Article

Determinants of Work Journal of Health Management

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Engagement Among Nurses © 2019 Indian Institute of
Health Management Research
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DOI: 10.1177/0972063419868556
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Mansi Rastogi1

Abstract
The present empirical study examines the effects of home and work domain resources (family–work
enrichment and supervisor’s support) on work engagement among nurses using the perspective of
job-demands resources model. Considering the dearth of literature in government health-care sector
especially in North Eastern Region (NER) of India, the study was conducted in Assam. Data were col-
lected using structured questionnaires from government hospitals. The results of multiple hierarchical
regression indicated that family–work enrichment and supervisor’s support both play a significant posi-
tive role in enhancing the work engagement levels among nurses. Thus, both hypotheses were sup-
ported. Limitations, future scope and conclusion are discussed.

Keywords
Nurses’ well-being, work engagement, Northeast India, healthcare

Introduction
Nursing is one of the most stressful professions of the world (Decker, 1997). Nursing professionals are
encountered with highly negative emotions such as sufferings, deaths and miseries on a regular basis,
while, at the same time they have to perform certain routine tasks (McGrath, Reid, & Boore, 2003).
Nurses play a vital role in critical health-care services. Their round the clock presence, intuitive exper-
tise and cautiousness enable specialists to improve, analyze and propose better treatment. Despite
their vital role in medical service domain, the healthcare industry is facing a critical shortage of health
workforce across the globe such as England (Connolly, 2018), Australia (Harrington & Jolly, 2013),
Canada (Steeves, 2018), China (Wu, Zhao, & Ye, 2016) and the USA (Varona, 2017). The lack in
health workforce is expanding the workload on the current workforce which may lead to negative

1
Department of Management Studies, National Institute of Technology Silchar, Assam, India.

Corresponding author:
Mansi Rastogi, Department of Management Studies, National Institute of Technology Silchar, Assam, India.
E-mail: mansi.dims@gmail.com
2 Journal of Health Management

outcomes also like turnover in most of the countries (World Health Organization [WHO], 2006).
According to an analysis by Indian Nursing Council (INC) and the World Health Organization (WHO),
the shortage number of nursing staff reached up to 1.94 million in India (IndiaSpend, 2017). The
shortage of nurses has resulted into adverse effects in medical health-care facilities in many Indian
states (IndiaSpend, 2017; Maya, 2016).
The situation of health-care services is getting poorer day by day in North-eastern states of India
(Business Standard, 2016; Morung Express News, 2017). Even the most populous state and also the
home for most advanced innovation driven medical facilities in the entire North Eastern region (NER),
Assam is also not left untouched by poor health-care services (Priyadarshini, 2016). The lack of skilled
nurses can be attributed as one of the reasons for poor patient care services. As per INC standards the
nurse-patient’s ratio is ought to be 1:3 for medical colleges and 1:5 for district hospitals. However, in
medical colleges and other hospitals of the state, there is just 1 nurse against 20–30 patients (Times of
India, 2013). The shortage of adequate health force puts a limit in the delivery of quality healthcare as
per patients’ requirements, the inability to perform well may often lead to negative psychological out-
comes such as moral distress among nurses (Corley, Minick, Elswick, & Jacobs, 2005). It is important to
state that nursing professionals are likely to experience more psychological distress as compared to
general people (Lee & Cummings, 2008). It is the time to acknowledge the current scenario of health-
care industry in Assam, which is characterized with less number of nurses with high pressure for delivery
and stress due to nature of work. Given the above background it becomes significant to offer appropriate
health-care services despite of shortage of health force. One such way of fostering efficiency among
nurses is by enriching their engagement at workplace. The role of highly engaged nurses is remarkably
important for providing efficient medical care.

Problem Statement
Though a great number of predictors to work engagement among various types of nurses have been
proposed, yet only a few of them have been examined empirically (Antoinette Bargagliotti, 2012).
Additionally, majority of these work engagement focussed studies are reported form Western economies
(Keyko, Cummings, Yonge, & Wong, 2016) such as Finland, the USA, Canada and Spain (Bamford,
Wong, & Laschinger, 2013; Jenaro, Flores, Orgaz, & Cruz, 2011; Mauno, Kinnunen, & Ruokolainen,
2007; Simpson, 2009). The cultural aspects of every country are deemed to be unique and that also influ-
ences the perceptions of employees regarding work and, subsequently, work engagement (Mercer, 2007;
Powell, Francesco, & Ling, 2009). Thus, the predictors of work engagement among nurses acknowl-
edged in developed economies may not be effective in Indian scenario. Highlighting the current Indian
scenario of nurses’ shortage, it becomes imperative to investigate the potential factors that can enhance
work engagement in existing health force in India. In this way, present study has adequate motivation to
contribute to the understudied Indian healthcare literature, which still remains under-represented in the
extant literature.

The Purpose of the Study

This study investigates the impact of family to work enrichment and support from supervisor on work
engagement among nurses employed in government hospitals of Assam.
Rastogi 3

Theoretical Foundation

The Job Demands–Resources Model

The work dynamics at hospitals can be straightforwardly understood with the help of job demands-
resources (JD-R) model (Bakker & Demerouti 2007; Xanthopoulou, Bakker, Demerouti, & Schaufeli,
2007). Healthcare industry is service oriented industry, where needs (demands) of patients are met with
the help of (resources) skills, knowledge, experience, positive outlook of nurses and doctors.
According to this model, nurses (employees) serve the requirements of patients, doctors and also the
hospitals with the help of available resources. More specifically, this highly stressed profession com-
prises of innumerable demands such as heavy workload, emergency shifts, long working hours with less
number of breaks in presence of emotional anxieties. In order to deal with the mentioned demands at
work effectively nurses take the support of work environments that offer several psychological, physical,
social and organizational resources. These resources play a functional role in accomplishing job-related
goals by decreasing the job-related demands (Demerouti, Bakker, Nachreiner, & Schaufeli, 2001). In the
present study, the positive attitudes and experiences generating from family domain and work domain
are considered as resources to meet the patient care demands.

Hypotheses
Work Engagement
In simple words of Schaufeli, Martinez, Pinto, Salanova, and Bakker (2002), work engagement is con-
ceptualized as a positive, fulfilling, work-related state of mind characterized by vigour, dedication and
absorption. Where, absorption refers to the level to which some individual feels concentrated or engrossed
in work so that their time passes quickly while performing the task which often leads to difficulties in
detachment from work. Vigour suggests the levels of energy and psychological resilience while perform-
ing his job-related duties. In a way, it also specifies the employees’ inclination to make noticeable efforts
in job, and tenacity in problematic circumstances. And, the last dimension dedication indicates the in-
depth psychological involvement in work along with the realization of importance, passion, motivation,
pride and challenge (Schaufeli et al., 2002).
Work engagement enhances the wellbeing of nurses (Freeney & Tiernan, 2009) and also results into
various positive work-related outcomes such as surge in patient satisfaction, quality of care, significantly
higher financial profitability of organizations, and decrease in hospital mortality rates (Antoinette
Bargagliotti, 2011; Christian, Garza, & Slaughter, 2011; Watson, 2010). It is also found to be a strong pre-
dictor of extra role behaviours among Spanish nurses (Salanova, Lorente, Chambel, & Martínez, 2011).
Family-to-work Enrichment to Work Engagement
The concept that revolutionized the direction of work-family literature by challenging the notion of tradi-
tional negative interdependencies between work and family is labelled as work-family enrichment. The
work-family enrichment is defined as the degree to which experience in one role enhances the quality of
life in another role (Greenhaus & Powell, 2006). This bi-directional concept displays that assets resulted in
role A (work or family) can directly lead to high performance and positive effect in role B (family or work).
Enrichment can occur from family to work domain as well as work to family domain. Family to work
enrichment occurs as soon as resources generated in family domain enhance the life of work sphere.
4 Journal of Health Management

Many studies have revealed that family has a positive impact on work as well as family related perfor-
mance factors (Crain & Hammer, 2013). For example, a study by Burke and Greenglass (1999) revealed
that support from partner in family decreases negative aspects in family domain such as the family to work
conflict. In Indian family-oriented culture, family is valued above all. In fact, the success derived from
work, top position in hierarchy, and status bring fame to the entire family (Chadda & Deb, 2013).
Additionally, it is also vital to highlight the importance of family in Indian culture. Given this background,
nurses who are playing multiple roles (e.g., mother, wife and daughter) in low egalitarian Indian society
understand the significance of family backing. When a nurse receives resources such as support from
members, motivation to excel, and also respect from family members, she tends to be relatively more
relaxed from workplace stress emerging from negative job duties and thus, more engaged in work. Thus,
nurses’ resources generated in family domain are enhancing their work performance at hospitals.
Supervisor Support and Work Engagement
Van Daalen, Willemsen, and Sanders (2006, p. 464) defined social support as ‘the exchange of resources
between at least two persons, with the aim of helping the person who receives the support’. Social sup-
port can be generated and obtained in work as well as family domains. In a study, Seiger and Wiese
(2009) reported that social support helps employees in retention of available resources and to gain new
resources. Social support is a positive key resource, that is, generated in support of performing work
demand expectations effectively.
Supervisors may help nurses’ in many ways such as management of work and family responsibilities,
flexible shifts at times, paying attention to their work-related problems, instruments requirements and
also by providing emotional support. Nursing is considered as a female dominated profession (Simpson,
2004). In addition to this, the highly masculine Indian society (Banerjee, 2012) which strictly adheres to
social role theory (Eagly, Wood, & Diekman, 2000) enforces that women are primarily responsible for
home domain responsibilities as their male counterparts are responsible for earning bread and butter.
Thus, in a way it implies that when female nurses receive instrumental support from their respective
supervisors they tend to manage both work and family domains better resulting into lower levels or
sometimes absence of home and work domain strains, which eventually allow them to have higher levels
of engagement at work.
The study proposes following hypotheses:

H1. Family–work enrichment significantly influences work engagement.

H2. Supervisor support significantly influences work engagement.

Methodology

Participants and Procedure

We adopted cross-sectional design for the purpose of testing the hypotheses. In order to collect data for
the study, the researchers adopted judgemental sampling. Judd, Smith, and Kidder defined judgemental
sampling as ‘picking cases that are judged to be typical of the population in which we are interested,
assuming that errors of judgment in the selection will tend to counterbalance one another’ (Judd, Smith,
& Kidder, 1991, p. 136). Depending upon the objectives of the study, the following facts have been
taken into the consideration while employing purposive sampling technique. At first, as the study aimed
to examine the predictors of work engagement of nurses in highly stressful work environment, the
Rastogi 5

researchers were intended to focus exclusively on best health-care providers located in Assam region
of India. Hence, total top five government medical colleges were selected as the most preferred loca-
tion for data collection as per the list provided by health and family welfare development, Government
of Assam (2017).
Second, in this study we restricted our study to only full-time working nurses as part-time nurses are
likely to be outsider, irregular and spend relatively less with the patients.
Third, according to Census of India (2011), Assam is the most populous state among NER states of
India. It has emerged as an important centre for health-care facilities in NER, India with access to numer-
ous top government and cutting edge private healthcare facilities.
Given the background of above information, data were collected from top five government medical
colleges of Assam. The data collection sites (hospitals) were visited personally and a brief introduction
about the study was given to nurses. The nurses were contacted according to their free time only. Nurses
were helped to understand the questionnaires before filling. The questionnaire consisted of a total of 24
relevant items on family–work enrichment, supervisor support and work engagement.
A total of 192 nurses were contacted, out of which 140 participated in the study yielding 73 per cent
response rate. These 140 samples were attained by personally meeting the nurses in their respective
hospitals and residence. Out of those 140 filled questionnaires by nurses, only 133 were included in the
final data analysis. Due to missing responses eight questionnaires were rejected. The survey question-
naire consisted of 24 items. The suggested criteria for determining the adequate sample size of the study
should be at least 5–10 times the number of the items (Hair, Black, Babin, Anderson, & Tatham, 2006).
Thus, with 24 items, this study is recommended to have 120–240 sample size. The current study includes
a total of 133 sample, which is appropriate in the present condition.

Measures
The dependent variable, work engagement was measured using nine-item scale from Utrecht Work
Engagement Scale (UWES) by Schaufeli et al. (2002). It has three dimensions (e.g., vigour, absorption
and dedication). A sample is ‘At my work, I feel bursting with energy’. Family–work enrichment was
measured by using three-item scale by Kacmar, Crawford, Carlson, Ferguson, and Whitten (2014) in a
five-point rating scale ranging from 1 = strongly agree and 5 = strongly disagree. A sample item is ‘My
involvement in my family helps me to acquire skill and this helps me be a better worker’. In order to
examine the perceptions about supervisor support a 12-item scale by Holton and Bates (2002) was used.
All responses were gathered using a five-point Likert scale from 1 = strongly disagree to 5 = strongly
agree. Additionally, the Cronbach (α) 0.791, 0.729 and 0.783 confirms reliability within measures for
work engagement, supervisor support and family–work enrichment, respectively (Table 1).

Table 1. Summary Statistics and Correlations of Observed Variables

Variables Mean Std. Deviation 1 2 3

FWE 1.5931 0.62302 (0.783)
SS 1.9166 0.34103 0.425* (0.729)
WE 1.8608 0.40801 0.287* 0.522* (0.791)
Source: The author.
Notes: FWE: Family–work enrichment; SS: supervisor’s support; WE: work engagement.
*Correlation is significant at 0.01 level (2-tailed). Values in the parenthesis represent the reliability values.
6 Journal of Health Management

Control variables. Nurses were asked to share some personal information as well such as age, gender
and length of service. Though we were aware of the fact that we would collect most of the data from
female nurses, despite of this we were interested to see the numbers of male nurses in present study. So,
we coded gender as 0 (male) and 1 (female) and age (years) as 1 (less than 25 years), 2 (26–35 years), 3
(36–45 years), 4 (above 46 years). The length of service of nurses was coded as 1 (less than 2 years), 2
(3–5 years) and 3 (more than 6 years). With a view to avoid confounding relationships, we controlled for
employees’ gender, length of service and age (Simpson, 2009).

Results

Descriptive Analysis
The values given in Table 2 show that being the female-dominated profession (Simpson, 2004), majority
of our respondents were females (98.1%), with an experience level of less than 2 years (58.4%). In terms
of age, most of them had not attained 25 years (58%).
Correlation Analysis
The research study considered two independent variables and one dependent variable. The first inde-
pendent variable is family to work enrichment followed by supervisor support, while work engagement
is the dependent variable.
The results displayed in the correlation matrix (Table 1) revealed that work engagement has been
positively associated with both independent variables, family–work enrichment (R = 0.287 p < 0.01) and
supervisor support (R = 0.522, p < 0.01). The independent variables were also found to be significantly
correlated with each other (R = 0.425, p < 0.01).
Hierarchical Regression Analysis
To test the hypotheses, multiple hierarchical regression was conducted. In the first step, control variables
such as age, gender, length of service and education were entered. The absence of any significant stand-
ardized beta coefficients in (model 1) depicts demographic variables failed to influence nurses’ level of
work engagement in present context.
In the second step, first independent variable family–work enrichment was entered. In support of
hypothesis 1 (H1), it was estimated that family to work support will significantly increase work engage-
ment among nurses (β = 0.287, p < 0.000, change R2 = 0.116). Family–work enrichment interpreted a
change of 11.6 per cent variance in work engagement. On behalf of hypothesis 2 (H2), the study pro-
posed that supervisor support will lead to work engagement. From the Table 3 (model 3) H2 was
accepted as supervisor’s support is positively related to work engagement (β = 0.450, p < 0.001, change
R2 = 0.266). After including supervisor’s support in the next model, both family–work enrichment and
supervisor’s support predicted 26.6 per cent variance in work engagement together.

Discussion
The findings of our study indicate two points. First, family to work enrichment is a positive influencer of
enhancing work engagement levels of nursing employees, and second, support form supervisor plays a signifi-
cant role in increasing work engagement levels of nurses. The justification of the findings is discussed below.
Rastogi 7

Table 2. Demographic Profile of the Respondents

Characteristic Frequency Percentage

Gender
Male 3 1.9
Female 153 98.1
Age
Less than 25 89 57.8
26–35 63 40.9
36–45 2 1.3
Length of service (years)
Less than 2 90 58.4
3–5 49 31.8
More than 6 13 8.4
Source: The author.

Table 3. Result of Hierarchical Multiple Regressions for Testing the Impact of FWE and SS on WE

Variables Model 1 Model 2 Model 3

Step 1 (CV as IV *)
(FWE* as IV) (SS* as IV)
Control variables
(Constant) b t b t b t
Gender 0.099 1.110 0.086 1.004 0.054 0.695
Age −0.010 −0.076 0.017 0.134 0.035 0.305
Length of service 0.216 1.578 0.160 1.204 0.080 0.657
Step 2 (first independent variable entered)
FWE 0.287*** 3.718 0.092 1.168
Step 3 (second independent variable entered)
SS 0.450*** 5.585
F-value 2.578 5.005 10.220
Sig F-value 0.040 0.000 0.000
R2
0.065 0.145 0.294
Adjusted R2 0.040 0.116 0.266
Delta R 2
0.065 0.08 0.178
Source: The author.
Notes: FWE: Family–work enrichment; SS: Supervisor’s support; WE: Work engagement; CV: Control variable; IV: Independent
variable.
***p < 0.001.
8 Journal of Health Management

Impact of Family to Work Enrichment on Work Engagement

The family–work enrichment plays a fundamental role in engaging the nurses in work at hospitals. The
rationale for the relationships can be easily understood with the help of resources generation in family
domain. Greenhaus and Powell (2006) proposed in their work-family enrichment model that perfor-
mance in home/family domain generates five types of resources categorized as skills and perspectives,
psychological and physical resources, social capital, flexibility and material resources. It is noteworthy
to mention that with availability of resources an employee feels positive and active at work resulting
into higher levels of engagement in work. In other words, when one has access to resources generated
in family domain like positive self-evaluations, self-esteem, optimism and physical health (Brockner,
1988; Seligman, 2002), social capital resources stemming from interpersonal relationships in family,
flexibility for timing, pace and location at which role responsibilities need to be carried out, and finally
material resources like money or any gifts that may assist individuals in achieving their goals, they tend
to be more engaged in their job at workplace. On the basis of above arguments in presence of empirical
evidences, it is found that nurses experience higher level of work engagement in presence of family to
work enrichment.
With the view of JD-R model (Bakker & Demerouti, 2007), the study suggests that flexibility
resources which provides choice of time to nurses when it comes to home domain responsibility, inter-
personal relations with family members and money resources in home domain enable the nurses to reach
at hospital with relatively more peace of mind resulting into higher engagement in stressful, and uncer-
tain work practices.

Impact of Supervisor Support on Work Engagement

The obtained results of the study favour the notion that supervisor support works as a significant predic-
tor of work engagement among Indian nurses, and thus, support from supervisor play a fundamental role
in enhancing the performance of the employee.
India is characterized with unique cultural characteristics reporting high power distance, family ori-
ented and collectivist society. In Indian society, people usually adhere to guru–shishya (mentor–student)
relationship, which operationalizes at workplace as well. The interpretation of current findings can be
easily understood in the light of Indian value system which is operationalized at the workplace as well.
Nurses functions in highly stressful, and unpredictable work environment, where they encounter a lot of
problems due to these day-to-day challenges. When they have access to supportive senior or supervisor,
with whom they can share their work and family related difficulties, with a belief to find a feasible solu-
tion, they feel more relaxed and positive from inside, which further results into high work engagement
at workplace. Support from supervisor is a key to not only perform effectively at work but also a motiva-
tion to continue the job. Many researchers have found that employees leave their jobs only due to poor
relationship with boss, or uncooperative attitude of boss (Lloyd, Boer, Keller, & Voelpel, 2015). Thus,
the positive supervisory support results into positive emotions among nurses despite of stressful work
situations, which increases the level of work engagement among them and further results into enhanced
quality of patient care, and reduction in mortality rates of patients (Antoinette Bargagliotti, 2012;
Christian et al., 2011; Van Bogaert, van Heusden, Timmermans, & Franck, 2014; Watson, 2010).
The results can be interpreted given the reference of JD-R model as well (Bakker & Demerouti,
2007). As it has already been established that the presented job-related demands can be efficiently met
with the support of personal and organizational resources accessible at workplace. The job description
Rastogi 9

of nurses is highly complicated, stressful, uncertain and full of negative emotions. Despite of this,
nurses are supposed to keep a wide smile on face while attending a patient. This is impossible to main-
tain smile when one is stressed by performing the routine job tasks. But, when a nurse is offered
resources in the guise of workplace social support, she tends to release the stress resulting into better
engagement at work. In this way support form supervisor can be understood as an organizational
resource for nurses which promote their better engagement at work ultimately leading to many positive
work-related outcomes.

Limitations and Future Scope

Despite of several contributions to healthcare literature, this study has some limitations too. There is
adequate scope for further investigations and additional research in future that should be noted. First, the
use of cross-sectional may raise some apprehensions concerning causality among the factors examined
under study. Therefore, it is suggested to take up longitudinal research designs in future research with a
view to increase causality. Second, as this study is focussed on health-care professionals, specifically
nurses, so the discoveries may not be relevant to other sample such as doctors and also in case of other
sectors. Hence, more studies are required to examine the predictors of work engagement among doctors
and numerous other service-oriented sectors. Third, in this present study is confined to government sec-
tor hospitals of Assam, India, which fails to provide the comprehensive picture of nurses of entire NER
of India. It is important to indicate that entire NER is facing the shortage of nurses and high work
engagement among nurses can work as an effective tool for better health services. Therefore, it is pro-
posed to collect data from entire NER in future research in order to investigate the predictors of work
engagement among nurses.

Conclusion
The results of this study generally conclude that positive behaviour of supervisors can do miracles and
enhance the healthcare services of hospital by enhancing the engagement levels of nurses in highly
complex, negative and uncertain environment in hospitals also. Additionally, the traditional notion
that employer and workplace related factors enhance performances of the employees, is also empiri-
cally supported by the present study. In present healthcare case, it is not always workplace resources
or practices that only enhance the productivity of the employees; family related life of the employees
also plays an important role in enhancing the productivity of nurses. Hence, the hospital should be
cautious in terms of family background, psychometric tests, emotional quotient apart from intellectual
quotient while acquiring the talent for their organization.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of
this article.

Funding
The author received no financial support for the research, authorship and/or publication of this article.
10 Journal of Health Management

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