stress and their job satisfaction (49,50), organizational commitment (51,52) and intentions to leave (53,54).According to the current study, employees at semi public hospitals reported higher occupational stress.Semi-public hospitals provide free of charge healthcare services to social security insured patients.Consequently, the demand for services in these hospitals is very high.Thus, employees at these hospitals experience more duty related stress.Managers were also more likely than employees to experience occupational stress.
Jobs should be designed in ways that provide meaning, motivation, and opportunities for employees to use their skills.Managers can apply techniques such as job enlargement, job enrichment, and job rotation to improve employees' satisfaction and productivity.Workload should be is in line with employees' capabilities and resources.Increased workloads may deteriorate employees' QWL (32).Employees' roles and responsibilities should be clearly defined.They should be given opportunities to participate in decisions and actions affecting their jobs.
This study revealed a reverse relationship existing between QWL and turnover intention.Improving employees' QWL will ultimately lead to increased job satisfaction and reduced turnover intention among employees.It is recommended that particular attention be given to improving employees' attitudes and morale through organizational change programmes.The results of this study suggest that management might be able to improve the level of QWL in the organization by increasing employees' satisfaction with organizational policies, work conditions, equal compensation and equal promotion.Changes in management systems and structure, changes in senior management behaviour, changes in organizational variables, such as benefit scales, employee involvement and participation in policy development, and work environment, and demonstrating value to staff could then be made in an effort to increase employees' QWL and decrease subsequent turnover.
Although recruiting more staff and increased compensation and benefits offset hospital staff dissatisfaction in the short term, improving employees' QWL would be a more long-term practical approach to improving hospital staff retention and reducing turnover.However, the success of QWL programmes depends on organizational culture and partnership between management and employees.The goal of QWL programmes is to improve the work design and requirements, the working conditions and environment and organizational effectiveness.It aims to create more involving, satisfying and effective jobs and work environment for employees at all levels of the organization.A decentralized organizational structure, a commitment to flexible working hours, an emphasis on professional autonomy, and improved communication between management and employees result in higher levels of employee job satisfaction and lower turnover.
Employee's involvement and cooperation is a key factor in the success of QWL.Empowered employees have more autonomy and control over their work conditions and as a result are more likely to have higher job satisfaction and organizational commitment, and lower job stress and burnout (55,56).However, introduction and implementation of QWL programmes involving greater employees' participation and involvement in the decision-making process may pose difficulties in countries where there is a greater power distance and separation of management and employee roles.Such programmes would probably meet with resistance from those people who would be adversely affected.Iran scored high on power distance index (16,57,58).Iranian managers might be somewhat reluctant to accept changes in their subordinates' and their own job responsibilities where this change meant a reduced power distance.Therefore, any attempt to apply participative management techniques in Iranian context should be adjusted.QWL efforts will require innovative thinking to construct a unique stance regarding the involvement of the employee in the decision-making process in light to the power distance in the culture.
The particular QWL approach in various cultures, in respect of formality and rule-orientation, might also vary with the level of uncertainty avoidance (59).QWL programmes involve change.These changes will be resisted by people in cultures characterised by a high uncertainty avoidance index.Therefore, in countries with high uncertainty avoidance like Iran ( 16) adequate rules and regulations are required to provide structure and certainty in the changing conditions created by QWL programmes.This assures that the employees are not overwhelmed with anxiety.When introducing QWL to various cultures, attention must be also given to the relative individual versus collective emphasis.Organizations operating in countries low on individualism may tend to deemphasise individual incentives and rewards and prefer to provide group incentives and opportunities for group problem-solving.In such countries with low individualism, organizational QWL programmes are likely to be group oriented and somewhat paternalistic in flavour.However, in nations high on individualism such as Iran (18,19,60), individual decisions are thought to be better than group decisions and as a result individual initiative is socially encouraged, and a strong importance is attached to freedom and challenge in jobs.
The implementation of QWL often leads to changes in the nature of work to increase job meaning and therefore employee motivation and satisfaction.Techniques such as job rotation (alternating task assignments), job enlargement (expanding the scope of the job by adding more task variety) and job enrichment (expanding the depth of the job by adding more responsibility and authority) are examples of job redesign interventions to improve employee satisfaction.However, QWL intervention must be cognizant of the degree to which any work changes are seen as interfering with personal areas of people's lives (59).Iran scored considerably lower on the Hofstede masculinity/ femininity index (16).Hofstede indicated that in more masculine cultures, humanised jobs should provide more opportunities for recognition, advancement, and challenge whereas in less masculine cultures, the emphasis would be more on cooperation and good working atmosphere (16).Thus, in lower masculine countries, organizations should not interfere with the private lives of their employees, whereas in higher masculine countries this interference in private lives is seen to be more legitimate.

Conclusion
In a cross sectional study, the level of employees' QWL among a group of hospital employees in Iranian hospitals was measured.The hospital employees' QWL was low.
Factors that influenced employees' QWL in this study were demographic variables of gender, graduation level, place of work, type of employment, and the nine dimensions of QWL as indicted in Table 1.Poor treatment by managers, dissatisfaction with job security and career prospects, and a perception that pay was not sufficient and fair were the main reasons for employees' low QWL.Employees who experienced lower QWL had more intention to leave their organization, if they find another job opportunity.

Theoretical implications
This study makes several distinct contributions.First, using a cross sectional approach, the level of QWL among a group of hospital employees in Iranian hospitals were examined.Second, factors contributing to employees' QWL were identified.Third, the relationship between employees' QWL and their turnover intention was examined.

Managerial implications
There are several practical implications that can be derived from the findings.Healthcare managers should be encouraged to monitor employees' QWL and improve it by applying the right human resources polices.The most contributor to employees QWL in this study were lack of management support, lack of job security, inadequate pay, inequality at work, too much work, staff shortages, and lack of recognition and promotion prospects.Organizational factors were the main predictors of employees' QWL.Hospital managers and policy makers must manage these organizational variables more constructively to enhance employees' QWL and subsequently performance.They should try to satisfy both employees' work and personal needs.

Limitations and implications for future research
The findings should be interpreted with caution since the participants were employees from six hospitals in Iran.More research in this area is needed before generalizing the study findings.The cross-sectional nature of the research limits inferences concerning causality between QWL and turnover intention.The optimal approach would be longitudinal studies to detect changes in employees' turnover intention due to changes in their QWL.Interviews with employees on factors influencing their QWL and turnover intention would be also useful.

Figure 1 .
Figure 1.Hypothesized relationship between QWL and turnover intention
. Lack of control, autonomy, and participation in decision-making are negatively linked with employees' QWL and may result in employees' turnover.Managers should develop and communicate corporate vision, goals and values, create high quality work environments, provide more training and

Table 2 .
Percentage of participants and the mean score of their QWL

Table 3 .
The mean of employees' QWL in different hospitals (on a 5 scale)

Table 4 .
The mean of employees and managers' QWL (on a 5 scale)

Table 5 .
inter-correlations between job stress and QWL **Correlation is significant at the 0.01 level(2-tailed)