The effect of nurses’ perception of decent work on sickness presenteeism and work-related flow experiences

Abstract

Background

Nurses’ vitality, perceptions of decent work, and sickness presenteeism play a crucial role in patient safety and quality of care. However, these factors remain underexplored in the literature, underscoring the need for further research to examine the relationships among them. The study aims to examine the relationships between nurses’ perceptions of decent work, sickness presenteeism and work-related flow experiences.

Methods

The study used a cross-sectional, correlational design. A sample of 374 nurses employed at a university hospital in a province of Turkey was selected using convenience sampling. Data were collected using the Decent Work Scale, Sickness Presenteeism Scale-Nurse, The Work-Related Flow Inventory, on an Introductory Information Form. Pearson correlation analysis, multiple linear regression, independent samples t-test, and one-way ANOVA were conducted.

Results

A positive correlation was found between the total scores of the decent work scale and the work-related flow inventory. in addition, a weak significant correlation was found between the total scores of the sickness presenteeism scale-nurses and the work-related flow scale. According to the results of multiple linear regression analysis decent work significantly positively predicts work-related flow (β = 0.327, t = 6.84, p < 0.001). On the other hand, sickness presenteeism significantly negatively predicts work-related flow (β = -0.211, t = -4.42, p < 0.001).

Conclusion

Decent work was positively associated with concentration and engagement at work, while sickness presenteeism was negatively associated with work-related flow.

Clinical trial number

Not applicable.

Introduction

Sustainable organizational performance increasingly depends on the establishment of humane and supportive work environments that safeguard employee dignity and well-being. Within this context, the concept of Decent Work (DW) has gained growing attention as a comprehensive framework encompassing fair treatment, safe working conditions, social support, and opportunities for development. Beyond objective working conditions, DW also reflects employees’ subjective perceptions of respect, security, and meaningfulness at work. Within the contemporary Job Demands–Resources Model, such favorable working conditions are conceptualized as key job resources that enhance motivation, psychological functioning and buffer the negative effects of job demands [1, 2]. Recent evidence further emphasizes that resourceful work environments play a central role in shaping employee well-being and behavioral outcomes in high-demand professions such as healthcare [3].

Grounded in positive organizational psychology, Work-Related Flow (WOLF) refers to a positive, work-specific psychological state characterized by deep absorption, intrinsic motivation, and enjoyment of work. Based on Flow Theory [4], flow emerges when perceived job challenges are optimally balanced with individual skills. In modern organizational settings, job resources such as autonomy, performance feedback, and social support facilitate this balance and promote optimal functioning [5]. Empirical studies consistently show that WOLF is associated with higher performance, creativity, and lower burnout and emotional exhaustion [6, 7].

Within the Job Demands–Resources (JD–R) framework, job resources not only stimulate motivational states but also mitigate strain-related outcomes [1, 8]. One important behavioral outcome is Sickness Presenteeism (SP), defined as attending work despite illness. SP has been increasingly recognized as a costly organizational phenomenon associated with reduced productivity, delayed recovery, and long-term health risks [9, 10]. Recent studies highlight that SP arises from a complex interplay of high job demands, organizational pressure, and individual work commitment [11].

By integrating these perspectives, DW, WOLF, and SP can be conceptualized within a unified JD-R framework that links work conditions, optimal psychological states, and health-related behaviors. Specifically, DW is assumed to satisfy employees’ basic psychological needs and foster WOLF by enhancing intrinsic motivation [12]. Employees who perceive their work environments as fair, safe, and supportive are more likely to experience deep absorption, enjoyment, and intrinsic engagement in their work activities. In turn, accumulating evidence suggests that flow experiences are associated with lower levels of stress, improved emotional regulation, and more favorable health outcomes [5]. These psychological and health-related benefits may reduce the likelihood of attending work while ill. However, recent studies indicate that the relationship between WOLF and SP may be more complex than previously assumed. Highly engaged employees may voluntarily engage in presenteeism due to a strong professional identity, a heightened sense of responsibility, or perceived moral obligations toward their work and colleagues [13]. Accordingly, the association between WOLF and SP may be contingent upon contextual and individual factors rather than being strictly linear. Furthermore, supportive and resource-rich work environments can mitigate excessive job demands and facilitate healthier decisions regarding attendance at work. In contrast, unfavorable working conditions may increase the prevalence of presenteeism and other adverse work-related outcomes [14]. Taken together, the proposed framework suggests that DW functions as a contextual job resource that promotes WOLF, which subsequently influences SP, while DW may also exert a direct effect on SP.

The aim of this study is to examine the relationships between decent work perception, sickness presenteeism, and work-related flow among nurses. Accordingly, our research hypotheses are:

H0

There is no significant relationship between nurses’ perceptions of decent work, sickness presenteeism, and work-related flow experiences.

H1

There is a significant relationship between nurses’ perceptions of decent work, sickness presenteeism, and work-related flow experiences.

Methods

Design

This is a descriptive, correlational, and cross-sectional study. This study was reported in accordance with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE), which is used in cross-sectional studies.

Population and sample

The study population consisted of nurses employed at a university hospital providing tertiary healthcare services in a metropolitan city in Turkey (n = 737). When determining the sample size, the minimum number of nurses required using a known population sampling method was calculated as 253, with a 95% confidence level, a 5% margin of error, and 95% statistical power. The final sample, selected through convenience sampling, included 374 nurses who completed the data collection instruments (n = 374).

The inclusion criteria were: (1) having worked as a nurse at the study hospital for at least six months, and (2) actively working during the data collection period. Nurses employed for less than six months and those on long-term leave (e.g., maternity leave) were excluded.

Sample characteristics

An examination of the participants’ descriptive characteristics revealed that 46.3% were aged between 32 and 42, with an average age of 34.2 years. In addition, 33.5% were in the age group of 39 to 52, 77.8% were women, 61.8% were married, and 85% held a bachelor’s degree. Regarding professional characteristics, 47.6% had 1 to 10 years of professional experience, 63.4% had 1 to 10 years of experience at the current hospital, and 32.4% worked in internal medicine units. Furthermore, 71.9% of participants worked in shifts, and 89.6% held nursing positions. It was found that 59.4% of the participants worked in units with 1 to 10 nurses, with an average of 14.89 nurses per unit. In addition, 42.8% expressed satisfaction with their unit (M = 2.16, SD = 0.81), while 37.7% reported dissatisfaction with their profession (M = 1.96, SD = 0.84), and 54.5% were dissatisfied with their institution (M = 1.63, SD = 0.76) (Table 1).

Table 1.

Demographic characteristics of participants (n = 374)

Variable	N	%
Age(years)
21–31	152	40.6
32–42	173	46.3
> 43	49	13.1
Gender
Male	291	77.8
Female	83	22.2
Marital Status
Married	231	61.8
Single	143	38.2
Education
Associate degree	30	8.0
Bachelor degree	318	85.0
Master degree	26	7.0
Total years of employment in the profession
Less than 1 year	14	3.7
1–10 years	178	47.6
11–20 years	130	34.8
20 years and more	52	13.9
Years of working at the hospital
Less than 1 year	15	4.0
1–10 years	237	63.4
11–20 years	96	25.7
20 years and more	26	7.0
Unit
İnternal clinic	121	32.4
Surgical clinic	103	27.5
Intensive care unit	98	26.2
Emergency room	28	7.5
Polyclinic and administrative unit	24	6.4
Professional title
Nurse Nurse in charge	335 39	89.6 10.4
Working shift
Continuous daytime	99	26.5
Constantly at night	6	1.6
Shift	269	71.9
Number of nurses working in the unit
1–10 nurses	222	59.4
11–20 nurses	36	9.6
21 nurses and above	116	31.0
Satisfaction with the unit
Not satisfied	99	26.5
Neither satisfied nor not	115	30.7
Satisfied	160	42.8
Job satisfaction
Not satisfied	141	37.7
Neither satisfied nor not	108	28.9
Satisfied	125	33.4
Satisfaction with the Institution
Not satisfied	204	54.5
Neither satisfied nor not	104	27.8
Satisfied	66	17.6
	Min-Max	±SS
Age(years)	21–51	34.2 ± 6.62
Number of nurses working in the unit	1–38	14.89 ± 10.02
Satisfaction with the unit	1–3	2.16 ± 0.81
Job satisfaction	1–3	1.96 ± 0.84
Satisfaction with the Institution	1–3	1.63 ± 0.76

Data collection

Data for the research were collected between March and August 2024. The data collection instruments used in the study included the Participant Information Form, the Decent Work Scale (DWS), the Sickness Presenteeism Scale-Nurses (SPS-N), and the Work-Related Flow Inventory (WOLF).Data were collected using a face-to-face survey method. To avoid disrupting clinical workflows, eligible participants were invited to participate in the study during their breaks. Questions were distributed individually by the researcher during daytime working hours (08:00–16:00) after obtaining written informed consent. Participants were given approximately 10–15 min to complete the questionnaire. Measures were taken to minimize selection, response, and measurement biases to ensure the methodological rigour and reliability of the study.

Instrument description

Participant information form

The form was designed to collect demographic and work-related information, such as the nurses’ age, gender, education level, total years of professional experience, total years of experience at the current hospital, job role, unit, working schedule (shifts vs. day), marital status, number of beds in the unit, and the total number of nurses in the unit.

Decent Work Scale Turkish Version (DWS-TR)

The scale, originally developed by Duffy et al. (2017), was adapted to Turkish by Buyukgoze-Kavas and Autin (2019) [15, 16]. The 15-item scale consists of five subscales, each containing three items: physically and interpersonally safe working conditions, access to healthcare, adequate compensation, hours that allow for free time and rest, and organizational values that complement family and social values. The scale employs a Likert-type format, with responses ranging from 1 to 7 (1 = Strongly disagree, 7 = Strongly agree), with four items reverse-coded [15]. As the score on the scale increases, the perception of decent work improves. The Cronbach’s alpha for the original scale is 0.86 for the overall scale, with subscale values ranging from 0.79 to 0.97 [15]. The Turkish adaptation of the scale, conducted by Buyukgoze-Kavas and Autin, has a Cronbach’s alpha of 0.80 for the overall scale, with subscale values ranging from 0.77 to 0.90 [16]. In this study, Cronbach’s alpha coefficient was found to be α = 0.75.

Sickness Presenteeism Scale-Nurse (SPS-N)

The scale, developed by Baris et al. (2023), consists of 21 items across four subscales. The validity of the scale was confirmed through both exploratory and confirmatory factor analyses, which supported its four-factor structure, explaining 57.9% of the total variance [17]. The subscales of the scale are as follows: general performance (items 1–5), patient safety (items 6–12), relationships within the team (items 13–15), and emotions (items 16–21). The items are rated on a 5-point Likert scale (1 = Strongly disagree, 5 = Strongly agree). The Cronbach’s alpha coefficient for the overall scale is 0.928, while the Cronbach’s alpha coefficients for the subscales range from 0.804 to 0.903. The scale does not have a cutoff point, with higher total scores indicating greater levels of presenteeism-related impairment in job performance. In this study, Cronbach’s alpha coefficient was found to be α = 0.93.

The Work-Related Flow Inventory (WOLF)

The WOLF was developed by Bakker in 2008 and consists of 13 items across three subscales: absorption (items 1–4), work enjoyment (items 5–8), and intrinsic work motivation (items 9–13) [18]. The Cronbach’s alpha coefficients for the subscales of the original scale range from 0.75 to 0.90 [18]. For the Turkish version, the Cronbach’s alpha coefficients for the subscales range from 0.77 to 0.93 [19]. The scale uses a 7-point Likert scale, with responses ranging from “1- Never” to “7- Always.” Higher scores on the scale indicate a greater level of work-related flow. In this study, Cronbach’s alpha coefficient was found to be α = 0.94.

Ethical considerations

Ethics committee approval was obtained from the Ethics Committee of Clinical Research (Approval date: February 21, 2024; Approval Number: 2024/197). Institutional permissions were granted by the hospitals involved in the study. Permissions were also obtained from the authors who developed and adapted the scales to Turkish. Prior to completing the data collection instruments, nurses were provided with an informational text about the study and asked to indicate their voluntary participation by marking the statement, “I agree to participate in the study” on the data collection form. Data were then collected through face-to-face interactions with nurses who consented to participate. All stages were carried out in accordance with the Declaration of Helsinki.

Data analysis

Statistical analysis was performed using SPSS-26. Measurement data corresponding to a normal distribution were expressed as means and standard deviations. Independent sample t-tests were employed to compare differences between two groups, while one-way ANOVA was used to examine differences across multiple groups. The Tukey HSD test was applied post-hoc to identify the specific sources of significant differences. Pearson correlation analysis was conducted to explore the relationships between perceptions of decent work, sickness presenteeism and work-related flow. A multiple regression analysis was conducted on decent work and sickness presenteeism in relation to work-related flow. Prior to conducting the regression analysis, the assumptions of multiple regression were tested. Multicollinearity was assessed using tolerance, variance inflation factor (VIF), and condition index values, which indicated no multicollinearity problem (Tolerance = 1.00; VIF = 1.00; Condition Index = 10.38). Independence of errors was supported by the Durbin-Watson statistic (DW = 1.91). Examination of standardized residual histograms and normal probability plots indicated that residuals were approximately normally distributed. Additionally, the scatterplot of standardized residuals against predicted values showed no clear pattern, suggesting that the assumptions of linearity and homoscedasticity were met. A significance level of α = 0.05 was set, with p < 0.05 indicating statistically significant differences.

Results

Descriptive statistics scales

Table 2 also shows the average scores of researchers regarding their perceptions of decent work (54.35 ± 14.94), their average scores for illness-related work absence (51.78 ± 16.32), and their average scores for work-related findings (40.84 ± 14.36).

Table 2.

Descriptive statistics scales

Variables	Cronbach Alpha	Min-Max	M ± SD
DWS	0.75	15–91	54.35 ± 14.94
SPS-N	0.93	21–105	51.78 ± 16.32
WOLF	0.94	13–85	40.84 ± 14.36

Min-Max: Minimum-Maximum, M: Mean, SD: Standard Deviation, DWS: Decent Work Scale; SPS-N: Sickness Presenteeism Scale-Nurse; WOLF: The Work-Related Flow Inventory

Examining the relationship between participants’ scores on scales

Table 3 shows a weak positive correlation between perceived decent work and experienced work-related flow, which is statistically significant (r = 0.329; p < 0.01). As the total score for perceived decent work increases, the work-related flow scale score also increases. A weak, negative, and statistically significant correlation was found between the total score of the sickness presenteeism scale and the total score of the work-related flow scale (r=-0.214; p < 0.01). A weak, negative, and statistically significant correlation was found between the total score of the sickness presenteeism scale and the total score of the work-related flow scale (r=-0.214; p < 0.01). As the total score from the sickness presenteeism scale increases, the total score from the work-related flow scale decreases.

Table 3.

Examining the relationship between participants’ scores on scales *p < 0,001

	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15
1. Safe working conditions	1
2. Access to healthcare	0.627 0.00*	1
3. Adequate compensation	− 0.176 0.00*	− 0.159 0.00*	1
4. Free time and rest	0.045 0.39	0.049 0.34	0.328 0.00*	1
5. Complementary values	0.495 0.00*	0.468 0.00*	− 0.130 0.01	0.046 0.37	1
6. Decent work perception-Total	0.748 0.00*	0.755 0.00*	0.209 0.00*	0.417 0.00*	0.707 0.00*	1
7. General performance	− 0.010 0.84	0.104 0.04	− 0.143 0.00*	0.002 0.96	0.091 0.07	0.029 0.57	1
8. Patient safety	0.012 0.82	0.135 0.00*	0.118 0.02	0.190 0.00*	0.135 0.00*	0.193 0.00*	0.464 0.00*	1
9. Relationships within the team	− 0.103 0.04	0.003 0.95	− 0.026 0.61	− 0.054 0.29	0.105 0.04	− 0.019 0.71	0.453 0.00*	0.449 0.00*	1
10. Emotions	− 0.097 0.06	− 0.057 0.26	− 0.252 0.00*	− 0.225 0.00*	− 0.020 0.70	− 0.199 0.00*	0.558 0.00*	0.285 0.00*	0.492 0.00*	1
11. Sickness presenteeism-Total	− 0.060 0.24	0.059 0.25	− 0.114 0.02	− 0.035 0.49	0.090 0.08	− 0.008 0.87	0.809 0.00*	0.725 0.00*	0.707 0.00*	803 0.00*	1
12. Focused engagement	− 0.287 0.00*	0.119 0.02	− 0.102 0.04	0.121 0.02	0.124 0.01	0.198 0.00*	− 0.115 0.02	− 0.148 0.00*	− 0.124 0.01	− 0.084 0.10	− 0.150 0.00*	1
13. Work enjoyment	0.320 0.00*	0.183 0.00*	− 0.029 0.57	0.213 0.00*	0.194 0.00*	0.307 0.00*	− 0.092 0.07	− 0.146 0.00*	− 0.174 0.00*	− 0.166 0.00*	− 0.187 0.00*	0.783 0.00*	1
14. İntrinsic work motivation	0.264 0.00*	0.225 0.00*	0.133 0.01	0.239 0.00*	0.177 0.00*	0.352 0.00*	− 0.085 0.10	− 0.097 0.06	− 0.126 0.01	− 0.323 0.00*	− 0.225 0.00*	0.581 0.00*	0.721 0.00*	1
15. Work-related Flow-Total	0.324 0.00*	0.203 0.00*	0.014 0.79	0.221 0.00*	0.188 0.00*	0.329 0.00*	− 0.107 0.03	− 0.143 0.00*	− 0.159 0.00*	− 0.227 0.00*	− 0.214 0.00*	0.859 0.00*	0.933 0.00*	0.882 0.00*	1
Mean	12.83	11.88	8.14	9.40	12.11	54.35	13.01	13.78	6.54	18.46	51.78	12.90	14.03	13.92	40.84
SD	5.370	5.808	4.411	4.009	5.579	14.941	5.059	6.109	3.040	7.045	16.322	4.510	5.458	6.117	14.363
Min- Max	3–21	3–21	3–18	3–20	3–21	15–91	5–25	7–35	3–15	6–30	21–105	4–26	4–27	5–33	13–85

Comparison of participants’ scale scores according to descriptive characteristics

When comparing the scores obtained from the scales according to the descriptive characteristics of the participants (Table 4);

Table 4.

Comparison of participants' scale scores according to descriptive characteristics (n = 374)

Variable	N	DWS\bar X±SS	SPS-N\bar X±SS	WOLF\bar X±SS
Age(years)
21–31 a	152	55.98 ± 15.32	51.60 ± 16.93	37.32 ± 11.70
32–42 b	173	53.23 ± 14.67	52.79 ± 16.25	41.52 ± 15.09
> 43 c	49	53.29 ± 14.51	48.82 ± 14.44	49.41 ± 15.48
F		1.523	1.147	14.462
p		.21	.31	.00
				c > a,b
Marital Status
Married	231	52.98 ± 14.76	52.29 ± 15.80	41.58 ± 15.14
Single	143	56.57 ± 15.01	50.96 ± 17.15	39.65 ± 12.95
t		-2.267	.769	1.314
p		.02	.44	.19
Education
Associate degreea	30	49.27 ± 14.96	46.37 ± 13.73	32.20 ± 7.50
Bachelor degreeb	318	54.43 ± 15.21	52.25 ± 16.31	40.62 ± 14.05
Master degreec	26	59.27 ± 8.92	52.31 ± 18.47	53.54 ± 15.83
F		3.187	1.804	16.963
p		.04	.16	.00
		c > a		c > a,b
Unit
İnternal clinica	121	52.23 ± 15.73	48.92 ± 16.00	39.91 ± 14.10
Surgical clinicb	103	55.69 ± 15.02	51.19 ± 16.92	40.20 ± 14.44
Intensive care unitc	98	55.07 ± 15.72	57.00 ± 16.67	39.36 ± 14.76
Emergency roomd	28	53.21 ± 10.60	54.86 ± 10.68	40.89 ± 8.67
Polyclinic ve  administrative unite	24	57.71 ± 10.23	43.88 ± 13.02	54.33 ± 12.97
F		1.219	5.365	6.045
p		.30	.00	.00
			c > a	e > a,b,c,d
Professional title
Nurse	335	53.87 ± 14.58	52.34 ± 15.98	39.48 ± 13.21
Nurse in charge	39	58.46 ± 17.37	46.97 ± 15.50	52.59 ± 18.25
t		-1.820	1.951	-4.356
p		.07	.05	.00
Working shift
Continuous daytimea	99	54.59 ± 16.01	48.18 ± 16.65	49.96 ± 15.99
Constantly at nightb	6	64.00 ± 13.46	51.50 ± 11.13	46.33 ± 13.00
Shiftc	269	54.05 ± 14.53	53.12 ± 16.13	37.37 ± 12.12
F		1.319	3.348	33.120
p		.26	.03	.00
Total years of employment in the profession
Less than 1 yeara	14	67.43 ± 9.74	46.79 ± 20.32	38.43 ± 13.89
1–10 yearsb	178	53.83 ± 14.21	54.08 ± 17.11	37.27 ± 11.76
11–20 yearsc	130	52.92 ± 16.12	49.65 ± 15.59	42.13 ± 15.45
20 years and mored	52	56.21 ± 13.91	50.62 ± 13.17	50.52 ± 15.14
F		4.432	2.471	13.199
p		.00	.06	.00
		a > b,c	-	d > a,b,c
Years of working at the hospital
Less than 1 yeara	15	68.13 ± 9.77	45.67 ± 20.05	38.53 ± 13.39
1–10 yearsb	237	52.60 ± 14.96	53.57 ± 16.70	38.06 ± 12.98
11–20 yearsc	96	56.08 ± 14.62	49.00 ± 14.41	46.38 ± 15.43
20 years and mored	26	55.96 ± 13.92	49.27 ± 15.35	47.15 ± 15.67
F		6.107	2.830	10.221
p		.00	.03	.00
		a > b,c	-	d > b,c
Satisfaction with the unit
Not satisfieda	99	47.15 ± 14.35	54.37 ± 16.71	34.05 ± 12.80
Neither satisfied nor notb	115	54.54 ± 13.05	53.16 ± 14.73	40.70 ± 11.37
Satisfiedc	160	58.68 ± 14.94	49.19 ± 16.87	45.16 ± 15.57
F		20.063	3.721	20.172
p		.00	.02	.00
		c > a,b	a > c	c > a,b
Job satisfaction
Not satisfieda	141	48.74 ± 14.14	54.87 ± 15.69	32.21 ± 11.72
Neither satisfied nor notb	108	56.79 ± 12.22	54.20 ± 14.47	42.69 ± 12.43
Satisfiedc	125	58.58 ± 16.06	46.22 ± 17.18	49.00 ± 13.31
F		17.836	11.595	61.687
p		.00	.00	.00
		c > a, b > a	a,b > c	c > a,b
Satisfaction with the Institution
Not satisfieda	204	47.59 ± 13.96	52.92 ± 16.94	35.66 ± 14.05
Neither satisfied nor notb	104	59.47 ± 10.42	51.94 ± 15.18	43.32 ± 9.57
Satisfiedc	66	67.20 ± 12.11	48.03 ± 15.76	52.98 ± 13.33
F		70.568	2.256	48.136
p		.00	.10	.00
		c > b,a	-	c > b,a
Number of nurses working in the  unit
1–10 nursesa	222	54.68 ± 15.56	50.41 ± 16.14	41.93 ± 14.71
11–20 nursesb	36	51.89 ± 10.46	47.14 ± 17.80	39.78 ± 15.22
21 nurses and abovec	116	54.50 ± 14.93	55.86 ± 15.48	39.10 ± 13.29
F		.546	6.028	1.588
p		.58	.00	.20
		-	c > a,b	-

A significant difference in DWS scores was found according to marital status, with single nurses scoring higher than married nurses (t = − 2.267, p = 0.02). DWS scores also differed significantly according to education level (F = 3.187, p = 0.04), and post-hoc analysis indicated higher scores among nurses with a master’s degree compared with those with an associate degree.

Significant differences in DWS scores were also observed according to total years of professional experience (F = 4.432, p < 0.001) and years of working at the hospital (F = 6.107, p < 0.001), with nurses having less than one year of experience reporting higher scores than those with longer work experience.

In addition, DWS scores differed significantly according to satisfaction with the unit (F = 20.063, p < 0.001), job satisfaction (F = 17.836, p < 0.001), and satisfaction with the institution (F = 70.568, p < 0.001), with higher scores observed among nurses who reported being satisfied.

Significant differences in SPS-N scores were observed according to several work-related characteristics. SPS-N scores differed significantly by unit (F = 5.365, p < 0.001), with post-hoc analysis indicating higher scores among nurses working in intensive care units compared with those working in internal clinics. A significant difference was also found according to professional title (t = 1.951, p = 0.05), with staff nurses scoring higher than charge nurses. Additionally, SPS-N scores differed significantly according to working shift (F = 3.348, p = 0.03), with nurses working shift schedules reporting higher scores than those working continuous daytime shifts.

Significant differences were also observed according to years of working at the hospital (F = 2.830, p = 0.03). Furthermore, SPS-N scores differed significantly according to satisfaction with the unit (F = 3.721, p = 0.02), job satisfaction (F = 11.595, p < 0.001), and the number of nurses working in the unit (F = 6.028, p < 0.001). Post-hoc comparisons indicated higher scores among nurses who were not satisfied with their unit compared with those who were satisfied, higher scores among nurses who were not satisfied or neutral about their profession compared with those who were satisfied, and higher scores among nurses working in units with 21 or more nurses compared with units with fewer nurses.

Significant differences in WOLF scores were observed according to several demographic and work-related characteristics. WOLF scores differed significantly by age (F = 14.462, p < 0.001), with nurses aged 43 years and older reporting higher scores than younger age groups. Significant differences were also found according to education level (F = 16.963, p < 0.001), with postgraduate nurses scoring higher than those with associate or bachelor’s degrees.

WOLF scores also differed significantly according to the unit in which nurses worked (F = 6.045, p < 0.001), with higher scores observed among nurses working in polyclinic and administrative units compared with other clinical units. A significant difference was found according to professional title (t = − 4.356, p < 0.001), with charge nurses reporting higher scores than staff nurses. Additionally, WOLF scores differed significantly according to working shift (F = 33.120, p < 0.001), with nurses working continuous daytime shifts scoring higher than those working shift schedules.

Furthermore, significant differences in WOLF scores were observed according to total years of professional experience (F = 13.199, p < 0.001) and years of working at the hospital (F = 10.221, p < 0.001), with nurses having 20 years or more experience reporting higher scores. WOLF scores also differed significantly according to satisfaction with the unit (F = 20.172, p < 0.001), job satisfaction (F = 61.687, p < 0.001), and satisfaction with the institution (F = 48.136, p < 0.001), with higher scores observed among nurses who reported being satisfied.

Multiple regression analysis results on decent work and sickness presenteeism as predictors of work-related flow

The results of the multiple regression analysis conducted regarding the prediction of work-related flow by decent work and sickness presenteeism are shown in Table 5. According to the analysis results, both decent work and sickness presenteeism statistically significantly was associated with work-related flow (F = 33.43, p < 0.001). Decent work and sickness presenteeism together explain approximately 15% of the total variance in work-related flow (R² = 0.153, Adjusted R² = 0.148). Results showed that decent work was a significant positive associated with of work-related flow (B = 0.314, β = 0.327, t = 6.84, p < 0.001, 95% CI [0.224, 0.405]). In contrast, sickness presenteeism significantly and was negatively associated with work-related flow (B = -0.186, β = − 0.211, t = -4.42, p < 0.001, 95% CI [-0.269, -0.103]).

Table 5.

Multiple regression analysis results on decent work and sickness presenteeism as predictors of work-related flow (n = 374)

	ꞵ	Stand. ꞵ		Lower Bound	Upper Bound	t	p
(Constant)		-		-	-	9,83	< 0.001**
Decent Work	0,314	0,327		0.224	0.405	6,84	< 0.001**
Sickness Presenteeism	-0,186	-0,211		-0,269	-0,103	-4,42	< 0.001**
			F = 33.43, p < 0.001, R2 = 0.153

Discussion

The aim of this study is to examine the relationships between nurses’ perceptions of decent work, sickness presenteeism, and work-related flow experiences.

This study demonstrates that decent work is associated with increased work-related workflow experience and contributes to the nursing literature on decent work. While previous nursing studies have highlighted the role of decent work in promoting positive behaviors [20;21], current research on decent work has addressed only a limited number of nursing behaviors [20]. Therefore, academics have advocated for more research on other outcomes associated with decent work [21]. Thus, our study stands out as one of the first attempts to link decent work with sickness presenteeism in a nursing context.

The results of this study revealed a positive correlation between nurses’ workflow and their perception of decent work; this is consistent with the findings of previous studies [22, 23]. Ensuring nurses’ perception of decent work is crucial for both individuals and organizations. A positive work environment is associated with higher levels of work engagement among nurses and may be linked to better professional competence and quality of healthcare delivery [23].

The study results revealed a negative correlation between sickness presenteeism and work-related flow. This finding is consistent with previous studies [4, 24]. Presenteeism has been associated with lower engagement and performance and may be linked to poorer patient care and overall quality outcomes [25].

In this study, weak, statistically significant correlations were found between the DWS scores and the subscales of patient safety, emotions, absorption, work enjoyment, and intrinsic work motivation. These findings are consistent with previous research [22, 23]. Patient safety remains a critical issue in healthcare delivery. Each year, thousands of patients are injured or die due to preventable medical errors [26]. Through evidence-based practices, nurses play a crucial role in preventing many of these errors and ensuring the delivery of safe healthcare to patients [27]. Nurses working while experiencing health problems may experience emotional distress, which has been associated with lower job performance and engagement [28]. Social relationships and managerial support have been shown to enhance nurses’ workflow and emotional well-being. Decent work, which upholds human dignity, equality, freedom, and security, is a fundamental resource for nurses [15]. Nurses employed in supportive work environments are more likely to receive psychological and financial benefits from their institutions [21]. Therefore, healthcare organizations may consider implementing policies and practices that promote decent work, as these are associated with high-quality and sustainable care practices.

The correlation between SPS-N and the subscales of adequate compensation, absorption, work enjoyment, and intrinsic work motivation was found to be weak, negative, and statistically significant. Similar findings have been reported in previous studies [4, 29]. Presenteeism is a widespread global phenomenon, with studies showing it affects 30% to 90% of employees [30]. In the nursing profession, sickness presenteeism is particularly concerning, with one study estimating the global rate at 49.2% [31]. Financial pressures and the threat of job loss often force nurses to work while unwell or work excessive overtime [32]. In addition, the 24/7 nature of hospital services contributes to extended working hours for healthcare professionals. One study found that longer work hours are positively correlated with employee fatigue and negatively correlated with job participation and performance [33]. Therefore, sickness presenteeism may be linked to lower quality of life and work motivation among nurses, particularly those required to work long or irregular hours.

The WOLF scores were weakly and significantly correlated with physically and interpersonally safe working conditions, access to healthcare, hours that allow free rime and rest, organizational values that complement family and social values, general performance, patient safety, relationships within the team, and emotions subscales. These findings are consistent with previous studies [11, 24]. Work-related flow has been associated with lower levels of work fatigue, higher awareness, and greater engagement in daily tasks, and may be linked to fewer workplace errors [24]. Other studies demonstrate that absorption in work has been associated with lower negative emotions, reduced job apathy, and lower turnover intentions, stabilizing the nursing workforce, and improving patient satisfaction [34, 35]. Absorption experiences have been related to higher job satisfaction, creativity, motivation, and overall well-being, as well as lower levels of burnout. Consequently, positive work-related flow experiences appear to be an important factor associated with the well-being of the nursing workforce [35].

DWS scores varied across sociodemographic characteristics, with higher scores observed among single nurses, those with postgraduate education, early-career nurses, and those reporting satisfaction with their unit, profession, and institution, suggesting that both individual attributes and perceived work conditions may shape perceptions of decent work. Similar findings were reported in a study by Xue et al. (2024), where nurses with less than five years of experience had significantly higher perceptions of decent work [36]. However, contrary to these results, Bowen and Xue (2024) found that nurses with less than five years of professional experience tended to score lower on the decent work criteria [37].

This difference may be attributed to the fact that nurses with longer professional experience often perceive limited career development or insufficient promotional opportunities, which could negatively impact their perception of decent work [38]. A study by Büyükgöze-Kavas and Autin (2019) found a positive relationship between decent work and job satisfaction, a finding consistent with the results of this study [16]. Health organizations and policymakers can enhance job satisfaction among nurses by ensuring access to safe and supportive work environments, fair remuneration, and professional development opportunities [36].

Sickness presenteeism scores varied across sociodemographic characteristics, with higher levels observed among nurses working in intensive care units, service nurses, and those engaged in shift work, as well as among nurses with mid-level institutional experience (1–10 years) and those reporting dissatisfaction with their unit or profession. These patterns suggest that high job demands and unfavorable work conditions may play a critical role in shaping presenteeism.

These findings align with the results of previous studies [39, 40]. Health institutions, characterized by shift work, irregular working hours, staff shortages, heavy workloads, and low job satisfaction, often exhibit a high likelihood of presenteeism [39]. Nurses who continue working while unwell may be less efficient than usual, which has been associated with compromised patient safety and increased operational costs.

Higher WOLF scores among older, more experienced, and highly educated nurses, as well as those in managerial roles, suggest that accumulated professional resources may facilitate flow experiences. Within the framework of the Job Demands–Resources (JD-R) model, experience, education, and role responsibility can be conceptualized as key resources that enhance competence, autonomy, and professional confidence, thereby promoting engagement. This interpretation is supported by evidence indicating that higher educational attainment and professional competence are associated with improved work outcomes and innovative behaviors [41]. Similarly, nurses working in outpatient clinics and administrative units may benefit from more structured and less physically demanding work environments, which can support sustained attention and engagement.

Conversely, lower WOLF scores among nurses working rotating shifts may reflect the adverse effects of irregular schedules on cognitive and psychological resources. Previous studies have shown that nurses exposed to high stress and psychological burden—particularly in demanding or unstable working conditions—experience reduced well-being and coping capacity [42, 43]. From this point of view, shift work may act as a job demand that constrains the ability to achieve flow by disrupting energy balance and concentration.

In addition, higher flow scores among nurses satisfied with their unit, profession, and institution highlight the importance of perceived work quality and organizational context. Research suggests that supportive and secure work environments are associated with stronger professional commitment and retention [38], as well as higher perceptions of decent work [44], both of which may contribute to more positive engagement experiences.

The regression analysis indicated that decent work and sickness presenteeism were significantly associated with work-related flow, together explaining 15% of its variance (R² = 0.153, Adjusted R² = 0.148). Although statistically significant, this reflects a modest level of explained variance, suggesting that work-related flow is influenced by a broader set of individual and organizational factors beyond those included in the model [45].

The positive association between perceived decent work and flow (β = 0.327) can be interpreted within the Job Demands–Resources framework, where supportive and fair work conditions function as key job resources that enhance intrinsic motivation and engagement. In contrast, the negative association with sickness presenteeism (β = −0.211) may be explained by resource depletion processes, whereby reduced physical and cognitive capacity constrains the ability to sustain focused engagement [46].

Taken together, while both variables are meaningful predictors, their combined contribution remains limited, indicating moderate rather than strong associations and highlighting the need to consider additional factors such as workload, leadership, and personal resources. Given the cross-sectional design, causal inferences cannot be drawn, and the observed relationships may be influenced by unmeasured confounders. Future longitudinal research is therefore needed to clarify the direction and underlying mechanisms of these associations.

Limitations and recommendations

This study has several limitations. It was conducted in a single institution and used a cross-sectional design; this limits the generalizability of the findings and hinders causal inferences. All data were obtained through self-report; this may lead to social desirability and common method bias. The study was conducted in a single tertiary hospital with a 50.7% response rate; therefore, the results may not be generalizable. It is recommended to target larger and more diverse samples that include nurses from various healthcare settings to enhance the representativeness of the data in future research.

Conclusion

This study examined the relationship between decent work, work-related flow, and sickness presenteeism among nurses. The analysis revealed that decent work is linked to higher work-related flow, while sickness presenteeism is associated with lower engagement and performance. When nurses perceive a work environment that is respectful, supportive, and values their well-being, they are more motivated to fully engage in their tasks, leading to enhanced work performance and improved quality of patient care. In contrast, excessive workloads, high job demands, and poor working conditions can result in both physical and mental health issues for nurses, challenging their ability to immerse themselves in their work. This is evident in the context of recent global and local crises (e.g., the pandemic, earthquakes), which have highlighted that the principles of decent work are often inadequately implemented in healthcare settings. Such challenges have been associated with poorer physical and mental well-being among healthcare professionals, particularly nurses, further emphasizing the need for improved working conditions and support systems in the healthcare sector.

Implications for nursing practice and health policy

Policymakers and managers should prioritize the establishment of regional minimum wage standards to ensure fair compensation for nurses. In addition, they should support career advancement through providing training programs that promote professional development, as well as implement flexible working hours to better balance work and professional life, thereby enhancing the professional well-being of nurses. Hospitals should provide organizational support, ensure the safety of the work environment in the department, establish sound hospital rules and regulations, protect the rights and interests of nurses, prioritize the development of a decent work environment for nurses, and improve the fair, scientific, and reasonable division of labor.

Implıcatıons for nursing management

Nursing managers, in particular, should take proactive and effective measures to improve nurses’ perceptions of decent work for clinical nurses, identify instances of sickness presenteeism, and create work environments that fosters work-related flow among nurses.

From a managerial perspective, reducing sick leave in healthcare settings can contribute to increased nurse motivation and job commitment. Therefore, nursing managers may consider implementing supportive workplace policies, promoting appropriate sick leave use, and improving staff conditions to minimize sick leave and create healthier and more productive work environments.

Author contributions

Conceptualization: AYK, MA; Data curation: AYK; Formal analysis: AYK, MA; Methodology: AYK, MA; Original draft: AYK, MA; Edit & Review: AYK, MA. All authors read and approved the final manuscript.

Funding

This work was not supported by any funding.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to the institution’s policy but are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethics committee approval was obtained from the Ethics Committee of Clinical Research (Approval date: February 21, 2024; Approval Number: 2024/197). Institutional permissions were granted by the hospitals involved in the study. Permissions were also obtained from the authors who developed and adapted the scales to Turkish. Prior to completing the data collection instruments, nurses were provided with an informational text about the study and asked to indicate their voluntary participation by marking the statement, “I agree to participate in the study” on the data collection form. Data were then collected through face-to-face interactions with nurses who consented to participate. All stages were carried out in accordance with the Declaration of Helsinki.

Consent for publication

Participants provided consent for their data to be published.

Competing interests

The authors declare no competing interests.