Work-life spillover, clinical decision-making, and quality of care in nursing: the role of negative interference

Abstract

Background

Work-life balance has emerged as a critical issue in nursing, directly influencing job satisfaction, professional performance, and patient outcomes. Nurses’ ability to make timely and effective clinical decisions is essential for delivering high-quality care, yet it may be compromised by imbalances in their personal and professional lives.

Aim

This study evaluated the relationship between nurses’ work-life balance and their clinical decision-making skills and the quality of nursing care they provide.

Methods

The study was cross-sectional with 252 nurses working in a hospital between March 21 and April 10, 2025. The data were collected using the Descriptive Information Form, Work Life Balance Scale, Clinical Decision Making Scale in Nursing and Quality Nursing Care Scale. Data were analyzed using t-test, ANOVA, Pearson correlation and multiple regression analyses.

Results

According to the study findings, nurses’ work-life balance (48.55 ± 8.93) was below average, while their clinical decision-making (134.90 ± 13.68) and perceptions of quality nursing care (163.04 ± 18.05) were significantly above average. A positive and significant correlation (r: 0.369, p < 0.001) was found between nurses’ clinical decision-making scores and the level of quality nursing care; No significant correlation was found between work-life balance and clinical decision-making and quality nursing care (p > 0.05). However, a negative and significant relationship was found between the Negative Impact of Life on Work and the Clinical Decision Making in Nursing Scale (r=-0.240, p < 0.001). A positive and significant correlation was found between the Negative Impact of Work on Life and the Clinical Decision Making in Nursing Scale (r = 0.140, p = 0.027) and the Quality Nursing Care Scale (r = 0.184, p = 0.003).

Conclusion

While the findings indicate that overall work-life balance is not associated with clinical decision-making and quality nursing care, they do suggest that life, and the negative impact of work on life, play a critical role. Therefore, nurses demonstrate that achieving work-life balance is a critical factor not only for individual well-being but also for patient safety and quality of care. The finding of a significant negative correlation between nurses’ low work-life balance and the negative impact of work on life, clinical decision-making, and quality nursing care suggests that developing strategies to support work-life balance at the institutional level will be an important step toward improving the sustainability and quality of nursing services.

Clinical trial number

Not applicable.

Introduction

Nursing is a professional group that aims to protect and improve the health of individuals and cure them in case of illness, and requires constant attention, high responsibility and decision-making ability [1]. Although many factors affect the quality of patient care, service delivery, organizational performance and productivity of nurses, who constitute the basic building block in health services, work-life balance is one of the most important issues that come to the fore among them [2]. Work-life balance is defined as an individual’s ability to balance personal needs and professional responsibilities. The main purpose of work-life balance is to establish a healthy balance between work, family, leisure time and other vital activities and to distribute one’s attention and time between different areas of life in a balanced, sustainable and efficient manner [3]. Disruption of work-life balance leads to negative outcomes such as stress, burnout, faulty clinical decision-making and low job satisfaction [4]. It is of critical importance for individuals working in the health sector to maintain their work-life balance to maintain the quality of health services and professional efficiency, as they perform a profession that has a high physical and mental workload, requires emotional resilience and stands out with intense working hours [5].

Work-life balance, psychological resilience, professional performance, clinical decision-making skills and quality of care are among the variables that directly affect nurses who have high decision-making responsibility in the provision of health services [6]. Clinical decision-making skills of nurses develop depending on their problem-solving skills, cognitive flexibility and analytical thinking capacity and it is a cognitive process. In the clinical decision-making process, it is aimed to provide the most appropriate nursing care by making clinical evaluation of patients [7]. Nurses with impaired work-life balance have decreased problem-solving skills, weakened cognitive flexibility, and clinical decision-making processes are negatively affected [8]. In this context, nurses’ work-life balance stands out as an important protective factor in patient safety-oriented processes that require rapid and accurate decisions in clinical settings [2].

Quality nursing care, another variable directly affected by work-life balance, is a fundamental professional responsibility that refers to the provision of safe, effective, individualized and holistic health care [9]. The quality of care provided depends not only on professional knowledge and skills, but also on nurses’ psychological well-being, satisfaction levels and work-life balance [10]. When work-life balance is disrupted, the risk of burnout, dissatisfaction and errors in decision-making increases in nurses, which is directly reflected in the quality of care [11]. In cases where occupational stress and workload cannot be managed, the error rate increases in the care provided by nurses, patient outcomes are negatively affected, and the overall quality of health care delivery decreases [12].

In this context, the work-life balance of nurses is considered as a critical variable that directly affects not only individual well-being but also patient safety and quality of care. However, the relationship between WLB and professional outcomes may be complex and indirect, potentially mediated by specific aspects of the work-life interface such as negative spillover, rather than the overall balance itself. While the overall level of WLB is often studied, its multidimensional nature, particularly the distinct pathways of negative and positive spillover between work and life, may have differential effects on professional outcomes. This study examines not only global WLB but also its specific sub-dimensions. The existing literature is limited in terms of studies addressing the relationships between work-life balance and clinical decision making and nursing care quality simultaneously and holistically. This study aims to examine the relationship between nurses’ work-life balance and their clinical decision-making skills and the quality of nursing care they provide, and to identify areas for improvement at both individual and institutional levels. This study examines nurses’ work-life balance levels, the level of their clinical decision-making skills, and their perceptions of quality nursing care. It also investigates whether there is a relationship between nurses’ work-life balance, clinical decision-making processes, and quality nursing care; in addition, it examines whether these three variables differ according to nurses’ sociodemographic characteristics.

Materials and methods

Type of research

This study was cross-sectional.

Population and sample of the study

The study population consists of nurses working at Gaziantep City Hospital. G Power 3.1. program was used to calculate the sample size. Previous studies [13, 14] were examined and the expected confidence intervals of the “Clinical Decision Making Scale in Nursing” were determined and the confidence interval α = 0.05, the power of the test (1-β) 0.95, the effect size d = 0.2100840 were calculated as 247 nurses. At the end of the study, the study was completed with 252 nurses agreed to participate in the study.

Inclusion criteria

To be working in the relevant hospital, to be over 18 years old, speaking and understanding Turkish, volunteering to participate in the study and giving consent.

Exclusion criteria

Having any disability that will prevent you from answering the survey questions, the nurse volunteered to participate in the study and then wanted to withdraw from the study, filling in the data collection forms of the research incompletely.

Data collection

The research data were collected face-to-face between March 21 and April 10, 2025, through a questionnaire form created by the researchers. At the beginning of the questionnaire, participants were informed in a short text that no information revealing their identity would be requested in the questionnaire, that the study would be used solely for scientific purposes, and that objective answers to the questionnaire questions were crucial in highlighting the importance of the subject. Completing the questionnaire took an average of 20 min.

Data collection tools

The data were collected through the Introductory Information Form created by the researchers and the Work Life Balance Scale (WLBS), Clinical Decision Making Scale in Nursing (CDMNS) and Quality Nursing Care Scale (QNCS) in the literature.

Introductory information form

It was created by the researchers as a result of the literature review on the subject and consists of 13 questions evaluating the participants’ age, gender, marital status, number of children, education and income level, working year, working style, desire and liking for the profession, suitability for the profession, the clinic where they work and the number of patients [15, 16].

Work life balance scale

The scale developed by Fisher et al. (2009) was adapted into Turkish by Ekinci and Sabancı (2021) [17, 18]. The scale consists of 4 sub-dimensions and 17 items in total: Negative Impact of Life on Work (e.g., My personal life consumes the energy I need to do my job), Negative Impact of Work on Life (e.g., My job makes it difficult for me to maintain the personal life I want), Positive Impact of Life on Work (e.g., My personal life gives me the strength to do my job), Positive Impact of Work on Life (e.g., My mood at home is better thanks to my job). Each item is rated on a 5-point Likert scale: 1 = Strongly Disagree, 2 = Disagree, 3 = Undecided, 4 = Agree, 5 = Strongly Agree. In the evaluation of the scale, the sub-dimensions Negative Effects of Life on Work and Negative Effects of Work on Life are scored reversely (5 = Strongly Disagree, 4 = Disagree, 3 = Undecided, 2 = Agree, 1 = Strongly Agree). The minimum score that can be obtained from the total scale is 17 and the maximum score is 85. The scale has no cut-off score. The sum of all sub-dimensions is calculated as a total score. As the total score increases, employees’ work-life balance also increases. The scale measures separate dimensions of the work-life interface rather than an overall assessment of ‘balance’. In the study adapting the scale to Turkish, Cronbach’s alpha value was determined as 0.701 [17]. In this study, the Cronbach’s alpha value of the scale was found to be 0.754.

Clinical decision making scale in nursing

The scale developed by Jenkins (1983) was adapted into Turkish by Edeer and Sarıkaya [19, 20]. The scale is designed to explore options and ideas (e.g., If a clinical decision is vital and there is time, I do a detailed search for options.), Investigating Goals and Values (Ex: When my values conflict with the patient’s values, I am objective enough to make the decision that is necessary for the situation), Evaluating Outcomes (Ex: When evaluating an important clinical decision, I make a list of positive and negative outcomes.), Seeking Information and Adopting New Knowledge Impartially (Ex: When I need to make a decision, I use different ways to gather as much information as possible). Each subscale consists of 10 items. Each item in the scale is scaled with a 5-point Likert scale as 5 = Always, 4 = Frequently, 3 = Sometimes, 2 = Rarely, 1 = Never. In the scale, 22 items are positively and 18 items are negatively significant. The 18 negatively significant items are reverse-scored. The total scale is scored between 40 and 200 and each sub-dimension is scored between 10 and 50 and the scale has no cut-off score. A high score on the scale indicates that the perception of decision making is high, while a low score indicates that the perception of decision making is low. The Cronbach alpha value in the study in which the scale was adapted into Turkish was 0.78 [19]. The Cronbach’s alpha value of the scale in this study was 0.777.

Quality nursing care scale

The scale developed by Liu et al. (2021) to assess the quality of nurses’ nursing care was adapted into Turkish by Karaca et al. (2022) [21, 22]. The scale consists of 3 sub-dimensions and 38 items in total, including Physical Environment (e.g., I provide a comfortable environment where the patient can rest), Nursing Care Activities (e.g., I am very careful while performing my nursing duties), Patient Outcomes (e.g., I do not receive any complaints from patients and their relatives). Each item in the scale was scaled with a 5-point Likert scale where 5 = Strongly Agree, 4 = Agree, 3 = Undecided, 2 = Disagree, 1 = Strongly Disagree. The minimum score is 38 and the maximum score is 190. The scale has no cut-off score. Since it is a scale developed for nurses, the high scores of the participating nurses on the scale are interpreted as a high evaluation of the quality of nursing care provided. The Cronbach’s alpha value in the study in which the scale was adapted into Turkish was 0.99 [21]. The Cronbach’s alpha value of the scale in this study was 0.978.

Evaluation of data

The Statistical Package for the Social Sciences (SPSS) 27.0 package program was used to evaluate the data. Whether the data were normally distributed was evaluated with Skewness and Kurtosis values. In the literature, Skewness and Kurtosis values in the range of + 1.5/-1.5 are considered sufficient for normal distribution [23]. In this study, Skewness: 0.225, Kurtosis: 0.975 in Work Life Balance Scale; Skewness: 0.612, Kurtosis: -0.540 in Clinical Decision Making in Nursing Scale and Skewness: 0.028, Kurtosis: -0.632 in Quality Nursing Care Scale. In addition, the dentrended graphs obtained from the data show that the data have a normal distribution. The demographic data obtained from the study are given with frequency and percentage distributions. In addition, in the analysis of the scores obtained from the scales according to the demographic characteristics of the participants, a t-test was used for categorical variables with two groups and one-way ANOVA analysis was used for categorical variables with three or more groups. Levene’s Test sonuçlarına göre varyans homojenliği varsayımı sağlanmıştır (p > 0.05). LSD test, one of the post-hoc tests, was used to determine the difference between groups as a result of variance analysis. However, alternative post-hoc methods (Bonferroni, Tukey HSD, etc.) were also evaluated, LSD was selected due to the exploratory nature of the group comparisons and the need for higher statistical power, acknowledging its more liberal approach. Eta squared (η²) was used to determine the effect size in One Way ANOVA analysis. Pearson correlation analysis was used to analyze the relationship between the scores obtained from the scales and multiple regression analysis was used to evaluate the effect of variables. Adjusted R² was used to determine the effect size in regression analysis. In the research results, p < 0.05 was considered statistically significant.

Ethical dimension of the research

The Declaration of Helsinki was complied with during the research process. Ethics committee approval was obtained from Gaziantep Islam Science and Technology University Non-Interventional Clinical Research Ethics Committee (dated 15.01.2025 and numbered 509.42.14). Institutional approval was obtained from the Provincial Health Directorate (dated 18.03.2025 and numbered E-87825162-663.08-271554300) and written informed consent was obtained from the individuals.

Results

Sociodemographic characteristics of the participants are presented in Table 1.

Table 1.

Sociodemographic and professional characteristics

		n	(%)
Age	18–25 Age	121	48
	26–33 Age	116	46
	34-and over	15	6
Gender	Male	62	24.6
	Female	190	75.4
Marital Status	Married	82	32.5
	Single	170	67.5
Child Presence	Yes	42	16.7
	No	210	83.3
Income Status	Income less than expenditure	114	45.2
	Income equal to expenditure	101	40.1
	Income more than expenditure	37	14.7
Education Status	Health Vocational High School	14	5.6
	Associate Degree	23	9.1
	Bachelor’s Degree	202	80.2
	Postgraduate	13	5.2
Years of Service as a Nurse	Less than one year	83	32.9
	1–3 years	62	24.6
	4–10 years	94	37.3
	11 years and above	13	5.2
Mode of Operation	Day	60	23.8
	Night	28	11.1
	Sometimes day, sometimes night	164	65.1
Choosing a profession voluntarily	Yes	151	59.9
	No	101	40.1
Love for the Profession	Yes	180	71.4
	No	72	28.6
Occupation Eligibility	Yes	159	63.1
	No	93	36.9
Working Unit	a-ICU	73	29
	b-Internal Service	103	40.9
	c-Surgical Service	58	23
	d-Other (Emergency, Polyclinic, etc.)	18	7.1
Number of Patients in a Shift	a-2 and below	68	27
	b-3-8	127	50.4
	c-9-15	25	9.9
	d-16 and above	32	12.7

The majority of the participants were between the ages of 18–25, female, single, bachelor’s degree graduates, nurses whose income was less than their expenses and who did not have children. When the professional opinions of the nurses were examined, the majority of the nurses were nurses who had been working for 4–10 years, sometimes worked day and sometimes night shifts, worked in internal services and cared for an average of 3–8 patients in each shift, chose their profession willingly, loved and saw their profession as suitable for themselves (Table 1). As a result of the analysis, there is no significant difference between the nurses’ age, gender, education status, years of service as anurse and WLBS, CDMNS, QNCS (p > 0.05).

Median scores were used as the basis for evaluating the total and sub-dimensions of the nurses’ work-life balance scale. In this direction, the participants’ negative impact of life on work was found to be above average (20.40 ± 5.89) according to the median score [18], the negative impact of work on life was found to be below average (10.88 ± 4.23) according to the median score [15], the positive impact of life on work was found to be above average (9.46 ± 2.97) according to the median score [9], and the positive impact of work on life was found to be below average (7.80 ± 3.08) according to the median score [9]. The total score of the work-life balance scale was found to be below average (48.55 ± 8.93) according to the median score (51) (Table 2). As a result of the analysis;

Table 2.

Comparison of sociodemographic and professional characteristics of nurses with mean total scores of WLBS

Sociodemographic and Professional Characteristics		Work Life Balance Scale (WLBS)
		Negative Impact of Life on Work	Negative Impact of Work on Life	Positive Impact of Life on Work	Positive Impact of Work on Life	Total
Marital Status	Married	14.47 ± 5.90	18.82 ± 4.40	9.40 ± 2.88	7.50 ± 2.97	49.59 ± 8.31
	Single	16.14 ± 5.83	19.25 ± 4.15	9.50 ± 3.01	7.95 ± 3.13	48.05 ± 9.20
Test and Significance		t: -2.115 p: 0.035	t: -0.754 p: 0.452	t: -0.244 p: 0.808	t: -1.091 p: 0.276	t: 1.287 p: 0.199
Child Presence	Yes	13.71 ± 5.84	17.71 ± 4.73	9.90 ± 2.68	7.97 ± 3.04	52.45 ± 8.96
	No	15.97 ± 5.84	19.40 ± 4.08	9.38 ± 3.02	7.77 ± 3.10	47.77 ± 8.74
Test and Significance		t: 2.288 p: 0.023	t: 2.376 p: 0.018	t: 1.043 p: 0.298	t: 0.392 p: 0.696	t: 3.150 p: 0.002
Income Status	a-Income less than expenditure	15.14 ± 6.41	19.93 ± 3.96	9.50 ± 3.12	7.66 ± 3.28	48.08 ± 9.20
	b-Income equal to expenditure	16.60 ± 5.38	18.57 ± 3.94	9.26 ± 2.74	8.05 ± 2.94	48.14 ± 8.04
	c-Income more than expenditure	14.24 ± 5.20	18.08 ± 5.33	9.89 ± 3.08	7.54 ± 2.87	51.10 ± 10.17
Test and Significance		F: 2.816 p: 0.062 n2: 0.022	F: 4.183 p: 0.016 n2: 0.033	F: 0.616 p: 0.541 n2: 0.005	F: 0.591 p: 0.555 n2: 0.005	F: 1.782 p: 0.171 n2: 0.014
Post-Hoc			b > c
Mode of Operation	a-Day	14.10 ± 5.21	18.43 ± 4.56	9.11 ± 2.59	7.08 ± 2.65	49.66 ± 8.76
	b-Night	14.42 ± 5.95	19.39 ± 3.83	9.17 ± 3.04	7.17 ± 3.11	48.53 ± 8.04
	c-Sometimes day, sometimes night	16.34 ± 5.98	19.32 ± 4.17	9.64 ± 3.08	8.17 ± 3.18	48.15 ± 9.15
Test and Significance		F: 3.899 p: 0.022 n2: 0.030	F: 1.035 p: 0.357 n2: 0.008	F: 0.847 p: 0.430 n2: 0.007	F: 3.470 p: 0.033 n2: 0.027	F: 0.629 p: 0.534 n2: 0.005
Post-Hoc		c > a
Choosing a profession voluntarily	Yes	15.37 ± 5.67	18.92 ± 4.24	9.44 ± 2.94	7.87 ± 3.04	49.01 ± 8.99
	No	15.93 ± 6.23	19.41 ± 4.21	9.50 ± 3.02	7.70 ± 3.16	47.86 ± 8.85
Test and Significance		t: -0.729 p: 0.467	t: -0.909 p: 0.364	t: -0.160 p: 0.873	t: 0.431 p: 0.667	t: 1.009 p: 0.314
Love for the Profession	Yes	15 ± 5.48	18.55 ± 4.25	9.66 ± 2.89	8 ± 2.88	50.11 ± 9.16
	No	17.09 ± 6.63	20.52 ± 3.88	8.97 ± 3.12	7.30 ± 3.50	44.65 ± 7
Test and Significance		t: -2.377 p: 0.019	t: -3.409 p: 0.001	t: 1.683 p: 0.094	t: 1.631 p: 0.104	t: 4.554 p < 0.001
Occupation Eligibility	Yes	14.60 ± 5.21	18.18 ± 4.26	9.71 ± 2.73	8.15 ± 2.87	51.07 ± 8.70
	No	17.30 ± 6.59	20.70 ± 3.69	9.04 ± 3.30	7.21 ± 3.34	44.24 ± 7.60
Test and Significance		t: -3.375 p: 0.001	t: -4.750 p < 0.001	t: 1.661 p: 0.099	t: 2.342 p: 0.020	t: 6.287 p < 0.001
Working Unit	a-ICU	16.49 ± 5.38	19.01 ± 4.05	9.38 ± 2.98	8.05 ± 3.11	47.93 ± 8.29
	b-Internal Service	14.98 ± 6.48	19.18 ± 4.24	9.55 ± 3.25	7.95 ± 3.24	49.33 ± 8.59
	c-Surgical Service	16.01 ± 5.24	19.62 ± 3.94	8.82 ± 2.30	7.13 ± 2.67	46.32 ± 9.45
	d-Other (Emergency, Polyclinic, etc.)	14.16 ± 6.12	17.55 ± 5.60	11.38 ± 2.37	8.11 ± 3.25	53.77 ± 9.68
Test and Significance		F: 1.395 p: 0.245 n2: 0.017	F: 1.113 p: 0.344 n2: 0.013	F: 3.561 p: 0.015 n2: 0.041	F: 1.200 p: 0.310 n2: 0.014	F: 3.754 p: 0.012 n2: 0.043
Post-Hoc				d > a d > b d > c		d > a d > b d > c
Number of Patients in a Shift	a-2 and below	15.86 ± 5.60	18.86 ± 4	9.77 ± 3.03	8.44 ± 3.17	49.48 ± 8.35
	b-3-8	16.03 ± 6.16	18.81 ± 4.58	9.47 ± 2.98	7.83 ± 3.1	48.45 ± 9.64
	c-9-15	14.48 ± 5.31	19.36 ± 3.23	8.40 ± 2.43	7.44 ± 1.85	48 ± 7
	d-16 and above	14.18 ± 5.76	20.65 ± 3.74	9.62 ± 3.09	6.62 ± 3.24	47.40 ± 8.71
Test and Significance		F: 1.189 p: 0.315 n2: 0.014	F: 1.739 p: 0.160 n2: 0.021	F: 1.362 p: 0.255 n2: 0.016	F: 2.693 p: 0.047 n2: 0.032	F: 0.456 p: 0.713 n2: 0.005
Post-Hoc					a > d b > d
Mean ± SD (Min-Max)		20.40 ± 5.89 (6–30)	10.88 ± 4.23 (5–25)	9.46 ± 2.97 (3–15)	7.80 ± 3.08 (3–15)	48.55 ± 8.93 (17–77)

WLBS: Work Life Balance Scale, t: Student T Test. F: One Way ANOVA Test, Post-hoc: Indicates the groups from which significance is derived, Post-hoc comparisons are indicated in the table by letter codes (a, b, c, d)

• The Negative Impact of Work on Life was significantly higher (p < 0.05) in single nurses, who had no children, worked sometimes during the day and sometimes at night, did not like their profession and did not think that their profession was suitable for them (Table 2).

• The Negative Impact of Work on Life is significantly higher in nurses who do not have children, whose income is less than their expenses, do not like their profession and do not think that their profession is suitable for them (p < 0.05) (Table 2).

• The Positive Impact of Life on Work is significantly higher in nurses working in units such as emergency services and outpatient clinics (p < 0.05) (Table 2).

• The Positive Impact of Work on Life was significantly higher in nurses who saw the profession as suitable for them, and lower in nurses with 16 or more patients in each shift (p < 0.05) (Table 2).

• The Work Life Balance of nurses who have children, love their profession, think that their profession is suitable for them and work in units such as emergency and outpatient clinics is significantly higher than the other groups (p < 0.05) (Table 2).

Median scores were used as the basis for evaluating the total and sub-dimensions of Clinical Decision Making in Nursing Scale. Accordingly, the participants’ scores for the Exploring Options and Ideas (34.81 ± 4.65), Investigating Purposes and Values (33.01 ± 3.32), Evaluating Results (34.44 ± 5.11), and Seeking Knowledge and Adopting New Knowledge Impartially (32.62 ± 3.41) sub-dimensions were found to be above average based on the median score [30]. Similarly, the total scale score (134.90 ± 13.68) was also above average based on the median score (120) (Table 3). As a result of the analysis;

Table 3.

Comparison of sociodemographic and professional characteristics of nurses with mean total scores of CDMNS

Sociodemographic and Professional Characteristics		Clinical Decision Making in Nursing Scale (CDMNS)
		Exploring Options and Ideas	Investigating Purposes and Values	Evaluating Results	Seeking Knowledge and Adopting New Knowledge Impartially	Total
Marital Status	Married	33.97 ± 4.77	32.39 ± 3.11	33.68 ± 4.67	32.04 ± 3.26	132.09 ± 12.90
	Single	35.21 ± 4.55	33.31 ± 3.38	34.81 ± 5.27	32.90 ± 3.45	136.25 ± 13.88
Test and Significance		t: -1.996 p: 0.047	t: -2.089 p: 0.038	t: -1.657 p: 0.099	t: -1.865 p: 0.063	t: -2.277 p: 0.024
Child Presence	Yes	35.80 ± 5.44	33.45 ± 3.04	34.45 ± 5.20	32.45 ± 3.46	136.16 ± 13.49
	No	34.61 ± 4.47	32.92 ± 3.37	34.44 ± 5.10	32.65 ± 3.40	134.64 ± 13.74
Test and Significance		t: 1.336 p: 0.187	t: 0.932 p: 0.352	t: 0.006 p: 0.996	t: -0.354 p: 0.723	t: 0.656 p: 0.513
Income Status	Income less than expenditure	34.88 ± 4.72	33.13 ± 3ç61	34.19 ± 4.97	32.73 ± 3.52	134.94 ± 13.85
	Income equal to expenditure	34.59 ± 4.48	32.69 ± 3.13	34.54 ± 5.22	32.28 ± 3.41	137.16 ± 13.48
	Income more than expenditure	35.45 ± 4.92	33.54 ± 2.81	34.97 ± 5.31	33.18 ± 2.99	134.90 ± 13.68
Test and Significance		F: 0.604 p: 0.547 n2: 0.005	F: 1.007 p: 0.367 n2: 0.008	F: 0.353 p: 0.703 n2: 0.003	F: 1.063 p: 0.347 n2: 0.008	F: 0.713 p: 0.491 n2: 0.006
Mode of Operation	Day	34.31 ± 5.04	32.81 ± 3.06	34.08 ± 4.65	32.38 ± 3.34	133.60 ± 13.10
	Night	34 ± 4.33	31.78 ± 3.24	34.53 ± 5.01	32.10 ± 2.94	132.42 ± 11.90
	Sometimes day, sometimes night	35.13 ± 4.55	33.29 ± 3.39	34.56 ± 5.30	32.79 ± 3.51	135.79 ± 14.15
Test and Significance		F: 1.159 p: 0.315 n2: 0.009	F: 2.655 p: 0.072 n2: 0.021	F: 0.200 p: 0.819 n2: 0.002	F: 0.684 p: 0.505 n2: 0.005	F: 1.081 p: 0.341 n2: 0.009
Choosing a profession voluntarily	Yes	35.27 ± 4.83	33.46 ± 3.35	34.79 ± 5.32	32.64 ± 3.37	136.17 ± 14.16
	No	34.12 ± 4.30	32.34 ± 3.17	33.93 ± 4.74	32.59 ± 3.47	133 ± 12.76
Test and Significance		t: 1.919 p: 0.056	t: 2.646 p: 0.009	t: 1.317 p: 0.189	t: 0.110 p: 0.913	t: 1.811 p: 0.071
Love for the Profession	Yes	34.99 ± 4.72	33.17 ± 3.13	34.62 ± 5.12	32.50 ± 3.28	135.30 ± 13.56
	No	34.36 ± 4.49	32.62 ± 3.75	34 ± 5.08	32.91 ± 3.70	133.90 ± 14.04
Test and Significance		t: 0.975 p: 0.330	t: 1.182 p: 0.238	t: 0.880 p: 0.379	t: -0.864 p: 0.389	t: 0.731 p: 0.465
Occupation Eligibility	Yes	34.61 ± 4.66	32.91 ± 3.11	34.20 ± 4.96	32.29 ± 3.27	134.02 ± 13.28
	No	35.16 ± 4.65	33.19 ± 3.66	34.86 ± 5.36	33.18 ± 3.58	136.39 ± 14.28
Test and Significance		t: -0.906 p: 0.366	t: -0.621 p: 0.535	t: -0.978 p: 0.329	t: -2.004 p: 0.046	t: -1.330 p: 0.185
Working Unit	ICU	35.04 ± 4.34	33.08 ± 3.47	34.93 ± 5.15	32.63 ± 3.54	135.68 ± 13.67
	Internal Service	34.31 ± 4.75	32.62 ± 3.29	33.79 ± 4.54	32.26 ± 2.95	132.99 ± 12.51
	Surgical Service	35.39 ± 4.68	33.36 ± 3.30	34.96 ± 5.64	33.15 ± 3.59	136.87 ± 14.36
	Other (Emergency, Polyclinic, etc.)	34.88 ± 5.30	33.88 ± 2.82	34.55 ± 6.16	32.94 ± 4.60	136.27 ± 17.39
Test and Significance		F: 0.761 p: 0.517 n2: 0.009	F: 1.119 p: 0.342 n2: 0.013	F: 0.977 p: 0.404 n2: 0.012	F: 0.907 p: 0.438 n2: 0.011	F: 1.217 p: 0.304 n2: 0.015
Number of Patients in a Shift	a-2 and below	34.97 ± 4.44	33.29 ± 3.30	34.45 ± 5.08	32.32 ± 3.19	135.04 ± 13.31
	b-3-8	34.11 ± 4.80	32.31 ± 3.20	34.05 ± 5	32.45 ± 3.45	132.93 ± 13.69
	c-9-15	35.68 ± 4.11	33.80 ± 3.82	35.44 ± 5.81	33.04 ± 3.66	137.96 ± 14.67
	d-16 and above	36.59 ± 4.47	34.59 ± 2.73	35.21 ± 5.08	33.59 ± 3.44	140 ± 12.40
Test and Significance		F: 2.904 p: 0.035 n2: 0.034	F: 5.155 p: 0.002 n2: 0.059	F: 0.805 p: 0.492 n2: 0.010	F: 1.268 p: 0.286 n2: 0.015	F: 2.831 p: 0.039 n2: 0.033
Post-Hoc		d > b	a > b c > b d > b			a > b c > b d > b
Mean ± SD (Min-Max)		34.81 ± 4.65 (27–47)	33.01 ± 3.32 (24–43)	34.44 ± 5.11 (25–47)	32.62 ± 3.41 (24–43)	134.90 ± 13.68 (114–173)

CDMNS: Clinical Decision Making in Nursing Scale, t: Student T Test. F: One Way ANOVA Test, Post-hoc: Indicates the groups from which significance is derived, Post-hoc comparisons are indicated in the table by letter codes (a, b, c, d)

• Single nurses and nurses with 16 or more patients in each shift had significantly higher Investigating Options and Ideas and Clinical Decision Making in Nursing Scale scores (p < 0.05) (Table 3).

• While the Investigation of Goals and Values scores of single nurses and nurses who chose the profession willingly were significantly higher, those with 3 to 8 patients per shift had significantly lower scores (p < 0.05) (Table 3).

• Nurses who did not consider the profession suitable for themselves had a significantly higher score for Investigating Information and Impartially Adopting New Information (p < 0.05) (Table 3).

Median scores were used to evaluate the nurses’ total and sub-dimensions of the quality nursing care scale. Accordingly, the participants’ Physical Environment (25.78 ± 3.16) and Patient Outcomes (25.67 ± 3.14) scores were above average based on the median score [18]. Similarly, Nursing Care Activities (111.58 ± 12.51) was also above average based on the median score (78), and the total scale score (163.04 ± 18.05) was found to be above the median score of 114 (Table 4). As a result of the analysis;

Table 4.

Comparison of sociodemographic and professional characteristics of nurses with mean total scores of QNCS

Sociodemographic and Professional Characteristics		Quality Nursing Care Scale (QNCS)
		Physical Environment	Nursing Care Activities	Patient Outcomes	Total
Marital Status	Married	25.54 ± 3.24	110.85 ± 13.48	25.41 ± 3.30	161.81 ± 19.22
	Single	25.90 ± 3.13	111.94 ± 12.03	25.79 ± 3.07	163.64 ± 17.48
Test and Significance		t: -0.838 p: 0.403	t: -0.646 p: 0.519	t: -0.897 p: 0.371	t: -0.751 p: 0.453
Child Presence	Yes	26.50 ± 3.26	113.78 ± 12.80	26.09 ± 3.28	166.38 ± 18.70
	No	25.64 ± 3.13	111.14 ± 12.43	25.58 ± 3.12	162.38 ± 17.89
Test and Significance		t: 1.598 p: 0.111	t: 1.249 p: 0.213	t: 0.958 p: 0.339	t: 1.313 p: 0.190
Income Status	Income less than expenditure	25.76 ± 3.21	111.49 ± 12.59	25.53 ± 3.13	162.78 ± 18.12
	Income equal to expenditure	25.54 ± 3.10	111.12 ± 11.64	25.66 ± 2.96	162.33 ± 16.86
	Income more than expenditure	26.54 ± 3.14	113.13 ± 14.61	26.10 ± 3.67	165.78 ± 21.02
Test and Significance		F: 1.351 p: 0.261 n2: 0.011	F: 0.353 p: 0.703 n2: 0.003	F: 0.462 p: 0.631 n2: 0.004	F: 0.513 p: 0.599 n2: 0.004
Mode of Operation	Day	25.68 ± 3.50	111 ± 14.36	25.28 ± 3.65	161.96 ± 20.88
	Night	25 ± 3.79	110 ± 12.75	25.85 ± 3.13	160.85 ± 18.57
	Sometimes day, sometimes night	25.96 ± 2.90	112.07 ± 11.77	25.78 ± 2.95	163.81 ± 16.88
Test and Significance		F: 1.153 p: 0.317 n2: 0.009	F: 0.413 p: 0.662 n2: 0.003	F: 0.602 p: 0.549 n2: 0.005	F: 0.461 p: 0.631 n2: 0.004
Choosing a profession voluntarily	Yes	26.06 ± 3.25	112.92 ± 12.66	26.05 ± 3.03	165.04 ± 18.27
	No	25.37 ± 2.99	109.58 ± 12.05	25.09 ± 3.23	160.05 ± 17.37
Test and Significance		t: 1.702 p: 0.090	t: 2.093 p: 0.037	t: 2.380 p: 0.018	t: 2.165 p: 0.031
Love for the Profession	Yes	26.02 ± 3.23	112.96 ± 12.03	25.93 ± 3.04	164.91 ± 17.59
	No	25.20 ± 2.93	108.15 ± 13.08	25.01 ± 3.32	158.37 ± 18.44
Test and Significance		t: 1.852 p: 0.065	t: 2.793 p: 0.006	t: 2.110 p: 0.036	t: 2.629 p: 0.009
Occupation Eligibility	Yes	26.03 ± 3.22	113.04 ± 12.12	25.97 ± 3.08	165.05 ± 17.71
	No	25.36 ± 3.03	109.09 ± 12.82	25.15 ± 3.20	159.61 ± 18.19
Test and Significance		t: 1.632 p: 0.104	t: 2.441 p: 0.015	t: 2.019 p: 0.045	t: 2.330 p: 0.021
Working Unit	ICU	26.02 ± 3.14	111.91 ± 12	25.63 ± 3.03	163.57 ± 17.47
	Internal Service	25.66 ± 3.29	110.92 ± 12.56	25.61 ± 3.23	162.19 ± 18.18
	Surgical Service	25.68 ± 3.02	112.18 ± 13.09	25.86 ± 3.15	163.74 ± 18.62
	Other (Emergency, Polyclinic, etc.)	25.88 ± 3.16	112.11 ± 13.15	25.55 ± 3.25	163.55 ± 19.08
Test and Significance		F: 0.218 p: 0.884 n2: 0.003	F: 0.168 p: 0.918 n2: 0.002	F: 0.095 p: 0.963 n2: 0.001	F: 0.129 p: 0.943 n2: 0.002
Number of Patients in a Shift	2 and below	26.16 ± 3.09	112.58 ± 11.36	25.79 ± 2.89	164.54 ± 16.55
	3–8	25.63 ± 3.19	110.39 ± 13.41	25.43 ± 3.26	160.60 ± 18.71
	9–15	25.08 ± 3.42	110.24 ± 13.34	25.28 ± 3.54	168.06 ± 14.98
	16 and above	26.15 ± 2.96	115.25 ± 9.75	26.65 ± 2.75	163.04 ± 18.05
Test and Significance		F: 0.972 p: 0.407 n2: 0.012	F: 1.552 p: 0.202 n2: 0.018	F: 1.459 p: 0.226 n2: 0.017	F: 1.466 p: 0.224 n2: 0.017
Mean ± SD (Min-Max)		25.78 ± 3.16 (16–30)	111.58 ± 12.51 (74–130)	25.67 ± 3.14 (17–30)	163.04 ± 18.05 (111–190)

QNCS: Quality Nursing Care Scale, t: Student T Test. F: One Way ANOVA Test

Those who chose their profession willingly, love their profession, and find their profession suitable for themselves had significantly higher Nursing Care Activities, Patient Outcomes, and QNCS scores than other groups (p < 0.05) (Table 4).

Correlations between total scale scores

Pearson correlation analysis revealed no significant relationship between the total Work-Life Balance Scale score and the total Clinical Decision Making in Nursing Scale score (r = -0.016, p = 0.798) or the total Quality Nursing Care Scale score (r = -0.097, p = 0.126). A positive and significant correlation was found between the total scores of the Clinical Decision Making in Nursing Scale and the Quality Nursing Care Scale (r = 0.369, p < 0.001) (Table 5).

Table 5.

Correlation of nurses’ means of WLBS, CDMNS and QNCS total scores

Scale Total and Sub-Scales	1	2	3	4	5	6	7	8	9	10	11	12	13	14
1.Negative Impact of Life on Work	-	r: 0.218 * p < 0.001	r: 0.224 * p < 0.001	r: 0.377 * p < 0.001	r: -0.558 p < 0.001	r: -0.248 p < 0.001	r: -0.170 p: 0.007	r: -0.194 p: 0.002	r: -0.169 p: 0.007	r: -0.240 p < 0.001	r: 0.010 p: 0.872	r: 0.021 p: 0.744	r: -0.003 p: 0.961	r: 0.016 p: 0.806
2.Negative Impact of Work on Life		-	r: -0.139 p: 0.028	r: -0.297 p < 0.001	r: -0.767 p < 0.001	r: 0.111 p: 0.079	r: 0.131 p: 0.038	r: 0.128 p: 0.042	r: 0.089 p: 0.157	r: 0.140 p: 0.027	r: 0.142 p: 0.024	r: 0.180 p: 0.004	r: 0.196 p: 0.002	r: 0.184 p: 0.003
3.Positive Impact of Life on Work			-	r: 0.447 p < 0.001	r: 0.405 p < 0.001	r: -0.057 p: 0.367	r: -0.052 p: 0.407	r: -0.050 p: 0.433	r: 0.012 p: 0.845	r: 0.054 p: 0.396	r: 0.079 p: 0.211	r: 0.074 p: 0.239	r: 0.039 p: 0.536	r: 0.072 p: 0.253
4.Positive Impact of Work on Life				-	r: 0.386 p < 0.001	r: -0.231 p < 0.001	r: -0.177 p: 0.005	r: -0.241 p < 0.001	r: -0.203 p: 0.001	r: -0.262 p < 0.001	r: -0.079 p: 0.213	r: -0.052 p: 0.410	r: -0.098 p: 0.122	r: -0.067 p: 0.290
5.WLBS					-	r: 0.012 p: 0.844	r: -0.028 p: 0.653	r: -0.033 p: 0.604	r: -0.005 p: 0.937	r: -0.016 p: 0.798	r: -0.075 p: 0.236	r: -0.092 p: 0.144	r: -0.111 p: 0.077	r: -0.097 p: 0.126
6.Exploring Options and Ideas						-	r: 0.631 p < 0.001	r: 0.640 p < 0.001	r: 0.608 p < 0.001	r: 0.884 p < 0.001	r: 0.399 p < 0.001	r: 0.433 p < 0.001	r: 0.401 p < 0.001	r: 0.440 p < 0.001
7.Investigating Purposes and Values							-	r: 0.559 p < 0.001	r: 0.472 p < 0.001	r: 0.784 p < 0.001	r: 0.338 p < 0.001	r: 0.356 p < 0.001	r: 0.329 p < 0.001	r: 0.363 p < 0.001
8.Evaluating Results								-	r: 0.512 p < 0.001	r: 0.854 p < 0.001	r: 0.170 p: 0.007	r: 0.190 p: 0.002	r: 0.188 p: 0.003	r: 0.195 p: 0.002
9.Seeking Knowledge and Adopting New Knowledge Impartially									-	r: 0.762 p < 0.001	r: 0.171 p: 0.006	r: 0.238 p < 0.001	r: 0.232 p < 0.001	r: 0.236 p < 0.001
10.CDMNS										-	r: 0.324 p < 0.001	r: 0.364 p < 0.001	r: 0.344 p < 0.001	r: 0.369 p < 0.001
11.Physical Environment											-	r: 0.765 p < 0.001	r: 0.703 p < 0.001	r: 0.828 p < 0.001
12.Nursing Care Activities												-	r: 0.951 p < 0.001	r: 0.993 p < 0.001
13.Patient Outcomes													-	r: 0.956 p < 0.001
14.QNCS														-

WLBS: Work Life Balance Scale, CDMNS: Clinical Decision Making in Nursing Scale, QNCS: Quality Nursing Care Scale, r: Pearson correlation analysis

Correlations between sub-dimensions

A negative and significant relationship was found between the Negative Impact of Life on Work and the Clinical Decision Making in Nursing Scale (r=-0.240, p < 0.001). A counter-intuitive, positive and significant correlation was found between the Negative Impact of Work on Life and the Clinical Decision Making in Nursing Scale (r = 0.140, p = 0.027) and the Quality Nursing Care Scale (r = 0.184, p = 0.003). The subscales of the Clinical Decision Making in Nursing Scale and the Quality Nursing Care Scale are positively and significantly correlated with each other (p < 0.05) (Table 5).

In the multiple regression analysis conducted to investigate the effects of nurses’ work life balance and clinical decision making skills on quality nursing care, the established model was found to be statistically significant (F = 21.045, p < 0.001). The Durbin-Watson value being between 1.5 and 2.5 indicates that there is no autocorrelation problem in the model (DW = 1.882) [24]. While it was determined that nurses’ work life balance did not significantly affect quality nursing care (p = 0.123), clinical decision making skills were significantly effective (p < 0.001). Work life satisfaction and clinical decision-making skills in nursing explain 13.8% of quality nursing care (R²=0.138) (Table 6).

Table 6.

The effect of nurses’ WLBS and CDMNS levels on QNCS

Dependent Variable	Independent Variable	β	t	p	F	Model (p)	Adjusted R2	DW
QNCS	Constant Value	106.492	8.846	< 0.001	21.045	< 0.001	0.138	1.882
	WLBS	-0.183	-1.546	0.123
	CDMNS	0.485	6.275	< 0.001

WLBS: Work Life Balance Scale, CDMNS: Clinical Decision Making in Nursing Scale, QNCS: Quality Nursing Care Scale

In the multiple regression analysis conducted to investigate the effects of nurses’ work life balance subdimensions on quality nursing care, the established model was found to be statistically significant (F = 3.131, p = 0.015). The Durbin-Watson value between 1.5 and 2.5 indicates that there is no autocorrelation problem in the model (DW = 1.784) [24]. The analysis found that negative impact of life on work, positive impact of life on work, and positive impact of work on life did not significantly affect quality nursing care (p > 0.05). The negative impact of work on life had a significant effect on quality nursing care (p = 0.006). All these variables explain 03.3% of the variance in quality nursing care (R²=0.033) (Table 7).

Table 7.

The effect of nurses’ WLBS subdimensions levels on QNCS

Dependent Variable	Independent Variable	β	t	p	F	Model (p)	Adjusted R2	DW
QNCS	Constant Value	143.895	19.487	< 0.001	3.131	0.015	0.033	1.784
	Negative Impact of Life on Work	-0.109	-0.490	0.625
	Negative Impact of Work on Life	0.825	2.762	0.006
	Positive Impact of Life on Work	0.800	1.891	0.060
	Positive Impact of Work on Life	-0.321	-0.694	0.488

WLBS: Work Life Balance Scale, QNCS: Quality Nursing Care Scale

In the multiple regression analysis conducted to investigate the effects of nurses’ clinical decision making subdimensions on quality nursing care, the established model was found to be statistically significant (F = 18.296, p < 0.001). The Durbin-Watson value between 1.5 and 2.5 indicates that there is no autocorrelation problem in the model (DW = 1.923) [24]. The analysis found that seeking knowledge and adopting new knowledge impartially did not significantly affect quality nursing care (p > 0.05). The exploring options and ideas, investigating purposes and values and evaluating results had a significant effect on quality nursing care (p < 0.05). All these variables explain 21.6% of the variance in quality nursing care (R²=0.216) (Table 8).

Table 8.

The effect of nurses’ CDMNS subdimensions levels on QNCS

Dependent Variable	Independent Variable	β	t	p	F	Model (p)	Adjusted R2	DW
QNCS	Constant Value	95.563	8.265	< 0.001	18.296	< 0.001	0.216	1.923
	Exploring Options and Ideas	1.796	5.371	< 0.001
	Investigating Purposes and Values	1.071	2.630	0.009
	Evaluating Results	-0.674	-2.495	0.013
	Seeking Knowledge and Adopting New Knowledge Impartially	-0.220	-0.576	0.565

CDMNS: Clinical Decision Making in Nursing Scale, QNCS: Quality Nursing Care Scale

Discussion

Global work–life balance and the importance of examining sub-dimensions

The primary aim of this study was to examine the relationships between nurses’ work–life balance, clinical decision-making, and quality nursing care. The findings demonstrated that overall work–life balance was not significantly associated with either clinical decision-making skills or quality nursing care. This result suggests that evaluating work–life balance as a global construct may obscure the differential effects of its sub-dimensions. Similar findings in the literature indicate that nurses often report low levels of work–life balance while maintaining high levels of professional performance, highlighting the limitations of using an overall balance score alone [6, 25, 26].

In contrast, examining directional spillover dimensions provides a clearer understanding of how different aspects of work–life interaction influence professional outcomes. Previous research emphasizes that work–life balance is shaped by the reciprocal and asymmetric interaction between work and personal life domains, and these interactions may have distinct implications for cognitive, emotional, and professional functioning [6, 12]. Therefore, focusing on the negative impact of life on work and the negative impact of work on life allows for a more nuanced interpretation of how work–life balance relates to clinical decision-making and care quality in nursing practice.

Negative impact of life on work and its detrimental role in clinical decision-making

One of the key findings of this study is the significant negative relationship between the negative impact of life on work and nurses’ clinical decision-making skills. This finding indicates that stressors originating from nurses’ private lives such as family responsibilities, financial strain, or psychosocial difficulties can adversely affect their ability to make sound, timely, and accurate clinical decisions. Previous studies have shown that disruptions in personal life increase psychological strain and reduce cognitive flexibility, which are critical components of effective clinical decision-making [6, 27].

Consistent with this interpretation, low work–life balance and increased life-to-work interference have been associated with impaired professional functioning, higher burnout levels, and reduced decisional confidence among nurses [25, 26]. These findings suggest that when life-related stressors intrude into the work domain, they may function primarily as obstructive factors that undermine attentional resources and cognitive processing required for clinical decision-making. Accordingly, interventions aimed at supporting nurses’ personal lives and reducing life-to-work interference may play a critical role in protecting clinical decision-making capacity and patient safety.

The paradoxical effect of work on life spillover: a challenge-hindrance stressor perspective

A noteworthy and paradoxical finding of this study is the positive association between the negative impact of work on life and both clinical decision-making skills and quality nursing care. Although work-related strain is generally expected to impair professional outcomes, this finding suggests that certain work-related demands may simultaneously challenge nurses and contribute to the development of professional competence.

This paradoxical relationship can be theoretically understood through the Challenge-Hindrance Stressor Framework [28, 29]. According to this framework, work stressors can be categorized as either challenge stressors (demanding but growth-promoting) or hindrance stressors (obstructive with no developmental benefit). The negative impact of work on life may function as a challenge stressor that, despite creating strain, provides opportunities for skill development through exposure to complex clinical situations and frequent decision-making demands. In contrast, the negative impact of life on work appears to operate primarily as a hindrance stressor that depletes cognitive resources without offering compensatory professional growth.

Previous research supports this interpretation, indicating that demanding clinical environments characterized by high workload, time pressure, and complex patient care situations may expose nurses to frequent decision-making opportunities, thereby strengthening their decisional skills through repeated practice and experience [7]. Similarly, studies have shown that nurses with strong professional commitment and resilience are able to maintain high care quality despite adverse working conditions [30].

However, the literature also cautions that sustained exposure to intense work demands may have cumulative negative effects over time, leading to burnout and diminished well-being [31]. Therefore, while the negative impact of work on life may be associated with short-term gains in decision-making skills and care quality through a challenge mechanism, this relationship should be interpreted cautiously. Without adequate organizational support, recovery opportunities, and workload regulation, prolonged work-related interference may ultimately transition from a challenge to a hindrance stressor, compromising both nurses’ well-being and the sustainability of high-quality care.

Clinical decision-making as a determinant of quality nursing care

In this study, a positive relationship was identified between nurses’ clinical decision-making skills and the quality of nursing care, and clinical decision-making emerged as a significant predictor of quality nursing care. This finding highlights the central role of decision-making competence in delivering effective, patient-centered nursing care. Nurses with strong clinical decision-making abilities are more capable of accurately assessing patient needs, prioritizing interventions, and implementing individualized care plans, which directly contributes to improved care quality and patient outcomes [7, 9, 21, 22, 30].

Consistent with previous studies, effective decision-making in nursing has been associated with higher levels of patient safety, ethical sensitivity, and professional accountability [7, 30]. These findings suggest that clinical decision-making functions not only as a cognitive process but also as a core professional competency that bridges knowledge, experience, and care delivery. Therefore, strengthening nurses’ decision-making skills through continuous education, reflective practice, and supportive clinical environments may be a key strategy for improving the quality of nursing care at both individual and organizational levels.

Work–life balance, professional commitment, and the sustainability of high performance

Despite reporting low levels of overall work–life balance, nurses in this study demonstrated high perceptions of clinical decision-making skills and quality nursing care. This pattern suggests that strong professional commitment, intrinsic motivation, and dedication to patient care may enable nurses to maintain high performance even under challenging work–life conditions [10, 30]. Similar findings in the literature indicate that nurses often continue to perform at high levels despite experiencing work–life imbalance and role strain [25, 26].

However, maintaining high performance in the context of sustained imbalance raises concerns regarding long-term sustainability. Previous studies have shown that prolonged work–life imbalance is associated with burnout, reduced psychological resilience, and declining mental well-being among nurses [27, 32, 33]. While professional commitment may buffer the negative effects of imbalance in the short term, reliance on individual resilience alone may increase vulnerability to adverse outcomes over time. Therefore, organizational policies that promote work–life balance are essential to sustaining nurses’ professional performance, clinical decision-making capacity, and quality of care in the long term.

Integrated influence of demographic and professional characteristics

When demographic and professional variables were considered together, the findings indicate that nurses’ work–life balance, clinical decision-making, and quality of care are shaped by a complex interaction of individual life circumstances, professional adaptation, workload, and economic conditions.

Single nurses, nurses without children, and those reporting income inadequacy or low professional satisfaction experienced higher levels of negative spillover, particularly from work to life, which may negatively affect their overall well-being [6, 10, 34, 35]. In a study conducted with single participants, it was reported that individuals might struggle to manage work stress and perceive their work–life balance more negatively due to feelings of loneliness and lack of social support after work [36]. At the same time, for nurses without children, work may constitute a large part of their focus, which could contribute to an increase in the corrosive effect of work on private life. Kida et al. (2024) similarly reported that nurses without children tended to work overtime and night shifts, received less social support, and experienced higher levels of professional burnout [34]. In another study, it was emphasized that married nurses had more flexibility in shift selection and were able to support their work–life balance by reducing their workload and working hours [35]. Similarly, Zhang et al. (2024) stated that income-expense imbalance can directly affect the non-work life of employees by increasing mental preoccupation [6]. Dousin et al. (2021) argued that nurses with low levels of professional satisfaction experience decreases in both job satisfaction and life satisfaction, and this leads to burnout [10]. These findings suggest that improving nurses’ work–life balance requires attention not only to institutional regulations but also to factors such as individual lifestyle, private life conditions, and social support systems.

Workload emerged as a critical factor influencing both work–life balance and decision-making processes. Nurses caring for a high number of patients (16 or more) per shift may gain increased exposure to clinical decision-making situations, potentially strengthening decisional skills through practice. Single nurses who cared for 16 or more patients in each shift had higher clinical decision-making scores, which may be explained by the fact that single nurses have fewer off-the-job responsibilities and can focus more on professional development. Another factor may be related to the fact that single nurses work more night shifts and overtime [37]. However, the literature emphasizes that intense workload may cause mental exhaustion over time and this may increase the risk of errors in decision-making processes [38, 39]. Although high decision-making scores are a positive finding, it is important to take supportive measures for the sustainability of this performance and the cognitive health of nurses. Zhou et al. (2019) emphasized that intense workload causes physical and mental exhaustion in nurses and negatively affects their private lives [38]. Similarly, Chan et al. (2023) stated that intense workload limits the social interactions and well-being of individuals in their private lives [40]. Although factors such as a high number of patients and intense workload are thought to reduce nurses’ cognitive resilience [41], the relationship between workload and decision-making is complex. Farčić et al. (2020) state that nurses’ cognitive robustness and self-efficacy are determinants in their decision-making skills and that these competencies develop with various clinical experiences [7]. This dual effect underscores the importance of distinguishing between skill-building exposure and cognitively depleting overload.

On the other hand, the high scores of “Investigating Goals and Values” of single nurses and nurses who chose their profession willingly indicate that personal motivation and intrinsic reasons for choosing a profession strengthen the ethical and value dimensions in the decision-making process. In the literature, it is emphasized that professional love and intrinsic motivation are positively related to the quality of professional decisions and ethical sensitivity [10]. It is an interesting finding that the scores of “Seeking Information” and “Adopting New Information Impartially” were higher in nurses who did not see their profession as suitable for them. This may be explained by the fact that nurses who cannot adopt their profession feel that they have to resort to more information. Kruczek et al. (2020) reported that problem solving skills and cognitive flexibility ability lead individuals to information seeking behavior in stressful situations and environments [8]. It can also be considered as a need to obtain objective information due to a lack of self-confidence.

In contrast, voluntary career choice, professional commitment, and perceived suitability of the profession were consistently associated with more positive professional outcomes. The scores of nursing care activities, patient outcomes and quality nursing care were significantly higher in nurses who chose their profession willingly, liked their profession and considered their profession suitable for them. Dousin et al. (2021) stated that occupational adjustment in nurses strengthens the perception of quality care and increases patient-centered practices [10]. Similarly, Labrague and de los Santos (2021) revealed that professional commitment and intrinsic motivation directly affect nurses’ performance in the care process and improve the quality of care [30]. Urban et al. (2024) also stated that professional satisfaction has direct and indirect effects on the quality of care and patient outcomes [11]. As a result of the study, while the positive impact of work on life was high in nurses who considered their profession suitable for them, this sub-dimension score was found to be significantly lower in nurses who cared for 16 or more patients in each shift. This suggests that professional adaptation plays an important role in nurses’ ability to transfer positive effects from their work to their private lives, while excessive workload prevents this positive transfer.

The study also reveals that the work–life balance scores of nurses who have children, love their profession, find their profession suitable for them and work in units such as emergency/polyclinic are significantly higher than the other groups. This shows that both the diversity of individual life roles and professional satisfaction positively affect work–life balance. In the literature, it is stated that having children supports the individual’s search for meaning in life and this strengthens the ties established with life outside of work [30]. Nurses working in emergency and outpatient clinic units generally work in a certain division of labor, benefit from team-based support, and can adapt to their private lives more easily after the shift due to more predictable workflows. In the literature, it is stated that the regularity of the work environment, team cooperation and balanced distribution of workload positively affect the private life of nurses [30].

These findings suggest that improving nurses’ work–life balance and professional functioning requires multidimensional strategies that address workload regulation, economic security, professional development opportunities, and the strengthening of professional identity and job satisfaction. Interventions should be tailored to consider not only institutional factors but also individual life circumstances and career stage, recognizing that work–life balance is influenced by the dynamic interplay between personal, professional, and organizational domains.

Strengths and limitations of the study

This study is a highly theoretical investigation examining three key variables: work-life balance, clinical decision-making, and quality nursing care. It contributes to filling gaps in the existing literature. Data were collected directly from nurses working in clinical settings. This increases the internal validity of the study and ensures that the findings overlap with real life.

However, the study has some limitations. First of all, since the study has a cross-sectional design, it is not possible to establish a cause-and-effect relationship. Long-term follow-up studies can more clearly reveal how the relationship between work-life balance, decision-making processes and quality of care changes. In addition, since the study was conducted in a single hospital, more comprehensive studies are needed to evaluate the experiences of nurses in different institutions.

Conclusion and recommendations

This study examined the relationship between nurses’ perceptions of work-life balance, clinical decision-making skills and quality nursing care. The study results revealed no significant relationship between overall work-life balance and nurses’ clinical decision-making skills or perceptions of quality nursing care. However, important nuances were identified at the subdimension level. An increased negative impact of life on work was associated with reduced clinical decision-making skills. In contrast, the negative spillover of work into personal life was linked to both clinical decision-making and perceptions of quality nursing care. These findings suggest that it is not overall balance but rather the specific negative interactions between work and personal life that play a critical role in shaping professional outcomes. At the same time, significant differences were found between socio-demographic variables such as individual characteristics, commitment to the profession, patient load and choice of profession and work-life balance, clinical decision-making skills and quality nursing care. The findings showed that there was a strong positive relationship between clinical decision-making skills and quality of care. In conclusion, it is critical to balance nurses’ workloads and provide professional support to increase nurses’ professional satisfaction and ensure the sustainability of quality nursing service delivery. In this direction, the following recommendations can be offered:

• Given the clear negative impact on clinical decision-making, institutions should develop targeted policies to reduce negative life-to-work implications, such as through strong employee assistance programs and childcare support.

• Strong “right to disconnect” regulations should be implemented, as should policies to minimize off-shift communication.

• Managerial focus should shift from promoting general ‘balance’ to identifying and mitigating the specific factors that cause work to negatively spill into nurses’ personal lives, such as excessive workload and unpredictable schedules.

• Adequate staffing and workload management policies should be developed to reduce nurses’ fatigue in decision-making processes and the negative impact of quality nursing care on their personal lives.

• Flexible working hours and shift systems should be redesigned to reduce not only the pressure of work on life but also the burden of personal life on work. Additional rest periods and sleep-support practices should be provided, particularly for nurses working night shifts. This should accelerate nurses’ adaptation to their personal lives after night shifts.

• Qualitative studies (e.g., in-depth interviews, focus groups) should be conducted to comprehensively examine nurses’ experiences of work-life balance and how these experiences impact clinical decision-making and quality of care. Based on these findings, the effectiveness of implemented intervention programs should also be regularly measured and integrated into managerial decision-making processes.

• Shift scheduling and social support systems should be restructured to consider the bidirectional effects of work-life conflict.

• Professional development and training opportunities should be supported to enhance nurses’ resilience and professional commitment, thereby minimizing the negative effects of work-life conflict.

Author contributions

Ayşe EMİNOĞLU GÜVEN: AEG, Gaziantep Islam Science and Technology University of Health Sciences Department of Nursing, Gaziantep/Turkey. Burcu ÇAKI DÖNER: BÇD, Gaziantep Islam Science and Technology University of Health Sciences Department of Nursing, Gaziantep/Turkey. Mina MUŞLUOĞLU: MM, Gaziantep City Hospital, Gaziantep/Turkey. Conceptualization: AEG, BÇD, MM; Data curation: AEG, BÇD, MM; Formal analysis: AEG, BÇD; Funding acquisition: AEG, BÇD, MM; Investigation: AEG, BÇD, MM; Methodology: AEG, BÇD; Project administration: AEG, BÇD, MM; Resources: AEG, BÇD; Software: AEG, BÇD; Supervision: AEG, BÇD; Validation: AEG, BÇD, MM; Visualization: AEG, BÇD, MM; Writing-original draft: AEG, BÇD, MM; Writing – review & editing: AEG, BÇD, MM. All authors reviewed the manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

Anonymous data supporting the findings of this study can be obtained from the relevant author upon reasonable request.

Declarations

Ethics and consent to participate

Ethics committee approval was obtained from Gaziantep Islam Science and Technology University Non-Interventional Clinical Research Ethics Committee (dated 15.01.2025 and numbered 509.42.14). Institutional approval was obtained from the Provincial Health Directorate (dated 18.03.2025 and numbered E-87825162-663.08-271554300) and written informed consent was obtained from the individuals.

Competing interests

The authors declare no competing interests.