1 Klaudija Lenić
2 Martina Mikšaj
3 Kata Ivanišević
1 Clinical Hospital Center Rijeka, Rijeka, Croatia
2 University Hospital Center Zagreb, Zagreb, Croatia
3 University of Rijeka, Faculty of Health Studies, Rijeka, Croatia
https://doi.org/10.24141/2/9/2/9
Author for correspondence:
Klaudija Lenić
Clinical Hospital Center Rijeka, Rijeka, Croatia E-mail: klaudijalenic99@gmail.com
Keywords: quality of life, WHOQOL-BREF, emergency care, nurses
8.9) participated by completing an anonymous online survey. The World Health Organization Quality of Life Questionnaire (WHOQOL-BREF) was used to evaluate four domains of QoL: physical health, psychological health, social relationships and environmental. Sta- tistical analysis included descriptive statistics, the Kolmogorov-Smirnov test, Mann-Whitney U test, Kruskal-Wallis test, and, where appropriate, post hoc analyses. Statistical significance was set at p < 0.05.
Nurses constitute the largest group of healthcare professionals and play a vital role in maintaining the efficiency and quality of healthcare services. Their ability to deliver high-quality care is strongly influ- enced by factors such as working conditions, quality of life, and job satisfaction (1, 2). Among all health- care environments, the emergency department pre- sents particularly challenging conditions due to its unpredictable, high-pressure, and dynamic nature. Nurses working in these settings are frequently ex- posed to time-sensitive procedures, trauma cases, and emotionally charged situations, all of which contributes to increased physical and psychological strain (3, 4).
Emergency nursing is commonly associated with ir- regular shift work, including night shifts, weekends, and holidays, which disrupt circadian rhythms and make it difficult for nurses to maintain a consistent personal life. These schedules often restrict partici- pation in family and social activities, leading to nega- tive consequences for nurses’ physical, psychological, and social well-being (5,6). In addition, work-related stress, heavy workloads, insufficient staffing, and lack of institutional support are consistently cited as major contributors to emotional exhaustion, burnout, and workforce attrition (2, 7).
Quality of life among nurses is influenced by an in- terplay of physical health, mental well-being, ma- terial conditions, social relationships, and personal perceptions of life satisfaction (8). While subjective and objective indicators are interrelated, individual perception is essential for understanding how nurs- es experience their professional and personal lives.
Previous research shows conflicting results: some studies indicate that younger nurses and those with higher education report better physical health and stronger social support networks, while others sug- gest that older, more experienced staff demonstrate greater psychological resilience and work-life bal- ance (6, 9).
However, current research on nurses’ QoL in emer- gency settings remains limited and inconsistent. Many studies focus on general hospital staff, use small or non-representative samples, or do not ac- count for intersecting variables such as age, gender, and educational background. These methodological limitations, combined with varying institutional and cultural contexts, may partly explain the contradic- tions in the findings. Importantly, there is a lack of studies specifically examining these issues within the Croatian healthcare system, especially in high- intensity units such as emergency departments. This gap underscores the need for localized, context- sensitive research to explore how demographic and workplace factors influence nurses’ quality of life in Croatia.
Despite financial compensation for night and over- time work, numerous studies show that the negative impact of shift work on nurses’ quality of life, par- ticularly physical exhaustion and social disruption, persists (10). Healthcare institutions therefore play a crucial role in enhancing nurses’ QoL by ensuring safe working conditions, providing adequate staff- ing, and fostering work-life balance, which in turn improves the quality of patient care (11).
This study is grounded in the theoretical framework of the World Health Organization’s multidimensional definition of quality of life. The WHO defines QoL as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expec- tations, standards and concerns“ (12). The WHOQOL- BREF instrument, based on this definition, is espe- cially suited for evaluating well-being in complex environments like emergency departments, as it captures four key domains: physical health, psycho- logical health, social relationships, and environment. Its comprehensive nature allows for a holistic assess- ment aligned with both global standards and local oc- cupational realities.
Based on this framework, the aim of the study is to evaluate the quality of life of nurses employed in emergency departments in Rijeka and Zagreb, and to examine whether variables such as gender, age, education level, and workplace setting are associ- ated with variations in their perceived quality of life.
Nurses working in emergency departments in Ri- jeka and Zagreb participated in this cross-sectional study, which was conducted during July and August 2024. The participants were selected using a non- probabilistic convenience sampling method based on voluntary participation. Inclusion criteria required at least one year of continuous professional experience in their current position, regardless of age, gender, or educational background. Interns and nurses with less than one year of experience were excluded to ensure that the sample consisted of experienced healthcare professionals working in the high-stress environ- ment of emergency departments.
This study aimed to include all eligible nurses work- ing in the emergency departments of Rijeka and Za- greb during the study period. Out of a total popula- tion of 125 nurses, 99 met the inclusion criteria and voluntarily participated, resulting in a high response rate of 79.2%. Since the study covered the majority of the available population, a separate sample size calculation was not necessary.
Data were collected through an anonymous online questionnaire distributed via digital communication platforms (e.g., Viber, WhatsApp, and Messenger). Participation was voluntary, and informed consent was obtained electronically prior to completing the survey. Respondents were informed about the pur-
pose of the study, the anonymity of their responses, and their right to withdraw at any point without pro- viding a reason.
The survey was composed of two sections:
Ethical approval for this study was granted by the Ethics Committee of the Faculty of Health Studies, University of Rijeka (approval code: 600-05/24- 01/243). All participants were informed about the purpose of the study, assured of the confidentiality of their responses, and notified of their right to with- draw at any time without consequences. Informed consent was obtained electronically before partici- pation. The study involved minimal risk and did not collect any sensitive personal data. All results are presented in aggregate form to protect participant anonymity.
Data were analyzed using Statistica 14.0.0.15 (TIB- CO Software Inc., Palo Alto, CA, USA) and Microsoft Excel 2013 (Microsoft Corporation, Redmond, WA, USA). Descriptive statistics (mean, standard devia- tion, median, interquartile range) were used to sum- marize demographic variables and QoL scores.
The normality of data distribution was tested using the Kolmogorov-Smirnov test. Since the assumptions for parametric tests were not met, non-parametric methods were applied. Differences between two inde- pendent groups (e.g., gender, location) were analyzed using the Mann-Whitney U test. The Kruskal-Wallis test was used for comparisons among three or more categories (e.g., age groups, education level, work ex- perience), followed by post hoc Dunn’s tests with Bon- ferroni correction where significant differences were detected. Statistical significance was set at p < 0.05.
Given the small number of participants aged 56 and older (n = 3), this age category was merged with the preceding group (46-55 years) to ensure statistical validity of comparisons.
Table 1. Demographic characteristics of participants | ||
Characteristic | Category | n (%) |
Gender | Male | 45 (45.5) |
Female | 54 (54.5) | |
Age | ≤ 25 years | 22 (22.2) |
26-35 years | 38 (38.4) | |
36-45 years | 16 (16.2) | |
46-65 years (merged) | 23 (23.3) | |
Education | Secondary education | 32 (32.3) |
Bachelor’s degree | 51 (51.5) | |
Master’s degree | 16 (16.2) | |
Workplace | ED Zagreb | 53 (53.5) |
ED Rijeka | 46 (46.5) | |
A total of 99 nurses participated in the study, of whom 54 were female (54.5%) and 45 were male (45.5%). The largest proportion of participants was in the 26-35 age group (38.4%), while only 3% were 56 years or older. Due to the small size of this group, it was merged with the 46-55 category for statistical analysis (Table 1).
The overall mean quality of life score was M = 57.0, SD = 27.5, suggesting a moderate level of perceived well-being. Among the WHOQOL-BREF domains, the highest scores were recorded in social relationships, followed by environment, psychological health, and physical health, which had the lowest mean score (Table 2).
Table 2. Mean quality of life domain scores | ||
Domain | Mean (M) | Standard Deviation (SD) |
Physical Health | 50.8 | 27.8 |
Psychological Health | 58.2 | 26.2 |
Environment | 59.7 | 27.0 |
Social Relationships | 65.4 | 26.8 |
Overall QoL | 57.0 | 27.5 |
The Kruskal-Wallis test revealed statistically signifi- cant differences in quality of life scores across age groups in the domains of psychological health (χ² = 14.21, p = 0.001), social relationships (χ² = 16.88, p
< 0.001), and environment (χ² = 12.32, p = 0.002).
Post hoc comparisons using Dunn’s test with Bonfer- roni correction indicated that nurses aged ≤ 25 years reported significantly higher quality of life in these three domains compared to those aged 46-65 years (Table 3).
No statistically significant differences in quality of life scores were found between male and female par- ticipants across any domain (all p > 0.05).
Nurses employed in Rijeka reported higher scores in the environment domain (M = 63.4, SD = 26.1) than those in Zagreb (M = 56.3, SD = 27.5). This difference was statistically significant (U = 935, p = 0.029).
Kruskal-Wallis tests showed statistically signifi- cant differences in psychological health (χ² = 7.31, p = 0.027) and social relationships (χ² = 6.55, p = 0.038) across education levels. Post hoc analysis us- ing Dunn’s test with Bonferroni correction revealed that nurses with secondary education reported sig- nificantly higher scores than those with a master’s degree in both domains (Table 4).
This study explores the quality of life of nurses work- ing in emergency departments in Croatia, specifically in Rijeka and Zagreb. The findings reveal several significant patterns in the interaction between de- mographic and occupational factors and QoL, contrib- uting to a broader understanding of the challenges faced by emergency healthcare workers.
The overall QoL score of 57.0, indicating a moderate level of life satisfaction, is lower than that reported in previous studies, such as Gabrić’s research in Kar- lovac County, which showed a score of 72.2 (1). This discrepancy may reflect regional differences in work- load, staffing levels, and the availability of resources. Additionally, participants in this study reported the highest satisfaction in the domain of social relation-
ships, and the lowest in physical health, which is in line with findings from Poland and other interna- tional research highlighting the physical demands of emergency care work (14). These findings under- score the importance of targeted interventions to improve physical well-being, such as implementing wellness programs, making ergonomic adjustments, and promoting physical activity among emergency department staff.
The results revealed a significant relationship be- tween age and quality of life in the domains of psychological health, social relationships, and envi- ronment, with younger participants (≤ 25 years) re- porting higher scores than older ones (≥ 46 years). Interestingly, no significant difference was found in the domain of physical health, which contrasts with previous studies that typically associate younger age with better physical functioning.
This unexpected result may be due to the uniform- ly high physical demands placed on all emergency nurses, regardless of age, which could diminish age- related differences in perceived physical health. However, studies from Saudi Arabia report the oppo- site trend, where older healthcare workers showed better QoL, potentially due to increased work experi- ence, stronger professional relationships, and more stable work-life integration (15). These differences highlight the influence of cultural and institutional factors, suggesting the need for age-sensitive inter- ventions, such as flexible work schedules and well- ness programs tailored to older staff.
Table 3. Statistically significant differences by age group identified using the Kruskal-Wallis test | |||||||
Domain | χ² (K-W) | p (K-W) | M (≤ 25 yrs) | SD (≤25 yrs) | M (46-65 yrs) | SD (46-65 yrs) | p (post hoc) |
Psychological health | 14.21 | 0.001 | 63.5 | 24.1 | 52.1 | 27.0 | 0.008 |
Social relationships | 16.88 | <0.001 | 70.3 | 25.6 | 60.0 | 27.2 | 0.003 |
Environment | 12.32 | 0.002 | 64.1 | 26.4 | 55.3 | 27.7 | 0.010 |
Table 4. QoL scores by education level | ||||||||||
Domain | χ² (K-W) | p (K-W) | M (Secondary) | SD | M (Bachelor) | SD | M (Master’s) | SD | Post hoc comparison | p (post hoc) |
Psychological health | 7.31 | 0.027 | 62.3 | 28.7 | 56.1 | 24.9 | 56.6 | 24.1 | Secondary > Master’s | 0.022 |
Social relationships | 6.55 | 0.038 | 70.8 | 29.8 | 65.4 | 25.2 | 54.7 | 22.3 | Secondary > Master’s | 0.035 |
Some differences in average QoL scores were ob- served between male and female participants, with male nurses reporting slightly higher scores in over- all quality of life, physical health, and environment. However, these differences were not statistically significant across any domain in the present study. This contrasts with findings from studies conducted in Saudi Arabia and Brazil, which reported better QoL among male healthcare workers compared to their female colleagues (16, 17). Although the present study does not confirm consistent gender-based dif- ferences across all domains, previous research sug- gests that factors such as increased physical and emotional strain, domestic responsibilities, and struc- tural inequalities in the workplace may contribute to lower perceived QoL among female nurses.
Recent research confirms that female emergency nurses experience significantly higher levels of emo- tional exhaustion and work-family conflict compared to males, due to gendered role expectations and the emotional toll of caregiving roles (18). To address these issues, organizational change is needed, in- cluding the implementation of gender equality poli- cies, access to childcare support, and fair promotion systems.
Contrary to expectations, nurses with secondary education reported better QoL in the domains of psychological health, social relationships, and overall satisfaction compared to those with higher educa- tion levels. In the Croatian context, secondary edu- cation refers to a five-year vocational nursing pro- gram at the secondary school level, which qualifies individuals to work as registered nurses. This finding challenges the assumption that more education cor- relates with greater well-being and is consistent with Gabrić’s findings (1). Possible explanations include lower job-related stress and responsibility in roles requiring only secondary education, and more realis- tic expectations regarding work-life balance. These results suggest that increased professional demands placed on more educated nurses may negatively af- fect their QoL. Further research is needed to exam- ine how job responsibilities and expectations differ by education level and how they impact well-being.
The participants working in Rijeka reported signifi- cantly higher scores in the environment domain com- pared to those working in Zagreb, likely reflecting the advantages of a smaller and less congested city. Fac- tors such as reduced traffic, lower cost of living, and better access to green spaces may contribute to this
outcome. These findings are consistent with studies associating higher QoL with smaller urban environ- ments which provide more accessible community re- sources and a slower pace of life (19). However, the lack of significant differences in other domains sug- gests that institutional factors, such as management practices, staffing levels, and workplace culture, also play a role in shaping perceived QoL.
These international comparisons suggest that cul- tural context, healthcare system structure, and workplace support mechanisms all contribute to how demographic variables affect perceived QoL. They highlight the need for location-specific and demo- graphically sensitive interventions aimed at improv- ing the quality of life of emergency nurses.
Recommended strategies include increasing staffing to reduce workload, providing wellness and mental health programs, ensuring gender equality policies, and offering flexible schedules for older staff. In larg- er cities such as Zagreb, interventions should focus on reducing environmental stressors, while in smaller cities, initiatives could build on existing community strengths.
This study has several limitations. The cross-section- al design restricts causal inference, and reliance on self-reported data introduces the risk of response bias due to participants’ subjective perceptions. Ad- ditionally, the sample was geographically limited to emergency departments in two Croatian cities, which may reduce the generalizability of findings to other regions or healthcare systems. One notable limita- tion concerns the age distribution of the participants: only three respondents were aged 56 or older, which led to the merging of this group with the 46-55 cat- egory for statistical analysis, potentially masking age-specific trends.
While post hoc tests were performed for statistically significant results in age and education, the limited sample size in some subgroups still reduces statis- tical power. Future research should consider longi- tudinal designs to observe changes over time and
should include a broader, more diverse sample, both geographically and across different healthcare set- tings, to allow for comparisons between institutions, specialties, and countries.
This study examined the quality of life of nurses work- ing in emergency departments in Rijeka and Zagreb. The overall QoL was found to be moderate, with the highest satisfaction reported in the domain of social relationships and the lowest in physical health. Statis- tically significant differences were identified across age, education level, and workplace in specific QoL domains, while no significant gender-based differ- ences were observed. Younger nurses and those with secondary education reported higher scores in several areas, while nurses employed in Rijeka rated the envi- ronment domain more positively than those in Zagreb. These findings address the research questions and emphasize the relevance of demographic and contex- tual factors in evaluating nurse well-being.
Conceptualization and methodology (KL, KI); Data cu- ration and formal analysis (KL, MM, KI); Investigation and project administration (KL, MM, KI); and Writing – original draft and review & editing (KL, MM, KI). All authors have approved the final manuscript.
The authors declare no conflicts of interest.
The authors thank the nurses working in the emer- gency departments in Rijeka and Zagreb for their participation in the research.
This research did not receive any specific grant from funding agencies in the public, commercial, or not- for-profit sectors.
Gabrić M. Quality of life of healthcare workers at the Emergency Medical Institute of Karlovac County: rese- arch-based thesis [Master’s thesis]. Rijeka: University of Rijeka, Faculty of Health Studies; 2022.
Strapajević D. Assessing the impact of the integrated hospital emergency department service on the health and working ability of employees. Sestrinski glasnik. 2015;20(3):231–9.
Slišković A. Problems of shift work. Arh Hig Rada Toksi- kol. 2010;61(4):477. https://doi.org/10.2478/10004-
1254-61-2010-2080
Protić I. The impact of shift work on quality of life and sleep quality among nurses [Master’s thesis]. Rijeka: University of Rijeka, Faculty of Health Studies; 2021.
Dujić I, Gregov Lj, Slišković A. The relationship betwe- en shift work and the social and family life of workers. Medica Jadertina. 2014;44(1–2):13–25.
Lozančić A, Kovačević J, Matić M, Matić M, Kovačević
N. Quality of life of emergency medical staff. In: Ne- sek Adam V, Važanić D, editors. Proceedings and ab- stracts. Vodice: Croatian Medical Association; Croatian Society for Emergency Medicine; Croatian Nursing So- ciety for Emergency Medicine; 2020.
Pavlović B, Pavić J. Self-assessment of the quality of life and work of nurses at Zagreb Health Center. J Appl Health Sci. 2022;8(2):269–80. https://doi. org/10.24141/1/8/2/14.
Kovačić Kačar Ž. Comparison of the quality of life and health of nurses working in family medicine practices and home healthcare institutions [Master’s thesis]. Split: University of Split; 2018. Available at: https:// urn.nsk.hr/urn:nbn:hr:176:996546.
Dall’Ora C, Ball J, Reinius M, Griffiths P. Burnout in nursing: a theoretical review. Hum Resour Health. 2020;18(1):41. https://doi.org/10.1186/s12960-020-00469-9
Juan-García C, Plaza-Carmona M, Fernández-Martínez
N. Sleep analysis in emergency nurses’ department. Rev Assoc Med Bras (1992). 2021;67(6):862–7.
https://doi.org/10.1590/1806-9282.20210648
Córdova-Martínez A, Pérez-Valdecantos D, Caballero- García A, Bello HJ, Roche E, Noriega-González D. Relati- onship between strength and professional quality of li- fe of nurses working hospital emergency departments. Int J Environ Res Public Health. 2023;20(3):2052. https://doi.org/10.3390/ijerph20032052
World Health Organization. WHOQOL: User Manual. Geneva: Division of Menthal Health and Prevention of Substance Abuse [Internet]. World Health Organizati- on; 1998. Available at: https://iris.who.int/bitstream/ handle/10665/77932/WHO_HIS_HSI_Rev.2012.03_ eng.pdf?sequence=1
Silva PAB, Soares SM, Santos JFG. Cut-off point for WHOQOL-bref as a measure of quality of life of older adults. Rev Saude Publica. 2014;48(3):390–7. https:// doi.org/10.1590/S0034-8910.2014048004912
Orszulak N, Kubiak K, Kowal A, Czapla M, Uchma- nowicz I. Nurses’ quality of life and healthy behaviors. Int J Environ Res Public Health. 2022;19(19):12927. doi:10.3390/ijerph191912927.
Alharbi MF, Alahmadi BA, Alali M, Alsaedi S. Quality of nu- rsing work life among hospital nurses in Saudi Arabia: A cross-sectional study. J Nurs Manag. 2019;27(8):1722–
30. https://doi.org/10.1111/jonm.12856
Maqsood MB, Islam MA, Nisa Z, Nagvi AA, Qarni AA, Al-karasneh AF, et al. Assessment of quality of work life (QWL) among healthcare staff of intensi- ve care unit (ICU) and emergency unit during CO- VID-19 outbreak using WHOQoL-BREF. Saudi Pharm
J. 2021;29(11):1348–54. https://doi.org/10.1016/j. jsps.2021.10.002
Monteiro QR, Lobato CM, Amaral TLM, Costa JMM, Boas ACV, Monteiro IL, et al. Quality of life evaluati- on of emergency professionals of public units of re- ference. Braz J Dev. 2022;8(1):8144–61. https://doi. org/10.34117/bjdv8n1-563
Diao D, Chen X, Zhong L, Zhang H, Wang S. Sex diffe- rences in burnout and work-family conflict among Chinese emergency nurses: A cross-sectional study. Front Public Health. 2024;12:1492662. https://doi. org/10.3389/fpubh.2024.1492662
Batrnek T, Gašpert M. Quality of life of nurses in Osijek. Croat Nurs J. 2018;2(2):99–109. https://doi. org/10.24141/2/2/2/2