quality of nursing care: the influence of work conditions

Accepted Manuscript

Quality of Nursing Care: The Influence of Work Conditions and Burnout

Rola H. Mudallal, Mohammad Y.N. Saleh, Hanan M. Al-Modallal, Rania YAbdel-Rahman

PII: S2214-1391(17)30004-5DOI: http://dx.doi.org/10.1016/j.ijans.2017.06.002Reference: IJANS 58

To appear in: International Journal of Africa Nursing Sciences

Received Date: 17 January 2017Revised Date: 8 June 2017Accepted Date: 13 June 2017

Please cite this article as: R.H. Mudallal, M.Y.N. Saleh, H.M. Al-Modallal, R.Y. Abdel-Rahman, Quality of NursingCare: The Influence of Work Conditions and Burnout, International Journal of Africa Nursing Sciences (2017),doi: http://dx.doi.org/10.1016/j.ijans.2017.06.002

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Quality of Nursing Care 1

Quality of Nursing Care: The Influence of Work Conditions and Burnout

*Rola H. Mudallal, PhD, RN

Full Time Lecturer

Community and Mental Health Department, Hashemite University, Zarqa, Jordan

Mohammad Y. N. Saleh, RN, MSN, PhD

Associate Professor

Clinical Nursing Department, The University of Jordan, Amman, Jordan

Hanan M. Al-Modallal, PhD, RN

Associate Professor

Community and Mental Health Department, Hashemite University, Zarqa, Jordan

Rania Y Abdel-Rahman, MSN, RN

Teacher Assistant

Maternal, Child, and Family Department, Hashemite University, Zarqa, Jordan

*Corresponding author’s address:

The Hashemite University, School of Nursing

P.O. Box 150459, Zarqa 13115, Jordan

Telephone: 962(5) 3903333, Ext. 5552

Fax: 962-5-3903337

e-mail: [email protected]

Introduction

mailto:[email protected]


Providing quality health care is one of the most challenging issues for health care systems all

over the world. Increasing demand on health care services associated with shortage of health care

professionals and massive advances in health sciences and technology has created an overload of

work and job stress, which lead to an increase in errors and a decrease in work quality (The

Institute of Medicine [IOM], 1999, 2001, 2013).

Prompt changes in the health care system, a work overload, consistant interaction with

suffering patients and continuously unmet psychological needs will lead to burnout; which is a

state of emotional, intellectual and physical exhaustion (Azeem, Nazir, Zaidi, & Akhtar, 2014;

Maslach, Schaufeli, & Leiter, 2001; Patrick & Lavery, 2007). Sever burnout is manifisted by

fatigue, job dissatisfaction, low self esteem, poor concentration and reasoning, as a result, this

may lead to emotional depletion, uncaring perception of the clients, negative self evaluation and

quitting job (Maslach & Jackson, 1981; Maslach, Schaufeli, & Leiter, 2001). Nurses burnout

reduces their work productivity, increases the potential of health related errors (Montgomery,

Panagopoulou, Kehoe, & Valkanos, 2011), rises turnover rate and directly affects the quality of

nursing care (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Leiter & Maslach, 2009). In a

study that aimed to investigate the influence of burnout on some work related variables,

researchers found that emotional exhaustion was associated with absenteeism, intention to leave

profession, personal and family deterioration, also, depersonalization was linked to the

perception of having made errors (Su˜ner-Soler et al., 2014). Therefore, it is a key to recognize

the factors in nurse burnout that may affect the quality of nursing care.

Quality is a health care services level that is consistent with updated professional knowledge

and allows desired outcomes to be obtained (IOM, 1990). Several studies explored and examined

the different environmental factors that are related to the quality of nursing care and required


improvement at health care systems. Laschinger, Shamian and Thomson (2001) studied the

effects of magnet hospital characteristics on nurses’ job satisfaction, trust, perceived quality of

care, and burnout among nurses. Authors reported the organizational traits of autonomy, control,

and collaboration were negatively correlated with burnout, which in turn is associated negatively

with the perceived quality of care, although trust in management was positively correlated with

nurses’ perceived quality of care. In a recent study, Van Bogaert, Van Heusden, Timmermans and

Franck (2014b) suggested that nurse work environment such as “nurse-physician collaboration”

and “nurse management” at both unit and hospital levels are influential to nurse-assessed quality

of care as mediated by nurse-work characteristics. In addition, effective leadership styles have an

influential role in providing quality nursing care, nurses in departments with effective leadership

styles reported lower rates of medication errors, patient falls, pneumonia, urinary tract infections,

brain hemorrhage and patient mortality (Houser, 2003). Similarly, in Jordan, factors related to

work environment, competent management, and nurses’ job satisfaction; specifically satisfaction

with psychological rewards, rotating work shifts and daily census, were reported as significant

indicators of quality of nursing care (Mudallal, 2013). Furthermore, quality of nursing care in

Jordanian hospitals was significantly dependent on nature (type) of the hospital (Mrayyan, 2008;

Mudallal, 2013).

In addition, nurse burnout reflected a unique role in the quality of nursing care provided

through different studies. Vahey, Aiken, Sloane, Clarke and Vargas (2004)-study revealed that

quality of nursing care indicator “patient satisfaction” was negatively associated with nurse

burnout. A substantial relationship between burnout and quality of nursing care was evident in a

secondary analysis of a cross-national data from six countries in which the investigators found

that high level of nurse burnout was significantly associated with low or fair level of quality


nursing care (Poghosya, Clarke, Finlayson, & Aiken, 2010). On the same extreme of

understanding, a Belgian study included 546 registered nurses from 42 units demonstrated that

emotional exhaustion is a significant predictor of job satisfaction, turnover and quality of nursing

care (Van Bogaert, Clarke, Roelant, Meulemans, & Van de Heyning, 2010). Similarly, a recent

cross-sectional survey, using a multilevel modelling technique to analyze data of 709 nurses from

different levels and were working in 25 residential aged care services demonstarted that

emotional exhaustion and depersonalization were substantial idicators of the quality of nursing

care (Van Bogaert, Dilles, Wouters & Van Rompaey, 2014a).

Although a limited number of studies highlighted the influence of burnout on the quality of

nursing care, burnout has been found a mediater of the pathway between some organizational

traits or interventions and the quality of nursing care. For example, burnout played a mediator

role in the relationship between nursing work environment and patient’s safety (Laschinger &

Leiter, 2006), influenced nursing work environment on job outcomes (Van Bogaert, Meulemans,

Clarke, Vermeyen, & Van de Heyning, 2009) and quality of nursing care (Spann, Baban, Bria,

Lucacel, & Dumitrascu, 2013). Of the aspects of burnout, emotional exhaustion besides

workload have mediated the relationship between work enivironment in terms of “nurse-

physician relationship”, “hospital and nurse management” and “organisational support” and the

quality of nursing care; all of which were found to have predictive performance of the quality of

nursing care (Van Bogaert, Kowalski, Weeks, Van Heusden, & Clarke, 2013).

Based on previous evidences, environmental factors and nurse characteristics have

influenced both burnout and the quality of nursing care (Aiken et al., 2002; Houser, 2003;

Laschinger et al., 2001; Mrayyan, 2008; Mudallal, 2013; Van Bogaert et al., 2014b) and

substantiate the mediation role of burnout in relation to the quality of nusring care (Laschinger &


Leiter, 2006; Spann et al., 2013;Van Bogaert et al., 2009; Van Bogaert et al., 2013). Limited

number of studies demonstarted the influence of burnout on the quality of nursing care

(Poghosya et al., 2010; Van Bogaert et al., 2010; Van Bogaert et al., 2014a), although the

influence of workers’ stress level on productivity has been addressed. Therefore, the aim of this

study is to investigate the influence of nurse burnout, general work conditions, nurse and patient

characteristics on the quality of nursing care.

Methods

Design.

Cross-sectional, correlational designs were employed to explore the influence of nurse

burnout on the quality of nursing care.

Sample and Setting.

The data of this study was collected from both: nurses and patients. The sample size was

estimated using statistical power procedures. the estimated sample size was 178 particepants for

each group (nurses and patients).

A convenience sample of 270 registered nurses and 270 hospitalized patients from 24 units of

eight hospitals in Jordan was recruited. Only registered nurses with a minimum experience of at

least one year in a clinical area and adult patients who were conscious, oriented, free of pain and

able to speak and communicate were included in the study.

The selected hospitals for this study were from three major Jordanian governorates. The

health care system in Jordan has three major sectors: Public (Ministry of Health (MOH), Royal

Medical Services (RMS) and educational hospitals), private and donors. For this study, the data

were collected from nurses in (MOH), private and educational hospitals.


Ethical Considerations.

The human rights and ethical considerations were protected all over the study. The

researchers obtained the ethical approval to use the study instruments. Institute Review Board

(IRB) approval for each hospital was also guaranteed. Participants were informed of the purpose

of the study, and their right to withdraw without penalty at any time. To keep anonymity, the

questionnaires did not include any information regarding the participant identity. Return of

completed questionnaires by nurses and patients was considered as a signed agreement to

participate in this study. After filling the questionnaire by the participant it was coded by a

number and kept in secure place; no one has an access to the data except the researcher.

Measurement.

The data in this study was collected through the following tools:

Service Quality Scale (SERVQUAL).

This instrument was originally developed by Zeithaml, Parasuraman and Berryin 1985 to

measure service quality. It is a reliable and valid scale that can be used by researchers, managers

and professionals to assess service quality (W. Clark & L. Clark, 2007; Parasuraman, Zeithaml,

& Berry, 1988; Scardina, 1994). Service quality is the difference between what the consumer

expects from the service and what he or she perceives the service to be in the experienced

situation. According to this instrument, service quality has the following five dimensions:

tangibility, reliability, responsiveness, assurance and empathy (Parasuraman, Zeithaml, & Berry,

1988; Scardina, 1994). The scale was completed by adult patients in different hospital

departments. The Arabic version of the instrument was used by the researchers to facilitate the

understanding of items by Jordanian patients. The arabic version of SERVQUAL has been used

and studied in different research through which it was valid, and demonstrated high reliability-


Cronbach alpha was more than 0.90 for the total scale (Al-Borie & Damanhouri, 2013). In this

study, Cronbach alpha for the total SERVQUAL is 0.93.

The SERVQUAL consists of 22-Likert-type items with five points (1= very much below my

expectations, 2= below my expectations, 3= meet my expectations, 4= above my expectations,

5= very much above my expectations). The responses for the whole scale were summed into 110.

Higher scores reflect higher levels of quality of nursing care services.

Maslach Burnout Inventory (MBI).

The MBI-human services survey instrument consists of 22-items designed to address three

dimensions of burnout for professionals in human services. Nine items measure Emotional

Exhaustion (EE); the feeling of being overstressed in addition to emotional and physical

resources depletion. Five items measure depersonalization (DP) which is unfeeling and negative

attitude about clients. Eight items measure personal accomplishment (PA) the feelings of

competence, achievement and productive at work (Maslach, Schaufeli, & Leiter, 2001).

The nurses responses for each item ranged from 0 “never” to, 6 “every day.” The responses

for each sub-scale were summed. High EE and DP scores reflect high levels of burnout, while

low PA scores reflect high levels of burnout (Maslach & Jackson, 1981).

The nurses completed the English version of the questionnaire; because they were familiar

with English terms in nursing more than Arabic ones, since English is the teaching language in

nursing schools in Jordan. The instrument was found to be highly reliable and valid in many

studies when it was used to measure burnout. For this study, Cronbach alpha for the three

subscales ranged from 0.779-0.906.

Nurses, Patients and Work Characteristics.


The demographic data of the nurses involved in this study included: gender, marital status,

working shift (fixed shift or rotating (A, B, C or day, night)), educational level (Bachler or

master), age and years of experience as a registered nurse. General work conditions included:

department type (medical , surgical, maternal and child care, intensive care units), daily census

(the average number of inpatients or occupied beds in the department), the model of nursing care

provision (functional, team, or total patient care), and the leadership style of the direct supervisor

(autocratic, democratic, permissive, or situational).

The demographic data for the patients included: gender, marital status, educational level, age

and length of stay in hospital.

Data Collection.

The data of the present study was collected by trained research assistants. The research

assistants were available to answer any questions. The data were collected from both nurses and

patients. Nureses reported their level of burnout through the MBI. Because burnout is expected

to affect nurses’ ability to judge quality (Maslach & Jackson, 1981), quality nursing care was

measured through patients’ responses on the SERVQUAL. Completed MBIs were matched to

SERVQUAL questionnaires which were completed by patient participants who received care by

those nurses who completed MBIs during hospitalization. The pair of surveys was then given a

code for analysis. Research assistants used the assignment sheet to decide on matched pairs.

Assignment sheet is a document used by departement manager to design the job and distribute

workload on nurses each shift; this document provided research assistants with information

regarding patient care assignment, to recognise the nurse who had the most contact with the

patient, which helped in maching process.

Analysis.


Univariate descriptive statistics were used to assess means (M) and standard deviation (SD)

for continuous variables. Frequencies were used to describe the categorical demographic

characteristics of the sample.

Before running stepwise multiple regression model, two inferential tests were used to

determine the factors that may influence the quality of nursing care: 1) Pearson Correlation

Coefficient (Pearson r) to assess the relationship between continuous variables including nurse

burnout, census, nurses’ and patients’ age, experience, length of stay and quality of nursing care.

2) One way analysis of variance (ANOVA) to determine factors may influence the quality of

nursing care including categorical variables of demographics and departmental characteristics.

Stepwise regression analysis was used to determine the predictive performance of those

factors that had a statistically significant correlation with the quality of nursing care. The

researchers examined the normality of the outcome variable, linearity of predictors, homogeneity

of variance and independence of variables before running the regression analysis (Warner, 2008).

Results

Descriptive Analysis.

A total of 300 registered nurses were approached. Two hundred seventy registered nurses

completed the questionnaires, with a response rate of 90%. Approximately 45% (n=121) of the

participants were males, and 55% (n=149) were females. The mean age of the nurse participants

was 29.40 years (SD=6.29), ranging from 23 to 47 years. Nurse participants had mean years of

experience of 6.71 years (SD=5.75). Approximately half of the nurse participants were married

(n=141, 52.20%), 121 (44.80%) of nurse participants were single, and some were divorced or

widowed (8, 3%). Most of the nurse participants (n=242, 89.70%) had a baccalaureate degree;

the residue had a Master degree. Results revealed that most nurse participants (n=204, 75.6%)

Quality of Nursing Care

10

rotated on either A, B, C or day and night shifts and 66 (24.4%) were fixed on A shift.

The patient participants response rate was 96%. Most of the participants were females

(n=168, 62.20%) and married (n=170, 63%). The mean age of patient participants was 36.42

years (SD=16.83), and their educational level ranged from primary school to graduate studies.

The length of stay ranged from 2 to 37 days (M=3.99, SD=3.95). For most patients, 211 (78%)

were experienced hospitalization for the first time.

In regard to the work environment; approximately 158 (58.52%) nurse participants worked in

general medical and surgical departments, 65 (24.7%) in intensive care units and the remanent

were in obstetric or maternity departments. In terms of the model of nursing care, 116 (43%)

nurse participants were assigned to total patient care, while 102 (37.8%) were assigned in teams.

According to the results, 109 (40.40%) managers adopted a democratic leadership style, 63

(23.30%) were autocratic and 51 (18.90%) managers had a permissive leadership style. The

average daily census was (M=21.39, SD=15.88) patients in different departments. The data were

collected from three types of hospitals: MOH (n=118, 43.70%), private (n=105, 38.89%) and

educational (n=47, 17.41%)

Preliminary Analysis.

Results revealed that nurse participants conveyed a relatively moderate level of burnout in

terms of EE (M=27.02, SD=12.02), DP (M=13.37, SD=6.18) and PA (M=34.95, SD=9.14).

Moreover, the patients reported that the quality of nursing care was congruent with their

expectations (M=65.16, SD=15.70).

To measure the strength and direction of the linear relationship between nurse burnout,

demographics and departmental characteristics and the quality of nursing care, ANOVA used for

categorical variables (Table 1) and Pearson r for continuous variables (Table 2). The results


11

showed a significant negative correlation (α=0.01) between the total scores of the quality of

nursing care and the total EE and DP scores and a positive correlation with PA (Table 2). The

highest correlation was found between the total scores of the quality of nursing care and PA (r

=0.440). A significant relationship was detected between the quality of nursing care and nurses’

characteristics including gender, working shift, and level of education (Table 1), age and

experience (Table 2). Regarding work environment, the daily census had a significant negative

correlation with the quality of nursing care (r=-0.226) (Table 2). In addition, quality of nursing

care was significantly varies among the three types of studied hospitals (Table 1).

Unexpectedly, patient participants evaluated the quality of nursing care that was provided by

male nurses (M=70.56, SD=20.48) better than the quality of nursing care that was provided by

female nurses (M=60.78, SD=19.90). Moreover, results revealed that better quality of nursing

care was provided by young, single nurses (M=71.18, SD=19.90), who were working on

different rotating shifts (M=68.5, SD=20.80) and primarily in obstetric and maternity

departments (M=70.06, SD=18.32).

Table 1. Quality of nursing care in relation to nurse, patient and department characteristics (n=270)

Characteristics n % Quality of Nursing Care

Mean SD F P-Value

Nurse participants

Gender 3.97 <0.001*

Male 121 44.80 70.66 20.48

Female 149 55.20 60.77 19.90

Marital Status 1.32 0.07

Single 121 44.80 71.18 19.90

Married 141 52.20 61.13 20.25

Divorced/Separated 5 1.90 40.20 2.17

Widowed 3 1.10 53.33 9.50

Shift Worked 23.72 <0.001*

Fixed A (8 hours) 66 24.40 54.80 19.64


12

Rotating 204 75.60 68.51 19.96

Level of Education 2.07 0.04*

Baccalaureate 242 89.70 64.73 21.03

Master 28 10.30 73.39 19.26

Patient participants

Gender 0.98 0.53

Male 102 37.80 62.84 21.62

Female 168 62.20 66.57 20.10

Marital Status 0.78 0.90

Single 66 24.40 66.95 21.16

Married 170 63.00 65.44 19.93

Divorced/Separated 18 6.70 57.94 22.83

Widowed 16 5.90 63.00 24.43

Level of Education 0.91 0.67

Elementary 55 20.30 61.73 21.85

High School 76 28.10 60.95 19.40

Diploma 60 22.20 61.88 21.02

Baccalaureate 61 22.60 72.74 18.64

Post Graduate 18 6.70 78.78 16.90

Presence of Chronic Illness 0.95 0.57

Yes 58 21.50 63.59 20.75

No 212 78.50 65.60 20.77

General work conditions

Department type 1.09 0.31

Medical & Surgical 158 58.52 61.77 22.03

Obstetric/Maternity 47 17.41 70.06 18.32

Intensive Care Units 65 24.07 66.24 19.91

Nursing Care Model 1.04 0.42

Total patient care 116 43.00 66.32 20.31

Team 102 37.80 66.22 21.88

Functional 49 18.10 61.80 18.60

Unclear 3 1.10 39.33 6.66

Leadership Style 0.75 0.92

Autocratic 63 23.30 61.30 21.40

Democratic 109 40.40 65.88 20.71

Permissive 51 18.90 66.16 18.18

Situational 47 17.40 68.17 22.14

Hospital Type 232.45 < 0.001*

MOH 118 43.70 46.48 9.42

Private 105 38.89 80.24 16.26

Educational 47 17.41 78.38 9.55

*ANOVA is significant at α=0.05 , 2-tailed test.


13

Table 2. Correlations between quality of nursing care, nurse burnout, demographics and department characteristics among registered nurses in jordanian hospitals (n=270)

Study Variables Quality of Nursing Care

Mean SD Pearson r

Nurse Age 29.40 6.29 -0.367**

Nurse Experience 6.71 5.75 -0.362**

Daily Census Rate 21.39 15.88 -0.226**

Patient Age 36.42 16.83 0.052

Length of Stay 3.99 3.95 0.007

Burnout

EE 27.02 12.02 -0.439**

DP

PA

13.37

34.95

6.18

9.14

-0.278**

0.440**

**Correlation is significant at α=0.01, 2-tailed test

Predictors of Quality of Nursing Care.

Stepwise regression analysis was used to identify predictors of quality of nursing care. All

factors that were found to have a significant relationship with quality of nursing care were

entered in step one regression analysis; except nurses’ age as it is correlated with nurses’

experience (increase in the nurse’s years of experience means increase in nurse’s age). The data

was screened for multicollinearity. Dummy variables were created for all categorical variables

before performing the regression analysis (Warner, 2008).

The stepwise regression analysis revealed a significant overall model of three predictors:

Hospital type, census rate, and rotating shift worked. These predictors were accounted for

approximately 58% of the variance of the quality of nursing care.

Hospital type was the dominant predictor of the quality of nursing care; it was responsible for

55.9 % of the variance. Burnout variables (EE, PA and DP) were excluded from the model when

other predictors were statistically superior (Table 3). Furthermore, two factors related to work

conditions were significant: census rate (1.6%) and working on rotating shifts (A, B and C or day

and night) (0.7%) (Table 3).


14

Table 3. Predictors of quality nursing care as perceived by jordanian nurses (n=270)

Variables B Adjusted R2 R

2-Change F-Change df p

Hospital Type (P) 16.48 0.558 0.559 340.10 1/268 0.00

Census rate -0.16 0.572 0.016 9.86 1/267 0.00

Nursing shift work (Rotating) 3.47 0.577 0.007 4.42 1/266 0.03

Predictors of quality of nursing care final model produced at α= 0.05; Excluded variables are: EE, DP, PA, Nurse

age, Nurse experience, Nurse gender, Nurse level of education.

Discussion

The present study demonstrates work conditions in terms of hospital type, census rate, and

rotating shift as significant predictors of the patients’ reported quality of nursing care. Hospital

type was the dominant variable predicting quality of nursing care. Jordanian hospitals are

different in their nature of work environment, departmental characteristics, climates, polices and

level of technology used (Mrayyan, 2008; Mrayyan, Mudallal, & Hamaideh, 2010; Mudallal,

2013). Indeed, Private and educational hospitals have a favorable environment for both patients

and nurses in terms of better nurse-patient ratio, low daily census rate, collaborative nurse-

physician relationship, higher standards of quality of nursing care, advanced technology in use,

leadership support, nurses’ autonomy and adequate health care professionals (Mrayyan,

Mudallal, & Hamaideh, 2010; Mudallal, 2013). Moreover, private and educational hospitals in

Jordan were pioneers in generating national and international accreditation and quality assurance

programs.

On the other hand, MOH hospitals -the largest health care sector in Jordan which covers most

Jordanian governorates- are facing different challenges starting with insufficient funding,

increasing demand on health care services, shortage of health care professionals; this means

nurses perform nursing and non-nursing duties, limited quality improvement programs,


15

centralized management practices, and lack of staff development programs (Halasa, 2008), all of

which reflected negative impact on nurses’ and patients’ satisfaction. However, health care

system in Jordan is undergoing a huge reform and development that is focusing on improvement

of health care management and clinical practices, and in order to improve the quality of nursing

care; technology, informatics and national competencies for registered nurses and nurse

managers are being introduced.

Daily census was an additional factor predicting the quality of nursing care. This finding was

congruent with a previous investigation conducted in Jordan (Mudallal, 2013). An increase in

daily census was found to reduce the quality of care. An increased census means an increase in

patients’ number in the department, which decreases the time spent on caring for each patient,

this consequently increases job stress and reduces the quality of care (Williams, 1998; Sochalski,

2001).

Nursing shift work was considered a good indicator of the quality of nursing care. Patients

reported higher-quality nursing care is provided by nurses on rotating shifts. Quality of nursing

care processes differs according to the situation elements; most of the time, nurses on the A-shift

are overloaded with direct and indirect patient care activities which negatively impacts the

quality of nursing care and creates higher job stress (Williams, 1998).

Compared to work conditions, nurse burnout and nurse characteristics had lower influence on

the quality of nursing care. The correlation results of this study revealed that high level of nurse

burnout, as defined by high EE, DP and low PA, was associated with the patients’ report of poor

quality of nursing care. This result is consistent with that of Vahey and colleagues (2004) study;

nurses feeling EE and lack of PA significantly affected patient satisfaction. Additionally, the

results of this study are similar to Poghosya et al. (2010); Van Bogaert et al. (2010), and Van


16

Bogaert et al. (2014), all of which found a significant negative relationship between nurse

burnout and the quality of nursing care. But, unexpectedly and despite a moderate correlation

between nurse burnout and quality of nursing care, nurse burnout was not showing a prediction

performance of the quality of nursing care. This may explain that burnout is a common problem

in most Jordanian hospitals and it may play a mediator role between nursing work environment

and quality of nursing care. This result supports the findings of Van Bogaert and colleagues and

Laschinger and Leiter (2006). However, further studies are needed to assess the burnout

phenomenon and the mediator role of burnout and nurse characteristics in Jordan. In addition to

burnout, nurse gender, age, experience and educational level were also not having a prediction

performance in relation to quality of nursing care.

Surprisingly, the results of this study revealed that the quality of nursing care was negatively

associated with nurse experience; an increase in years of experience was asscociated with a

decrease in the quality of nursing care level. The nurses’ role in patient care, direct contact with

patients’ suffering, work overload, difficult work conditions and increased use of technology may

lead to burnout, especially if these factors are associated with social responsibilities (home and

family) (Azeem et al., 2014; Gandi, Paul, Haruna, & Zubaira, 2011; Jacobs, Hill, Tope &

O’Brien, 2016). Progression in nurses’ age and experience in nursing profession leads to further

exposure to work environment related factors, add to this, older nurses in Jordan are less familiar

with technology and informatics which creates a bigger burden. Furthermore, one of the most

common challenges facing women work in the Arab world, is the community perception

regarding the roles for both women and men that women have more social responsibilities

regarding home and family beside profession, and are more dependable than men (Dajani, 2012),

which leads to an increasing load on married, female nurses. This may explain why the quality of


17

nursing care was better when provided by male, single, young and less experienced nurses in this

study.

In addition to predictive elements of quality of nursing care, this study found that the highest

patients’ perception of the quality of nursing care was more often found in maternity departments

compared to other departments. These findings are consistent with Sochalski (2001) and Boyle

and colleagues (2006). This result may be explained in that although the quality of nursing care

usually implemented in terms of hospital standards similarly at all departments of the same

hospital; patients’ past experiences and psychological status affect their perception of quality

nursing care provided. Patients in wards other than maternity department suffer the consequences

of their diseases while feel happy most of the time in the maternity wards.

This study also, revealed that department type, nursing care model and leadership style do

not have a significant influence on the quality of nursing care. However, these factors were

relevant to quality of nursing care in previous studies (Houser, 2003; Laschinger & Leiter, 2006;

Mudallal, 2013; Van Bogaert et al., 2009; 2010; 2013; 2014a and 2014b). This may be explained

in a way related to unclear systems for nurses as a result of health care system reform. However,

further studies are needed to explore this arena.

Limitations, Implications and Recommendations

This study suggested that “work conditions” is the main influential factor of the quality of

nursing care, whereas burnout and nurses characteristics have lower impact. The results of this

study are unique because the quality of nursing care was measured using a comprehensive tool

rather than using one or two items and was completed by patients to avoid self-evaluation bias.

On the other hand, this study used non-probability sampling procedure and the data was limited

to eight hospitals in Jordan, hence, the generalizability of these results may be limited. Further


18

studies are recommended using random sampling procedure and involvement of other health care

settings to improve the generalizability of these findings.

The results of this study are important for developing nursing practice, education, and

research. Nurse managers may consider changes in nursing work environment to reduce nurses’

stress level and improve nurses’ and patients’ satisfaction such as improving in nurse to patient

ratio, nursing mix, opportunity for staff development, boost multidisciplinary collaboration,

support the work environment with enough and advanced equipment, and using transformational

leadership style to inspire, empower and motivate nurses and to enhance effective change.

Although the results showed that young nurses provide relatively better quality of care, which

reflects a recent improvement in nursing education; it is recommended to teach caring concepts

with a focus on the quality dimensions, informatics and stress management. Further staff

developemt programs are required in hospital settings to followup nurses development.

Additional outcome studies are needed to assess the unique influence of different factors on

the quality of nursing care. In addition, more interventional studies are recommended to evaluate

the effects of different programs designed to reduce work stress as means to improve the quality

of nursing care worldwide.

Conclusion

The purpose of this study was to examine the influence of nurse burnout, nurse

characteristics and work conditions on the quality of nursing care. This study illustrated that

“work conditions” variable has the most impact on the quality of nursing care. Mediation effect

is expected for nurse burnout and nurse characteristics; thus, various studies are required to

investigate these phenomena. Consequently, it is important for nurse mangers and policy makers

to improve nursing work conditions in a way that improves nurses’ competencies and decrease


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stress level among nurses which will reflect positively on the quality of nursing care. Activities

such as increasing nurses’ autonomy over their practice, improving nurses’ leadership abilities,

providing sufficient staffing and resources, and supporting nurses with continuous educational

programs can improve nurses’ work conditions, competencies and enhance the quality of care.

Competing Interests Statement

The authors declare that there is no conflict of interests regarding the publication of this

paper.


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Highlights

- Nurses’ burnout do not affect quality of nursing care when controlling other factors.

- Nurses’ burnout and nurses’ characteristics have indirect influence on the quality of

nursing care.

- Improving nursing work conditions enhances the quality of nursing care.

- Different nursing care models and leadership styles did not have significant influence on

the quality of nursing care

- Young and male nurses provide better quality of nursing care.

quality of nursing care: the influence of work conditions

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