Poor Nurses’ Work Environment Increases Quiet Quitting and Reduces Work Engagement: A Cross-Sectional Study in Greece

1. Introduction

Nurses are the largest professional cohort within a healthcare organization, and the quality and safety of the services rendered frequently hinge on their contributions [1,2]. Donabedian's model posits that the structure and processes of a healthcare organization impact the outcomes of health service delivery [3]. Nurses are the most important resource (structure) of the healthcare system and through the implementation of nursing interventions (process) they contribute decisively to its outcomes. However, the working environment of nurses can also influence the outcomes of nurses themselves, and indeed nurse and organizational outcomes occur concurrently [4]. The influence of the work environment on nurses' professional conduct is not a fresh issue but has afflicted healthcare systems for decades. As early as the 1980s, the first study exploring the effect of the working environment on the recruitment and retention of nurses in hospitals was recorded, as there was a large shortage of nurses due to nursing dropouts. The survey revealed 41 hospitals, designated as Magnet Hospitals, notable for their effectiveness in retaining and recruiting nursing staff. The criteria that designated these hospitals as Magnet encompassed a series of structural and process factors of nurses work environment such as management and leadership style, staffing, opportunities for professional development, organizational structure (including nursing participation in hospital committees), personnel policies (such as promotion opportunities), quality of patient care (including the implementation of professional practice models), and education (emphasis on the value of education and teaching by nurses) [5].

While the literature previously focused on nurses' turnover intention, the COVID-19 pandemic has introduced a novel concept pertaining to a new work behavior known as “quiet quitting”. The notion gained widespread recognition with a short video on the social media platform TikTok. Subsequently, the management consulting company “Gallup” carried out research in the US revealing that 50% of business sector employees have engaged in quiet quitting [6]. To attain a work-life balance, employees engage in quiet quitting by diminishing their performance and fulfilling only the minimum job criteria to evade termination, instead of exceeding expectations, arriving early, or working overtime [7]. The problem is notably prevalent in the healthcare sector, with nurses engaging in quiet quitting at a rate of 67%, much above that of healthcare workers [8]. The phenomenon is very novel, and a reliable and valid measurement tool has just lately been created, resulting in restricted studies within the health sector [9]. Factors contributing to the quiet quitting among nursing personnel include burnout and bullying at work [10,11], whereas moral resilience, emotional intelligence, and support for innovation serve as protective elements [12,13,14]. Nurses who engage in quiet quitting are more prone to express turnover intentions [15]. Research on the impact of the aspects of nurses work environment on the prevalence of quiet quitting is notably scarce [16]. Research outside the health sector has identified several predictors of quiet quitting, including poor management, lack of specific policies such as support systems for new mothers and provisions for health and mental well-being, ineffective leadership or nepotism among superiors, disparities in salary and compensation, and role conflicts that negatively impact well-being and exacerbate burnout, ultimately resulting in quiet quitting [6,17,18].

A positive work behavior is that of work engagement, which can be defined as “a positive, fulfilling, work-related state of mind that is characterized by vigor, dedication, and absorption”[19]. An employee exemplified by vigor, dedication, and absorption demonstrates high energy levels, mental resilience, and a commitment to exerting effort in work, while also being deeply engaged and experiencing a sense of significance, enthusiasm, inspiration, pride, and challenge. A work engaged employee is also characterized by complete concentration and a joyful immersion in one's job, resulting in the rapid passage of time and difficulty in disengaging from tasks [19,20]. The nurses work engagement yields numerous advantages for both patients and the nurses themselves. In terms of patient outcomes, work engagement shown a favorable association with nurses' perceived quality of care and patient satisfaction, while demonstrating a negative association with adverse events occurrences. The impact of work engagement on nurses encompasses a positive association with job satisfaction, career fulfillment, compassion satisfaction, work effectiveness, productivity, and overall well-being, alongside a negative association with burnout, compassion fatigue, and intentions to leave the profession [21,22,23,24]. The work environment significantly influences nurses' work engagement, particularly the components comprising this environment, including nurse involvement in hospital affairs, the nursing foundation for quality care, nurse manager competence and leadership, adequacy of staffing resources, and the nurse-physician relationship [25]. Management plays a significant role at both the ward and organizational levels, along with the leadership style employed [26]. Dominant leadership styles with positive association have emerged as those of transformational leadership as well as task-focused, authentic, ethical, resonant, and servant leadership styles [27,28,29].

To the best of our knowledge, this is the first study that investigated the impact of nurses’ work environment on their quiet quitting. Moreover, we examined the association between nurses’ work environment and work engagement.

2. Materials and Methods

2.1. Study Design

A cross-sectional study was conducted with a sample of nurses in Greece. We collected our data in October 2024 through a web-based survey. In particular, we used Google forms to create an online version of the study questionnaire, and then we posted it in nurses’ groups in Facebook. In this way, we obtained a convenience sample of nurses. We applied the following inclusion criteria: (a) nurses who have been working in clinical settings, (b) nurses who have been working at least one year, and (c) nurses who understand the Greek language.

We used G*Power version 3.1.9.2. to calculate sample size in our study. Thus, considering a low effect size (f²=0.05) of nurse work environment on quiet quitting and work engagement, the number of independent variables (five predictors and five confounders), a confidence level of 95%, and a margin of error of 1%, sample size was estimated at 370 nurses.

2.2. Measurements

Regarding demographic variables we measured sex (females or males), age (continuous variable), work in understaffed ward (no or yes), shift work (no or yes), and work experience (continuous variable).

We used the short form of the Practice Environment Scale of the Nursing Work Index (PES-NWI), The “Practice Environment Scale-5” (PES-5), to measure nurse work environment [30]. The PES-NWI was developed to measure the nursing practice environment, which was defined as the organizational traits that support or undermine professional nursing practice [31]. The PES-5 comprises five items that represent five dimensions of work environment. In particular, the item “Administration that listens and responds to nurse concerns” refers to the dimension “Nurse participation in hospital affairs”, the item “A supervisor who is a good manager and leader” refers to the dimension “Nurse manager ability, leadership, and support”, the item “Good teamwork between nurses and physicians” refers to the dimension “Collegial nurse-physician relationships”, the item “Enough staff to get work done” refers to the dimension “Staffing and resource adequacy”, and the item “A clear philosophy of nursing that pervades the patient care environment” refers to the dimension “Nursing foundations for quality of care”. Answers are on a four-point Likert scale from completely disagree (1) to completely agree (4). Higher values indicate better nurse work environment, with values greater than 2.5 indicating a supportive work environment, while values less than or equal to 2.5 indicating an unsupportive environment [31]. We used the valid Greek version of the PES-5 [32]. In our study, Cronbach’s alpha for the PES-5 was 0.604.

We used the “Quiet Quitting Scale” (QQS) to measure levels of quiet quitting among our nurses [9]. The QQS consists of nine items, and answers are on a five-point Likert scale from strongly disagree/never (1) to strongly agree/always (5). Example items are the following: “I do the basic or minimum amount of work without going above and beyond”, “I find motives in my job”, and “I feel inspired when I work”. Score on the QQS is the average of the answers to the five items. Thus, score on the QQS ranges from 1 to 5. Higher values indicate higher levels of quiet quitting. We used the suggested cut-off point of 2.06 to separate our nurses into quiet quitters and non-quiet quitters [33]. We used the valid Greek version of the QQS [8]. In our study, Cronbach’s alpha for the QQS was 0.855.

We used the “Utrecht Work Engagement Scale-3” (UWES-3) to measure work engagement in our sample [34]. The UWES-3 comprises three items (e.g., “At my work, I feel bursting with energy”), and answers are on a seven- point Likert scale from never (0) to every day (6). Mean score on UWES-3 ranges from 0 to 6 with higher values indicate higher levels of work engagement. We used the valid Greek version of the UWES-3 [35]. In our study, Cronbach’s alpha for the UWES-3 was 0.812.

2.3. Ethical Issues

The Ethics Committee of the Faculty of Nursing, National and Kapodistrian University of Athens approved our study protocol (approval number; 01, September 26, 2024). Moreover, we took into our consideration the Declaration of Helsinki to conduct our study [36]. An information sheet on the online version of the study questionnaire informed participants about the aim and the design of the study. Then, we asked participants if they consent to participate in our study. Nurses with a positive answer can further answer our questionnaire.

2.4. Statistical Analysis

We present categorical variables as numbers and percentages. Also, we use mean, standard deviation (SD), median, minimum value, maximum value to present continuous variables. We used the Kolmogorov-Smirnov test and Q-Q plots to examine the distribution of continuous variables. The five dimensions of the PES-5 were our independent variables, while scores on QQS and UWES-3 were our dependent variables. Since the dependent variables were continuous variables that followed normal distribution, we applied the linear regression analysis. First, we performed univariate linear regression analysis and then we created a final multivariable linear regression model including all independent variables. We adjusted multivariable models for gender, age, understaffed ward, shift work, and work experience. We present unadjusted and adjusted coefficients beta, 95% confidence intervals (CI), and p-values. P-values less than 0.05 were considered as statistically significant. We used the IBM SPSS 21.0 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) for statistical analysis.

3. Results

3.1. Demographics

Study population included 425 nurses. Mean age of nurses was 41.1 years (SD; 10.0 years). In our sample, 88.9% (n=378) were females, while 11.1% (n=47) were males. Among our nurses, 72.0% (n=306) reported that they work on shifts, while 82.1% (n=349) reported that they work on understaffed wards. Mean years of clinical experience was 16.5 years (SD; 13.9 years).

3.2. Study Scales

Table 1 shows descriptive statistics for the study scales. Nurses work environment was considered unsupportive to professional nursing practice as indicated by collegial nurse-physician relationships (mean; 2.48, SD; 0.71), nurse manager ability, leadership, and support (mean; 2.29, SD; 0.86), and nursing foundations for quality of care (mean; 2.16, SD; 0.76). Also, staffing and resource adequacy (mean; 1.66, SD; 0.76), and nurse participation in hospital affairs (mean; 1.64, SD; 0.67) indicated low levels of a supportive nurse work environment. Applying the suggested cut-off point for the QQS, 66.1% (n=281) of our nurses could be considered as quiet quitters, while 33.9% (n=144) could be considered as non-quiet quitters. Mean score on QQS was 2.40 (SD; 0.73). Mean score on UWES-3 indicated moderated levels of work engagement among our nurses (mean; 3.53, SD; 1.59).

3.3. Impact of Nurse Work Environment on Quiet Quitting

Table 2 presents results from univariate and multivariable analysis with nurse work environment as the independent variable, and quiet quitting as the dependent variable. We found that worse nurse work environment was associated with higher levels of quiet quitting. The final multivariable linear regression model showed that four out of five dimensions of nurse work environment has a negative impact on quiet quitting. In particular, lower nurse participation in hospital affairs increased levels of quiet quitting (beta = -0.116, 95% CI = -0.218 to -0.014, p-value = 0.026). Moreover, worse collegial nurse-physician relationships (beta = -0.134, 95% CI = -0.232 to -0.037, p-value = 0.007), and worse nursing foundations for quality of care (beta = -0.133, 95% CI = -0.229 to -0.038, p-value = 0.006) were associated with higher levels of quiet quitting. Also, we found a negative association between nurse manager ability, leadership, and support and quiet quitting (beta = -0.177, 95% CI = -0.259 to -0.095, p-value < 0.001).

3.4. Impact of Nurse Work Environment on Work Engagement

Table 3 shows results from linear regression analysis with work engagement as the dependent variable. We found that three dimensions of nurse work environment has a positive impact on work engagement. Our multivariable linear regression analysis showed that nurse manager ability, leadership, and support (beta = 0.335, 95% CI = 0.156 to 0.514, p-value < 0.001), collegial nurse-physician relationships (beta = 0.391, 95% CI = 0.179 to 0.603, p-value < 0.001), and nursing foundations for quality of care (beta = 0.340, 95% CI = 0.131 to 0.549, p-value = 0.001) were associated with higher levels of work engagement among nurses.

4. Discussion

This study evaluated the nursing work environment and examined the association between work environment, quiet quitting, and work engagement. The results of our study indicated that the work environment for nurses is unsupportive, since low scores were observed across every dimension of the work environment. The majority of nurses chose quiet quitting, exhibiting low levels of work engagement, while the work environment was negatively associated with quiet quitting and favorably associated with work engagement.

In recent years, various aspects of the nursing work environment have consistently deteriorated, as numerous studies have emphasized nursing understaffing in healthcare organizations, the resignation of nurses from the profession, managements’ and leaderships’ failure to support nurses, and the insufficient representation of nurses on hospital committees [37,38,39,40]. A study conducted by The American Association of Critical-Care Nurses indicates the prolonged decline of the nurses' work environment [41]. The current study identifies the two lowest score dimensions as staffing and resources, and nurses' participation in hospital issues. These findings align with studies conducted in Greece and in other countries, emphasizing these two dimensions as the least supportive to nurses work environment [42,43,44]. In addition to the widespread withdrawals of nurses from the profession, a large proportion declares their turnover intention. The turnover intention strongly predicts actual turnover [45], suggesting that understaffing could provide a substantial challenge to the effective operation of healthcare services. Nurses employed in understaffed wards, facing elevated workloads and minimal participation in hospital affairs, exhibit diminished work engagement and satisfaction [42,46]. Insufficient job satisfaction among nurses correlates with a decreased work engagement, which subsequently results in a reduced assessment of the quality of healthcare services and heightens nurses' propensity to depart from their positions [47]. Consequently, we ascertain that healthcare systems, organizations, and nursing personnel are ensnared in a detrimental cycle, wherein an unsupportive work environment adversely impacts nurses' work behavior and their turnover intention, thus generating job vacancies and further deteriorating the work environment.

The present study emphasized the impact of the work environment dimension of "nurse manager ability, leadership, and support" on both nurse work engagement and quiet quitting. Several studies have highlighted different leadership styles that positively influence nurses' work engagement. Nurse managers exhibiting ambidextrous leadership traits empower their staff with greater responsibility, influence, support, and guide them to innovate and question traditional top-down control. As a result, ambidextrous nurse managers are likely to foster leadership among staff nurses and enhance their work engagement [48]. Also, the transformational leadership style of nurses fosters trust and confidence among their staff, cultivates a shared sense of mission and values, articulates a clear vision, promotes innovation and creativity, and empowers staff by encouraging autonomy and voice, thereby positively influencing work engagement among nurses [49]. Furthermore, nurse leaders who adopt an empowering leadership style and disseminate information to facilitate subordinate involvement in decision-making, thereby conferring power and responsibility, while promoting accountability and fostering skill development and coaching for innovative performance, establish optimal conditions for improving nurses' work engagement [50]. There exists a research gap concerning the association between leadership and quiet quitting, as the phenomenon of quiet quitting is recent and necessitates investigations on predictive factors. The present research is the inaugural study to establish an association between nursing leadership and nurses' inclination towards quiet quitting. A business sector study identifies poor management as a significant predictor of quiet quitting, emphasizing the necessity to enhance the competencies of those in leadership roles and to mitigate disengagement and burnout [6]. In modern healthcare systems, characterized by elevated levels of dissatisfaction, burnout, and turnover intentions among nurses, the administrative competencies of nurse supervisors are inadequate. Leadership abilities are essential to inspire, engage, and empower nurses to enhance retention and work engagement and minimize quiet quitting work behavior.

Our study had several limitations. First, we collected our data through a web-based survey. Thus, our convenience sample cannot be representative of nurses in Greece. Thus, we cannot generalize our findings. Second, we used valid tools to measure nurse work environment, quiet quitting, and work engagement but information bias is still probable since these tools are self-reported. Third, we adjusted our multivariable models for several confounders, but several other variables may introduce confounding in the association between nurse work environment, quiet quitting, and work engagement. Fourth, the cross-sectional nature of our study did not allow us to infer a causal relationship between independent and dependent variables.

5. Conclusions

The work environment of nurses can affect their behavior, hence impacting the quality of healthcare services and the efficiency of healthcare organizations. This study emphasized the poor work environment, elevated levels of quiet quitting, and moderate work engagement among nurses. The elements of the work environment were identified as predictors of both work engagement and quiet quitting. The ongoing endeavor to enhance all aspects of nurses' working conditions by healthcare organization administrations is essential for optimizing nurses' performance, facilitating organizational operations, and ensuring service quality.