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

Abstract

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

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Quality of Nursing Care: The Influence of Work Conditions and Burnout
Rola H. Mudallal, Mohammad Y.N. Saleh, Hanan M. Al-Modallal, Rania Y
Abdel-Rahman
PII: S2214-1391(17)30004-5
DOI: http://dx.doi.org/10.1016/j.ijans.2017.06.002
Reference: IJANS 58
To appear in: International Journal of Africa Nursing Sciences
Received Date: 17 January 2017
Revised Date: 8 June 2017
Accepted Date: 13 June 2017
Please cite this article as: R.H. Mudallal, M.Y.N. Saleh, H.M. Al-Modallal, R.Y. Abdel-Rahman, Quality of Nursing
Care: The Influence of Work Conditions and Burnout, International Journal of Africa Nursing Sciences (2017),
doi: http://dx.doi.org/10.1016/j.ijans.2017.06.002
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Quality of Nursing Care 1
Quality of Nursing Care: The Influence of Work Conditions and Burnout
*Rola H. Mudallal, PhD, RN
Full Time Lecturer
Community and Mental Health Department, Hashemite University, Zarqa, Jordan
Mohammad Y. N. Saleh, RN, MSN, PhD
Associate Professor
Clinical Nursing Department, The University of Jordan, Amman, Jordan
Hanan M. Al-Modallal, PhD, RN
Associate Professor
Community and Mental Health Department, Hashemite University, Zarqa, Jordan
Rania Y Abdel-Rahman, MSN, RN
Teacher Assistant
Maternal, Child, and Family Department, Hashemite University, Zarqa, Jordan
*Corresponding author’s address:
The Hashemite University, School of Nursing
P.O. Box 150459, Zarqa 13115, Jordan
Telephone: 962(5) 3903333, Ext. 5552
Fax: 962-5-3903337
e-mail: rula@hu.edu.jo
Introduction

Quality of Nursing Care 2
Providing quality health care is one of the most challenging issues for health care systems all
over the world. Increasing demand on health care services associated with shortage of health care
professionals and massive advances in health sciences and technology has created an overload of
work and job stress, which lead to an increase in errors and a decrease in work quality (The
Institute of Medicine [IOM], 1999, 2001, 2013).
Prompt changes in the health care system, a work overload, consistant interaction with
suffering patients and continuously unmet psychological needs will lead to burnout; which is a
state of emotional, intellectual and physical exhaustion (Azeem, Nazir, Zaidi, & Akhtar, 2014;
Maslach, Schaufeli, & Leiter, 2001; Patrick & Lavery, 2007). Sever burnout is manifisted by
fatigue, job dissatisfaction, low self esteem, poor concentration and reasoning, as a result, this
may lead to emotional depletion, uncaring perception of the clients, negative self evaluation and
quitting job (Maslach & Jackson, 1981; Maslach, Schaufeli, & Leiter, 2001). Nurses burnout
reduces their work productivity, increases the potential of health related errors (Montgomery,
Panagopoulou, Kehoe, & Valkanos, 2011), rises turnover rate and directly affects the quality of
nursing care (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Leiter & Maslach, 2009). In a
study that aimed to investigate the influence of burnout on some work related variables,
researchers found that emotional exhaustion was associated with absenteeism, intention to leave
profession, personal and family deterioration, also, depersonalization was linked to the
perception of having made errors (Su˜ner-Soler et al., 2014). Therefore, it is a key to recognize
the factors in nurse burnout that may affect the quality of nursing care.
Quality is a health care services level that is consistent with updated professional knowledge
and allows desired outcomes to be obtained (IOM, 1990). Several studies explored and examined
the different environmental factors that are related to the quality of nursing care and required

Quality of Nursing Care 3
improvement at health care systems. Laschinger, Shamian and Thomson (2001) studied the
effects of magnet hospital characteristics on nurses’ job satisfaction, trust, perceived quality of
care, and burnout among nurses. Authors reported the organizational traits of autonomy, control,
and collaboration were negatively correlated with burnout, which in turn is associated negatively
with the perceived quality of care, although trust in management was positively correlated with
nurses’ perceived quality of care. In a recent study, Van Bogaert, Van Heusden, Timmermans and
Franck (2014b) suggested that nurse work environment such as “nurse-physician collaboration”
and “nurse management” at both unit and hospital levels are influential to nurse-assessed quality
of care as mediated by nurse-work characteristics. In addition, effective leadership styles have an
influential role in providing quality nursing care, nurses in departments with effective leadership
styles reported lower rates of medication errors, patient falls, pneumonia, urinary tract infections,
brain hemorrhage and patient mortality (Houser, 2003). Similarly, in Jordan, factors related to
work environment, competent management, and nurses’ job satisfaction; specifically satisfaction
with psychological rewards, rotating work shifts and daily census, were reported as significant
indicators of quality of nursing care (Mudallal, 2013). Furthermore, quality of nursing care in
Jordanian hospitals was significantly dependent on nature (type) of the hospital (Mrayyan, 2008;
Mudallal, 2013).
In addition, nurse burnout reflected a unique role in the quality of nursing care provided
through different studies. Vahey, Aiken, Sloane, Clarke and Vargas (2004)-study revealed that
quality of nursing care indicator “patient satisfaction” was negatively associated with nurse
burnout. A substantial relationship between burnout and quality of nursing care was evident in a
secondary analysis of a cross-national data from six countries in which the investigators found
that high level of nurse burnout was significantly associated with low or fair level of quality

Quality of Nursing Care 4
nursing care (Poghosya, Clarke, Finlayson, & Aiken, 2010). On the same extreme of
understanding, a Belgian study included 546 registered nurses from 42 units demonstrated that
emotional exhaustion is a significant predictor of job satisfaction, turnover and quality of nursing
care (Van Bogaert, Clarke, Roelant, Meulemans, & Van de Heyning, 2010). Similarly, a recent
cross-sectional survey, using a multilevel modelling technique to analyze data of 709 nurses from
different levels and were working in 25 residential aged care services demonstarted that
emotional exhaustion and depersonalization were substantial idicators of the quality of nursing
care (Van Bogaert, Dilles, Wouters & Van Rompaey, 2014a).
Although a limited number of studies highlighted the influence of burnout on the quality of
nursing care, burnout has been found a mediater of the pathway between some organizational
traits or interventions and the quality of nursing care. For example, burnout played a mediator
role in the relationship between nursing work environment and patient’s safety (Laschinger &
Leiter, 2006), influenced nursing work environment on job outcomes (Van Bogaert, Meulemans,
Clarke, Vermeyen, & Van de Heyning, 2009) and quality of nursing care (Spann, Baban, Bria,
Lucacel, & Dumitrascu, 2013). Of the aspects of burnout, emotional exhaustion besides
workload have mediated the relationship between work enivironment in terms of “nurse-
physician relationship”, “hospital and nurse management” and “organisational support” and the
quality of nursing care; all of which were found to have predictive performance of the quality of
nursing care (Van Bogaert, Kowalski, Weeks, Van Heusden, & Clarke, 2013).
Based on previous evidences, environmental factors and nurse characteristics have
influenced both burnout and the quality of nursing care (Aiken et al., 2002; Houser, 2003;
Laschinger et al., 2001; Mrayyan, 2008; Mudallal, 2013; Van Bogaert et al., 2014b) and
substantiate the mediation role of burnout in relation to the quality of nusring care (Laschinger &

Quality of Nursing Care 5
Leiter, 2006; Spann et al., 2013;Van Bogaert et al., 2009; Van Bogaert et al., 2013). Limited
number of studies demonstarted the influence of burnout on the quality of nursing care
(Poghosya et al., 2010; Van Bogaert et al., 2010; Van Bogaert et al., 2014a), although the
influence of workers’ stress level on productivity has been addressed. Therefore, the aim of this
study is to investigate the influence of nurse burnout, general work conditions, nurse and patient
characteristics on the quality of nursing care.
Methods
Design.
Cross-sectional, correlational designs were employed to explore the influence of nurse
burnout on the quality of nursing care.
Sample and Setting.
The data of this study was collected from both: nurses and patients. The sample size was
estimated using statistical power procedures. the estimated sample size was 178 particepants for
each group (nurses and patients).
A convenience sample of 270 registered nurses and 270 hospitalized patients from 24 units of
eight hospitals in Jordan was recruited. Only registered nurses with a minimum experience of at
least one year in a clinical area and adult patients who were conscious, oriented, free of pain and
able to speak and communicate were included in the study.
The selected hospitals for this study were from three major Jordanian governorates. The
health care system in Jordan has three major sectors: Public (Ministry of Health (MOH), Royal
Medical Services (RMS) and educational hospitals), private and donors. For this study, the data
were collected from nurses in (MOH), private and educational hospitals.

Quality of Nursing Care 6
Ethical Considerations.
The human rights and ethical considerations were protected all over the study. The
researchers obtained the ethical approval to use the study instruments. Institute Review Board
(IRB) approval for each hospital was also guaranteed. Participants were informed of the purpose
of the study, and their right to withdraw without penalty at any time. To keep anonymity, the
questionnaires did not include any information regarding the participant identity. Return of
completed questionnaires by nurses and patients was considered as a signed agreement to
participate in this study. After filling the questionnaire by the participant it was coded by a
number and kept in secure place; no one has an access to the data except the researcher.
Measurement.
The data in this study was collected through the following tools:
Service Quality Scale (SERVQUAL).
This instrument was originally developed by Zeithaml, Parasuraman and Berryin 1985 to
measure service quality. It is a reliable and valid scale that can be used by researchers, managers
and professionals to assess service quality (W. Clark & L. Clark, 2007; Parasuraman, Zeithaml,
& Berry, 1988; Scardina, 1994). Service quality is the difference between what the consumer
expects from the service and what he or she perceives the service to be in the experienced
situation. According to this instrument, service quality has the following five dimensions:
tangibility, reliability, responsiveness, assurance and empathy (Parasuraman, Zeithaml, & Berry,
1988; Scardina, 1994). The scale was completed by adult patients in different hospital
departments. The Arabic version of the instrument was used by the researchers to facilitate the
understanding of items by Jordanian patients. The arabic version of SERVQUAL has been used
and studied in different research through which it was valid, and demonstrated high reliability-

Quality of Nursing Care 7
Cronbach alpha was more than 0.90 for the total scale (Al-Borie & Damanhouri, 2013). In this
study, Cronbach alpha for the total SERVQUAL is 0.93.
The SERVQUAL consists of 22-Likert-type items with five points (1= very much below my
expectations, 2= below my expectations, 3= meet my expectations, 4= above my expectations,
5= very much above my expectations). The responses for the whole scale were summed into 110.
Higher scores reflect higher levels of quality of nursing care services.
Maslach Burnout Inventory (MBI).
The MBI-human services survey instrument consists of 22-items designed to address three
dimensions of burnout for professionals in human services. Nine items measure Emotional
Exhaustion (EE); the feeling of being overstressed in addition to emotional and physical
resources depletion. Five items measure depersonalization (DP) which is unfeeling and negative
attitude about clients. Eight items measure personal accomplishment (PA) the feelings of
competence, achievement and productive at work (Maslach, Schaufeli, & Leiter, 2001).
The nurses responses for each item ranged from 0 “never” to, 6 “every day.” The responses
for each sub-scale were summed. High EE and DP scores reflect high levels of burnout, while
low PA scores reflect high levels of burnout (Maslach & Jackson, 1981).
The nurses completed the English version of the questionnaire; because they were familiar
with English terms in nursing more than Arabic ones, since English is the teaching language in
nursing schools in Jordan. The instrument was found to be highly reliable and valid in many
studies when it was used to measure burnout. For this study, Cronbach alpha for the three
subscales ranged from 0.779-0.906.
Nurses, Patients and Work Characteristics.

Quality of Nursing Care 8
The demographic data of the nurses involved in this study included: gender, marital status,
working shift (fixed shift or rotating (A, B, C or day, night)), educational level (Bachler or
master), age and years of experience as a registered nurse. General work conditions included:
department type (medical , surgical, maternal and child care, intensive care units), daily census
(the average number of inpatients or occupied beds in the department), the model of nursing care
provision (functional, team, or total patient care), and the leadership style of the direct supervisor
(autocratic, democratic, permissive, or situational).
The demographic data for the patients included: gender, marital status, educational level, age
and length of stay in hospital.
Data Collection.
The data of the present study was collected by trained research assistants. The research
assistants were available to answer any questions. The data were collected from both nurses and
patients. Nureses reported their level of burnout through the MBI. Because burnout is expected
to affect nurses’ ability to judge quality (Maslach & Jackson, 1981), quality nursing care was
measured through patients’ responses on the SERVQUAL. Completed MBIs were matched to
SERVQUAL questionnaires which were completed by patient participants who received care by
those nurses who completed MBIs during hospitalization. The pair of surveys was then given a
code for analysis. Research assistants used the assignment sheet to decide on matched pairs.
Assignment sheet is a document used by departement manager to design the job and distribute
workload on nurses each shift; this document provided research assistants with information
regarding patient care assignment, to recognise the nurse who had the most contact with the
patient, which helped in maching process.
Analysis.

Quality of Nursing Care 9
Univariate descriptive statistics were used to assess means (M) and standard deviation (SD)
for continuous variables. Frequencies were used to describe the categorical demographic
characteristics of the sample.
Before running stepwise multiple regression model, two inferential tests were used to
determine the factors that may influence the quality of nursing care: 1) Pearson Correlation
Coefficient (Pearson r) to assess the relationship between continuous variables including nurse
burnout, census, nurses’ and patients’ age, experience, length of stay and quality of nursing care.
2) One way analysis of variance (ANOVA) to determine factors may influence the quality of
nursing care including categorical variables of demographics and departmental characteristics.
Stepwise regression analysis was used to determine the predictive performance of those
factors that had a statistically significant correlation with the quality of nursing care. The
researchers examined the normality of the outcome variable, linearity of predictors, homogeneity
of variance and independence of variables before running the regression analysis (Warner, 2008).
Results
Descriptive Analysis.
A total of 300 registered nurses were approached. Two hundred seventy registered nurses
completed the questionnaires, with a response rate of 90%. Approximately 45% (n=121) of the
participants were males, and 55% (n=149) were females. The mean age of the nurse participants
was 29.40 years (SD=6.29), ranging from 23 to 47 years. Nurse participants had mean years of
experience of 6.71 years (SD=5.75). Approximately half of the nurse participants were married
(n=141, 52.20%), 121 (44.80%) of nurse participants were single, and some were divorced or
widowed (8, 3%). Most of the nurse participants (n=242, 89.70%) had a baccalaureate degree;
the residue had a Master degree. Results revealed that most nurse participants (n=204, 75.6%)

Quality of Nursing Care
10
rotated on either A, B, C or day and night shifts and 66 (24.4%) were fixed on A shift.
The patient participants response rate was 96%. Most of the participants were females
(n=168, 62.20%) and married (n=170, 63%). The mean age of patient participants was 36.42
years (SD=16.83), and their educational level ranged from primary school to graduate studies.
The length of stay ranged from 2 to 37 days (M=3.99, SD=3.95). For most patients, 211 (78%)
were experienced hospitalization for the first time.
In regard to the work environment; approximately 158 (58.52%) nurse participants worked in
general medical and surgical departments, 65 (24.7%) in intensive care units and the remanent
were in obstetric or maternity departments. In terms of the model of nursing care, 116 (43%)
nurse participants were assigned to total patient care, while 102 (37.8%) were assigned in teams.
According to the results, 109 (40.40%) managers adopted a democratic leadership style, 63
(23.30%) were autocratic and 51 (18.90%) managers had a permissive leadership style. The
average daily census was (M=21.39, SD=15.88) patients in different departments. The data were
collected from three types of hospitals: MOH (n=118, 43.70%), private (n=105, 38.89%) and
educational (n=47, 17.41%)
Preliminary Analysis.
Results revealed that nurse participants conveyed a relatively moderate level of burnout in
terms of EE (M=27.02, SD=12.02), DP (M=13.37, SD=6.18) and PA (M=34.95, SD=9.14).
Moreover, the patients reported that the quality of nursing care was congruent with their
expectations (M=65.16, SD=15.70).
To measure the strength and direction of the linear relationship between nurse burnout,
demographics and departmental characteristics and the quality of nursing care, ANOVA used for
categorical variables (Table 1) and Pearson r for continuous variables (Table 2). The results

Quality of Nursing Care
11
showed a significant negative correlation (α=0.01) between the total scores of the quality of
nursing care and the total EE and DP scores and a positive correlation with PA (Table 2). The
highest correlation was found between the total scores of the quality of nursing care and PA (r
=0.440). A significant relationship was detected between the quality of nursing care and nurses’
characteristics including gender, working shift, and level of education (Table 1), age and
experience (Table 2). Regarding work environment, the daily census had a significant negative
correlation with the quality of nursing care (r=-0.226) (Table 2). In addition, quality of nursing
care was significantly varies among the three types of studied hospitals (Table 1).
Unexpectedly, patient participants evaluated the quality of nursing care that was provided by
male nurses (M=70.56, SD=20.48) better than the quality of nursing care that was provided by
female nurses (M=60.78, SD=19.90). Moreover, results revealed that better quality of nursing
care was provided by young, single nurses (M=71.18, SD=19.90), who were working on
different rotating shifts (M=68.5, SD=20.80) and primarily in obstetric and maternity
departments (M=70.06, SD=18.32).
Table 1. Quality of nursing care in relation to nurse, patient and department characteristics
(n=270)
Characteristics
n
%
Quality of Nursing Care
Mean
SD
F
P-Value
Nurse participants
Gender
3.97
<0.001*
Male
121
44.80
70.66
20.48
Female
149
55.20
60.77
19.90
Marital Status
1.32
0.07
Single
121
44.80
71.18
19.90
Married
141
52.20
61.13
20.25
Divorced/Separated
5
1.90
40.20
2.17
Widowed
3
1.10
53.33
9.50
Shift Worked
23.72
<0.001*
Fixed A (8 hours)
66
24.40
54.80
19.64

Quality of Nursing Care
12
Rotating
204
75.60
68.51
19.96
Level of Education
2.07
0.04*
Baccalaureate
242
89.70
64.73
21.03
Master
28
10.30
73.39
19.26
Patient participants
Gender
0.98
0.53
Male
102
37.80
62.84
21.62
Female
168
62.20
66.57
20.10
Marital Status
0.78
0.90
Single
66
24.40
66.95
21.16
Married
170
63.00
65.44
19.93
Divorced/Separated
18
6.70
57.94
22.83
Widowed
16
5.90
63.00
24.43
Level of Education
0.91
0.67
Elementary
55
20.30
61.73
21.85
High School
76
28.10
60.95
19.40
Diploma
60
22.20
61.88
21.02
Baccalaureate
61
22.60
72.74
18.64
Post Graduate
18
6.70
78.78
16.90
Presence of Chronic Illness
0.95
0.57
Yes
58
21.50
63.59
20.75
No
212
78.50
65.60
20.77
General work conditions
Department type
1.09
0.31
Medical & Surgical
158
58.52
61.77
22.03
Obstetric/Maternity
47
17.41
70.06
18.32
Intensive Care Units
65
24.07
66.24
19.91
Nursing Care Model
1.04
0.42
Total patient care
116
43.00
66.32
20.31
Team
102
37.80
66.22
21.88
Functional
49
18.10
61.80
18.60
Unclear
3
1.10
39.33
6.66
Leadership Style
0.75
0.92
Autocratic
63
23.30
61.30
21.40
Democratic
109
40.40
65.88
20.71
Permissive
51
18.90
66.16
18.18
Situational
47
17.40
68.17
22.14
Hospital Type
232.45
< 0.001*
MOH
118
43.70
46.48
9.42
Private
105
38.89
80.24
16.26
Educational
47
17.41
78.38
9.55
*ANOVA is significant at α=0.05 , 2-tailed test.

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13
Table 2. Correlations between quality of nursing care, nurse burnout, demographics and
department characteristics among registered nurses in jordanian hospitals (n=270)
Study Variables
Quality of Nursing Care
Mean
SD
Pearson r
Nurse Age
29.40
6.29
-0.367**
Nurse Experience
6.71
5.75
-0.362**
Daily Census Rate
21.39
15.88
-0.226**
Patient Age
36.42
16.83
0.052
Length of Stay
3.99
3.95
0.007
Burnout
EE
27.02
12.02
-0.439**
DP
PA
13.37
34.95
6.18
9.14
-0.278**
0.440**
**Correlation is significant at α=0.01, 2-tailed test
Predictors of Quality of Nursing Care.
Stepwise regression analysis was used to identify predictors of quality of nursing care. All
factors that were found to have a significant relationship with quality of nursing care were
entered in step one regression analysis; except nurses’ age as it is correlated with nurses’
experience (increase in the nurse’s years of experience means increase in nurse’s age). The data
was screened for multicollinearity. Dummy variables were created for all categorical variables
before performing the regression analysis (Warner, 2008).
The stepwise regression analysis revealed a significant overall model of three predictors:
Hospital type, census rate, and rotating shift worked. These predictors were accounted for
approximately 58% of the variance of the quality of nursing care.
Hospital type was the dominant predictor of the quality of nursing care; it was responsible for
55.9 % of the variance. Burnout variables (EE, PA and DP) were excluded from the model when
other predictors were statistically superior (Table 3). Furthermore, two factors related to work
conditions were significant: census rate (1.6%) and working on rotating shifts (A, B and C or day
and night) (0.7%) (Table 3).

Quality of Nursing Care
14
Table 3. Predictors of quality nursing care as perceived by jordanian nurses (n=270)
Variables
B
Adjusted R2
R2-Change
F-Change
df
p
Hospital Type (P)
16.48
0.558
0.559
340.10
1/268
0.00
Census rate
-0.16
0.572
0.016
9.86
1/267
0.00
Nursing shift work (Rotating)
3.47
0.577
0.007
4.42
1/266
0.03
Predictors of quality of nursing care final model produced at α= 0.05; Excluded variables are: EE, DP, PA, Nurse
age, Nurse experience, Nurse gender, Nurse level of education.
Discussion
The present study demonstrates work conditions in terms of hospital type, census rate, and
rotating shift as significant predictors of the patients’ reported quality of nursing care. Hospital
type was the dominant variable predicting quality of nursing care. Jordanian hospitals are
different in their nature of work environment, departmental characteristics, climates, polices and
level of technology used (Mrayyan, 2008; Mrayyan, Mudallal, & Hamaideh, 2010; Mudallal,
2013). Indeed, Private and educational hospitals have a favorable environment for both patients
and nurses in terms of better nurse-patient ratio, low daily census rate, collaborative nurse-
physician relationship, higher standards of quality of nursing care, advanced technology in use,
leadership support, nurses’ autonomy and adequate health care professionals (Mrayyan,
Mudallal, & Hamaideh, 2010; Mudallal, 2013). Moreover, private and educational hospitals in
Jordan were pioneers in generating national and international accreditation and quality assurance
programs.
On the other hand, MOH hospitals -the largest health care sector in Jordan which covers most
Jordanian governorates- are facing different challenges starting with insufficient funding,
increasing demand on health care services, shortage of health care professionals; this means
nurses perform nursing and non-nursing duties, limited quality improvement programs,

Quality of Nursing Care
15
centralized management practices, and lack of staff development programs (Halasa, 2008), all of
which reflected negative impact on nurses’ and patients’ satisfaction. However, health care
system in Jordan is undergoing a huge reform and development that is focusing on improvement
of health care management and clinical practices, and in order to improve the quality of nursing
care; technology, informatics and national competencies for registered nurses and nurse
managers are being introduced.
Daily census was an additional factor predicting the quality of nursing care. This finding was
congruent with a previous investigation conducted in Jordan (Mudallal, 2013). An increase in
daily census was found to reduce the quality of care. An increased census means an increase in
patients’ number in the department, which decreases the time spent on caring for each patient,
this consequently increases job stress and reduces the quality of care (Williams, 1998; Sochalski,
2001).
Nursing shift work was considered a good indicator of the quality of nursing care. Patients
reported higher-quality nursing care is provided by nurses on rotating shifts. Quality of nursing
care processes differs according to the situation elements; most of the time, nurses on the A-shift
are overloaded with direct and indirect patient care activities which negatively impacts the
quality of nursing care and creates higher job stress (Williams, 1998).
Compared to work conditions, nurse burnout and nurse characteristics had lower influence on
the quality of nursing care. The correlation results of this study revealed that high level of nurse
burnout, as defined by high EE, DP and low PA, was associated with the patients’ report of poor
quality of nursing care. This result is consistent with that of Vahey and colleagues (2004) study;
nurses feeling EE and lack of PA significantly affected patient satisfaction. Additionally, the
results of this study are similar to Poghosya et al. (2010); Van Bogaert et al. (2010), and Van

Quality of Nursing Care
16
Bogaert et al. (2014), all of which found a significant negative relationship between nurse
burnout and the quality of nursing care. But, unexpectedly and despite a moderate correlation
between nurse burnout and quality of nursing care, nurse burnout was not showing a prediction
performance of the quality of nursing care. This may explain that burnout is a common problem
in most Jordanian hospitals and it may play a mediator role between nursing work environment
and quality of nursing care. This result supports the findings of Van Bogaert and colleagues and
Laschinger and Leiter (2006). However, further studies are needed to assess the burnout
phenomenon and the mediator role of burnout and nurse characteristics in Jordan. In addition to
burnout, nurse gender, age, experience and educational level were also not having a prediction
performance in relation to quality of nursing care.
Surprisingly, the results of this study revealed that the quality of nursing care was negatively
associated with nurse experience; an increase in years of experience was asscociated with a
decrease in the quality of nursing care level. The nurses’ role in patient care, direct contact with
patients’ suffering, work overload, difficult work conditions and increased use of technology may
lead to burnout, especially if these factors are associated with social responsibilities (home and
family) (Azeem et al., 2014; Gandi, Paul, Haruna, & Zubaira, 2011; Jacobs, Hill, Tope &
O’Brien, 2016). Progression in nurses’ age and experience in nursing profession leads to further
exposure to work environment related factors, add to this, older nurses in Jordan are less familiar
with technology and informatics which creates a bigger burden. Furthermore, one of the most
common challenges facing women work in the Arab world, is the community perception
regarding the roles for both women and men that women have more social responsibilities
regarding home and family beside profession, and are more dependable than men (Dajani, 2012),
which leads to an increasing load on married, female nurses. This may explain why the quality of

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17
nursing care was better when provided by male, single, young and less experienced nurses in this
study.
In addition to predictive elements of quality of nursing care, this study found that the highest
patients’ perception of the quality of nursing care was more often found in maternity departments
compared to other departments. These findings are consistent with Sochalski (2001) and Boyle
and colleagues (2006). This result may be explained in that although the quality of nursing care
usually implemented in terms of hospital standards similarly at all departments of the same
hospital; patients’ past experiences and psychological status affect their perception of quality
nursing care provided. Patients in wards other than maternity department suffer the consequences
of their diseases while feel happy most of the time in the maternity wards.
This study also, revealed that department type, nursing care model and leadership style do
not have a significant influence on the quality of nursing care. However, these factors were
relevant to quality of nursing care in previous studies (Houser, 2003; Laschinger & Leiter, 2006;
Mudallal, 2013; Van Bogaert et al., 2009; 2010; 2013; 2014a and 2014b). This may be explained
in a way related to unclear systems for nurses as a result of health care system reform. However,
further studies are needed to explore this arena.
Limitations, Implications and Recommendations
This study suggested that “work conditions” is the main influential factor of the quality of
nursing care, whereas burnout and nurses characteristics have lower impact. The results of this
study are unique because the quality of nursing care was measured using a comprehensive tool
rather than using one or two items and was completed by patients to avoid self-evaluation bias.
On the other hand, this study used non-probability sampling procedure and the data was limited
to eight hospitals in Jordan, hence, the generalizability of these results may be limited. Further

Quality of Nursing Care
18
studies are recommended using random sampling procedure and involvement of other health care
settings to improve the generalizability of these findings.
The results of this study are important for developing nursing practice, education, and
research. Nurse managers may consider changes in nursing work environment to reduce nurses’
stress level and improve nurses’ and patients’ satisfaction such as improving in nurse to patient
ratio, nursing mix, opportunity for staff development, boost multidisciplinary collaboration,
support the work environment with enough and advanced equipment, and using transformational
leadership style to inspire, empower and motivate nurses and to enhance effective change.
Although the results showed that young nurses provide relatively better quality of care, which
reflects a recent improvement in nursing education; it is recommended to teach caring concepts
with a focus on the quality dimensions, informatics and stress management. Further staff
developemt programs are required in hospital settings to followup nurses development.
Additional outcome studies are needed to assess the unique influence of different factors on
the quality of nursing care. In addition, more interventional studies are recommended to evaluate
the effects of different programs designed to reduce work stress as means to improve the quality
of nursing care worldwide.
Conclusion
The purpose of this study was to examine the influence of nurse burnout, nurse
characteristics and work conditions on the quality of nursing care. This study illustrated that
“work conditions” variable has the most impact on the quality of nursing care. Mediation effect
is expected for nurse burnout and nurse characteristics; thus, various studies are required to
investigate these phenomena. Consequently, it is important for nurse mangers and policy makers
to improve nursing work conditions in a way that improves nurses’ competencies and decrease

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19
stress level among nurses which will reflect positively on the quality of nursing care. Activities
such as increasing nurses’ autonomy over their practice, improving nurses’ le adership abilities,
providing sufficient staffing and resources, and supporting nurses with continuous educational
programs can improve nurses’ work conditions, competencies and enhance the quality of care.
Competing Interests Statement
The authors declare that there is no conflict of interests regarding the publication of this
paper.

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Highlights
- Nurses’ burnout do not affect quality of nursing care when controlling other factors.
- Nurses’ burnout and nurses’ characteristics have indirect influence on the quality of
nursing care.
- Improving nursing work conditions enhances the quality of nursing care.
- Different nursing care models and leadership styles did not have significant influence on
the quality of nursing care
- Young and male nurses provide better quality of nursing care.