Work-Life Conflict and Psychological Health Among Healthcare Sector Employees: A Comparative Study of Employees of Public and Private Hospitals

Sombala Ningthoujam
Associate Professor, The Institute of Banking Personnel Selection, Mumbai, Maharashtra, India. E-mail: drsombala@gmail.com

Teena Singh
Associate Professor, Department of HR & OB, New Delhi Institute of Management, New Delhi, India. E-mail: teena.singh@ndimdelhi.org

Vikas Gautam
Associate Professor, Department of Marketing & Strategy, IBS Hyderabad (Under IFHE - A Deemed to be University u/s 3 of the UGC Act, 1956), Hyderabad, Telangana, India; and is the corresponding author. E-mail: vgautam78@gmail.com

Anupama D Raina
Deputy Director, ICFAI Business School, Gurgaon, India. E-mail: anupamar@ibsindia.org

Maria Zafar
Research Scholar, IIT Delhi, Delhi, India. E-mail: mariazafar7595@gmail.com

In the current situation of Covid-19, it is clear as to how health professional warriors are fighting against disease, distress, social discrimination and many atrocities while upholding their profession and compassion. Moreover, they are exposing themselves to the risk of infection and death to save the lives of patients from a life-threatening disease. The study examines the relationship between work-life conflict and psychological health of healthcare sector employees and the flexible workplace arrangement. Further, it examines if there is any difference between those employed in public hospitals and those in private hospitals. Comparison of means using t-test, means, frequency and correlation analysis is done in order to achieve the study objectives. The results confirm low levels of overall conflict as well as family-work and work-family conflicts. With regard to comparison between government and private hospitals, a significant difference is found between the two at burnout levels only and not in terms of conflict and health.

Introduction

Greenhaus and Beutell (1985) conceptualized Work-Family Conflict (WFC) as a form of inter-role conflict that arises when one's work and family roles interact and result in three sources of conflict: time-based, strain-based, and behavior-based, while investigating the work-life balance of doctors in the UK from the perspective of trainers and trainees.WFC is said to occur when one's work-related demands and responsibilities make it difficult for them to fulfil their family roles and responsibilities. Family-to-work Conflict (FWC) is the opposite (Pickering, 2006). Haar et al. (2014) found WFC to be positively associated with job as well as life satisfaction and negatively associated with anxiety and depression. They found these relationships across seven cultures. Further, examining the role of culture, they found two variables moderating these relationships:

individualism/collectivism and gender egalitarianism. WFC has been found to be a potential cause of undesirable work-related outcomes like work dissatisfaction (Carlson and Kacmar, 2000), absenteeism, and intention to change jobs (Allen et al., 2000). Most studies have further identified work and/or family demands and responsibilities towards dependents as antecedents, gender and social support as moderators, and job satisfaction, job performance, and physical and psychological health as consequences of work-life balance (Brough et al., 2014).

A few studies have also focused on the role of culture and found that WFC has a less negative impact on individuals living in collectivistic cultures as compared to those in individualistic cultures (e.g., Spector et al., 2004; and Lu et al., 2010). Brough et al. (2014) found WFC to be negatively associated with work demands, turnover intentions, and psychological strain, and positively associated with family as well as job satisfaction. Tasdelen-Karckay and Bakalim (2017) have shown work-life balance to be a mediator in the relationship between WFC and life satisfaction, as well as between family-work conflict (FWC) and life satisfaction.

Healthcare professionals play an important role as frontline warriors in pandemic situation and work continuously without tiring in a stressful situation, while staying away from family for a long period of time. Healthcare professionals often have to work long hours and odd shifts, and experience a conflict between their personal and professional roles (Shivakumar and Pujar, 2016). Nurses also have to sometimes work in poor working environment with extreme workload (Nurumal et al., 2017). Other consequences included high levels of job stress (Sehlen et al., 2009), increased burnout (Shanafelt et al., 2015), higher emotional exhaustion (Umene-Nakano et al., 2013), and reduced job satisfaction (Cortese et al., 2010).

In today's economic setting, doctors who work round the clock to save human lives, compromise on their personal obligations. Research indicates that doctors' workload is too heavy and as a result it leads to poor work-life balance and reduced job and life satisfaction (Kaliannan et al., 2016). A heavy workload means they have less time and energy available for their family and other non-work-related activities (Swanson et al., 1998). Shanafelt et al. (2012) found that out of about 7000 US physicians, roughly 46% reported at least one symptom of burnout. When compared with the general working US population, physicians were found to be more likely to experience symptoms of burnout as well as dissatisfied with their work-life balance.

Specifically, among women healthcare professionals, Goyal (2014) found that more than half of women nurses and doctors perceive their career development to have slowed down due to family responsibilities. An even greater proportion reported difficulties managing household and work responsibilities. Okoshi et al. (2013) also reported that female doctors work while carrying out greater household and child-rearing responsibilities as against their male counterparts. Pas et al. (2011) noted in their study of Dutch female doctors that offering family-friendly HR practices such as flexible working hours gives scope for improving work-life balance.

Even among medical professionals, comparisons have been made between surgeons and other physicians. Okoshi et al. (2012) found that surgeons tended to work longer hours and for lower incomes. Surprisingly, however, they tend to have low fatigue levels and were satisfied with their working environment. Turner (2017) investigated the coping strategies adopted by medical doctors to manage work-life balance and gender differences amongst the male and female medical doctors in Nigeria. It was found that work in the medical sector is intense and is characterized by long working hours, intense work demand and staff shortage. Women particularly have to work harder to achieve a 'delicate balance' between subordination to male authority, domestic responsibilities and ambition/achievement in a professional career.

One of the factors associated with work-life conflict that has not received much attention is psychological health. Hence, this study proposes to examine the relationship between work-life conflict and psychological health of healthcare sector employees. Moreover, this study will address differences between employees of public and private hospitals with reference to work-life conflict, psychological health and burnout.

Literature Review

Flexible Work Arrangement (FWA)

FWA can simply be understood as work-related options that allow one certain amount of flexibility with regard to "where" their work is done (i.e., telecommuting or flexplace) and/or "when" their work is completed (flextime or scheduling flexibility) (Rau and Hyland, 2002). Flextime and flexplace can further be differentiated in terms of availability and use. The distinction becomes important when one realizes that all users of FWA seemingly have FWA available, but not everyone who reports FWA availability is a user. Furthermore, the use versus availability distinction differs in the context of WFCs.

Logically, the use of FWA should be more strongly associated with less WFCs than simply the availability of FWA. Research suggests that the availability of FWA is associated with more positive job attitudes (Grover and Crooker, 1995) as well as positive attitudes towards one's organization (Batt and Valcour, 2003). Such findings are in line with the Social Exchange Theory: that is, employees appreciate having flexibility available to them in their work and, therefore, they exhibit favorable attitudes toward the organization. Availability of FWA also increases employees' perceptions of psychological control which can help alleviate their experience of WFCs; FWA use, along with its availability, further increases perceptions of psychological control (Kossek et al., 2006). This can be understood in terms of the Resource Allocation Theory: the use of flexibility will empower employees to effectively be able to manage both work and family roles and responsibilities.

The two ways in which flexibility may be made available to employees are not interchangeable. Aggregating them to form a single construct, thus, may involve risk of masking differential effects, if any. The existing literature fails to accurately capture this distinction. Gajendran and Harrison (2007), for example, had a distinct focus on flexplace, while Mesmer-Magnus and Viswesvaran (2006) included as part of flexibility both the "flexibility of work location and schedule" (p. 561). Michel et al. (2011), on the other hand, included multiple aspects (schedule flexibility, flexitime, telecommuting, and shift work) of flexibility as part of their variable of interest. Lastly, Byron (2005) studied "schedule flexibility."

Measurement of Work-Life Conflict

Kahn et al. (1964) defined inter-role conflict as a form of conflict in which the roles and pressures associated with one's membership of one group gets in conflict with those arising out of membership in other group(s). Greenhaus and Beutell (1985) specifically conceptualized WFC as a form of inter-role conflict that arises when one's work and family roles interact and result in three sources of conflict: time-based, strain-based, and behavior-based.

A time-based conflict is said to occur when the time that one dedicates to one role makes it difficult for them to fulfil the requirements of their second role. Strain-based conflicts, on the other hand, occur when the strain one experiences from one role makes it difficult for them to fulfil the requirements of a second role. Lastly, behavior-based conflicts happen when the specific behaviors required in one role makes it difficult for the person to fulfil the requirements of another role. Along similar lines, Netemeyer et al. (1996) defined WFC as a form of inter-role conflict in which the general demands of time devoted to and strain created by one's job interfere with their ability to perform their family-related responsibilities. Various validated scales to measure WFC exist today.

Psychological Health

Ofili et al. (2004) studied the psychological health of doctors in Nigeria. They found 14% of them to be at an increased likelihood of having a psychological disorder. Further, more than half of their respondents (54%) reported dissatisfaction with their jobs. Michie and Williams (2003) reviewed studies on work factors and psychological ill-health of healthcare workers. They found important work factors associated with psychological ill-health to be long working hours, work overload and pressure, lack of control over work, lack of involvement in decision-making, poor social support, unclear management, and ambiguous work roles.

Interventions that increased participation in decision-making and problem solving, increased support and feedback, and improved communication were found to be successful in improving psychological health. Poor psychological health of doctors is a cause for concern as it has been associated with healthcare provided by these professionals (Firth-Cozens, 2001).

In China, He et al. (2012) found doctors and nurses to have relatively poor health as compared to the general population with respect to usual activities, self-reported pain or discomfort, and anxiety or depression. Not just trained and working doctors and nurses, but medical students too have been studied by researchers to explore their stress levels, workload and psychological health. Ofili et al. (2009), for example, explored stress and psychological health of medical students; they found an overwhelming number of students (86%) to feel that medicine was a stressful course, such that almost 32% students even reported that given a second chance, they would not opt to study medicine again. Dissatisfied students were also found to be more likely to have some form of psychological disorder as compared to satisfied students.

Studying emotional distress in doctors, King et al. (1992) found that most doctors experience some form of emotional distress, to which pressures from work greatly contribute. They also brought to attention the hesitation of doctors in seeking available professional help for their psychological issues, making it imperative that the management should take a proactive role in helping their staff prevent and manage their distress. Doctors working in emergencies are likely to be exposed to greater stress and work pressures. Erdur et al. (2006) found doctors working in emergency units in Turkey to exhibit considerable anxiety and depression levels. They further found not having a hobby and having high anxiety to significantly contribute to symptoms of depression, while being a woman, having low income and high depression score significantly contributed to anxiety levels.

Interestingly, even among non-physician employees of medical institutes, psychiatric morbidity has been found to be high, with the severity of psychological distress being negatively associated with job satisfaction (Lee et al., 2009). Among the different disorders studied, the prevalence of insomnia was highest (28.36%), followed by depression, hostility, anxiety and inferiority. Problems like anxiety and depression are also found among physicians. Gong et al. (2014) found anxiety and depressive symptoms to be common among physicians in China, with these symptoms also being associated with poor self-reported physical health, frequent workplace violence, lengthy working hours, frequent night shifts, and lack of regular physical exercise.

The healthcare sector comprises an even greater challenge to researchers studying work-life conflict as the employees here (doctors, nurses, paramedics, etc.) face special work demands not necessarily experienced by those in other sectors. Healthcare workers often have to work long hours and odd shifts, and experience a conflict between their personal and professional roles (Shivakumar and Pujar, 2016). Nurses also have to sometimes work in poor working environment under conditions of extreme workload (Nurumal et al., 2017). Other consequences include high levels of job stress (Sehlen et al., 2009), increased burnout (Shanafelt et al., 2015), higher emotional exhaustion (Umene-Nakano et al., 2013), and reduced job satisfaction (Cortese et al., 2010).

Burnout

Burnout is the result of exposure to chronic stress or permanent organizational situations that lead to repetitive stress and deplete the resources available to individuals to cope (Maslach and Schaufeli, 1993; Schaufeli et al., 1993; and Truchot, 2004). The term burnout was first coined by Freudenberger (1974) to describe the emotional exhaustion that is experienced by workers employed in public services. Although the initial focus was on emotional exhaustion, Maslach and Jackson (1986) later conceptualized burnout as a three-dimensional construct.

Burnout is now understood as comprising emotional exhaustion (weakening of the resources one uses to cope with stress), depersonalization (cynicism or disengagement), and reduced personal accomplishment (poor work performance). According to Maslach et al. (1996 and 2001), burnout is a process in which an individual first depletes their emotional resources, and this gradually leads to their disengagement from the tasks at hand. This conceptualization, thus, introduces the idea of a phase of cynic depersonalization which results in loss of fulfilment at work (Lee and Ashforth, 1996; and Maslach and Jackson, 1981). In the present study, the authors have adopted the Maslach Burnout Inventor Scale (MBI) (Maslach et al., 1996). The scale measures burnout across three dimensions: emotional exhaustion, depersonalization, and personal accomplishment.

Many work-related factors can lead to high burnout. Bawa and Kaur (2010) identified some of these factors: higher role conflicts, unrealistic group and political pressures, under-participation, strenuous working conditions and overall occupational stress. Job demands, job resources, and work-family pressures are other significant predictors of burnout (Martinussen et al., 2007). Besides personal and work-related variables, organizational issues such as work-home imbalance, lack of consultation and communication, no control over one's workload, inadequate support, and very high workload are also important stressors (Collins and Gibbs, 2003).

Objectives

• To examine the relationship between work-life conflict, psychological health and burnout among the healthcare employees.
• To compare work-life conflict among employees of private and public hospitals.

Data and Methodology

The study adopted cross-sectional, descriptive and correlation research design. The study was conducted among 73 healthcare professionals working in private and public sector hospitals in the NCR region. Primary data was collected with the help of a structured questionnaire (see Appendix) by using purposive sampling method. Permission was taken from respondents to participate in the study. WHO-5, Wellbeing scale, Maslach Burnout Inventory scale and Work-Life Conflict scale by Netemeyer et al. (1996) were used for the study. Comparison of means using t-test, means, percentage and correlation analysis was done in order to achieve the study objectives.

As shown in Table 1, most (60.3%) of the participants were employed in private hospitals, while only 39.7% were government hospital employees. The sample comprised more females (56.2%) than males (43.8%), more younger age group individuals (58.9%) than older age group (41.1%), and more single (68.5%) employees than married ones (31.5%).

It can be seen from Table 8 that flexitime is the only facility with the highest frequency for being both available and used. Facilities not available and also not needed are compressed work week, telecommuting, part-time work, on-site child-care, and child-care information/referral services. Most importantly, two services can be seen most commonly marked as not available but needed: subsidized local child-care and paid maternity leave/paternity leave.

Discussion

The study aimed to explore work-life conflict among healthcare professionals in India. The authors looked at how work-life conflict differs across various demographic factors like kind of hospital (public vs. private), gender, age group, and marital status. Since the review shows that work-life conflict is associated with various desirable outcomes, the study also examined its association with psychological health and burnout. Finally, the study assessed what facilities for ensuring work-life conflict are available to employees. As shown in Table 2, the sample shows low levels of overall conflict, as well as family-work and WFCs as measures of work-life balance. One reason for this may be that most

of the participants were established practitioners and not newcomers-older doctors, who had been working for a long time, perceive their work-life balance as more favorable compared to younger doctors who are still in training (Kaliannan et al., 2016). On emotional exhaustion, depersonalization, and burnout also, participants have demonstrated low to average levels-which may be due to low levels of work-life conflicts and also employees have a clarity of how well they are doing in their jobs and how their works have substantially impacted the lives of other people, and reported less burnout and higher personal adequacy and accomplishment (Maslach et al., 1996).

Previous studies have also found work-life balance to be negatively associated with anxiety and depression (Haar et al., 2014), psychological strain (Brough et al., 2014), and burnout (Young, 2013). Finally, personal adequacy and health dimensions showed average to high means for the study sample. Contrary to what previous studies show, the current study found low levels of conflicts and psychological ill-effects, and high levels of psychological health.

With regard to comparisons between government and private hospitals (Table 4), a significant difference was found between the two on burnout levels only and not conflict and health. On burnout levels, government hospital employees were significantly higher than private hospital employees. One reason for this may be that in government hospitals, doctors and nurses have to see more patients, infrastructure and facilities available to them may not be as good as those available to workers in private hospitals; and less monetary benefits. Further, public and private hospitals also differ in terms of close supervision, work safety and support (Addagabottu and Battu, 2015), factors which may also have an influence on their work-life balance. On conflict and health, however, there is no significant difference. Both report low levels of conflict and high levels of health. With regard to gender, contrary to previous studies, no significant difference was found in any of the three variables (Table 5).

Another demographic variable on which significant difference was obtained was marital status (Table 6) such that married employees were significantly lower than single employees on health. Although not statistically significant, married employees were higher than single employees on conflict levels. Because these employees have greater family responsibilities and are more likely to experience work-life conflicts even when their work responsibilities are the same as that of single employees, they may be experiencing poorer health.

The poor health may be a result of stress experienced due to conflicts or even lack of time for seeking check-ups or treatment. Single employees, on the other hand, have fewer family responsibilities and thus would be less likely to experience work-life conflict even when demands of work are very high. This may in turn be associated with their high health levels.

Finally, age group differences were also looked at between employees in the age groups 21 to 35 years and 36 years and above (Table 7). As shown, younger employees were significantly higher on conflict levels as compared to the older age group. No significant difference was found in health and burnout levels. WFC has a less negative impact on individuals living in collectivistic cultures as compared to those in individualistic cultures (e.g., Spector et al., 2004; and Lu et al., 2010). The younger generation today is more individualistic and self-centric than the older ones, which may be contributing to their higher conflict levels.

Collectivistic individuals/cultures tend to view work also as an integral part of life, the way family is, and would not mind putting in extra time and effort, even at the cost of personal and/or family time. But among individualistic individuals/cultures, the demarcations and boundaries are more concrete and thus conflicts would be more likely to be experienced.

The associations between work-life conflict, health and burnout levels were also examined. As shown in Table 7, the only significant negative association was that between work-life conflict and health (r = -0.24). All the correlation coefficients, however, were small in magnitude/strength. Lastly, the study used frequency analysis (Table 8) to identify which work- life balance facilities are available, used and needed by employees. Flexitime is the only facility with the highest frequency for being both available and used. Facilities not available and also not needed are compressed work week, telecommuting, part-time work, on-site child care, and child care information/referral services. Most importantly, two services can be seen most commonly marked as not available but needed: subsidized local child-care and paid maternity leave/paternity leave.

Conclusion

The current study found that healthcare workers in India enjoy, on an average, low levels of conflict and its associated negative outcomes. Differences in burnout, health, and conflict levels were found between different groups in terms of type of hospital, marital status, and age, respectively, thus highlighting the role of demographic factors. Gender differences, however, were not found to be significant on any variable. Significant and negative correlation was also obtained between conflict and health. Finally, the study identified subsidized local child-care and paid maternity leave/paternity leave as two facilities that employees need but which are not available to them. Also, there are studies which focused on intervention strategies for reducing burnout among doctors like work engagement, identified in occupational health psychology as preventative measures against burnout (Baker et al., 2008) and building resilience as a preventative strategy against burnout among doctors (Carver, 1998).

Limitations and Future Scope: The study has examined the work-life conflict of healthcare employees and also the relationship among work-life conflict, psychological health and burnout among the healthcare employees. Further, it also compared work-life conflict among employees of private and public hospitals. Nevertheless, the study explored the work-life facilities available in the healthcare sector.

Firstly, the data was collected from employees of heathcare sector in the National Capital Region of India. Therefore, the direct results of this study are limited to this geographical location only. Further, the dominance of private sector hospitals in this part of country may not represent the actual image to all. Thus, an expansion of this study to the national level would be useful in further examining the usefulness of the conceptualization of work-life balance used in this study. Furthermore, empirical research at a pan-India level with a focus on strategic reformation of the human resources policies specifically in the healthcare industry is critical to distinguish and resolve the prominence of work-life balance problems. It is a well-known fact that in this industry, the retention of healthcare talent is a very difficult task, hence there should be efforts by the future researchers to identify current worldwide employment trends as well as to incorporate work-life balance policy in the Indian context. Future in-depth research and exploration in this area is needed to further examine role-specific differences among all employees of healthcare sector for streamlining all activities and achieving overall success.

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