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Bakhshi E, Gharagozlou F, Moradi A, Naderi M R. Quality of work life and its association with job burnout and job performance among Iranian healthcare employees in Islamabad-e Gharb, 2016 . JOHE. 2019; 8 (2) :94-101
URL: http://johe.rums.ac.ir/article-1-336-en.html
1- Health Center, Islamabad-e-Gharb Health Network, Kermanshah University of Medical Science, Kermanshah, Iran. , ehsanbakhshi63@gmail.com
2- Department of Occupational Health, School of Public Health, Kermanshah University of Medical Science, Kermanshah, Iran.
3- Kermanshah Branch, Islamic Azad University, Kermanshah, Iran.
4- Islamabad-e-Gharb Health Network, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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Quality of work life and its association with job burnout and job performance among Iranian healthcare employees in Islamabad-e Gharb, 2016  

Ehsan Bakhshi1*, Faramarz Gharagozlou2, Ali Moradi3, Mohammad Reza Naderi4
 
1- MSc of Ergonomics, Health Center, Islamabad-e-Gharb Health Network, Kermanshah University of Medical Science, Kermanshah, Iran.
2- Assistant Prof., Department of Occupational Health, School of Public Health, Kermanshah University of Medical Science, Kermanshah, Iran.
3- Faculty of Humanities, Kermanshah Branch, Islamic Azad University, Kermanshah, Iran.
4- Medical Doctor, Islamabad-e-Gharb Health Network, Kermanshah University of Medical Sciences, Kermanshah, Iran.

* Corresponding author:  Ehsan Bakhshi,  E-mail:  Ehsanbakhshi63@gmail.com


Abstract
Background:
Health care centers play an important role in providing health service to the public and maintaining the health of the community. This study was an attempt to evaluate the quality of work life and its association with job burnout and job performance among healthcare employees.
Material and Methods: This cross-sectional study was carried out on 136 employees of healthcare centers and health homes in Islamabad-e Gharb in 2016. The data collection tools were a demographic characteristics questionnaire, Walton's Quality of Work Life Questionnaire, Maslach Burnout Inventory, and Hersey and Goldsmith's Job Performance Questionnaire. The statistical analysis was conducted using descriptive statistics, the spearman correlation coefficient, one-way ANOVAs, and independent t-tests.
Results: The quality of work life was obtained to be low for only over a quarter of participants, whereas only 0.7% of them reported it to be high. The majority of respondents (72.63%), however, stated it as moderate. The quality of work life had a significant negative correlation with job burnout (r= -0.291 P = 0.001) and held a significant positive association with job performance (r=0.642 P = 0.000).
Conclusion: The findings of this study suggested a clear link between the quality of working life and both job burnout and job performance. Therefore, taking actions such as providing opportunities for the staff to continue their education, increasing their salaries and benefits as well as promoting their jobs would be considered as common-sense approaches contributing to enhancing the quality of work life.
 
Keywords: Burnout, Job Performance, Healthcare Workers, Iran.
Introduction
Health organizations play an important role in the maintenance and development of health in human societies (1) while the fulfillment of this objective requires a healthy and highly motivated workforce (2).
Quality of work life refers to the conceptions and thoughts that employees have about their job, the extent to which they are satisfied with their job, and the way they consider their job relative to their goals (3). In the unfavorable quality of work life, dissatisfaction and maladjusted behavior may arise among personnel. By contrast, high quality of work life leads to a climate of trust and mutual respect, in which employees can be active and develop their psychological as well as reducing the rigid control mechanisms in organization (4). Quality of work life contains two basic concepts in its definition. First, it includes a subjective concept and, second, it has a multidimensional structure. In terms of dimensions, it includes the physical, psychological, and environmental factors that compare the desires and needs of individuals between what they should have and what is available (5). The concept of quality of work life is currently related to a philosophy in the organizations that seek to increase employees' dignity. In some organizations, managers aim to enhance employees' trust, engagement, and problem-solving skills by implementing appropriate quality of work life plans and, thereby, to enhance organizational satisfaction and effectiveness (6). .These plans and programs will exert significant impacts on employee’s behavioral responses such as job satisfaction, work participation, job performance, intention for job resignation, and organizational change and transformation (7). Hood & Smith believe that of managers’ close attention to quality of work life variables can facilitate a more humanistic work environment, which not only addresses the basic needs of employees but also encompasses the needs of higher levels, continuous growth, and improved performance (8). Much attention has been recently drawn to QWL as an approach to balancing job burnout (9).
Job burnout arises from the response to long-term stress in the workplace, and this syndrome is related to the workplace, in which one's attitudes towards efforts and endeavors in the workplace are negatively affected (10). People with burnout often suffer from headaches, sleep disorder, irritable mood, anxiety, depression, and hypertension (11). Job burnout reduces cognitive ability and, hence, results in reduced job satisfaction and increased disorder in organizational commitment as well as personal injury (12). The imbalance between expectations, knowledge, and skills of employees on one hand, and job requirements, job resources, and responsibilities on the other hand lead to burnout. In addition, high workload and the lack of social support are among the other major risk factors for this phenomenon (13). Since job burnout creates a negative attitude toward the job and a sense of disconnection with the patient during care delivery, it leads to a serious loss of quality of healthcare services; therefore, a careful identification of more effective factors in this area will be beneficial for improving the quality of services provided in the field of health and treatment (14). In addition to job burnout, quality of work life could also have impact on job performance of employees.
Job performance has a significant association with an organization's goals, and it is necessary for the organization to pay special attention to it (15). Job performance refers a set of behaviors controlled by individuals, which affect the goals of the employing organization. The main key to the development and improvement of job performance of individuals is the identification of the various organizational factors that influence individuals' performance (16). The employees’ attitude towards different organizational issues, especially towards the job and the profession they perform, as well as promotions, assigned tasks, selection for training, and pay raise based on assessment can play an important role in increasing their motivation and cause them to perform their duties and responsibilities in the best way, which, in turn, leads to an increase in the effectiveness and efficiency of the organization (17, 18). Today, healthcare organizations are in need of strong support on part of managers in terms of performance evaluation. Performance measurement is one of the most important strategic processes that determines the extent to which the goals and plans of an organization are fulfilled inasmuch as the enhancement of accountability and responsiveness (19). Regarding the role of health staff in the quality of service delivery, it can be argued that the progress and enhancement of an organization hinges upon the employees, who must be aware of the quality of care in their organization. With regard to the important role of staff of health centers and public health centers in the maintenance of people's health, this study aimed to evaluate quality of work life and its effect on burnout and job performance.
 
Materials and Methods
In the beginning, this project was approved by the Vice Chancellor of Research Affairs at Kermanshah University of Medical Sciences, Iran (ID code: IR.KUMS.REC.1397.988).
This cross-sectional, descriptive study was conducted based on the census methods at the healthcare centers in Islamabad-e Gharb in 2016. In total, 180 questionnaires were distributed among the participants, and 136 questionnaires were completed and returned (response rate: 75%)
In this study, the following four questionnaires were used:
A demographic characteristics questionnaire: It included information about age, gender, marital status, work experience, education level, history of smoking, place of employment, and employment status.
Walton's Quality of Work Life Questionnaire: This questionnaire is constructed based on Walton's components (20). The reliability of the questionnaire was reported by Ghaleei et al. to be 0.78 (21). This questionnaire includes such components as adequate and fair compensation, safe healthy working environment, opportunity for continued growth and security, constitutionalism in the work organization, social relevance of work life, social integration and cohesiveness, and the development of human capacities. The questionnaire items are scored based on a five-point, qualitative Likert scale (very low =1, low = 2, moderate = 3, high = 4, very high = 5). The scores can range from 32 to160, where scores lower than 74 are considered as low, 75 to117 as moderate, and those higher than 118 are known as high. 
Maslach Burnout Inventory: This questionnaire is one of the most common tools used for the measurement of burnout, which consists of 22 statements. It was designed by Maslach and measures three dimensions of job burnout (22). where nine items pertain to emotional exhaustion, five items relate to depersonalization, and eight statements are about personal accomplishment. The reliability and validity of this questionnaire were confirmed in Iran for the first time by Filian, who reported a test-retest reliability index of 0.78 (23). for the questionnaire. The total score range for total job burnout varies between 0 and 132, in which the scores below 44 (≤44) represent low job burnout, 45 to 89 show moderate job burnout, and those higher than 99 (≥90) indicate high job burnout. Hersey and Goldsmith's Job Performance Questionnaire: This questionnaire, developed by Hersey and Goldsmith, consists of 16 questions under seven components including ability, clarity of role, support, motivation, feedback, validity, and environment. The validity and reliability of this questionnaire were confirmed by Ardestani et al. with a Cronbach’s alpha of 0.86 (24). The Cronbach’s alpha reliability of this scale was calculated to be 0.75 in the present study. The scores are classified into three ranges: 16-37, 37-58, and 59-80 representing low, moderate, and high job performances, respectively.
The obtained data were analyzed using descriptive statistics, the spearman correlation coefficient, independent t-tests, and one-way ANOVAs at a confidence level of 0.95 in version 19 of the SPSS software.
 
Results
In this study, 48.52% of the participants were male. The mean and standard deviation of the participants' age was 36.4 ±8.1 years old. Table 1 shows the demographic characteristics of the staff in healthcare centers and health homes.
 
 
Table 1: The demographic characteristics of the staffs in healthcare centers and health homes
Variable N %
Sex Male 66 48.52
Female 70 51.48
Marital status Married 27 19.85
No married 109 80.15
Education level Less than diploma 18 13.23
Diploma 39 28.67
Associates degree 27 18.85
Bachelor degree 52 39.25
Age groups Under 30 22 16.17
31-40 55 40.53
41 and older 59 43.30
Years of service 1-10 years 55 40.44
11-20 years 52 38.24
21-30 years 29 21.32
Type of employment Contractual 26 19.11
Employment contract 28 20.58
Permanent 82 60.29
Job category Health center 77 56.61
Health house 59 43.38
Cigarette smoking Yes 12 9
No 124 91
 
 
In this research, the most experienced QWL level (72% of the participants) was at moderate, followed by low (26%). The mean and standard deviation of job burnout, job performance, and quality of work life were 45.95 ±17.77, 52.5 ±9, and 73.91 ±13.22, respectively. Table 2 illustrates the mean and standard deviation of all components of QWL, job performance and job burnout in staff of healthcare centers and health homes.
 
 
 
 
Table 2: Mean and standard deviation of QWL, job performance, job burnout and their aspects
Variable Mean ±SD Range of score
Quality of work life: 76.91±13.25 32-160
-Adequate and fair compensation 10±2.80 5-25
-Safe and healthy working conditions 7.61±2.10 3-15
-Opportunity for continued growth and security 7.50±2.41 3-15
-Organizational legality 14±4.92 6-30
-Social relevance of work life 8±2.51 3-15
-Work and the total life span 11.12±3.15 5-25
-Social integration in the work organization 8.70±2.31 4-20
-Developing human capabilities 9.71±2.82 3-15
Job burnout: 45.95±17.77 0-132
-Emotional Exhaustion 21.23±11.93 0-54
-Depersonalization 4.64±4.22 0-30
-Personal Accomplishment 30.17±8.26 0-48
Job performance: 52.51±9 16-80
-Ability 10.90±2.31 3-15
-Clarity 7.82±1.32 2-10
-Help 5.91±2 2-10
-Incentive 8.92±2.41 3-15
-Evaluation 5.62±2 2-10
-Validity 6.62±1.93 2-10
-Environment 6.821.91 2-10
 

Table 3: Association between aspects of quality of work life with job performance and job burnout
Dimensions of quality of work life Job performance Job burnout
r r
Adequate and fair compensation 0.397** -0.281**
Safe and healthy working environment 0.336** -0.184*
Growth and security 0.479** -0.205*
Organizational legality 0.675** -0.282**
Social relevance of work life 0.533** -0.192*
Work and the total life span -0.087 0.233*
Social integration in the work organization 0.561** -0.085
Developing human capabilities 0.537** -0.224*
Quality of work life 0.642** -0.291**
Job burnout -0.242** -
Spearman correlation efficiencies level of significant: p≤0.05      p<0.001**               p<0.050*  
 
The Pearson correlation coefficient showed that quality of work life had a significant effect on all components of job performance except the work environment. In addition, quality of work life was significantly correlated with emotional exhaustion (p-value≤0.05) (Table 4).
 
Table 4: Association of quality of work life with aspects of job performance and job burnout
Quality of work life  
0.642** Job performance:
0.307** -Ability
0.423** -Clarity
0.651** -Help
0.538** -Incentive
0.571** -Evaluation
0.506** -Validity
-0.070 -Environment
-0.291** Job burnout:
-0.329** -Emotional Exhaustion
-0.069 -Depersonalization
-0.136* -Personal Accomplishment
Spearman correlation coefficients level of significant: p≤0.05      p<0.001**               p<0.050*  
The one-way analysis of variance (ANOVA) showed that job performance and quality of work life were correlated with educational level (p-value <0.05). An independent t-test revealed a significant association between job performance and gender (p-value = 0.04). Table 5 shows the association between quality of work life, job performance, and job burnout with demographic and contextual variables.
 
Table 5: Association between quality of work life, job performance, and job burnout with demographic and contextual variables
Type of test Job burnout Quality of work life Job performance Variables
ANOVA 0.21 0.11 0.70 Age groups
T-TEST 0.355 0.31 0.04 * Sex
T-TEST 0.29 0.66 0.90 Married status
ANOVA 0.71 0.3 0.91 Type of employment
ANOVA 0.92 0.003 * 0.004* Education
ANOVA 0.31 0.36 0.31 Years of work
* P ≤0.05

Discussion
The results of this study showed that the quality of work life is inversely related to job burnout, while it has a direct significant correlation with job performance. Therefore, improving the quality of work life would lead to a reduction in job burnout and an increase in job performance. Furthermore, job burnout had a significant negative effect on job performance. Research has shown that employees usually experience high levels of job burnout (25).
Acar and Erkan, reported a negative significant association between quality of work life and burnout syndrome (26). In a study by Zhang et al. the association between quality of work life and job burnout with job stress were significant (27). It seems that, in order to prevent job stress and job burnout, it is necessary to promote quality of work life.
In Farsi et al.’s study, quality of work life was significantly correlated with the two components of emotional exhaustion and personal accomplishment. However, in the present study, only emotional exhaustion correlated significantly with quality of work life (28) .In a study carried out by Ashrafi et al. on nursing, it was revealed that quality of work life has a significant negative association with job burnout, which is consistent with results of the current study (29). Moreover, Karim's findings on prison staff indicated that there was a significant association between job burnout and quality of work life (30). Therefore, it can be said that it is feasible to reduce job burnout among the staff of all occupations through the enhancement of quality of work life. In this study, the components of constitutionalism in the work organization and adequate and fair compensation had a significant negative association with job burnout. On the other hand, Barret and Yates argue that low payment and salary is one of the causes of burnout (31). In addition, Aziznejad and Hosseini referred to low salaries and payment as the main cause of job burnout (32).
There is a strong significant correlation between quality of work life and job performance, which is an indicative of the fact that an increase in quality of work life leads to an increase in employees' job performance. The improvement of quality of work life is essential for the promotion of the organization's performance in such a way that the relation between some dimensions of quality of work life with organizational performance has been proven in the studies conducted by Aketch, et al, (33), Rai et al. (34). The results of the current study is in agreement with those of the study undertaken by Yazdani and Ghasemi  on employees of Shiraz Petrochemical Company, where it was shown that quality of work life has a significant association with job performance (35). In addition, the findings of this study regarding the association between quality of work life and job performance is consistent with those of the study carried out by Shahbazi et al., (36). In this study, the components of social integration and cohesiveness, opportunity for continued growth and security, constitutionalism in the work organization, and social relevance of work life were found to have a significant association with staffs' performance, which is in line with the findings of Abasalt's study. Thus, one of the most important steps in improving employees’ performance is to increase the quality of their work life. Indeed, a work environment is of high quality if individuals are considered as the main and core members of the organization and if the workplace enjoys indicators such as in-service training, employee participation in decision-making, job security, and fair pay (37).
In this study, job burnout was revealed to have a significant negative association with job performance; on the other hand, research findings have shown that job burnout reduces work capacity (38). In this regard, Gandi et al. also argue that job burnout affects job performance (39). Another confirming the association between job burnout and job performance is Hosseini et al.'s study, which was conducted on auditors wherein it was revealed that there is a significant negative association between job burnout and job performance (40).
The promotion of quality of work life is essential in improving organizational performance (33) and individuals' job performance, and quality of work life can be improved through an autonomous work redesign, job security, opportunities for growth, administrative and organizational justice, job enrichment and job redesign, suggestions system, employee participation, and flexibility in work schedules (41).
The quality of work life is a comprehensive and inclusive plan that enhances employees' satisfaction, promotes their learning in the environment, and helps them with tasks pertaining to management, change, and transformation. Employees’ dissatisfaction with quality of work life is detrimental to all employees, but it is relatively difficult to determine exactly what indicators are correlated with quality of work life (42). However, a study conducted in China shows that all occupational features, including autonomy, support, and feeling of worthiness should be taken into consideration by organizations so that employees will be motivated and get enabled to achieve the goals of the organization (43).  
Both job burnout and job performance may also be affected by other factors such as stress and organizational factors, in addition to quality of work life. Therefore, it is suggested that other factors should be considered in this respect for future studies.
Regarding the limitations, it is worth mentioning that, since this research was a cross-sectional study, it only addressed the relationships among factors, not the cause and consequences. Another limitation was related to the fear of disclosing information which, in some cases, could have led the participants to give unreal responses, but the attempts were made to tackle this issue by making the subjects aware of the confidentiality of the research project and the security of the data.
 
Conclusion
Quality of work life is significantly correlated with job burnout and job performance. Consequently, it should be noted that each organization needs to have employees who are physically and mentally healthy in order to achieve its goals because occupational burnout significantly affects job performance. Thus, it is possible to reduce job burnout and improve job performance through promoting quality of work life, improvement of salary payment, observance of rules and fairness in dealing with all staff, the provision of a healthy physical and mental environment, promoting employees' job status, encouraging employees to continue education, and job-time adjustment.
 
Acknowledgement
We extend our gratitude to all the colleagues at the Vice Chancellor of Research Affairs, the hospitals, and health centers for assisting us in this research project.
 
Conflict of interest: None declared.
 
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© The Author(s) 2019; All rights reserved. Published by Rafsanjan University of Medical Sciences Press.   

 
Type of Study: original article | Subject: Occupational Health
Received: 2018/12/1 | Accepted: 2019/05/4 | ePublished: 2019/07/9

References
1. Farsi Z, Dehghan Nayeri N, Sajadi A. General health status and burnout of the hematopoietic stem cell transplantation nurses in Tehran. Int J Community Based Nurs Midwifery 2013; 1(1):52-61. [Article]
2. Suner‐Soler R, Grau‐Martin A, Font‐Mayolas S, Gras ME, Bertran C, Sullman MJ. Burnout and quality of life among Spanish healthcare personnel. J Psychiatr Ment Health Nurs 2013; 20(4):305-13. [DOI] [PMID]
3. Hashemi Dehaghi Z, Sheikhtaheri A. Quality of work life and job satisfaction of nursing managers. Iran J Public Health 2014; 43(4):537-8. [PMID] [PMCID]
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