Job Satisfaction and Intention to Stay in Relation to Sport and Exercise Activities Among Nurses of University Hospitals

Objectives : This study was designed to achieve the following three objectives. The first objective was to ascertain the current status of sport and exercise engagement among nurses. The second objective was to examine factors affecting nursesʼ sport and exercise activities, and the third objective was to examine the relationship between nursesʼ sport and exercise activities and their job satisfaction and intention to continue working intention to stay. Design : Cross-sectional design was used. Methods : An anonymous self-administered questionnaire survey was conducted targeting 1,091 nurses at two university hospitals. Results : After excluding male nurses and missing data, the data of 891 female nurses were used in the final analyses. The findings can be summarized into the following three points; the first finding was that more than half of the nurses have not engaged in sport and exercise in the past year and running, jogging, and marathon training were the most popular among those who have engaged, the second finding was that the sport and exercise engagement rate of nurses with pre-primary children tends to be lower, and the third finding was that nurses who engaged in sport and exercise 1-2 times a week tended to have higher levels of job satisfaction and intention to continue working in terms of their relationship with their superiors, overtime and workload, approval, and sense of fulfillment compared to nurses who did not engage in sport and exercise at all. Conclusions : This research suggests the importance for medical institutions such as hospitals to try and promote engagement in sport and exercise among nurses from the viewpoint of job satisfaction and retention of nurses.


Introduction
Health and productivity management, which is the management method designed to boost a companyʼs productivity by looking at employeeʼs health from a managerial perspective 1) , has long been attracting attention in Japan, ever since Rosen presented the notion that healthy employees drive profitable businesses in his book The Healthy Company 2) . Many companies are taking strategic measures to maintain and promote the health and wellbeing of their employees by promoting engage-ment in sport and exercise (hereinafter referred to as exercise) among them. Health and productivity management is expected to reduce the rate of medical expenses and absenteeism among employees and boost job satisfaction and intentions to stay in oneʼs job. However, despite an awareness that exercise is importance, exercise engagement rate among adults in Japan is low for reasons such as people do not have sufficient time and are busy with work 3)-5) .
On the other hand, regarding the level of engagement in exercise among nurses, despite there being very little research on the topic, it is known that engagement levels are low in Japan 6) 7) . When examining the workplace, with the rapidly advancing aging population and declining birthrate in Japan as well as technical advancements in medical care, nursing care is growing in both quantity and quality, and despite the efforts to improve the working environment for nurses such as putting a support system in place for childcare leave 8) , the long working hours, the enormous workload, the chronic shortage of human resources, and night shifts place a huge physical and mental burden on nursing staff. These factors have contributed to a job turnover rate of around 11% for nurses in Japan for the last decade 9) . This study sheds light on the need to improve job retention and satisfaction levels among nurses.
Amidst these circumstances, it is considered necessary for even nursing organization to take on a health and productivity management perspective. However, of the 1,317 corporations certified as superior health and productivity management organizations in fiscal 2018, only 16 are medical corporations 10) , which highlights the fact that we are still standing at the start line in terms of health and productivity management initiatives within nursing care organizations.
On the other hand, in previous research on the relationship between nursesʼ health and engagement in exercise, there are numerous findings to show that exercise activities are effective in improving nursesʼ work-life balance 11) , alleviating symptoms of depression 12) , reducing fatigue 13) , and work ability 14) . Despite the large pool of research on such topics, research has not extended to examine the relationship between exercise and nursesʼ job attitudes such as job satisfaction and their intention to continue working. Turning our attention to companies, there are reports that indicate that when employee wellness programs incorporating exercise are introduced, benefits such as fewer employees leaving the company can be seen 15) .
Our intention is to shed light on the relationship between engagement in exercise among nurses and job satisfaction and intention to continue working in nursing institutions. To do so, we are looking at factors relating to job satisfaction and intention to continue work which have not been the focus of research to date. To this end, this study was designed to achieve the following three objectives. The first objective was to ascertain the current status (events and frequency) of exercise engagement among nurses. The second objective was to examine factors (age, marital status, if they have any pre-primary children (aged 0-6), if any family members require nursing care, executive title, and employment type) affecting nursesʼ exercise activities. The third objective was to examine the relationship between nursesʼ exercise activities and their job satisfaction and intention to continue working.

Preliminary survey
This study was broken down into a preliminary survey and a main survey. In 2016, a semi-structured interview survey was conducted to create questions about job satisfaction among nurses (n = 10) working in university hospitals in the Tokyo metropolitan area, in relation to the nursesʼ exercise habits, employment status, factors that bring about job satisfaction, and factors that cause dissatisfaction. Then, after the narrative data obtained from interviews was segmented, keywords were extracted and grouped into 25 factors that contribute to job satisfaction among nurses. Following this, discussions with nursing managers, members of the workplace environment review committee, and specialists in nursing management science and administrative science were conducted to confirm the validity and wording of the questions based on these 25 factors, before creating the main survey that was made up of 61 questions related to job satisfaction.

Main survey
This survey was an anonymous self-administered questionnaire conducted in 2017 targeting nurses at two university hospitals in the Tokyo metropolitan area. The questionnaire was distributed to 1,091 nurses, excluding the nursing department managers and nursing department directors. After nurses responded to the survey, they were asked to put their survey sheets into a sealed collection envelope and post it into a collection box provided. As a result, 992 responses were obtained (response rate: 90.9%).
The study was approved by the ethics board of the authorsʼ institution (Application Number: . The participants were informed that participation in this study was voluntary and that no one was required to complete the questionnaire.

Face sheet
The survey face sheet asked respondents to include demographic attributes such as gender, age, family make-up including if they have any preprimary children, if they have any family members requiring nursing care, their job title, how many years of nursing experience, how many years they have worked at their current hospital and their current employment status.

Current status of exercise engagement
Based on the survey conducted by Sasakawa Sports Foundation 16) , we asked the respondents about the exercise activities they engaged in over the last year, including questions about the type of exercise, the frequency, duration per session, intensity of the activities, as well as who they exercised with.

Job satisfaction
Questions about job satisfaction that were devised for the preliminary survey and which consisted of 61 items such as"I can work in the department that I want to work in"and"it is a workplace where I can achieve a healthy work / life balance" , participants were asked to respond using a 5-point scale; 5 = I completely agree; 4 = I agree, 3 = I canʼt say either way, 2 = I donʼt really agree, 1 = I completely disagree.

Intention to continue working
A scale that was previously used by Mizuno et al. 17) and Tuchie & Nakamura 18) and was shown to be reliable and relevant was adopted as a way to measure participantsʼ degree of intention to continue working. The scale was broken down into three questions;"I want to continue working in my current department" ,"I want to continue working at my current hospital" ,"I want to continue working as a nurse" . Participants were asked to respond using a 5-point scale; 5 = I completely agree; 4 = I agree, 3 = I canʼt say either way, 2 = I donʼt really agree, 1 = I completely disagree.

Statistical analyses
As only 65 (6.6%) of the 992 respondents were male, these respondents were removed from the study. Additionally, in accordance to what is commonly known as complete case analysis, cases that were missing variables were dropped from the analysis. As a result, responses from 891 female nurses were included in the analysis (valid response rate of 81.7%).
Firstly, descriptive analysis was conducted in order to ascertain the participantsʼ state of exercise (type and frequency) engagement. Next, a chisquare test was used to compare the differences in the exercise engagement according to the attributes of the participants (their age bracket, marital status, family make-up including if they have any pre-primary children, any family members requiring nursing care, job title, and employment status).
Then, an exploratory factor analysis was performed on 61 job satisfaction survey items, and the average score of each of the 10 extracted factors and the average score of each of the three items for work continuation intention were calculated and used for the analysis. Following this, a binomial logistic regression analysis was performed in order to examine the relationship between exercise and job satisfaction and intention to continue working. In other words, there were 10 factors of job satisfaction and 3 items of intention to continue work set as dependent variables, exercise frequency as independent variables, and age bracket, marital status, pre-primary children, relatives needing nursing care, job status, and employment status as adjustment variables, and binomial logistic regression analysis was used by the forced entry method including all the adjustment variables mentioned above to calculate the adjusted odds ratio (Adjusted OR) regarding the degree of impact that exercise activities have on job satisfaction and the intention to continue working, and the magnitude of the influence of each factor was evaluated from the odds ratio.
As a procedure for this, using the quartile method, categorical variables were created with the top 25% of the average score in each 10 factors of job satisfaction as the high group, the other 75% as the control group, and similarly, the top 25% of the average score in 3 items for the intention to continue work as the high group and the other 75% was the control group. All statistical analyses were performed using IBM SPSS Statistics 25 for Windows.

Exercise engagement and frequency
Engagement in exercise was broken down into two segments; those who engaged in exercise more than once in the last year and those who did not engage at all. Of the 891 respondents, there were 423 (47.5%) who had engaged in exercise in the last year, and 468 (52.5%) who had not. In terms of frequency, of the 423 respondents who had exercised more than once in the last year, 99 said it was 1-3 times during the year, 108 said they had exercised between 4 and 11 times, 134 said 1-3 times a month, 64 said 1-2 times a week, and 18 nurses said more than 3 times a week.
Next, exercise engagement was examined by a chi-square test with each of the variables of age

Types of exercise
The types of exercise engaged in over the past year were running, jogging, and marathon training which were the most popular with engagement by 94 participants, followed by yoga, aerobics, ballet, and Pilates with 79 participants engaging, and 40 participants engaging in swimming. Looking at the exercise engagement rates by age bracket, there were more participants in their 20s, 30s and 40s who engaged in running / jogging / and marathon training, and more 50-somethings who engaged in walking for exercise (Table-2).

Exploratory factor analysis of the 61 items of job satisfaction
We conducted factor analysis using the maximum likelihood method for the 61 job satisfaction factors. Using promax rotation, only items with a factor loading of more than 0.4 were extracted, and 17 items that showed a factor loading of less than 0.4 or had 2 or more factors with a loading of 0.3 or more were left as remaining factors, which then underwent factor analysis again to leave a 10-factor structure. The factor name and job satisfaction mean score and standard deviation for each factor are as shown in Table-3.

Factors relating to the exercise activities
A binomial logistic regression analysis was performed to examine the relationship between exercise activities and job satisfaction and intention Iwaasa T, Mizuno M: Job satisfaction and intention to stay in relation to sport and exercise activities among nurses of university hospitals   week. In particular, compared to subjects with no engagement, the odds ratios for"fulfillment"and "approval"for engaging in exercise 1-2 times a week were 2.85 and 2.47 respectively, indicating a strong relationship. Furthermore, regarding intentions to continue working, findings for all three factors indicated that scores were significantly higher among nurses who engaged in exercise 1-2 times a week compared to those who did not engage at all (Table-4).

Discussion and Conclusions
This study ascertained the status of engagement in exercise among nurses and the relationship between job satisfaction and intention to continue working and engagement in exercise. As a result, the first finding was that more than half of the nurses have not engaged in exercise in the past year and running, jogging, and marathon training were the most popular among those who have engaged, the second finding was that the exercise engagement rate of nurses with pre-primary children tends to be lower, and the third finding was that nurses who engaged in exercise 1-2 times a Iwaasa T, Mizuno M: Job satisfaction and intention to stay in relation to sport and exercise activities among nurses of university hospitals Notes: All analyses were adjusted for age bracket, marital status, pre-primary children, relatives needing nursing care, job status, and employment status. OR = odds ratio; CI = confidence intervals Bold indicates significant at p <= 0.05. This table shows pathological analysis results as dependent variables and selected predictor variables from ultrasound examination for benign and malignant lymph node differential diagnosis week tended to have higher levels of job satisfaction and intention to continue working in terms of their relationship with their superiors, overtime and workload, approval, and sense of fulfillment compared to nurses who did not engage in exercise at all. Firstly, with regard to the first point, the rate of exercise engagement, the result of this survey was 47.5%, indicating that more than half of the nursing staff do not exercise. In previous study, the engagement rates of nurses were 33.2% and 36.9% 6) 7) , which generally supported the findings of the previous study. On the other hand, going on the findings of a survey by the Sports Agency, exercise engagement for women in their 20s to 50s overall is around 75% 19) . Compared to this figure, it can be said that the rate of exercise engagement among nurses is significantly low. In terms of the types of exercise engaged in, the top types were running, jogging, and marathon training, which were the same findings as in the survey conducted by the Sports Agency 19) . This suggests that the types of exercises selected do not require any kind of special preparation or training and can be performed easily by oneself.
For the second point, in recent years, despite there being an increasing number of hospitals that are working on such initiatives as adopting shorter and staggered working hours as well as offering irregular shifts in line with individual wishes and implementing overtime-free work days, there are still many nurses who decide to leave their jobs. In a survey of working women, some of the conditions that were identified as being important for engaging in exercise while working were that"a variety of working styles are recognized, and leisure time can be secured at the workerʼs own discretion 20) ." In other words, this suggests that not only is it important to have a system in place, but also that it is important to have autonomy at work to be able to exercise at oneʼs own discretion. However, in the field of nursing, nurses who are raising young children are also required to adapt to sudden work situations such as emergency hospitalization and sudden changes in patients, just like regular nurses. And this is thought to contribute to the lack of leisure time for exercise. In addition, it has been pointed out that a familyʼs lack of understanding about the importance of exercise is one of the factors that inhibits women in engaging in exercise activities during their child-rearing years 21) . It is thought that not only support in the workplace, but support at home is effective in promoting engagement in exercise among nurses during their childrearing years.
On the other hand, we identified that the exercise engagement rate differed depending on whether nurses had pre-primary children or not, but it did not differ in relation to whether they had family members who required nursing care. This is an old survey, but according to findings by the Economic Planning Agency in 1999, 71 minutes each week were required for nursing care 22) , and in a 2016 multi-choice survey by the Ministry of Health, Labor and Welfare, the majority of respondents said that they spend time on nursing care when it is required 23) but spend approximately 225 minutes a week on everyday activities like child raising 24) , which suggests that it is likely that time spent on everyday things in both surveys differs.
The third point is about engagement in exercise 1-2 times a week. This was shown to be significantly linked to job satisfaction and intention to continue working. Factors that influence an employeeʼs relationship with their superiors include the volume of overtime and workload, degree of approval and the sense of fulfillment. The first factor, relationship with their superiors, is determined by such factors as whether they think superiors treat all nurses equally and if they have a good relationship with their superiors. Therefore, it is possible that a close relationship with oneʼs superiors may contribute to smooth job performance, coordination of work shifts, and eventually to work-life balance. Next, with regard to overtime hours and workload, workload is related to leisure time, and it was shown that dissatisfaction with a heavy workload inhibited engagement in exercise 25) . This can be said to support the findings of this study.
Subsequently, with regard to the connection between approval and fulfillment in relation to job satisfaction ( "I want to continue working in the current department" ,"I want to continue working in the current hospital" ,"I want to continue working as a nurse in the future" ), firstly, regarding the sense of approval, according to Mizuno 14) , increasing the level of job satisfaction among nurses in terms of their sense of approval is a key factor in practicing retention management, which aims to retain and ground nurses. Next, fulfillment is a concept that is closely related to work engagement, which is defined as a positive, affective-motivational state of fulfillment that is characterized by vigor, dedication, and absorption from oneʼs work 26) , and it is considered to be one of the outcome indicators for health and productivity management. Thus, approval and feeling fulfilled are considered to be key factors that define job attitudes such as job satisfaction and job continuity.
This study indicates a strong link between exercise activities and job satisfaction and intention to continue work, and in terms of job satisfaction and intention to continue work, exercising 1-2 times a week is considered better. One of the noteworthy points of this study is that to start with there were few prior studies on the status of exercise among nurses, and this study uncovered the abovementioned results despite it being difficult to collect basic data. Previous studies have pointed out that the perception of work-life balance (WLB) is related to job satisfaction 9) , and that it is important to have opportunities to engage in exercise to feel satisfied with oneʼs WLB 27) . Furthermore, studies have identified that exercise are related to mental health and vitality 28) . It suggests that the underlying findings of this series of results, as indicated in previous studies, is that there are benefits to exercise, including that exercise contribute to the degree of satisfaction one has with their work-life balance.
This study also revealed that more than half of the nurses have not engaged in exercise in the past year. The pressing issue is that the level of exercise among nurses needs to be raised across the board. With regard to the underlying reasons for not engaging in exercise, this study revealed that nurses with pre-primary children have a low rate of engagement, indicating that oneʼs time at home may also be inhibiting engagement, but there are also other factors in play and we cannot rule out that participants may simply be adverse to being active or feel indifferent toward exercise. It is important to try and promote the creation of triggers for behavioral change among this type of subject. In recent years, the concept of health literacy has attracted attention. Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate healthrelated decisions 29) . Among the companies working in the health and productivity management field, a growing number of companies are working on improving employee health literacy, such as bringing onboard CHO (Chief Health Officers) and offering health-related seminars. Research also suggests that health literacy is associated with lifestyle and behavioral changes. Sakamoto et al. 30) found that about 60% of those with high health literacy engaged in exercise, while only 45% of those with lower health literacy engaged in exercise. Furuzawa et al. 31) demonstrated that those with high health literacy not only have a high rate of exercise but also a high engagement frequency. In addition, Fukuda 32) , through the companyʼs longterm measures to improve the health literacy of employees, reported that exercise engagement gradually increased when looking at levels before the implementation of measures, 5 years after implementation, and 10 years after implementation. These studies are focused on company employees and the challenge remains to accumulate research in the nursing field, however, it can be expected that efforts to improve organizational health literacy in the field can contribute to the creation of new exercise habits for nurses as well.
Japan has laid out a goal of achieving 65% sports engagement at least once a week for adults 33) . To that end, promotion of health and productivity management in a wide range of fields including hospitals and other medical institutions is essential. The fact that this research suggests a significant relationship between nursesʼ exercise activities and job satisfaction and retention (maintenance and retention of nurses) significantly implies that there are potential benefits to health and productivity management in medical institutions such as hospitals.

Limitations and future research
As this study is a cross-sectional survey, we cannot rationally explain the causal relationship between exercise activities and job satisfaction and intention to continue working, as well as the mechanisms that influences each other. In the future, it is necessary to consider a study that is based on a longitudinal design. Also, with regard to the state of exercise, participants were asked about their activities over the past year, so recall bias cannot be ruled out. Moving forward, data reliability will be improved by examining a method of measuring exercise volume quantitatively using wearable devices together with a survey questionnaire. Another limitation is that male nurses were not included in this study. The number of male nurses has increased significantly in recent years 34) . In the future, it is necessary to examine whether these research results can be applied to male nurses as well.