Exploring Factors that Affect the Well-Being of Healthcare Workers

While the literature on well-being has largely explored workers in different industries, and much has been written about patient well-being and quality of life in recent years, little attention has focused on the well-being of healthcare professionals. This study aims to provide a relevant state-of-the-art on the healthcare sector within the context of well-being. The paper employs a systematic literature review, following the PRISMA guidelines, to find relevant studies; the analysis of results is then provided by using Herzberg’s two-factor theory to explore factors affecting the well-being of healthcare workers. The literature review revealed that few relevant studies were conducted before the year 2013; only a recent increased attention to this theme, with a particular focus on nurses, enabled this study to confirm several factors individuated in the general literature on well-being and to highlight some other factors specific to healthcare. This paper provides suggestions to build a better and healthier work environment, highlighting that managers need to focus their attention on creating conditions that facilitate intraand interprofessional relationships, on providing healthcare workers with adequate solutions for their well-being, and on strengthening the individual employee’s identification with, and involvement in, the organization.

health (De Simone, 2015b).In healthcare systems, along with the more traditional occupational health risks, some critical challenges (e.g.exposure to infectious diseases, psychological stressors, night-call duties, and threats of malpractice) must be taken into account.A number of stressors are intrinsic to medical workplaces, including working with emotionally intense issues, suffering, fear, and death (Agarwal & Sharma, 2011).Healthcare workers now face the stress associated with increasing government regulations, malpractice suits, business aspects of medicine, increased clinical demands, less time with patients, and a rapidly expanding knowledge base; in addition, they must find ways to balance their personal and professional lives.Although it has largely acknowledged the existence of these types of stress, it is difficult to fully understand their effects on healthcare professionals' health (De Simone, 2015a).
Distress and dissatisfaction result in significant costs not only to the individual physician, but also to the patient and healthcare organization.The characteristics of the organization in which physicians practise have a substantial effect on physicians' perceptions of stress, job satisfaction, and, consequently, on their physical and mental well-being.Stress reverberates through the organizational matrix to affect the ways in which physicians think about and perform their everyday clinical work (De Simone, 2015a).
Since there is scant literature specific to the well-being of healthcare workers, this study attempted to fill this gap by exploring factors that influence the well-being of healthcare workers.A systematic literature review, with a specific focus on factors that negatively affect well-being, was conducted and analysed through the approach Herzberg used in his two-factor theory (Herzberg, Mausner, & Snyderman, 1959).
In this way, the present study contributes to the literature on well-being in general and, more specifically, to a state-of-the-art theme on the well-being of healthcare workers.
The paper is structured as follows: The next section describes the key concepts of Herzberg's two-factor theory (Herzberg et al., 1959), and the Method section illustrates the steps that were used to complete the literature review.The results and discussion are then provided, followed by the conclusions and possible future directions for research.

Herzberg's Two-Factor Theory
Herzberg's two-factor theory (also known as Herzberg's motivation-hygiene theory; Herzberg et al., 1959) maintains that there are some factors which operate independently on job satisfaction (motivators) and on job dissatisfaction (hygienic factors).According to Tosi and Pilati, Hygiene factors create dissatisfaction if they are not present.If they are present in a job setting, dissatisfaction will be lower, but satisfaction will not be high.Hygiene factors are associated with the context of a job…Motivators are related to high satisfaction and willingness to work harder.When they are present, these job factors may induce more effort, but if they are absent, it will not produce dissatisfaction in most people.Motivators are associated with the content of the job.(2011, p. 85) The presence of motivating factors generates job satisfaction, while their absence has no impact on job dissatisfaction.Without motivators, employees will perform their jobs as required; with motivators, however, employees will increase their efforts and exceed the minimum requirements.In contrast, the presence of hygienic factors has no impact on satisfaction, while their absence generates dissatisfaction.Herzberg's (1959) theory is well-suited to the aim of this study for two main reasons: -Given the particularity of the context, healthcare workers need continuous stimuli to maintain high levels of motivation, satisfaction, and well-being.

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The theory supports the relevance of factors that negatively influence job satisfaction, motivation, and, in turn, employee well-being.
In this paper, the presence of negative factors is considered to be as the absence of hygienic factors: The latter, in fact, generates job dissatisfaction and a decrease in employee motivation; similarly, the presence of negative factors generates dissatisfaction and, in some cases, leads to employee malaise.
In addition, one must also consider the following two criticisms of Herzberg's (1959) theory: first, it does not recognize individual perceptions of the factors that influence satisfaction; second, it does not move on a continuous scale from satisfaction to dissatisfaction.However, this study considers only those aspects related to the presence/absence of factors that undermine employee well-being.

Research Method
To find contributions on organizational well-being specific to healthcare workers, a systematic literature review was conducted following the PRISMA guidelines and according to the recommendations of Khan, Kunz, Kleijnen, and Antes (2003).Using keywords, the research was conducted on PubMed, Scopus, and ISI Web of Knowledge research engines, respectively.The results were then integrated via a second keyword search using the research engines of six journals.Most of the results, however, were obtained via the first keyword search.
The review process was completed using the following five steps (Khan et al., 2003): 1. Framing questions for a review by establishing useful keywords.
2. Eliminating duplicates and identifying relevant studies by selecting titles and abstracts.
3. Assessing the quality of studies by analysing full papers.

Interpreting the findings.
Pertaining to the general situation, the following inclusion criteria have been followed:

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Articles or reviews related to the theme of well-being for healthcare professionals; • Articles or reviews related to possible solutions to manage employee' malaise.
Indeed, the following exclusion criteria have been used: • Articles or reviews published in a language other than English; • Articles or reviews that do not consider the well-being in the specific context of healthcare organizations; • Articles or reviews that do not clearly meet the research subject and its purpose.
In more detail, the keywords used were "well-being" AND "healthcare workers" and "well-being" AND "hospital workers."The research was conducted by looking at all previous literature, and no time limit was set for this process.
In total, 124 articles emerged from the first step: 19 from PubMed, 47 from Scopus, 16 from ISI Web of Knowledge, and 42 from single journal research engines.
After eliminating duplicates, the second step consisted of selecting relevant studies by searching for keywords ("well-being" or "workplace" or "healthcare" or "employees" or "professionals" or "hospital" or "doctors" or "nurses") and coherence with the aim of this paper based on titles and abstracts (including results concerning specific topics on organizational well-being, such as burnout, depression, and stress).This step provided 21 articles.
The full-text analysis in Step 3 looked for the coherence of the articles by searching for a focus on organizational well-being for healthcare workers.Based on this analysis, two articles were discarded, since one focused on the comparison of two different measurement tools for organizational well-being, and the other focused on U.S. healthcare sector cost management.The selected 19 papers were then cross-referenced to find other relevant studies.After the cross-referencing, 11 articles that were cited at least two times proved to be consistent with the aim of this work.Thus, the final database comprised 30 papers.Figure 1 shows the review process from Step 1 through Step 3.   Considering the specific professional categories analysed, an interesting result to highlight, excluding the general reference to "healthcare or hospital workers" (13 articles), is the specific focus on nurses (7 articles).This focus could be mainly related to the fact that nurses experience prolonged exposure to stress or frustration at work.Despite increased professionalism in nursing and the increased emphasis on accountability in the clinical setting, many nurses perceive that their autonomy continues to be restricted.This may be due to the fact that a significant portion of work in nursing overlaps that of the medical profession.Possible reasons for insufficient autonomy in nursing are the patriarchal dominance of the medical professional and adherence to an outdated, bureaucratic style of management (Finn, 2001).Restricted autonomy can, in turn, limit the well-being of nurses.
An analysis of the articles clearly revealed a classic twofold approach to well-being that considered aspects related both to individual and organizational/context characteristics.
On the individual side, several authors (Gosseries et al., 2012;Kilfedder et al., 2001;Mason et al., 2016;Preposi Cruz, 2016;Sancassiani et al., 2015;Tepas et al., 2004;Tuisku et al., 2016) highlighted several physical and mental conditions/factors that influence well-being, with a particular emphasis on physical exhaustion, anxiety, depression, stress, and burnout.Sleep disorders comprise the factor that is specifically highlighted with respect to healthcare workers (Poissonnet & Véron, 2000;Rose & Glass, 2009), especially considering the effects of night shift-work and difficult work schedules.Some authors underlined the role of leisure activities and other off-job experiences in buffering the negative effects of the reported factors (Tuisku et al., 2016), since an improved general quality of life may positively affect employee well-being (Preposi Cruz, 2016).
The risks of hazard and injuries are particularly related to the perception of safety while working (Markwell and Wainer, 2009;Nixon et al., 2015); this is particularly true for the healthcare context since doctors and nurses are constantly in contact with patients that may suffer from different diseases.
Shift-work can impact on the three following aspects: the conflict between work-to-family and social life, physical well-being, and mental well-being (Barnes-Farrell et al., 2008;McVicar, 2003;Tepas et al., 2004).These aspects are particularly emphasized in cases of night shift-work (Tepas et al., 2004), with a reported higher health risk, as it produces symptoms that correspond closely to those of mild or moderate distress (McVicar, 2003).
Again, among organizational aspects affecting well-being, it is of interest to note Suresh et al.'s (2013) conclusions regarding inadequate preparation and training: In their study, the authors analysed stress and stressors among nurses and found that, in particular, nurses felt inadequately prepared in terms of clinical skills, knowledge, and emotional bearing.
More generally, relevance is placed on social aspects due to the great amount of time healthcare workers spend at work with their colleagues, in 12-or 24-hour shifts, sometimes combined, thus leading nurses and doctors to work for 36-48 hours consecutively.In fact, social relationships may undermine individual well-being, considering such aspects as mobbing, bullying, and uncivil behaviours from colleagues and superiors (Einarsen & Matthiesen, 1998;Galletta et al., 2016;Niedl, 1996;A. Yildirim & D. Yildirim, 2007).
Social aspects also represent a solution to the main causes of employee malaise: Several authors have underlined the importance of creating work environments that encourage employees to openly express their emotions to colleagues and managers and of offering training sessions on emotionally demanding work to make employees and managers more conscious about managing emotions (Coates & Howe, 2015); again, Jakobsen et al. (2015) found that social relationships and psychological well-being benefit from organized physical exercises at the workplace, since such exercises represent a social experience shared by employees.A positive work environment can help to improve outcomes by creating a positive perception of how processes are made, reducing work stress, and encouraging innovations as a response to environmental and organizational change (De Simone, 2014b).
The goal-sharing by organizational members engenders a positive climate that serves to increase organizational identification and to develop stronger relationships in the organization that in turn foster higher levels of organizational growth and performance (De Simone, 2014b).
Positive emotions engender social interactions: The emotional climate has important consequences for individual employees and for the organization as a whole.Organizational norms and the constructive use of emotion management are essential for developing and maintaining an emotional climate that enables individual well-being (De Simone, 2013a; 2013b).
Psychological capital (e.g.optimism, hope, and resilience) favourably influences employee attitudes, behaviours, and organizational change, especially through positive emotions.Cognitions fostered by positive emotions such as gratitude and appreciation contribute to increased organizational identification.When employees work together, they can encourage new ideas, share goals, and generate learning.Gratitude motivates and reinforces social actions, in both the giver and receiver of help, by inspiring positive actions.When an organization continues to cultivate a positive emotional climate, it will derive benefits from an increase in the strength of interpersonal relationships (De Simone, 2014b).

A Possible Framework of Factors Affecting the Well-Being of Patient Care Workers
Starting with the aspects arising from the literature review, we identified negative factors affecting the well-being of healthcare workers (see Table 2).The first implementation to consider, which is discussed in the literature, is the recognition of individual-and organizational/context-related factors that affect well-being.In turn, individual related factors may be distinct in physical and mental conditions, while organizational/context-related factors may be distinct in job tasks, demand and control, relationships with colleagues and superiors, and organizational environment.Véron, 2000;McVicar, 2003) strain due to schedule (e.g.Estrynbehar et al., 1990) number of working days (e.g.Barnes-Farrell et al., 2008) work-life balance (e.g.Barnes-Farrell et al., 2008) lack of autonomy (e.g.Markwell & Wainer, 2009) inadequate training (e.g.Estrynbehar et al., 1990) bureaucratic environment (e.g.Coates & Howe, 2015) Insufficient flexibility in managing working hours (e.g.Coates & Howe, 2015) workplace incivility (e.g.Galletta et al., 2016) Considering the factors reported in Table 2 under Herzberg's approach, we might affirm that the presence of such negative factors strongly undermines employee job satisfaction, organizational citizenship behaviour, motivation, and well-being.For example, above all, the lack of safety and the risk of injuries represent critical factors within healthcare contexts.Again, a context characterized by mobbing and bullying has a strong impact on psychological well-being and on job satisfaction.In a certain sense, considering that the absence of hygienic factors generates dissatisfaction, one could consider these (negative) factors as hygienic factors, since their presence generates dissatisfaction while their absence will not improve individual performance: It would be considered "normal" a work context where bullying and mobbing are not present.
Even the presence of other factors (e.g.distributive justice, recognition, and support) is interpreted as "normal": Martínez-Íñigo and Totterdell (2016) highlighted the importance of a distributive justice on exhaustion and on employees' well-being.
On this point, also other authors highlighted the prominent role of a distributive justice: for instance, Chenevert et al. (2013) contend that procedural and interactional justices have an indirect effect on exhaustion through distributive injustice, and that exhaustion, in turn, may generate absenteeism.Thus a greater sense of justice should be promoted by healthcare managers to increase employees' perception of procedural and interactional justice, and indirectly reduce exhaustion and absenteeism.
Indeed, the possibility of balancing work and private life within the healthcare context, which is characterized by long shifts, would be considered a "motivator," as would be increased autonomy and a reduced bureaucratic work schedule.
In conclusion, a reciprocal influence among these factors must also be recognized, as the presence of some contextual factors may generate the presence of some individual factors (e.g. the influence of work duration and shift work on physical exhaustion); on the other hand, even some individual factors may influence organizational/contextual factors (e.g.depression and stress may lead to perceived role uncertainty and conflict with colleagues and superiors).

Conclusions and Directions for Future Research
The aim of this paper was to obtain a state-of-the-art theme of well-being in the healthcare sector and to provide a complete framework of factors that affect the well-being of patient-care workers.
Through the analysis presented, this paper contributes to the general theme of employee well-being, and more specifically to the healthcare sector, by providing an updated literature review.
In particular, this study proposes an integrated view of well-being for healthcare workers by reviewing previous literature on the main factors influencing employee well-being.The analysis revealed several factors that negatively influence well-being, thereby providing the basis for a framework (see It must be recognized that the present findings were influenced by the significant number of articles focusing on nurses and thus might not be easily generalized to all healthcare professionals; however, it should also be highlighted that an integrated view of factors influencing well-being (despite the different categories) could better help healthcare organizations in searching for overall solutions for dealing with employee malaise.In fact, the review supported the notion that a combination of organizational, professional, and individual factors interact to determine the psychological well-being of healthcare workers.In addition, personal traits have a great influence over factors perceived as negative to well-being; thus, one should conclude that reported factors may be perceived differently, not only considering different professional categories but even considering different individuals within the same professional category.In fact, personal resources (e.g.self-efficacy, organization-based self-esteem, and optimism) were found to partly mediate the relationship between job resources and work engagement (Xanthopoulou, Bakker, Demerouti, & Schaufeli, 2007), and provide individuals with the ability to control and impact their environment successfully (Bakker, Demerouti, & Verbeke, 2004;Demerouti, Bakker, Nachreiner, & Schaufeli, 2001).
The real challenge for organizations is not to consider employees well-being as something fixed, since a high level of complexity characterizes both work contexts and individual characteristics.In fact, it is possible to assert that employee well-being is something dynamic rather than static and may vary over time and space, in the sense that personal conditions of employees may vary over time with respect to family conditions, health, economic situations, etc., and that workplace conditions as hygienic and hazard situations may vary from department to department even within the same organization (De Simone, 2014a).This is particularly true for patient-care workers who, every day, face significant emotional and work demands in hazardous contexts and have to continuously balance these work demands with those of their private lives.
Distress and well-being are intimately associated with factors essential to building an economically healthy and thriving healthcare organization, including the provision of good medical care (De Simone, 2015a).
Although individuals are responsible for their own wellness, healthcare organizations can play an important role in promoting worker well-being.In order to build a better and healthier work environment, managers need to focus their attention on creating conditions that facilitate intra-and inter-professional relationships, on providing healthcare workers with adequate breaks and more time to recover energy during the workday, and on strengthening the individual employee's identification with, and involvement in, the organization.This requires long-term commitment to resourcing, to workforce planning, and to achieving strategic aims.Cohesive ward teams developed with the leader's capacity to support staff who must cope with heavy workloads are also needed to achieve health improvements (De Simone, 2015a).Another solution, may result in considering the possibility of better involving employees in the decision-making process in order to increase their perception of procedural and interactional justice, and indirectly reduce exhaustion and absenteeism through a greater perception of distributive justice (Chenevert et al., 2013).
The present article suffers the typical limits of literature reviews, since different keywords may generate different results, both in the first step of research and in the following steps of the article-discarding process.
This study highlights the importance of conceptualizing employee well-being as a complex juxtaposition of individual-and organizational/context-related factors that can vary based on the different personal traits of individuals.All these factors are important when assessing employee well-being.Hence, a first suggestion for possible future research may be to assess the impact of all the factors reported in Table 2 in order to test a possible integrated model of well-being for healthcare workers.A further direction can be to evaluate the different impacts of these factors on the two patient-care categories (doctors and nurses).The focus on these differences may be of interest to managers while providing them with greater incentive to attend to organizational well-being.
Again, considering the significant weight social interactions have in the healthcare context, future studies might analyse personal/workplace interactions in more depth: It is unreasonable to expect any individual to separate the workplace from their personal lives; more research is needed to identify how personal circumstances exacerbate workplace stress and how they may be used to reduce stress.Also needed are preventative support services to assist nurses in their efforts to avoid health issues.This requires more research to identify the most effective way of detecting when individuals are experiencing early difficulties and thereby to improve their stress management techniques in order to prevent a transition to severe distress.
Figure 1.Lite physical exercise at the workplace has positive effects on the social relationship among colleagues and on the psychological well-being of the individual with /management style, professional conflict and emotional cost of caring, lack of reward, and shift work Niedl stress and its impact on well-being nurses comparative descriptive study; t-test and ANOVA stressors include excessive paperwork, meeting deadlines, frequent interruptions,

Table 1
The following table presents the results of the literature review, including the author(s), main topic, healthcare workers observed, method of analysis used, and factors influencing well-being/main results of the study.

Table 1 .
Literature review summary of results.

Table 2 .
Factors negatively influencing well-being of healthcare workers Table 2) through which both individual-and contextual/organizational-related factors were highlighted.The results confirm several factors that have been individuated by the literature in other domains; in addition, the study revealed other aspects of specific interest to healthcare sectors (e.g. the bureaucratic environment, shift-work [with particular emphasis on night shift-work], and the lack of safety).