nursing burnout dissertation

• Open access
• Published: 24 April 2024

Professional burnout of nurses and the level of rationing of nursing care: an observational preliminary study

• Patrycja Marczak 1 &
• Dorota Milecka   ORCID: orcid.org/0000-0001-8284-0107 2  

BMC Nursing volume  23 , Article number:  269 ( 2024 ) Cite this article

Metrics details

Nurses are one of the professional groups most exposed to experiencing professional burnout. Professional burnout has a negative impact on the quality of nursing care, including causing care rationing. Therefore, it is very important to understand the determinants of both professional burnout and care rationing, as well as their mutual relationships. The aim of the study was to understand the impact of professional burnout among nurses on the level of rationing of nursing care.

The study was conducted among 100 nurses at the Głogów County Hospital (Poland) from November 14, 2011, to November 18, 2022. The following Polish version of the standardized research tools were utilized: the Basel Extent of Rationing of Nursing Care– Revised (BERNCA-R) questionnaire and the Oldenburg Burnout Inventory (OLBI). Additionally, a survey designed by the authors was employed.

The BERNCA-R significantly correlates ( p  < 0.05) and positively ( r  > 0) with OLBI (disengagement), resulting in a higher degree of care rationing. The average overall BERNCA-R score was 1.56 points (SD = 0.62), indicating that the frequency of care rationing among respondents ranged from “never” to “rarely.” Among participants in the OLBI questionnaire, 63% of respondents had a moderate level of work exhaustion, 36% had a high level of work exhaustion, and 1% had a low level of work exhaustion. In turn, 58% of respondents had a moderate level of disengagement, 38% had a high level of disengagement, and 4% had a low level of disengagement. Moreover, a statistically significant association with the BERNCA-R score concerning the workplace (ward) and participation in training on preventing professional burnout was shown.

Conclusions

The rationing of nursing care was found to be at a low level. The higher the level of disengagement, the greater the level of care rationing was observed. In conservative units, nurses demonstrated a higher level of care rationing. Nurses’ expectations regarding the reduction of professional burnout include, among other things, higher remuneration, an increase in the number of staff, and an improvement in the work atmosphere.

Peer Review reports

Rationing of nursing care, as a concept, was first defined in 2006. It refers to the omission of entire, partial, or individual aspects of care [ 1 ]. Rationing of nursing care occurs when the available resources are insufficient to provide the required care to each patient. Among the factors contributing to this phenomenon are: staff reductions, new technologies that increase the demand for care, as well as new therapies and treatment options, and the level of patient knowledge [ 2 ]. Kalisch [ 1 ] identified 9 nursing activities that are most commonly omitted: repositioning, hygiene care, feeding, mobilizing patients, education, emotional support, documentation, discharge planning, and supervision. Rationing of nursing care is the delay or complete omission of required nursing activities. Rationing occurs when a nurse does not have sufficient resources to perform designated tasks. As a result, she is forced to decide which tasks will be postponed or entirely omitted [ 3 ]. According to Schubert [ 4 ], the concept of rationing of nursing care assumes that all actions performed by the nurse are equally important, facilitating the achievement of desired goals and actions expected by patients. These actions include diagnostic activities, prevention, rehabilitation, emotional support, and therapy. The nurse conducts a clinical assessment and presents nursing diagnoses, so difficulties in achieving the accepted care goals lead to the rationing of nursing care [ 5 ].

Problem of rationing of nursing care is clearly noticeable worldwide and poses a threat to patient safety. The Supreme Council of Nurses and Midwives in Poland [ 6 ] prepared a report in 2017 showing the employed and registered nurses and midwives from 2016 to 2030. The results indicate an increase in the number of registered nurses and midwives, but with pension rights, which means that staffing issues will deepen even further in the future.

One of the factors influencing the rationing of nursing care is professional burnout, stemming from emotional exhaustion, low job and life satisfaction, as well as fatigue and perceived stress [ 7 ]. A low level of resources in the workplace is one of the more significant causes of professional burnout, leading to a reduction in nurses’ engagement in performing their duties. The increase in the number of employees affected by professional burnout results in an increase in employee turnover. Consequently, by filling staffing gaps often with less qualified personnel, there is a decrease in the quality of care, including patient safety [ 7 , 8 ].

Due to the nature of their work, nurses are one of the leading professional groups most susceptible to professional burnout. The mechanism behind professional burnout is attributed to chronic stress [ 9 ]. According to nurses, the main sources of stress include: the pressure of being responsible for patients’ health and life [ 10 , 11 ], unsatisfactory financial gratification [ 10 , 12 ] inadequately equipped workstations, insufficient staffing, lack of support from superiors, demanding families of the patients, which, according to respondents, contributes to a lack of respect for their work [ 10 ], as well as fear of making mistakes and dealing with death [ 11 ].

Professional burnout leads to neglect in nursing care, resulting in more frequent occurrences of medical errors and adverse events. Therefore, preventive measures against professional burnout and the rationing of nursing care are extremely important. Considering the limited evidence on the association between professional burnout and the rationing of nursing care in the literature, the main objective of the conducted research was to determine the impact of nurses’ professional burnout on the level of rationing of nursing care.

Ethical considerations

The study was approved by the local Bioethics Committee of the Medical Institute at the State University of Applied Sciences in Głogów, Poland (no. 43/2022). The study adhered to the principles of the Helsinki Declaration and Good Clinical Practice, and it followed the STROBE guidelines for comprehensive and transparent reporting of observational studies.

Study participants

The study was conducted from November 14, 2021, to November 18, 2022, at the Głogów County Hospital. This hospital was chosen as the setting for our study due to several reasons. The hospital serves a diverse patient population, providing a broad representation of cases and conditions encountered in nursing practice. Moreover, the Głogów County Hospital has a well-established nursing staff with varying levels of experience and expertise, offering insights into different aspects of nursing care and potential factors contributing to professional burnout. And finally, the hospital administration expressed interest in participating in research aimed at improving nursing practice and staff well-being.

The study included a group of 110 nurses directly involved in patient care. One hundred questionnaires were returned, representing a response rate of 90.9%. The study ensured anonymity by deliberately excluding personal identifiers such as names and contact information from the survey forms. This approach aimed to prevent any potential identification of respondents throughout the data collection process. The questionnaires were administered during designated times, ensuring participation from a representative sample of nurses across different shifts and units within the hospital. All data collection procedures adhered to ethical guidelines and were conducted with full consent and confidentiality assured to participants.

Selection criteria

Participants eligible for inclusion in the study were required to be practicing nurses actively engaged in direct patient care responsibilities, such as administering medications and performing assessments. Additionally, participants had to provide informed consent to participate in the survey, indicating their willingness to share their experiences and opinions. Exclusion criteria encompassed individuals not directly involved in patient care, such as administrative staff or educators, as well as those holding managerial or supervisory roles within the nursing department. Furthermore, individuals who declined to participate in the survey were excluded from the study population.

Research tools

The Basel Extent of Rationing of Nursing Care Revised (BERNCA-R) questionnaire was developed by Schubert et al. [ 13 ] to determine the level of rationing of nursing care. The tool has a Polish language version of which the Cronbach’s alpha coefficient is 0.96 [ 14 ]. The questionnaire consists of 32 questions concerning situations in which rationing of nursing care may occur. The questions relate to activities related to patient care, including addressing the patient’s biopsychosocial problems, providing educational and emotional support, monitoring the patient’s condition, implementing medical orders, and conducting the nursing care process along with documenting the provided nursing care. Each question is assessed on a scale: no such need (0 points), never (1 point), rarely (2 points), sometimes (3 points), often (4 points). Respondents assessed how often in the last 7 working days they were unable to perform the activities listed in the questionnaire. The measurement is the sum of points, where a higher score indicates a higher level of rationing of nursing care.

The Oldenburg Burnout Inventory (OLBI) was developed by Demerouti et al. [ 15 ]. The tool was designed to measure burnout among different professional groups. The questionnaire allows the measurement of two dimensions: exhaustion and disengagement from work, consisting of 16 statements, eight for each of the two subscales [ 16 ]. There is a Polish adaptation of the OLBI of which the Cronbach’s alpha coefficient is 0.80 for exhaustion and 0.76 for disengagement from work [ 17 ], in which each subscale contains four positively and four negatively formulated items. Consequently, two ends of the measured dimensions are assessed: exhaustion-vigor and cynicism-dedication. Respondents mark one answer on a 4-point scale (where 1 means strongly agree and 4 means strongly disagree). The questionnaire does not have a neutral option. Scores are summed for negatively formulated questions, and then the average is calculated for each category/dimension. Higher scores indicate a greater intensity of the respective phenomenon.

The custom questionnaire consists of 20 questions (19 closed-ended, 1 open-ended, “Write what your employer can do– what is important for you at work to be satisfied with your job?“). The questionnaire comprised three parts. The first part pertained to sociodemographic characteristics such as age, gender, marital status, current education, and postgraduate education. The second part focused on job-related characteristics associated with the position of a nurse: department, length of service, number of job positions (full-time equivalents), number of overtime hours, working system, average number of patients under the care of a nurse during one shift, and participation in training on preventing professional burnout. The third part addressed the expectations of nurses regarding preventing professional burnout. Participants were asked questions such as: What can contribute to reducing professional burnout?; How many patients should one nurse be responsible for?; What preventive activities for professional burnout should be organized?; Are financial rewards granted?; Do employers commend well-performed work?

Statistical analysis

Analyses of quantitative variables (expressed in numbers) were conducted by calculating the mean, standard deviation, median, and quartiles. Analysis of qualitative variables (not expressed in numbers) was carried out by calculating the count and percentage of occurrences for each value. Analyzed variables did not follow a normal distribution, which was confirmed by the Shapiro-Wilk test. The comparison of quantitative variable values in two groups was performed using the Mann-Whitney U test. The comparison of quantitative variable values in three or more groups was done using the Kruskal-Wallis test. After detecting statistically significant differences, post-hoc analysis was performed using the Dunn test to identify groups that differed significantly. Correlations between quantitative variables were analyzed using the Spearman correlation coefficient. A significance level of 0.05 was adopted for the analysis. Thus, all p -values below 0.05 were interpreted as indicating significant relationships. The analysis was conducted using the R software, version 4.2.2 [ 18 ].

The group of participants in the study consisted of 100 nurses (Table  1 ). The largest group of participants were women– 87, while men were only– 13. The majority of participants in the study were in the age range of 20–30 years– 31 individuals. The most numerous group of respondents were individuals in a formal relationship– 49 people. The largest educational group, totaling 48 people, had a bachelor’s degree in nursing. Regarding postgraduate education, it was a multiple-choice question, and the respondents most frequently participated in qualification courses– 40 individuals, followed by specialized courses– 35 individuals, and nursing specialization– 29 individuals.

The department with the highest number of employees is the conservative ward– 31 individuals, and a similar number of people work in the surgical ward– 30 individuals. The most numerous group in terms of work experience were individuals with 0–5 years of experience– 45 individuals. The largest number of respondents declared working in one place– 45 individuals. The shift work system is the most frequently declared response– 84 individuals. The largest number of respondents works an additional 25 h per month– 32 individuals. The majority of respondents stated that they are responsible for 11–15 patients during a shift– 39 individuals, followed by 6–10 patients– 34 individuals. More than half of the study participants– 55 individuals– declared no participation in training on preventing professional burnout (Table  2 ).

Table  3 presents the results of the analysis of nurses’ expectations regarding the reduction of professional burnout. In response to the question “In your opinion, what could contribute to reducing professional burnout?“, the highest number of individuals selected the answer “Employing more nurses”– 61 people. The second most frequently chosen response was “Higher salary”– 49 people. The next most frequently selected responses, ranging from 39 to 38%, were “Better work atmosphere” and “Greater access to auxiliary staff.” Other responses received 29% and below 29% of participants’ answers in the study. The fewest respondents selected the answer “Greater access to training on preventing professional burnout” and “Greater support from nursing management”– 9 people each. According to the majority of respondents, one nurse should be responsible for 1–5 patients– 92 individuals, 6–10 patients– 6 individuals, and 11–15 patients– 2 individuals. Regarding activities related to preventing professional burnout, the highest number of individuals declared a willingness to participate in mindfulness-based stress reduction training– 33 people. In response to the question about receiving a financial reward, the most frequently chosen answer was “Never”– 44 people. The highest number of respondents in the question “Have you ever received praise for your work?” selected the answer “Several times”– 32 people (32%).

The most frequently chosen answer to the question “What patient care model do you prefer?” was (Model 1) the care method through the nursing process, involving the allocation of patients to nurses and the recognition of the patient’s condition, identification of nursing diagnoses, planning of patient care, implementation, and evaluation of nursing actions– 40 individuals. According to respondents’ answers to the question “What can the employer do to make you satisfied with your job?“, it can be inferred that the most expected action from the employer is salary increases and the awarding of recognition bonuses. An interesting suggestion from the respondents was also the organization of meetings with superiors to listen to the team’s expectations, grievances, and problems. Respondents expressed a desire to participate in courses and training organized and paid for by the employer. Some individuals reported the issue of outdated medical equipment. Nurses also showed a willingness to participate in team-building meetings to better get to know each other and enhance understanding among them (given the significant age difference among employees) (Table  3 ).

As much as 63% of participants experienced a moderate level of work exhaustion, 36% had a high level, and 1% of respondents had a low level. Regarding the level of job disengagement, 58% had a moderate level, 38% had a high level, and 4% had a low level (Table  4 ).

Table  5 presents the distribution of responses to individual questions in the BERNCA-R questionnaire. The most frequently rationed (highest average) were: assisting patients with limited/difficult mobility or immobilized in movement (question 7), observing confused patients, requiring them to be immobilized (question 20), activities related to oral hygiene of the patient (question 4), activities related to the patient’s tooth hygiene (question 5), and changing the position of patients with limited/difficult mobility or immobilized (question 8).

In our study, no statistically significant relationships were found indicating the influence of sociodemographic characteristics such as age, gender, undergraduate education, postgraduate education, and marital status on the level of rationing of nursing care (Table  6 ). In our study, statistically significant dependencies were found with the BERNCA result concerning the workplace (ward) (p˂0.05) and participation in training on preventing burnout (p˂0.05). The frequency of care rationing was significantly higher in conservative than in surgical, pediatric ward, and ICU wards. Additionally, the frequency of care rationing was significantly higher among those who couldn’t recall whether they participated in burnout prevention training compared to those who did not participate. However, no significant dependencies were observed concerning work experience, the number of job positions, monthly overtime hours, work schedule, and the number of patients under the nurse’s care during a shift (Table  6 ).

The BERNCA-R significantly (p˂0.05) and positively correlates with work disengagement. Therefore, the higher the level of work disengagement, the higher the degree of care rationing (Table  7 ).

The main aim of the conducted research was to examine the impact of burnout among nurses on the level of nursing care rationing. In our own study, it was demonstrated that BERNCA-R significantly and positively correlates with emotional disengagement from work. Therefore, the higher the level of disengagement from work, the higher the degree of nursing care rationing. Research conducted by Uchmanowicz et al. [ 19 ] indicates a significant correlation between BERNCA-R and MBI ( p  < 0.05). The BERNCA-R result reflected the emotional exhaustion of the examined group. Occupational burnout significantly influences the level of nursing care rationing. In the study by Piotrowska et al. [ 20 ] the BERNCA result correlated significantly and negatively with emotional exhaustion, a lack of professional accomplishment, and the overall MBI score. The research suggests that the higher the emotional exhaustion, the higher the level of nursing care rationing.

In our own study, the average total score of BERNCA-R was 1.56 points (SD = 0.62). It can be concluded that the frequency of nursing care rationing among respondents falls between “never” and “rarely.” The most frequently rationed activities by respondents include assisting patients with limited/difficult mobility or immobilized in movement, observing confused patients, requiring their immobilization, activities related to the oral hygiene of patients, activities related to the dental hygiene of patients, and changing the position of patients with limited/difficult mobility or immobilized. Similar results were obtained by Fabich [ 21 ] (1.64 ± 0.88). However, in the mentioned study, different frequently rationed activities were identified. These included checking the patient’s condition as precisely as required, talking to the patient or their family, checking the patient’s condition as precisely as prescribed by the doctor, familiarizing oneself with the situation of individual patients and care plans at the beginning of the shift, and assessing the needs of newly admitted patients [ 21 ]. In the study conducted by Schubert et al. [ 13 ] involving nurses working in the intensive care unit in Sweden, a much lower score was obtained for the entire scale (0.77 ± 0.52). The much lower level of care rationing in intensive care units may result from the specificity of the ward and the patients.

On the other hand, in the study by Baszkiewicz [ 22 ], which assessed nursing care rationing in a pediatric hematology ward, the BERNCA-R score was 2.47 points (SD = 0.64), and the frequency of care rationing ranged between “sometimes” and “rarely.” A difference can also be observed in the most frequently rationed activities: talking to the patient and their family, activities related to oral hygiene, developing a care plan for the patient, and monitoring the patient’s condition. Therefore, it can be concluded that the level of nursing care rationing varies depending on the care recipient and the place where care is provided.

In the current study, most participants reported a moderate level of work exhaustion and disengagement from work. The average score for occupational burnout in the study by Piotrowska et al. [ 20 ] was 49.27 (SD = 19.76). Emotional exhaustion had the most significant impact on occupational burnout (M = 63.56), contributing to a lesser extent was the lack of a sense of professional achievement (M = 47.05), and depersonalization was the least significant factor (M = 37.2). Conversely, in the study by Uchmanowicz et al. [ 23 ], the average score for occupational burnout was 38.14 (SD = 22.93). Emotional exhaustion was the primary factor in occupational burnout (M = 44.8), followed by dissatisfaction with personal achievements (M = 40.66), with depersonalization being the least significant (M = 28.95). In the study by Salvarani et al. [ 24 ], emergency nurses characterized by mindfulness, emotion regulation, and empathy skills were better able to cope with work-related stress. Furthermore, it was shown that work-related stress negatively affects the quality of life of cardiac nurses [ 25 ].

In the current study, sociodemographic characteristics such as gender, age, postgraduate education (postgraduate and other forms), work experience, and the number of workplaces showed no statistically significant correlation with the BERNCA results. The findings in this study align with results from other research. Radosz et al. [ 26 ] confirmed the lack of influence of sociodemographic characteristics on the level of care rationing. Similarly, Wagner-Łosieczka et al. [ 27 ] did not find a significant impact of sociodemographic characteristics of nursing staff on the level of nursing care rationing.

In addition to factors related to nursing personnel, the environment and working conditions have a significant impact on care rationing. A study conducted by Piotrowska et al. [ 20 ] in oncology departments showed an average BERNCA score of 1.55 (SD = 0.15). Thus, the level of care rationing ranged from “never” to “rarely.” According to research by Uchmanowicz et al. [ 23 ], the total BERNCA-R score in cardiology departments was 1.38 (SD = 0.62). This result indicates a frequency of care rationing between “never” and “rarely.” Studies conducted by Baszkiewicz [ 22 ] presented the BERNCA score in pediatric hematology and oncology departments at 2.47 (SD = 0.64). Consequently, the frequency of care rationing was between “sometimes” and “rarely.” The results presented partially confirm the findings of the current study. In the author’s research, the frequency of care rationing was higher in adult medical and surgical wards than in adult surgical wards, pediatric wards, and intensive care units (ICUs). The level of nursing care rationing in the studies mentioned above was in the range of “never” to “rarely” in both medical and surgical wards for adults. However, the frequency of care rationing in the third study was higher in pediatric wards, ranging from “sometimes” to “rarely”.

An important aspect of the current study was the questions regarding the expectations of nurses in reducing the level of occupational burnout. Nurses primarily expect the employment of more nurses, higher salaries, a better work atmosphere, increased access to support staff, and improved team communication. The results obtained in the current study partially confirm the findings of other studies or reports in the literature. Rosińczuk et al. [ 28 ] present nurses’ expectations regarding work-related changes: salary increases, the possibility of free education, and the creation of a more friendly work atmosphere. According to the study by Kędra et al. [ 29 ], respondents answering the question about actions to reduce the level of occupational burnout most frequently indicated: salary increases, taking into account their education, improvement of working conditions in every aspect, and an objective assessment of the work performed.

The concept of occupational burnout has been known and studied for a long time; however, many aspects of this issue remain unexplored. Conducting research on occupational burnout and its impact on nursing care rationing is a new research direction that enables prevention of its occurrence and the potentially harmful consequences for both patients and nurses. Studies aimed at measuring the level of occupational burnout among nurses have significant substantive value. Through such research, management personnel can gain information about occupational burnout, its symptoms, and preventive measures. Enhancing the qualifications of nurses reduces the risk of medical errors. Nurses with greater knowledge and qualifications are more inclined to make independent decisions based on current medical knowledge, significantly reducing the frequency of care rationing.

The study has several limitations. Firstly, it was conducted at a single hospital, which may limit the generalizability of the findings to other healthcare settings with diverse organizational cultures and patient populations. Secondly, the cross-sectional design used provides a snapshot of data at one point in time, making it challenging to establish causality between variables or capture changes over time. Thirdly, reliance on self-report measures, including the OLBI and BERNCA-R questionnaires, introduces the potential for response bias, as participants may provide socially desirable responses. Additionally, the sample size of 100 nurses is relatively small, and the geographic scope is limited, potentially affecting the representativeness and generalizability of the findings. Addressing these potential methodological limitations in future research could strengthen the understanding of the relationship between professional burnout and care rationing among nurses.

A higher level of nursing care rationing is associated with a higher level of work disengagement. Sociodemographic characteristics of the surveyed nurses do not affect the level of nursing care rationing. Nurses working in the conservative ward more often ration nursing care than those in other wards. The level of nursing care rationing in the surveyed group of nurses was low, ranging between “never” and “rarely.” The level of occupational burnout was moderate, both in terms of work exhaustion and disengagement from work. To minimize occupational burnout, nurses primarily expect: the hiring of more nurses, higher salaries, a better work atmosphere, increased access to support staff, and improved team communication.

Data availability

The datasets generated and/or analyzed during the present study are available from the corresponding author upon reasonable request.

Abbreviations

The Basel Extent of Rationing of Nursing Care Revised

The Oldenburg Burnout Inventory

Kalisch BJ. Missed nursing care: a qualitative study. J Nurs Care Qual. 2006;21:306–13. quiz 314–5.

Article   PubMed   Google Scholar  

Schubert M, Ausserhofer D, Desmedt M, Schwendimann R, Lesaffre E, Li B, et al. Levels and correlates of implicit rationing of nursing care in Swiss acute care hospitals–a cross sectional study. Int J Nurs Stud. 2013;50:230–9.

Schubert M, Glass TR, Clarke SP, Aiken LH, Schaffert-Witvliet B, Sloane DM, et al. Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital outcomes Study. Int J Qual Health Care J Int Soc Qual Health Care. 2008;20:227–37.

Article   Google Scholar  

Schubert M. Rationierung Von Pflege Assoziationen Mit Der Patientensicherheit Und Der Betreuungsqualität in Spitälern [Rationing of nursing care associations with patient safety and quality of hospital care]. Pflege. 2010;23:57–8.

Schubert M, Clarke SP, Aiken LH, de Geest S. Associations between rationing of nursing care and inpatient mortality in Swiss hospitals. Int J Qual Health Care J Int Soc Qual Health Care. 2012;24:230–8.

Raport Naczelnej Rady Pielęgniarek i Położnych. Zabezpieczenie Społeczeństwa Polskiego w Świadczenia Pielęgniarek i Położnych 2017 r [Report of the Supreme Council of Nurses and midwives: securing the Polish Society in Nursing and Midwifery Services 2017]. Warszawa: Naczelna Rada Pielęgniarek i Położnych; 2017.

Google Scholar  

Rutkowska K. Social competences– the buffer against nurses’ burnout. Med Ogólna Nauki Zdr. 2013;18:319–23.

Ustawa z dnia 23. grudnia 1994 r. o Najwyższej Izbie Kontroli [The Act of December 23, 1994 on the Supreme Audit Office]. https://isap.sejm.gov.pl/isap.nsf/DocDetails.xsp?id=WDU19950130059 . Accessed 29 Oct 2023.

Sęk H. Uwarunkowania i mechanizmy wypalenia zawodowego w modelu społecznej psychologii poznawczej [Determinants and mechanisms of job burnout in the social cognitive psychology model]. Wypalenie zawodowe, przyczyny i zapobieganie. Warszawa: Wydawnictwo Naukowe PWN; 2007. pp. 83–112.

Skorupska-Król A, Szabla A, Bodys-Cupak I. Opinie pielęgniarek na temat czynników stresogennych związanych z ich środowiskiem pracy [Opinions of nurses on stress-generating factors related to their work environment]. Nurs XXI Cent. 2014;1:23–6.

Kornakiewicz B, Krupa S. Factors affecting burnout syndrome of nurses in a hospital environment. Nurs Anaesthesiol Intensive Care. 2019;5:83–9.

Pietraszek A, Charzyńska-Gula M, Łuczyk M, Szadowska-Szlachetka Z, Kachaniuk H, Kwiatkowska J. An analysis of the causes of occupational stress in the opinions of nurses. J Educ Health Sport. 2016;6:643–52.

Schubert M, Glass TR, Clarke SP, Schaffert-Witvliet B, De Geest S. Validation of the Basel extent of rationing of nursing care instrument. Nurs Res. 2007;56:416–24.

Uchmanowicz I, Kirwan M, Riklikiene O, Wolfshaut-Wolak R, Gotlib J, Schubert M. Validation of Polish version of the Basel extent of rationing of nursing care revised questionnaire. PLoS ONE. 2019;14:e0212918.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Demerouti E, Bakker AB, Leiter M. Burnout and job performance: the moderating role of selection, optimization, and compensation strategies. J Occup Health Psychol. 2014;19:96–107.

Demerouti E, Bakker AB. The oldenburg burnout inventory: a good alternative to measure burnout and engagement. Stress and burnout in health care. Hauppage: Nova Sciences; 2008.

Chirkowska-Smolak T. Polska adaptacja kwestionariusza do pomiaru Wypalenia Zawodowego OLBI (the Oldenburg Burnout Inventory). Stud Oeconomica Posnaniensia. 2018;6:27–47.

R Core Team. R: a language and environment for statistical computing. R Foundation for Statistical Computing; 2022.

Uchmanowicz I, Kołtuniuk A, Młynarska A, Łagoda K, Witczak I, Rosińczuk J, et al. Polish adaptation and validation of the Perceived Implicit rationing of nursing care (PIRNCA) questionnaire: a cross-sectional validation study. BMJ Open. 2020;10:e031994.

Article   PubMed   PubMed Central   Google Scholar  

Piotrowska A, Lisowska A, Twardak I, Włostowska K, Uchmanowicz I, Mess E. Determinants affecting the rationing of nursing care and Professional Burnout among Oncology nurses. Int J Environ Res Public Health. 2022;19:7180.

Fabich E. Analiza czynników wpływających na racjonowanie opieki pielęgniarskiej oraz wypalenie zawodowe pielęgniarek pracujących na oddziałach zachowawczych [Analysis of factors affecting rationing of nursing care and professional burnout of nurses working in conservative wards]. Wrocław: Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu; 2020.

Baszkiewicz I. Racjonowanie opieki pielęgniarskiej na oddziale hematologii i onkologii dziecięcej [Rationing of nursing care at the Department of Hematology and Pediatric Oncology]. Contemp Nurs Publ Health. 2019;8:83–8.

Uchmanowicz I, Kubielas G, Serzysko B, Kołcz A, Gurowiec P, Kolarczyk E. Rationing of nursing care and Professional Burnout among nurses Working in Cardiovascular settings. Front Psychol. 2021;12:726318.

Salvarani V, Rampoldi G, Ardenghi S, Bani M, Blasi P, Ausili D, et al. Protecting emergency room nurses from burnout: the role of dispositional mindfulness, emotion regulation and empathy. J Nurs Manag. 2019;27:765–74.

Zaghini F, Biagioli V, Fiorini J, Piredda M, Moons P, Sili A. Work-related stress, job satisfaction, and quality of work life among cardiovascular nurses in Italy: structural equation modeling. Appl Nurs Res ANR. 2023;72:151703.

Radosz-Knawa Z, Kamińska A, Malinowska-Lipień I, Brzostek T, Gniadek A. Factors influencing the rationing of Nursing Care in selected Polish hospitals. Healthc Basel Switz. 2022;10:2190.

Wagner-Łosieczka B, Kolarczyk E, Młynarska A, Owczarek D, Sadowski M, Kowalczuk K, et al. The variables in the rationing of nursing care in cardiology departments. BMC Nurs. 2023;22:59.

Rosińczuk J. Wypalenie zawodowe i satysfakcja z pracy w opinii aktywnych zawodowo pielęgniarek [Professional burnout and job satisfaction in the opinion of professionally active nurses]. Badania naukowe w pielęgniarstwie i położnictwie. Wrocław: Continuo; 2014. pp. 298–307.

Kędra E, Sanak K. Stress and burnout in nurses. Piel Zdr Publ. 2013;3:119–32.

Download references

Acknowledgements

We would like to express our sincere gratitude to all the participants for their valuable contributions to the study.

This research was funded from the internal sources of the State University of Applied Sciences in Głogów, Poland.

Author information

Authors and affiliations.

Medical Institute, State University of Applied Sciences in Głogów, Piotra Skargi 5 Street, 67-200, Głogów, Poland

Patrycja Marczak

Dorota Milecka

You can also search for this author in PubMed   Google Scholar

Contributions

Both PM and DM made equal contributions to the conception, design, and methodology of the study. MP was responsible for data acquisition, analysis, and interpretation. Both authors actively participated in drafting the manuscript. DM played a crucial role in critically revising the manuscript and supervised the project. Both authors have provided their final approval for the version to be published.

Corresponding author

Correspondence to Dorota Milecka .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the local Bioethics Committee of the Medical Institute at the State University of Applied Sciences in Głogów (no. 43/2022). The study adhered to the principles of the Helsinki Declaration and Good Clinical Practice. All participants provided written informed consent to participate in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Marczak, P., Milecka, D. Professional burnout of nurses and the level of rationing of nursing care: an observational preliminary study. BMC Nurs 23 , 269 (2024). https://doi.org/10.1186/s12912-024-01940-x

Download citation

Received : 14 December 2023

Accepted : 15 April 2024

Published : 24 April 2024

DOI : https://doi.org/10.1186/s12912-024-01940-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Professional burnout
• Rationing of nursing care

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

Prevalence of Burnout Syndrome in Emergency Nurses: A Meta-Analysis

Affiliations.

• 1 Jose Luis Gómez-Urquiza is a nursing lecturer, University of Granada, Ceuta, Spain. Guillermo A. Cañadas-De la Fuente is an assistant professor in the Nursing Department, University of Granada, Ceuta, Spain. Emilia I. De la Fuente-Solana is a professor, University of Granada, Ceuta, Spain. Elena M. Ortega-Campos is a lecturer in the Methodology of the Behavioural Science Department, University of Granada, Ceuta, Spain. Luis Albendín-García is an emergency and critical care nurse at the Andalusian Health Service, Andalusia, Spain. Cristina Vargas-Pecino is an assistant professor in the Psychology Department, University of Valencia, Valencia, Spain. [email protected].
• 2 Jose Luis Gómez-Urquiza is a nursing lecturer, University of Granada, Ceuta, Spain. Guillermo A. Cañadas-De la Fuente is an assistant professor in the Nursing Department, University of Granada, Ceuta, Spain. Emilia I. De la Fuente-Solana is a professor, University of Granada, Ceuta, Spain. Elena M. Ortega-Campos is a lecturer in the Methodology of the Behavioural Science Department, University of Granada, Ceuta, Spain. Luis Albendín-García is an emergency and critical care nurse at the Andalusian Health Service, Andalusia, Spain. Cristina Vargas-Pecino is an assistant professor in the Psychology Department, University of Valencia, Valencia, Spain.
• PMID: 28966203
• DOI: 10.4037/ccn2017508

Objective: To determine the prevalence of burnout (based on the Maslach Burnout Inventory on the 3 dimensions of high Emotional Exhaustion, high Depersonalization, and low Personal Accomplishment) among emergency nurses.

Method: A search of the terms "emergency AND nurs* AND burnout" was conducted using the following databases: CINAHL, Cochrane, CUIDEN, IBECS, LILACS, PubMed, ProQuest, PsycINFO, SciELO, and Scopus.

Results: Thirteen studies were included for the Maslach Burnout Inventory subscales of Emotional Exhaustion and Depersonalization and 11 studies for the subscale of low Personal Accomplishment. The total sample of nurses was 1566. The estimated prevalence of each subscale was 31% (95% CI, 20-44) for Emotional Exhaustion, 36% (95% CI, 23-51) for Depersonalization, and 29% (95% CI, 15-44) for low Personal Accomplishment.

Conclusions: The prevalence of burnout syndrome in emergency nurses is high; about 30% of the sample was affected with at least 1 of the 3 Maslach Burnout Inventory subscales. Working conditions and personal factors should be taken into account when assessing burnout risk profiles of emergency nurses.

©2017 American Association of Critical-Care Nurses.

Publication types

• Meta-Analysis
• Attitude of Health Personnel*
• Burnout, Professional / epidemiology
• Emergency Nursing*
• Middle Aged
• Nursing Staff, Hospital / psychology*
• Stress, Psychological / epidemiology
• Surveys and Questionnaires

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

Burnout and Nursing Care: A Concept Paper

Vitor parola.

1 The Health Sciences Research Unit: Nursing (UICISA:E), Nursing School of Coimbra (ESEnfC), 3004-011 Coimbra, Portugal; tp.cfnese@ohleocsevenanairda (A.C.); tp.cfnese@sevenoguh (H.N.); tp.cfnese@sedranrebsevlaleafar (R.A.B.)

Adriana Coelho

Rafael a. bernardes, joana pereira sousa.

2 Center for Innovative Care and Health Technology—ciTechCare, School of Health Sciences, Polytechnic of Leiria, 2411-901 Leiria, Portugal; [email protected]

Nuno Catela

3 School of Health Sciences, Polytechnic of Leiria, 2411-901 Leiria, Portugal; [email protected]

Associated Data

Not applicable.

Burnout comprises a series of undetermined physical and psychosocial symptoms caused by an excessive energy requirement at work—it is a crisis in relationships with work itself and not necessarily a concern with underlying clinical disorders related to workers. Professions involving human interactions commonly involve emotional engagement, especially when the cared-for person needs assistance and support, as is the primary concern in the nursing profession. To some extent, the acknowledgment of the phenomena of burnout and how it affects people is sometimes addressed from a biomedical perspective. This concept paper aims to describe the burnout concept and reflect on the impact on nurses. Our intention with this reflection, considering the burnout impact on nurses, is to support a paradigm change in the prevention and management of burnout in healthcare contexts, promoting and fostering the well-being of nurses.

1. Introduction

The burnout concept was first mentioned by Herbert Freudenberg [ 1 ], in the 1970s, as involving a series of unspecific physical and psychosocial symptoms generated by an excessive energy requirement at work. This first definition of the concept served to identify, describe, and name an existing social problem based on observations. Nevertheless, those observations were not systematic or standardized [ 2 ]. However, with the development of standardized instruments in the 1980s, such as the Maslach Burnout Inventory and Burnout Measure, burnout started to be studied empirically.

Maslach and Leiter [ 3 ] extended the concept of burnout and redefined it as a crisis in interactions with work and not necessarily a concern with working people. Burnout is believed to result from continued exposure to work-related stressful events [ 4 ]. Maslach and colleagues indicated that burnout research is rooted in caregiving and service occupations, where the central core of the job is the relationship between the cared person and the caregiver [ 2 , 5 , 6 ]. Professions involving human interactions commonly involve emotional engagement, especially when the cared-for person needs assistance and support, as is the primary concern in the nursing profession.

According to Maslach and Leiter [ 3 , 5 ], burnout is characterized as a syndrome with three dimensions: ‘emotional exhaustion’, ‘depersonalization’, and a ‘lack of personal accomplishment at the workplace’ that occur when functional coping strategies fail. These dimensions are further explained.

Regarding ‘emotional exhaustion’, it arises when health professionals reach the limits of their capacity. As a result, there is a lack of emotional energy and a perception that emotional resources are depleting. For that reason, professionals cannot respond at an emotional level [ 2 , 5 ]. ‘Emotional exhaustion’ is the reaction to chronic stressors in the workplace, such as work overload, which are constant over time and introduce a pressure component on people’s daily lives, causing emotional exhaustion. It is the lack of emotional energy, not directly physical energy itself [ 2 , 5 , 7 ]. People are not physically fatigued from performing a strenuous job; the main issue is being emotionally drained from the lack of resources to deal with demands and stressors. The exhaustion increases the possibility of distancing oneself emotionally and cognitively from work, apparently as a way to cope with work overload. This lack of energy, perceived as a further loss of resources, can lead to maladaptive coping strategies such as emotional detachment from work or depersonalization [ 2 , 4 , 5 ].

Regarding ‘depersonalization’, it is defined as an impersonal and distant contact, where the nurse, for example, starts to use remote approaches toward patients and colleagues, actively ignoring the other’s unique and engaging qualities and developing negative feelings and cynical attitudes—a reason why the term ‘depersonalization’ is often synonymous with cynicism in the burnout literature. Depersonalization usually develops due to increased exhaustion, being self-protective at the beginning—an emotional defense of ‘detached concern’. It is seen as a coping mechanism because it distances workers from the job and other people, such as colleagues and/or patients. In the case of health care professionals, who evidence depersonalization attitudes at their job, the human service workers attempt to block negative emotions, decreasing emotional exhaustion and recovering resources, which increases energy [ 4 , 5 , 8 , 9 ].

Distancing arises as a coping mechanism to emotional exhaustion, disengaging the person from work and preventing additional emotional exhaustion. An attempt to cope with emotional exhaustion by becoming emotionally detached using distancing occurs. However, the consequence is that the detachment is capable of causing the loss of idealism and the dehumanization of others. With time, the nurse is not only creating a shield and cutting back on the amount of work but also creating an adverse response to others and to professional tasks and responsibilities. As a result, the nurse shifts from trying to do his/her very best to doing the bare minimum [ 2 , 3 , 4 , 5 , 10 ].

The ‘lack of personal accomplishment’ usually refers to negative feelings about competence and professional success, evidencing a lack of motivation and decreased productivity at work [ 2 , 5 ]. This dimension represents the self-evaluation component of burnout. For example, an expectable part of a nurse’s job is to care for others. Still, if the nurse is emotionally exhausted and depersonalizing his/her surrounding, he/she will perceive the tasks as inadequate, lacking in personal accomplishment, and reducing one’s perceived professional efficacy [ 2 , 3 , 4 , 5 ]. This sense of inefficacy may lead nurses affected by burnout to a severe dislike of the kind of person they think they have become, leading to a loss of confidence and an increased risk of having negative self-esteem [ 2 , 4 , 5 ].

At this point it is important to note that the most widely used concept of burnout (Maslach and Leiter) refers to these three dimensions. However, in the use of the instrument developed by the authors, it is often mentioned that burnout is considered to be present if (a) the three subscales are altered; (b) emotional exhaustion and/or the depersonalization scale are altered (the sub-scale personal accomplishment not being taken into consideration and a high score for one of the other two sub-scales are enough to be considered as burnout); and (c) there is at least one dimension with severely abnormal ratings [ 11 ].

Worldwide there are several studies about the incidence and prevalence of burnout. A survey carried out with intensive care nurses reveals that nurses reported a high level of emotional exhaustion (73.9%) and depersonalization (52.2%), and a medium level of personal accomplishment (40%) [ 12 ]. Another study evidenced a high burnout prevalence (70%) among nurses during the peak of the first wave of the COVID-19 pandemic [ 13 ]. Moreover, evidence shows that nearly half, 49.1% ( n = 194), of hospital bases nurses had high levels of burnout [ 14 ].

In summary, we can say that burnout is composed of three dimensions: emotional exhaustion, depersonalization, and a lack of personal accomplishment, which are related, with the lack of personal accomplishment dimension being more related to a nurse’s self-evaluation.

2. Materials and Methods

A conceptual, descriptive study was carried out to analyze and interpret sources published about the concept of burnout. According to a structural perspective, contextualization of the analysis produced regarding burnout in the nursing profession was complemented with the necessary contextual analysis of health contexts. An interpretative text was formulated with the necessary conclusions.

Studies were selected on the basis of a search conducted in Medline (via Pubmed), CINAHL with full text (via EBSCOHost), and Scopus, using keywords and Mesh-terms/CINAHL-headings adjusted to the respective databases. Two types of articles were chosen for this paper: reference documents and articles in the field to describe the concept; articles had to be published in recent years (5 years, prioritizing the last year) for specific aspects, for example, interventions/programs discussed or the impact of burnout, as they are more adjusted to the current reality and evidence current trends in the topic. The search strategy used for Medline (via PubMed) is presented in Table 1 .

Search conducted in Medline (PubMed).

3. Results and Discussion

From burnout conceptualization to maslach and leiter’s areas of work-life model.

Considering the three dimensions previously described, Maslach and Leiter [ 4 ] mentioned that the experience and etiology of burnout build based on exhaustion levels, starting a landslide and resulting in a personal career crisis.

Cynicism and depersonalization take the experience of exhaustion to a higher level and are compounded by inefficacy. Instead of giving the possible satisfaction, fulfilment, and validation of one’s identity, working in the healthcare sector becomes a joyless burden in need of minimization, avoidance, and escape. This could explain why burnout was significantly associated with depression in nurses [ 15 ].

In this sense, when a workplace is noticed as exceptionally demanding, emotional, mental, and spiritual exhaustion can occur because of a concomitant decrease in the levels of energy and confidence [ 4 , 10 ]. Eventually, workers’ enthusiasm, organizational commitment, and dedication to their work vanish, influencing nurses’ performance, quality of life, job satisfaction, and global personal health [ 2 , 16 ]. A recent systematic review about unfinished nursing care shows that working in highly demanding environments is associated with reduced job satisfaction, burnout, and intention to leave [ 17 ]. Given the challenges in nurse satisfaction, recruitment, and retention, future research needs to focus on nurses’ quality of work.

Some aspects should be clarified when discussing burnout since they are interrelated concepts. One of these aspects is the distinction between burnout and stress. The difference between them is a question of time. Burnout refers to the long-term breakdown in adaptation complemented by chronic malfunctioning at the workplace. A nurse who suffered from job stress would return to normal; however, one suffering from burnout would not do so since burnout results from chronic stressors in the workplace [ 6 , 7 ].

Another aspect to clarify is the possible misunderstanding between burnout and compassion fatigue concepts. The latter is frequently thought of as the caregiver’s cost of caring but occurs when nurses are exposed to recurrent interactions that demand high empathic commitment with distressed patients. At present, compassion fatigue can be a substantial influencing factor in nursing burnout [ 18 ]; several studies detected a significant positive correlation between compassion fatigue and burnout [ 19 , 20 ]. However, there is no systematic review on this topic. For example, education, awareness, and self-care are key elements in preventing compassion fatigue [ 18 ].

Having clarified the distinction between burnout, stress, and compassion fatigue, it is relevant to mention that other themes are also related to burnout (e.g., depression, anxiety, workload, work performance, co-worker relationships, quality of life), and they should be considered [ 19 , 20 , 21 ]

As stated earlier in this paper, nursing is a stressful profession dealing with human health and illness, eventually leading to job dissatisfaction and burnout [ 22 , 23 ]. When they care for people, the impact on nurses should be acknowledged. For that reason, nurses should recognize early signs of burnout and seek appropriate help [ 24 ]. The strategies for combating burnout are related to changing healthcare systems to provide support for nurses. To prevent this, institutions may explore alternative work schedules and lower patient loads [ 18 ].

The experience of burnout has been related to an extensive list of adverse outcomes, namely at a personal, social, and organizational level. These outcomes involve more medical errors and poor quality of patient care in healthcare [ 4 ]. Therefore, it is not unreasonable to presume that nurses’ burnout interferes with their performance and then with the care process [ 4 , 25 , 26 ]. Maslach and Leiter [ 4 ] state that when hospital staff experience high levels of burnout, their patients present lower satisfaction levels with the received care. The literature reveals a strong correlation between low personal accomplishment scores and the poor care behaviors of nurses [ 12 ].

A cross-sectional survey among nurses showed a positive correlation between emotional exhaustion, depersonalization scores, and patient care quality [ 27 ]. Another cross-sectional study in long-term care wards established an association between nurses’ burnout and objective care quality indicators. Higher emotional exhaustion was associated with statistically significant higher rates of pneumonia and pressure ulcers, and reduced personal accomplishment was associated with higher tube feeding rates [ 28 ]. In recent systematics reviews and meta-analyses about the influence of burnout on patient safety, the authors have revealed a relationship between high levels of burnout and worsening patient safety [ 29 , 30 ].

Burnout is additionally related to dysfunctional relationships with co-workers and a deeper intention to leave the health profession altogether [ 4 , 17 ]. For that reason, Maslach and Leiter [ 4 ], in their reflection, argue that it is urgent to address burnout levels among professionals, not only because of the natural discomfort of such an event but also because of other severe consequences at the workplace.

The majority of the research evidence indicates that burnout does not suggest something is wrong with the professional, but rather that there has been a fundamental shift in the workplace and the nature of the job. It follows that burnout does not begin as a personal failure [ 3 , 4 , 7 ], but develops in response to challenging relations among employees and their workplaces, also being a social and organizational issue. Both the person/professional and the organization to which they belong have a role in improving the workplace and people’s performance [ 3 , 4 , 6 ]. As Montgomery [ 18 ] highlighted in his study, burnout is an essential indicator of how the organization functions.

From Maslach and Leiter’s perspective [ 3 ], burnout occurs from chronic mismatches between the person and the job in terms of some or all the six areas of work-life (AW), described in Table 2 .

Description of the AW model.

Adapted from Maslach and Leiter [ 4 ].

The AW model indicates management areas in which professionals encounter disappointments that increase burnout levels. As Maslach and Leiter [ 7 ] mention, some mismatches in the areas described above impact an individual’s level of experienced burnout, which, in turn, determines numerous outcomes, such as job performance, social behaviors, and personal health. In a sense, the greater the disparity between person and profession, the greater the likelihood of developing a degree of burnout. One of the advantages of the AW model is that any of the six areas can be improved [ 4 , 7 , 31 ]. Additionally, some processes enhance the alignment of people with their work settings, holding great potential for positive changes [ 4 , 17 ].

Addressing burnout includes interventions to alleviate it when events arise and also to prevent it before an event occurs [ 4 , 7 , 24 ]. The first type of intervention occurs with individuals or workgroups are feeling levels of burnout that, even when high, are not necessarily serious enough to prevent them from working. Conversely, prevention strategies tend to concentrate on professionals generally not affected by burnout, helping them avoid the risk of developing burnout events [ 4 , 32 ].

Some individual strategies were adapted from previous studies on stress, coping, and health topics. Notably, (i) altering work patterns (e.g., working fewer hours, avoiding overtime work, balancing work with personal life); (ii) improving coping skills (e.g., cognitive restructuring, conflict resolution, time management); (iii) getting social support (from colleagues and family); (iv) using relaxation strategies; (v) encouraging good health and fitness; and (vi) developing a better self-understanding through diverse self-analytic techniques, counselling, or therapy [ 7 , 33 ]. As a practical approach, we could pose that if an intervention is more focused on the sense of efficacy, it might better respond to improvements, such as a more clear culture of recognition from colleagues and leaders [ 7 ].

Some studies have made further recommendations to cope with burnout. For example, the need to care for oneself, and not just about individual health and physical fitness, but also about psychological well-being. Other recommendations include encouraging a focus on spirituality and human nature; encouraging better social recognition of the challenging work being accomplished; and concentrating on the good aspects of life, at work and at home [ 7 , 22 , 34 ].

Considering the impact of the subject under analysis, which has been demonstrated in several studies, one of the highlighted aspects is the extreme physical and emotional demands requested from nurses. It is not surprising that there has been a growing number of studies on this topic about the magnitude of burnout during the pandemic because of the increased demand from all professionals [ 35 , 36 , 37 ]. That is why it is necessary to know this reality and create mechanisms that minimize its impact so that we are prepared as much as possible to respond to it, especially in situations where its incidence increases considerably [ 38 ].

4. Conclusions

When nurses focus on patients, they may forget to care for themselves. In this sense, this concept paper evidences the need for emotional support for healthcare team members. Furthermore, it is essential that evidence clearly explains the strategies nurses adopt, or should adopt, to help them in daily caring interventions. In addition, a clear understanding of the factors that affect nurses will directly impact the levels of emotional exhaustion, depersonalization, and personal accomplishment, which generate burnout. Thus, a deeper understanding of how nurses manage these factors and which strategies nurses adopt or should adopt is required.

As stressed by Maslach and colleagues, burnout research had its origins in professions involving human interactions, especially when the cared-for person needs assistance and support, as is the main concern in the nursing profession [ 3 , 4 , 7 , 39 ]. This article discussed the existing evidence to support a paradigm change in the prevention and management of burnout in healthcare contexts and provided incentives for future research promoting the well-being of nurses. As was mentioned by the authors, once the levels of burnout are known, it is vital to move towards interventions that mitigate it [ 8 , 15 , 17 , 18 , 39 ]. Institutions and stakeholders should consider this reality to develop appropriate psychological interventions and strategies to prevent, alleviate, or treat burnout among nurses.

Burnout in healthcare services is undoubtedly a critical issue. It needs to be addressed within the workplace, enhancing the teamwork perspective, for example, and the educational process, which prepares people for a healthier career. Therefore, this topic should be on the agenda, as it is essential that nurses and stakeholders know about it, discuss it regularly, and work with others to deal with it.

Acknowledgments

The authors acknowledge the support provided by Health Sciences Research Unit: Nursing (UICISA: E), hosted by the Nursing School of Coimbra (ESEnfC).

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, V.P., A.C., H.N., R.A.B., J.P.S. and N.C.; validation, V.P., A.C. and H.N; investigation, V.P., A.C. and R.A.B.; resources, V.P., N.C. and J.P.S.; writing—original draft preparation, V.P., A.C., H.N. and R.A.B.; writing—review and editing, V.P., A.C., H.N., R.A.B., J.P.S. and N.C. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Original research article
• Open access
• Published: 24 April 2024

Association of quality of nursing care with violence load, burnout, and listening climate

• Sigal Sיhafran Tikva   ORCID: orcid.org/0000-0003-1598-1545 1   na1 ,
• Gillie Gabay 2   na1 ,
• Or Shkoler   ORCID: orcid.org/0000-0002-7656-4297 3 &
• Ilya Kagan   ORCID: orcid.org/0000-0002-2298-0308 4  

Israel Journal of Health Policy Research volume  13 , Article number:  22 ( 2024 ) Cite this article

2 Altmetric

Metrics details

Violence against nurses is common. Previous research has recommended further development of the measurement of violence against nurses and integration of the individual and ward-related factors that contribute to violence against hospital nurses. This study was designed to address these issues by investigating the associations between violence, the listening climate of hospital wards, professional burnout, and perceived quality of care. For this purpose, we used a new operationalization of the violence concept.

We sought nurses to participate in the study through social media which yielded 765 nurses working in various healthcare systems across Israel who volunteered to complete a self-administered online questionnaire. 80% of the sample were hospital nurses, and 84.7% were female. The questionnaire included validated measures of burnout, listening climate, and quality of care. Instead of using the traditional binary measure of exposure to violence to capture the occurrence and comprehensive impact of violence, this study measured the incremental load of violence to which nurses are subjected.

There were significant correlations between violence load and perceived quality of care and between constructive and destructive listening climates and quality of care. Violence load contributed 14% to the variance of burnout and 13% to the variance of perceived quality of care. The ward listening climate moderated the relationship between burnout and quality of care.

Conclusions

The results of this study highlight the impact of violence load among nurses and the ward listening climate on the development of burnout and on providing quality care. The findings call upon policymakers to monitor violence load and allocate resources to foster supportive work environments to enhance nurse well-being and improve patient care outcomes.

Introduction

Workplace violence is a global ‘epidemic’ that affects all healthcare professionals [ 1 , 2 ]. Workplace violence includes incidents of threats, assault, and other offensive behaviors (including physical beating, kicking, slapping, stabbing, shooting, pushing, biting, and pinching), as well as incidents of psychological violence like rudeness, yelling, interrupting, bullying, undermining, and ignoring [ 3 , 4 ]. Such violence has been recognized as an occupational hazard, and its negative consequences are well-known [ 5 , 6 ]. By the early 1990s, the recognition of workplace violence toward nurses as an occupational risk in psychiatric settings was extended to other types of settings [ 7 ]. Since then, the great increase in research into workplace violence has contributed to raising awareness of the problem [ 8 , 9 , 10 ]. The COVID-19 pandemic has seen an increase in workplace violence with higher numbers of incidents of physical violence and verbal abuse and more difficulty in reporting incidents to management [ 10 , 11 , 12 , 13 ].

Workplace violence often increases the levels of distress, anxiety, depression, dissatisfaction with work, exhaustion, poor well-being, and other negative consequences for individuals [ 10 , 14 , 15 ]. On the organizational level, workplace violence is linked to higher turnover, lower morale, poor or missed nursing care, and increased burnout [ 16 , 17 , 18 ]. This is of great importance because nursing stands out as the profession with the highest levels of professional burnout [ 19 , 20 , 21 ]. This manifests as a progressive psychological response to chronic work stress with three main dimensions: (1) emotional exhaustion, (2) depersonalization, and (3) decline in professional efficacy [ 22 , 23 ].

Consequences of burnout in nurses include poor physical health, diminished mental health, decreased self-compassion, work–home conflicts, decreased job satisfaction, and impaired work performance. Furthermore, there are associations between burnt-out nurses with higher numbers of medical errors, suboptimal patient care, and lower levels of work involvement – all of which have adverse effects on patients, threaten nurse retention, and increase hospital costs [ 24 , 25 , 26 , 27 ].

Workplace violence occurs within an organizational climate, which can moderate the condition in either direction [ 28 ]. Organizations with a pervasive safety climate are firmly committed to protecting patients and nurses from harm. This commonly involves promoting open, non-punitive communication regarding adverse events, and commitment to learning from such events to avoid their recurrence [ 29 ]. An organizational climate may also moderate the relationships between workplace violence and workers’ engagement [ 30 ]. More specifically, an organizational climate that emphasizes the quality of the provider-patient relationship and the quality of listening may mitigate workplace violence against nurses [ 31 , 32 , 33 , 34 ].

Listening has three components: (1) attention (to the speaker), (2) comprehension (of the speaker), and (3) (positive) intention (e.g., being empathic and non-judgmental) [ 35 , 36 , 37 ]. A constructive listening climate is present when one perceives the other person as paying attention to him/her, understanding him/her, and relating to him/her positively (non-judgmental, empathic, etc.). The dysfunctional opposite is defined as destructive [ 38 ]. Studies suggest that the ward’s climate of constructive listening may reduce nurses’ exposure to workplace violence [ 38 , 39 ].

Classically, workplace violence has been viewed by researchers as part of a hospital’s quality dashboard, with hospital management recommended to examine trends in workplace violence incidents over time, evaluate the effects of workplace violence across units, and implement prevention programs [ 40 ]. However, monitoring workplace violence requires data concerning the magnitude of workplace violence across hospital units [ 40 ]. Previous studies on violence against nurses reduced it to a binary measure (i.e., exposed vs. not exposed). This binary approach fails to establish a measurement of the extent of exposure to workplace violence. Notably, a high prevalence of exposure in all areas invalidates comparisons across units [ 10 ]. This perspective ultimately monitor the continuum of workplace violence towards nurses: from no exposure at all to high exposure to workplace violence (i.e., more continuous properties). To address this issue, we have extended the measurement of violence by considering the exposure load of workplace violence on a continuum, namely, “Violence Load.”

Although there has been extensive research focused on workplace violence towards nurses, burnout, and the effect on quality of care, very few studies have focused on the relevant factors at the organizational level. In line with the recommendations of eminent researchers, we studied both personal and context-related factors of workplace violence [ 41 ]. Thus, this study were to examine the (a) associations between violence load, burnout, and quality of care, b) associations between the ward’s listening climate, nurse’s burnout, and quality of care, and (c) the mediating effect of burnout on the relationships between ward’s listening climate and violence load to quality of care. The study model is shown in Fig. 1 .

Path diagram with standardized regression coefficients (Beta). Notes . * p < .05, ** p < .01, *** p < .001. Controlling for age, tenure, and gender. Coefficients in parenthesis are the direct (bivariate) association between variables. For Listening climate (as depicted in its rectangle): coefficients above the regression line reflect “Constructive” climate, while coefficients below the regression line reflect “Destructive” climate. The model boasts superior fit (Byrne, 2010): χ2(df) = 16.30 (2), p = .072; SRMR = .05; CFI = .96; NFI = .96; TLI = .92; GFI = .99; RMSEA (90% CI) = .08 [.05-.14], p-close = .058

Sampling method

The minimum a priori sample size for the study, with a standard α error probability of 5%, power of 95%, and a fixed effect size of 0.15, was estimated by G*Power (v. 3.1.9.7) statistical software as n  = 138 (and n  = 204 for the effect size of 0.10). We therefore considered a sample size above 204 (as the stricter upper bound) as adequate for subsequent analysis.

A digital link to the anonymous online questionnaire was circulated among nurses via social network platform for specific nursing groups (Facebook and WhatsApp) from May to July 2020. We invited nurses to fill out the questionnaire with the following statement: “Staff nurses, please access a questionnaire that deals with violence towards nurses. We appreciate your time, and you can fill out the questionnaire using your preferred device.” This distribution method allowed us to reach out to nurses from different healthcare organizations and enabled the participants to respond anonymously to this sensitive topic. Before data collection, we conducted a pilot study among ten nurses to assess respondents’ understanding of the questionnaire.

Out of 1332 potential respondents who accessed the web link of the questionnaire, we excluded those with empty records and obtained a final sample of 765 nurses. Notably, this 58% response rate is above the response rate found in a meta-analysis on the adequacy of response rates in online surveys [ 42 ].

The study survey examined (a) exposure to violence load, (b) the ward climate of listening, (c) burnout, (d) quality of care, and (e) socio-demographic characteristics. The measures used in the current research were translated from the original English into Hebrew by the back-translation procedure [ 43 ]. All measures had adequate psychometrics. Four experts, two senior researchers, and two senior nurses who study violence at work reviewed the instruments for relevance and clarity. They suggested a few changes in wording, which were accepted and incorporated into the final version of the survey. The full questionnaire can be supplied upon a reasonable request.

Violence Load was assessed by a scale of nine items relating to verbal and physical violence in the last 6 months [ 3 ]. The types of violence are verbal violence, verbal threats, destruction of property, minor physical violence, severe physical violence, use of a weapon or a sharp object, sexual harassment, and social shaming (Additional file 1 ). The respondents were asked to rate their experience of violence as: (1) never, (2) yes, exposed to patient-perpetrated violence . This study exclusively examined patient-perpetrated violence. In order to acquire continuity and relativity for this binary construct, the overall score was derived as follows: (A) When the participant replied “yes” once, they were given a score of 1 for violence ; (B) when the answer “never” was selected, the score given as 0; (C) the responses were summed to obtain an incremental increase in Violence Load and create a continuous variable with higher statistical variability, instead of a dichotomous response construct, such that higher scores represent higher violence load, and vice versa (i.e., higher scores reflect “higher load,” or occurrence/frequency, of violence). The final variable can be regarded as continuous, although a reliability coefficient could not be calculated.

Quality of care was assessed by six items previously used to measure the reported quality of nursing care in the context of abusive behaviors [ 38 ]. For example, “ In my ward, the treatment of patients who demonstrate violence behavior is incomplete ” or “ The level of care for violent patients, as compared to other patients in my ward, is low.” Respondents were asked to rate each item on a Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The overall score was represented by the mean. A higher mean score indicated a lower quality of care (a higher impairment of the quality of care) of sexually harassing patients.

Respondents were asked to rate each item on a scale from 1 ( strongly disagree ) to 7 ( strongly agree ). One item was recoded. The overall score was represented by the mean of the construct, with a higher score indicating a higher quality of care. Reliability (Cronbach’s Alpha Coefficient) was adequate, α = 0.78 [ 44 ].

Burnout was assessed using the 14-item Shirom-Melamed Burnout Measure [ 45 ]. Participants were asked to rank the statements on a scale from 1 ( never ) to 7 ( always ). A high mean score reflects high burnout. The reliability (Cronbach’s Alpha Coefficient) was high α = 0.9. For example, “I feel physically fatigued” and I am too tired to think clearly.

Ward’s climate of Listening to Patients was assessed using measurements of both perceived “constructive” and “destructive” listening [ 35 , 36 ]. Respondents were asked to rate nine items (six items for constructive listening climate, and three destructive listening climate) on a scale from 1 (never) to 7 (always). Example items are: “ When nurses listen to patients, they listen carefully ” and “ When nurses listen to their patients, they try to understand what the patient is saying.”

The overall score was the mean value of the totals. The reliability (Cronbach’s Alpha Coefficient) for constructive climate was high, with α = 0.91, and was adequate for destructive climate, with α = 0.75.

Socio-demographic data included gender, age, institution, specialty, place of birth, seniority, profession, form of employment, and position.

Ethical considerations

The Institutional Review Board of Jerusalem College of Technology, the academic institution with which the first author is affiliated, granted ethical approval for this study (Approval #: 0313 − 17). The study adheres to Helsinki 1964 guidelines on ethics. Following the ethical approval, participants received a brief written explanation about the study’s aims. They were informed that the data collected would only be used for publication and statistical analysis. Completing the questionnaire served as consent to participate in the study.

Data analysis

After demographic frequency analysis to test the research model (see Fig. 1 ), zero-order Pearson correlations were calculated to assess the baseline associations between the research variables.

Structural equation modeling was employed to assess the study model and the prevalence of common-method bias [ 46 , 47 ]. Common method variance exists when the shared variance among variables is not due to the true underlying interrelationships but rather due to the measurement itself, namely self-reported data. Common method bias is a systematic error that can arise when respondents consistently rate items in a certain way, regardless of the actual relationships between the items [ 47 ]. Structural equation modeling was used because it allows researchers to model and analyze complex relationships among variables, handle both observed variables (measured variables) and latent variables (unobserved constructs), with more than one criterion, making it suitable for capturing intricate relationships that go beyond simple correlations [ 46 , 48 ]. In addition, Structural equation modeling addresses measurement errors by allowing researchers to model the relationships between latent variables and their corresponding observed indicators enhancing the accuracy of the estimation of the tested relationships between variables in cross-sectional studies [ 46 ].

Two methodologies were employed to test the possible impact of common-method variance on the results [ 49,50]. These are (a) Harman’s single-factor method (all items are loaded on one common factor) and (b) a common latent factor method (all items are loaded on two types of factors – their expected factors and one latent common method factor). Analysis by Harman’s single-factor model accounts for only 21.81% of the explained variance and is a good fit [ 11 , 46 , 48 , 49 , 50 ]. Indices were: χ 2 (2696) = 8,491.17; p  = .000; χ 2 /df = 3.15; Comparative Fit index = 0.78, Normed fit index = 0.75, The goodness of fit index = 0.86, SRMR = 0.13, and the root mean square error of approximation [90% CI] = 0.18 [0.14-0.29], p-close  = 0.004. In contrast, the common latent factor model explained 20.37% of the explained variance: χ 2 (2583) = 6,741.63; p  = .000; χ 2 /df = 2.61; Comparative fit index = 0.81, Normed Fit Index = 0.80, The goodness of fit index = 0.88, the difference between the observed correlation and the model implied correlation matrix was = 0.10, and the root mean square error of approximation [90% CI] = 0.11 [0.05-0.16], p-close  = 0.017. Notably, these findings do not exclude the presence of common method bias [ 47 ]. However, as previously reported [ 47 ], we note that if the variance explained by the first emerging factor is less than 50% ( R 2  < 0.50), then, in conjunction with a poor model fit for each analysis, common method bias is an improbable explanation of our findings (see also Table 1 ).

Finally (Fig. 1 ), Structural equation modeling was also utilized [ 49 ] to test the mediation model, and full mediation analysis was employed with bootstrapping (95% bias-corrected confidence intervals and 5,000 re-samples; [ 46 , 47 , 48 , 49 , 50 ]. Bootstrapping can counteract any potential skew of the data from a normal distribution. In this case, the predictors are violence load and listening climate, while the mediator is nurses’ work burnout, and the criterion is the quality of care.

This study complied with STROBE guidelines [ 51 ].

Participants

The research sample comprised 765 nurses, with females accounting for 84.7% of the sample. The persons in the sample ranged in age from 24 to 68 years ( M  = 41.48, SD  = 9.97). Hospital nurses comprised 80% of the sample. Seniority in nursing ranged from 1 to 42 years ( M  = 10.35, SD  = 9.18). Additional data are presented in Table 2 . It is paramount to note that although most respondents were hospital nurses, we analyzed the data with and without the non-hospital participants. Since the changes in statistical results were negligible, we decided to keep the non-hospital nurses in the final sample to improve the power considerations and external validity.

Correlational analysis

Table 1 presents the means and standard deviations of the study variables and the intervariable correlations. The modest strength of the correlations supports the notion that Common method bias is an improbable explanation for our findings.

Mediating effects

Table 3 presents the findings from the path analysis to test mediation effects, while Table 4 reports the indirect (mediation) effect tests. Finally, Fig. 1 illustrates the findings on a path diagram.

The findings indicate that violence load contributes 14% to the variance of burnout and 13% to the variance of perceived quality of care. Table 4 reveals that three out of the four tested mediation effects are statistically significant: (1) burnout partially mediates the association between violence load and quality of care, (2) burnout partially mediates the association between a climate of constructive listening and quality of care, and (3) burnout fully mediates the association between destructive listening climate and quality of care.

This study extends the standard measurement of workplace violence to assess the cumulative effect of violence load on nurses. The study findings expand the existing knowledge on workplace violence in the field of nursing research with a focus on the impact of violence load, listening climates, and nurse burnout on quality of care. The results should motivate policymakers to employ this measurement in health systems and monitor and compare workplace violence data in and across units over time. Such monitoring will identify the units that most require intervention and the groups of nurses who are subjected to higher violence loads, thereby risking their personal wellbeing and jeopardizing quality of care.

Targeted strategies must be identified and implemented to ensure a safe and supportive work environment for nursing professionals. Monitoring violence load in and across units can identify better-performing units and allow them to be studied. Thus, they can potentially contribute to spread of effective interventions to reduce workplace violence.

Analyzing mediation pathways and identifying the relationships between constructive and destructive listening climates and nurse burnout also highlights the importance of fostering a positive work culture that promotes effective communication and support. Addressing destructive listening climates can also positively affect nurse burnout and the quality of care provided. Our findings are in accordance with those of studies in other industries, where a constructive listening climate significantly affected exposure to workplace violence [ 35 , 36 ]. Notably, a byproduct of this study is the identification of a clear linkage between a constructive or destructive listening climate and the violence load. These effects may be explained by the emotional intelligence capability that constructive listening generates, which has been found to mitigate abusive behaviors [ 32 ]. In addition, our findings concerning listening climate support reports in the literature that meeting psychological needs help to reduce bullying and improve employee functioning [ 52 , 53 ], while burnout mediates the effects of workplace violence on patient safety [ 54 ].

We recommend policymakers allocate resources for nursing management training programs designed to: (a) raise awareness of workplace violence among all nurses, encourage them to report workplace violence incidents and allocate time to discuss the nature, specific characteristics, and rates of occurrence over time; (b) establish policies that foster a supportive work environment, encourage open reporting of violence incidents, and prioritize nurse well-being; (c) allocate resources to ensure adequate staffing levels and support services to manage the impact of violence load on nurses; (d) adopt a trauma-informed care approach by integrating trauma-informed care principles into healthcare practices to address the psychological effects of violence load on nurses; and (e) support research into the consequences of violence load on nurse burnout and patient outcomes to guide evidence-based policymaking.

Limitations

The use of single-source data and a cross-sectional design restricts causal inferences. We have tried to indicate possible causality by using Path Analysis. In addition, cultural influences may have impacted the results [ 55 ], and constructive listening may represent only one facet of a broader societal issue. In this study, we focused on the new measure of violence load on nurses, however, future research should explore the model in high workplace violence settings like emergency medicine, aged care, and mental health and replicate the studies in diverse countries to provide external and construct validity [ 56 ]. It may be informative to extend this approach to other health professionals in different healthcare settings since workplace violence extends beyond nursing and cultures [ 56 ]. It may also be useful to conduct longitudinal or cross-lagged studies designed to examine the association between violence load and post-traumatic stress [ 57 ].

This study highlights the significance of the violence load and the ward’s listening climate as contributors to nurse burnout. The mediating role of burnout on the relationship between violence load, listening climate, and the quality of care provided by nurses underscores the importance of addressing workplace violence and promoting a supportive work environment in healthcare settings. Based on the findings of this study, we have developed a set of targeted strategies and policies, beginning with regular monitoring of violence load in units of health systems that would prioritize violence prevention and workplace support in order to improve nurse well-being and quality of care.

Availability of data and materials

The data supporting this study’s findings are available from the corresponding author [SST] upon reasonable request.

Johnson J, Hall LH, Berzins K, Baker J, Melling K, Thompson C. Mental healthcare staff well-being and burnout: a narrative review of trends, causes, implications, and recommendations for future interventions. Int J Ment Health Nurs. 2018;27(1):20–32. https://doi.org/10.1111/inm.12416 .

Article   PubMed   Google Scholar  

Fasanya BK, Dada EA. Workplace violence and safety issues in long-term medical care facilities: nurses’ perspectives. Saf Health work. 2016;7(2):97–101. https://doi.org/10.1016/j.shaw.2015.11.002 .

Shafran-Tikva S, Zelker R, Stern Z, Chinitz D. Workplace violence in a tertiary care Israeli hospital-a systematic analysis of the types of violence, the perpetrators and hospital departments. Isr J Health Policy Res. 2017;6(1):1–1. https://doi.org/10.1186/s13584-017-0168-x .

Article   Google Scholar  

Zhao M, Jiang K, Yang L, Qu W. The big data research on violence against doctors: based on the media reports from 2000 to 2015. Medicine and philosophy (A). 2017(01):89–93. https://www.safetylit.org/citations/index.php?fuseaction=citations.viewdetails &citationIds[]=citjournalarticle_545846_12

Fottrell E. A study of violent behaviour among patients in psychiatric hospitals. Br J Psychiatry. 1980;136(3):216–21. https://doi.org/10.1192/bjp.136.3.216 .

Article   CAS   PubMed   Google Scholar  

Lanza ML. The reactions of nursing staff to physical assault by a patient. Psychiatric Serv. 1983;34(1):44–. https://doi.org/10.1176/ps.34.1.44 .  7.

Article   CAS   Google Scholar  

Lipscomb JA, Love CC. Violence toward health care workers: an emerging occupational hazard. AAOHN J. 1992;40(5):219–28. https://doi.org/10.1177/216507999204000503 .

Liu J, Gan Y, Jiang H, Li L, Dwyer R, Lu K, Yan S, Sampson O, Xu H, Wang C, Zhu Y. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med. 2019;76(12):927–37. https://doi.org/10.1136/oemed-2019-105849 .

Mento C, Silvestri MC, Bruno A, Muscatello MR, Cedro C, Pandolfo G, Zoccali RA. Workplace violence against healthcare professionals: a systematic review. Aggress Violent Beh. 2020;51:101381. https://doi.org/10.1016/j.avb.2020.101381 .

Timmins F, Catania G, Zanini M, Ottonello G, Napolitano F, Musio ME, Aleo G, Sasso L, Bagnasco A. Nursing management of emergency department violence—can we do more? J Clin Nurs. 2023;32(7–8):1487–94. https://doi.org/10.1111/jocn.16211 .

Byon HD, Sagherian K, Kim Y, Lipscomb J, Crandall M, Steege L. Nurses’ experience with type II workplace violence and underreporting during the COVID-19 pandemic. Workplace Health Saf. 2022;70(9):412–20. https://doi.org/10.1177/21650799211031233 .

Chirico F, Afolabi AA, Ilesanmi OS, Nucera G, Ferrari G, Szarpak L, Yildirim M, Magnavita N. Workplace violence against healthcare workers during the COVID-19 pandemic: a systematic review. Journal of Health and Social Sciences. 2022;7(1):14–35. https://dx.doi.org/10.19204/ 2022/WRKP2 .

Watson A, Jafari M, Seifi A. The persistent pandemic of violence against healthcare workers. Am J Manag Care. 2020;26(12):e377-9. https://doi.org/10.37765/ajmc.2020.88543 .

Bashir S, Cheema SM, Ashiq M. Impact of Workplace Violence on sustainable performance of nurses with the mediation of Social Well-being in the Pakistani context. J Manage Res. 2023;10(1). https://doi.org/10.29145/jmr.101.02 .

Cheung T, Yip PS. Workplace violence towards nurses in Hong Kong: prevalence and correlates. BMC Public Health. 2017;17(1):1–0. https://doi.org/10.1186/s12889-017-4112-3 .

Gabay G, Shafran Tikva S. Sexual harassment of nurses by patients and missed nursing care—A hidden population study. J Nurs Adm Manag. 2020;28(8):1881–7. https://doi.org/10.1111/jonm.12976 .

Sahiran MN, Minhat HS, Muhamad Saliluddin S. Workplace violence among healthcare workers in the emergency departments in Malaysia. J Health Res. 2022;36(4):663–72.

Saleem Z, Shenbei Z, Hanif AM. Workplace violence and employee engagement: the mediating role of work environment and organizational culture. Sage Open. 2020;10(2):2158244020935885. https://doi.org/10.1177/2158244020935885 .

Markwell P, Polivka BJ, Morris K, Ryan C, Taylor A. Snack and Relax®: a strategy to address nurses’ professional quality of life. J Holist Nurs. 2016;34(1):80–90. https://doi.org/10.1177/0898010115577977 .

Sabri B, St. Vil NM, Campbell JC, Fitzgerald S, Kub J, Agnew J. Racial and ethnic differences in factors related to workplace violence victimization. West J Nurs Res. 2015;37(2):180–96. https://doi.org/10.11772F0193945914527177.

Zubairi AJ, Ali M, Sheikh S, Ahmad T. Workplace violence against doctors involved in clinical care at a tertiary care hospital in Pakistan. J Pak Med Assoc. 2019;69(9):1355–9. https://pubmed.ncbi.nlm.nih.gov/31511724/ .

PubMed   Google Scholar  

Maslach C, Leiter MP. New insights into burnout and health care: strategies for improving civility and alleviating burnout. Med Teach. 2017;39(2):160–3. https://doi.org/10.1080/0142159X.2016.1248918 .

Tziner A, Shkoler O, Rabenu E, Oren L. Antecedents to burnout among hospital doctors: can they cope? Med Res Archives. 2018;6(10). https://doi.org/10.18103/mra.v6i10.1859 .

Alotni MA, Elgazzar SE. Investigation of burnout, its associated factors and its effect on the quality of life of critical care nurses working in Buraydah Central Hospital at Qassim Region, Saudi Arabia. The Open Nursing Journal. 2020;14(1). http://doi.org/10.2174/1874434602014010190.

Lebrón M, Tabak F, Shkoler O, Rabenu E. Counterproductive work behaviors toward organization and leader-member exchange: the mediating roles of emotional exhaustion and work engagement. Organ Manage J. 2018;15(4):159–73. https://doi.org/10.1080/15416518.2018.1528857 .

Shkoler O, Tziner A. The mediating and moderating role of burnout and emotional intelligence in the relationship between organizational justice and work misbehavior. Revista De Psicologia Del Trabajo Y De las Organizaciones. 2017;33(2):157–64. https://doi.org/10.1016/j.rpto.2017.05.002 .

Tavakoli M, Shokridehaki F, Marzband M, Godina R, Pouresmaeil E. A two-stage hierarchical control approach for the optimal energy management in commercial building microgrids based on local wind power and PEVs. Sustainable Cities Soc. 2018;41:332–40. https://doi.org/10.1016/j.scs.2018.05.035 .

Escribano RB, Beneit J, Garcia JL. Violence in the workplace: some critical issues looking at the health sector. Heliyon. 2019;5(3). https://doi.org/10.1016/j.heliyon.2019 . e01283.

Sorra JS, Dyer N. Multilevel psychometric properties of the AHRQ hospital survey on patient safety culture. BMC Health Serv Res. 2010;10(1):1–3. https://doi.org/10.1186/1472-6963-10-199 .

Hu H, Gong H, Ma D, Wu X. Association between workplace psychological violence and work engagement among emergency nurses: the mediating effect of organizational climate. PLoS ONE. 2022;17(6):e0268939. https://doi.org/10.1371/journal.pone.0268939 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Arnetz J, Hamblin LE, Sudan S, Arnetz B. Organizational determinants of workplace violence against hospital workers. J Occup Environ Med. 2018;60(8):693. https://doi.org/10.1097/JOM.0000000000001345 .

Article   PubMed   PubMed Central   Google Scholar  

Hutchinson M, Hurley J. Exploring leadership capability and emotional intelligence as moderators of workplace bullying. J Nurs Adm Manag. 2013;21(3):553–62. https://doi.org/10.1111/j.1365-2834.2012.01372.x .

Trépanier SG, Fernet C, Austin S, Boudrias V. Work environment antecedents of bullying: a review and integrative model applied to registered nurses. Int J Nurs Stud. 2016;55:85–97. https://doi.org/10.1016/j.ijnurstu.2015.10.001 .

Olsen E, Bjaalid G, Mikkelsen A. Work climate and the mediating role of workplace bullying related to job performance, job satisfaction, and work ability: a study among hospital nurses. J Adv Nurs. 2017;73(11):2709–19. https://doi.org/10.1111/jan.13337 .

Itzchakov G, Kluger AN, Castro DR. I am aware of my inconsistencies but can tolerate them: the effect of high quality listening on speakers’ attitude ambivalence. Pers Soc Psychol Bull. 2017;43(1):105–20. https://doi.org/10.1177/0146167216675339 .

Itzchakov G, DeMarree KG, Kluger AN, Turjeman-Levi Y. The listener sets the tone: high-quality listening increases attitude clarity and behavior-intention consequences. Pers Soc Psychol Bull. 2018;44(5):762–78. https://doi.org/10.1177/0146167217747874 .

Rogers CR, Roethlisberger FJ. Barriers and gateways to communication. Harvard Business Rev. 1991;69(6):105–11.

Google Scholar  

Shafran-Tikva S, Kluger AN, Lerman Y. Disruptive behaviors among nurses in Israel– association with listening, well-being and feeling as a victim: a cross-sectional study. Isr J Health Policy Res. 2019;8(1):1–9. https://doi.org/10.1186/s13584-019-0340-6 .

Shafran Tikva S, Gabay G, Asraf L, Kluger AN, Lerman Y. Experiencing and witnessing disruptive behaviors toward nurses in COVID-19 teams, patient safety, and errors in care. J Nurs Scholarsh. 2023;55(1):253–61. https://doi.org/10.1111/jnu.12857 .

Hamblin LE, Essenmacher L, Luborsky M, Russell J, Janisse J, Upfal M, Arnetz J. Worksite Walkthrough intervention: data-driven prevention of workplace violence on hospital units. J Occup Environ Med. 2017;59(9):875. https://doi.org/10.1097/JOM.0000000000001081 .

Judge TA, Zapata CP. The person–situation debate revisited: Effect of situation strength and trait activation on the validity of the big five personality traits in predicting job performance. Acad Manag J. 2015;58(4):1149–79. https://doi.org/10.5465/amj.2010.0837 .

Wu MJ, Zhao K, Fils-Aime F. Response rates of online surveys in published research: a meta-analysis. Computers Hum Behav Rep. 2022;7:100206. https://doi.org/10.1016/j.chbr.2022.100206 .

Brislin RW, editor. Handbook of cross-cultural psychology. Allyn and Bacon; 1980.

Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika Springer. 1951;16(3):297–334.

Shirom A, Melamed S. A comparison of the construct validity of two burnout measures in two groups of professionals. Int J Stress Manage. 2006;13(2):176. https://doi.org/10.1037/1072-5245.13.2.176 .

Byrne BM. Structural equation modelling with or: Basic concepts, applications, and programming (2nd edition). 2010. Taylor & Francis Group.

Podsakoff PM, MacKenzie SB, Lee JY, Podsakoff NP. Common method biases in behavioral research: a critical review of the literature and recommended remedies. J Appl Psychol. 2003;88(5):879. https://doi.org/10.1037/0021-9010.88.5.879 .

Arbuckle J. Amos (Version 26.0)[Computer program] Chicago. IL, USA: IBM SPSS; 2019.

Shkoler O, Kimura T. How does work motivation impact employees’ investment at work and their job engagement? A moderated-moderation perspective through an international lens. Front Psychol. 2020;11:38. https://doi.org/10.3389/fpsyg.2020.00038 .

Vasiliu C, Tziner A, Lebron MJ, Shkoler O, Rabenu E, Iqbal MZ, Ferrari F, Hatipoglu B, Roazzi A, Kimura T, Tabak F. Heavy-work investment: its dimensionality, invariance across 9 countries and levels before and during the COVID-19’s pandemic. Revista De Psicología Del Trabajo Y De las Organizaciones. 2021;37(2):67–83. https://doi.org/10.5093/jwop2021a8 .

Cuschieri S. The STROBE guidelines. Saudi J Anesth. 2019;13(Suppl 1):S31.

Drory A, Shkoler O, Tziner A. Abusive leadership: a moderated-mediation through leader-member exchange and by organizational politics. Front Psychol. 2022;13:983199. https://doi.org/10.3389/fpsyg.2022.983199 .

Trépanier SG, Fernet C, Austin S. Longitudinal relationships between workplace bullying, basic psychological needs, and employee functioning: a simultaneous investigation of psychological need satisfaction and frustration. Eur J Work Organizational Psychol. 2016;25(5):690–706. https://doi.org/10.1080/1359432X.2015.1132200 .

Liu J, Zheng J, Liu K, Liu X, Wu Y, Wang J, You L. Workplace violence against nurses, job satisfaction, burnout, and patient safety in Chinese hospitals. Nurs Outlook. 2019;67(5):558–66. https://doi.org/10.1016/j.outlook.2019.04.006 .

Hofstede G. Cultures and Organizations: Software of the Mind. McGraw Hill; 1991.

Thomas DC, Peterson MF. Cross-cultural management: essential concepts. Sage; 2016. Dec 30.

Vandenberghe C, Panaccio A, Bentein K, Mignonac K, Roussel P. Assessing longitudinal change of and dynamic relationships among role stressors, job attitudes, turnover intention, and well-being in neophyte newcomers. J Organizational Behav. 2011;32(4):652–71. https://doi.org/10.1002/job.732 .

Download references

Acknowledgements

Not applicable.

This research received no grant or funding.

Author information

Sigal Shafran Tikva and Gillie Gabay contributed equally to this work.

Authors and Affiliations

Jerusalem College of Technology; Head, Hadassah Research and Innovation Center in Nursing, Hadassah University Medical Center, Jerusalem, Israel

Sigal Sיhafran Tikva

School of Sciences, Multi-Disciplinary Studies, Achva Academic College, Arugot, Israel

Gillie Gabay

HEC Montreal, Montreal, QC, Canada

Nursing Department, Ashkelon Academic College, Ashkelon, Israel

You can also search for this author in PubMed   Google Scholar

Contributions

All authors read and approved the final manuscript.  SST Conceptualization, Methodology, Writing Original Draft, Resources, Data collection, Writing - Review & Editing.  GG Conceptualization, Methodology, Writing Original Draft, Writing - Review & Editing.  OS Formal analysis, Data Curation, Review & Editing.  IK Conceptualization, Methodology, Data Curation, Writing - Review & Editing.

Corresponding author

Correspondence to Sigal Sיhafran Tikva .

Ethics declarations

Ethics approval and consent to participate.

Approval was granted for this study by the Academic Institution with which the first author is affiliated - Approval #: 0313 − 17.

Anonymity was promised, and all data were coded without identifying details and were used for research purposes only. Completing the questionnaires was considered consent to participate in the study. All authors confirm that the protocol was performed in accordance with the ethical standards laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards.

Authorship: We confirm that all authors meet the criteria of substantial contribution to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.

Consent for publication

Reporting guidelines: STROBE reporting guidelines were used.

Competing interests

All Authors declare no conflict of interest.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary material 1., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Sיhafran Tikva, S., Gabay, G., Shkoler, O. et al. Association of quality of nursing care with violence load, burnout, and listening climate. Isr J Health Policy Res 13 , 22 (2024). https://doi.org/10.1186/s13584-024-00601-3

Download citation

Received : 13 August 2023

Accepted : 08 March 2024

Published : 24 April 2024

DOI : https://doi.org/10.1186/s13584-024-00601-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Listening climate
• Quality of care
• Violence load

Israel Journal of Health Policy Research

ISSN: 2045-4015

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]