Work-Family Conflict and the Role of Family Supervisor Support as a Promising Approach to Retain Qualified Nurses

Many hospitals worldwide have recently experienced a rise in turnover rates among their healthcare professionals. For example, in the United States, the turnover rate of healthcare professionals has dramatically increased from 13.5% in 2011 to 17.2% in 2015. Almost 40% of newly employed nurses in the United States intend to quit their jobs and search for new positions within the first year of their employment. The existing literature has documented many factors that can contribute to high turnover rates such as stress, feelings of inadequacy, lack of professional development and training, limited opportunities, and lack of the required skills and knowledge. However, a new factor that can lead to turnover has recently been discussed in the literature and is gaining greater attention: the conflict that exists between work and family demands. In this paper, we discuss the concept of workfamily conflict, its consequences, and a promising strategy to effectively tackle this issue and address its consequences. Helping healthcare providers to maintain the balance between work and family demands can reduce stress and increase job satisfaction among nurses, which can eventually lead to their retention in the workplace.


Background
Turnover Intention (TI), the cognitive stage that precedes actual turnover, among healthcare providers is considered one of the most critical issues in healthcare settings worldwide. It refers, in particular, to one's mental decision or thoughts about remaining or leaving a job [1], and it is considered to be a significant predictor of actual turnover [2]. There is no doubt that every healthcare system requires adequate, highly trained nursing personnel to provide a high level of quality care for patients. Yet, many countries around the globe are finding it challenging to retain qualified nurses. For example, in the United States, the turnover rate of healthcare professionals, including nurses, has dramatically increased from 13.5% in 2011 to 17.2% in 2015 [3,4]. It was also found that almost 40% of registered nurses in the US intended to quit their current jobs and search for new employment within the next year [5].
This turnover predicament is not limited to the US; many hospitals around the world, including those in developed and developing countries have recently experienced a rise in turnover rates among their healthcare professionals. For example, turnover rates have been reported as 10% in England [6], and nearly 20% in Canada [7]. In Saudi Arabia, the turnover rate among Saudi nurses is alarming, reaching 50% of the total number of the nursing workforce in recent years [8]. A high rate of nursing turnover creates a disruptive, unstable work environment that also negatively impacts the retention of other nurses and healthcare providers [9]. The result is a cycle of constant increase in the rate of turnover, which can lead to a crisis in the healthcare organization, and consequently, will affect the type and quality of healthcare services.
A considerable number of studies have examined this phenomenon and documented the factors that can lead to turnover among healthcare professionals in general and nurses in particular, such as lack of autonomy, high work load, carrying out non-nursing duties, staffing level, supervision, and low wages [10]. The relationship between these widely researched factors and healthcare professionals' turnover rates is known to many healthcare organizations [11]. As a result, a number of strategies have been proposed to improve this issue, including career development programs and training [12] and payment and rewards [13]. In this paper, however, we will shift the focus to another factor, yet more important, that can significantly influence the turnover intention among healthcare providers-work and family conflict-and discuss an effective approach to managing its potentially negative effects.

Method
An electronic literature search was conducted to review the published literature related to work and family conflict, supervisor support and turnover intention among healthcare providers. The search strategy that was used to maximize the comprehensiveness of the literature review was to employ and then link keywords, for example, "turnover AND work-family conflict AND family supervisor support" and "nursing retention AND supervisor support. " The online databases that were searched included Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Source, Web of Science, Science Direct and Medical Literature Analysis and Retrieval System Online (MEDLINE). There was no restriction on the type of research, which included qualitative, quantitative and review. Most of the articles were published within the last 10 years and conducted in a variety of different places.

Discussion
In this section, we framed our discussion critically and precisely around two major areas: work-family conflict and family supervisor support (FSS) as an effective approach that can lead to many positive results.

Work-family conflict
Work and family conflict has recently been gaining greater attention and prominence in the literature. It is frequently introduced by many behavioural, psychological, and career scholars due to its negative consequences on work stability [14][15][16]. The Work-Family Conflict (WFC) has been defined as "a form of inter-role conflict in which the role pressures from work and family domains are mutually incompatible in some respect. That is, participation in the work (family) role is made more difficult by virtue of participation in the family (work) role" [17].
The Work-Family Conflict has been linked to a number of harmful consequences, including job exhaustion [18], lower job satisfaction, lower organizational commitment [19], and was significantly related to sleep insufficiency and insomnia symptoms [20]. In a study assessing the impact of WFC on depression, it was found that 31% of participants had depression rates above the threshold of serious psychological distress [21]. In addition, WFC was found to have a strong association with increased turnover intention [22,23]. Individuals who perceive a higher level of conflict between work and family demands revealed a higher intention to leave their workplace [24]. Therefore, maintaining the balance between these obligations is not an easy task: as many as 60% of working adults reported having difficulty in balancing work and family demands [25].
If healthcare providers are unable to juggle their multiple roles, they need support and help to maintain balance. A new and promising approach that can help reduce TI [26], especially with the presence of high WFC [27], has been discussed in the literature. This approach is referred to as family supervisor support, which is defined as a set of behaviours exhibited by supervisors that are supportive of employees' family roles [28].

Family supervisor support (FSS)
Family Supervisor Support (FSS) refers to the degree to which employees perceive that supervisors "care about their ability to experience positive work-family relationships, and demonstrate this care by providing helpful social interaction and resources" [29]. It is noteworthy that since supervisors have more opportunities to demonstrate support, as they interact with their employees on a daily basis, than the organization itself, the level of perceived support from supervisors is more apparent to employees than the level of perceived support from the organization. Thus, perceived supervisor support has a greater influence on employees' turnover decisions [30][31][32][33]. As a result of such perceived support, employees should become more loyal, committed, and less intent on leaving their jobs [34].
Many scholars from social and organizational behaviour disciplines have demonstrated the benefits of FSS on turnover rate. For example, Mayo et al. in 2012 found a significant buffering effect of FSS on the relationship between physical stressors and medical symptoms [35]. Additionally, a recent study indicated the effect of FSS on buffering the relationship among WFC, job satisfaction, and life satisfaction [36]. In this study, FWC was associated with low job satisfaction and life satisfaction, but only for those who reported low levels of FSS [36]. The same study concluded that with low levels of FSS, employees who experienced FWC reported more symptoms of depression [36].
The benefits of family supervisor support were also revealed to be a buffering factor that reduces TI for those who have a high level of WFC [37]. This longitudinal study concluded that the relationship between WFC and TI is weaker when FSS is high. WFC was significantly associated with increases in TI when the level of FSS was low (β=0.13, p<0.001), but not significant at a high level of FSS (β=0.03). In this study, researchers concluded that FSS as a strategy can buffer the relationship between WFC and TI [27]. Further research also provided evidence for the importance of FSS in reducing WFC [29].
Given the negative impact of work-family conflict on job satisfaction and turnover intention, it is imperative to adopt the Family Supervisor Support approach in healthcare organizations. Such an approach can help maintain the continuity of high quality healthcare services and spare patients potential risks. It would also be useful in countries that have foreign healthcare providers who have left their families due to their economic circumstances for a better job and income. Therefore, healthcare organizations need to include the FSS approach in their policies and design programs to educate supervisors and managers on the beneficial effects of this approach for patients, supervisors, healthcare providers, and ultimately the organization. Such programs need to focus on the required skills and approaches that will enable supervisors and managers to effectively practice their FSS role. A number of authors have asserted that if supervisors are given sufficient time and resources to effectively support employees, they will be able to reduce their intention to leave [16,38].
The concept of supervisor support should be introduced to students who are studying in schools for healthcare professionals in general and in nursing in particular because nurses comprise the largest healthcare workforce and are directly involved in patient care. This introduction will prepare the students to enact the FSS approach during real practice. In this regard, further research is also recommended to examine the value of Family Supervisor Support on the work-family conflict among the nursing population. Interventional studies are also encouraged to evaluate the effectiveness of providing training programs for nursing supervisors to enhance their FSS behaviours.

Conclusion
The alarming rate of healthcare providers' turnover, particularly nurses' , that occurs in many countries worldwide requires healthcare organizations, leaders, and policy makers to make every effort to retain their healthcare workforce in order to maintain continuity of care. One of the factors discussed in this paper that can lead to significant turnover is related to the conflict between family and work demands. This issue is gaining more attention in the literature due to its influence on work stability and productivity. Research indicated that individuals with high WFC are more likely to have higher intentions to leave their job. Although turnover is a complex issue that may require multiple prevention strategies, Family Supervisor Support has been advocated by many scholars as an effective approach that can manage this issue. Applying such an approach, however, requires training and education for supervisors and managers in order to provide timely and effective support to their employees.