The overriding aim of this study was to provide a critical and comprehensive qualitative review of the current evidence regarding the impact of burnout on A&E nurses in England and how it affects the quality of patient care. The main objectives of the study included; to explore the epidemiology on burnout in hospital settings; to identify the factors which lead to burnout; to examine how the hospital workforce is planned to ensure the retainment of staff while ensuring efficiency; to investigate the application of Working Time Regulation 1998 by the Royal College of Nursing (RCN) and hinders managers from identifying burnout amongst staff; to examine how absenteeism inflicted by burnout impact on quality of care and to identify changes hospitals can implement to minimize burnout amongst staff while maintaining quality care. To achieve the research aim mentioned above, randomised control trials were electronically identified using the key terms and concepts, selecting relevant database and resources which included; PubMed, CINAHL, SciELO (Scientific Electronic Library Online), Scopus, LILACS, Science Direct (Elsevier), and the Proquest Platform (Proquest Health & Medical Complete). The study used 21 articles which were critically examined and analyzed with the aim of hiding sensitive personal information of the participants and avoiding plagiarism. The author prevented by presenting personal beliefs and reflections in the discussion, introduction and conclusion chapters only.  The main findings and analysis showed that burnout among nnurses is widespread and is caused by have long work hours, unfavourable work schedule and environment, minimal breaks in between the work shifts, low support of clinical, no open communication with the managers and supervisors, no team building affecting their levels of morale, motivation, and confidence. An improvement in the physical, psychological and mental state of the nurses reduces burnout, raising the standards of quality of patient care. In conclusion, adequate workload and clear work schedules ensure that nurses have proper attention in patient care. Nurses need to have some down time, in between work shifts, to ensure that they provide quality and standard patient care.

Keywords: Burnout, Quality of Care, England, Patients Care

Table of Content

Declaration. ii

Dedication. iii

Acknowledgement iv

Abstract v

Table of Content vii


1.1 Introduction to the Study. 1

1.2 Background Information. 3

1.3 Rationale of the Study. 4

1.4 Aim and Research Objectives. 6

1.5 Literature Search Strategy. 6

1.6 Ethical Consideration. 7

1.7 Structure and Outline of the Dissertation. 7

1.8 Summary. 8


2.1 Introduction. 9

2.2 Conservation of Resources. 9

2.3 Job Demands-Resources Model 10

2.4  The Maslach Theory on Burnout 12

2.5 Measurement and Diagnosis of Burnout 14

2.6 Burnout and Nursing. 15

2.6.1 Causes of Burnout on Nurses. 16

2.6.2 Impact of Burnout on Patients. 17

2.6.3 Effects of Burnout among Nurses. 19

2.6.4 Management of Burnout among Nurses. 20

2.7 Summary. 21


3.1 Introduction. 22

3.2 Research Design and Quality Assessment 22

3.3 Data Collection and Analysis. 23

3.4 Inclusion and Exclusion Criteria. 23

3.5 Ethical Considerations. 23

3.6    Summary. 24


4.1 Introduction. 25

4.2 Explore The Epidemiology On Burnout In Hospital Settings. 25

4.3 Factors that Lead to Burnout 27

4.4 How Hospital Workforce is Planned to Ensure the Retainment of Staff While Ensuring Efficiency  28

4.5 The Working Time Regulation 1998 in (RCN) and How it Hinders Managers from Identifying Burnout. 30

4.6 Effects of  Absenteeism on Quality of Care. 31

4.7 Management of Burnout to Maintain Quality Care. 33

4.8 Summary. 34


5.1 Introduction. 35

5.2 Discussion on main  objectives of the study. 35

5.3 Summary. 36


6.1 Introduction. 37

6.2 Conclusions. 37

6.3 Recommendations. 38

6.4    Summary. 40


1.1 Introduction to the Study

Burnout among nurses have become a concern in patient care globally and is recognized even more in the last two decades. The situation has been dire to Accident and Emergency(A&E). Nurses work in health institutions where they offer care to patients through maintaining patient records, administering patient medication, observe and monitor patient progress, and liaise with doctors for advanced treatment. A nurse is the first point of contact for patients once they visit a health facility. Since they are the links between doctors and patients; they have to work extra hard to meet the expectations of both parties. A significant challenge faced by these employees is long working hours which often results in burnout.  They overwork because in most cases a nurse has to serve a large number of patients. The government has not been able to balance the ratio of nurses to patients (Gail et al., 2016).

In 2013, the National Health Service (NHS) in England published a report on nurses quitting their careers because of consistent pressure and incapacity to offer quality care. The Royal College of Nursing disclosed that in a 2013 survey entailing 10, 000 nurses, 0.62 of them intended to resign due to stress and work-related burnout. Of the respondents, 61% mentioned hectic schedules as a hurdle for nurses in providing high-quality care and 0.83 attributed increase in workload to the resignation of more than 5, 000 nurses within three years of their profession.

A survey conducted in ten European countries on 23,159 nurses who work in medical and surgical wards reported high burnout levels among nurses and healthcare assistants in distinct nations; 42 % in England, 25 % in Belgium, 30% in Germany,  22% in Finland, 40% in Poland,  24% in Norway,  41% in Ireland,  29% in Spain, 10% in Netherlands,  and 15% in Switzerland.  The nurse who experienced burnout were more motivated to quit their jobs. Radio Canada, in Canada, 40% of nurses who participated in the study encountered burnout daily. Therefore, burnout is a problem that is facing the nursing profession. The available literature shows the prevalence of burnout in the nursing profession, especially in accidents and emergency sections; which negatively affects the personal delivery of quality care. Such information is essential in developing policies and measures to improve patients care and nursing service delivery. The current situation violates the nursing code of ethics which require the nurse to serve the patient efficiently. It begs to understand how nurses can efficiently serve patients when they are experiencing burnout which can lead to medical errors and reduce patient outcomes.

The total demand for nurses has risen in England. There were approximately 690,773 nurses in England (Nursing and Midwifery Council, 2018). Four key aspects have bolstered the demand for nurses in recent times are reforms, population, and the changing role of nurses. In terms of changes, the shift towards integrating the NHS and social care, combined with an emphasis on 7-day working, has increased the demand for nurses. On 25th February 2015, the General Secretary of the Royal College of Nursing (RCN), Dr. Peter Carter noted that the shortage of nurses is significantly affecting service delivery. He attributed the problem to the long wait for treatment and poor working conditions for nurses (Yasuhiro et al., 2018). The irony is that while the demand for nursing services in England is increasing, more nurses quitting, which will amplify the problem of nurses’ shortage. The concerned authority and health stakeholders should address the problem as a matter of urgency. These issues have been the cause behind nurses burnout and decrease in quality of care. Based on the provided argument, this research paper aims to explore the frequency of burnout amongst nurses in England and determine if it affects care standards.

1.2 Background Information

Nurses work in health care facilities and other institutions to provide healthcare to patients. Nursing entails prevention of disease, promotion of health, taking care of the sick, disabled, and terminally ill patients. The first role of a nurse is to link the patient with other medical practitioners. Secondly, the nurse ensures that the patient undergoes all tests recommended by the doctor also and also administer the prescribed medication. The nurse also maintains patient records and monitors the patient’s progress after treatment. If the patient requires a follow up outside the hospital setting, it is the nurse who does the follow-up.

In society, the nurse has the responsibility of promoting the well-being of the population through self-care education that serves to prevent illnesses and improve the quality of life. Health education to communities and specifically caregivers help to prevent and manage illnesses. The nurse also has the responsibility of informing a population of health risks that are present in their lives. An example is educating teenagers and adolescents on the dangers of eating junk foods and not exercising.

The shortage of nurses in all parts of the world has raised concerns. Several authors, (Shereen and Hussein, 2018) have attributed related the shortage or nurses to increased working hours and high patients to nurses ratio that causes stress in the workplace and leads to burnout. According to Mäkikangas and Kinnunen (2016), signs of burnout include exhaustion, cynicism, and reduced professional efficacy. When an individual has burnout, they have insomnia, are easily irritated, anxious, and have a sense of hopelessness (Hayley et al., 2015). According to the Nursing and Midwifery Council (NMC), the headcount of nurses in England fell by 1,783 to 690,773 in the year leading up to March 2018 (NMC, 2018). The NMC also stated there was a widening gap between nurses who were joining the profession and those that were leaving. The NMC surveyed nurses who retired before their retirement date and found out that the majority were under the age of 40. The study attributed the outcome to among other reasons; poor working conditions, nurse shortage, long working hours, fatigue; a situation that led to burnout (NMC, 2018).

The challenges in the nursing profession have led to an imbalance between those joining the career and nursing turnover. Those that decide to remain are compelled by situations beyond their control to overwork to meet the growing demand for nursing care; a factor that has led to burnout (Anna et al., 2018). In the UK over 33,530 nurses left the National Health Service (NHS) between September 2016 and 2017 (NHS Digital, 2018). Burnout has been attributed to understaffing in hospitals and poor working environment for nurses (Fawcett et al., 2015; Stockwell, 2015).

Anna et al., (2018), conducted a survey that involved both patients and nurses in acute settings. The results showed that there is an inverse relationship between burnout and the level of job satisfaction among nurses. The study also established that where there are right working conditions and the nurse to patient ratio was favorable; there was improved quality of care to patients and reduced burnout. The NHS aims to provide high-quality medical care to the population which means that those who give the patient-care should also be provided with a conducive environment to serve the patients devoid of burnout. By identifying the relation between burnout and provision of quality care, managers will be able to identify burnout in nurses and intervene on time to ensure patients receive quality care.

1.3 Rationale of the Study

It is important to note that the impact of burnout amongst nurses and how it affects the delivery of patients care has been an area of interest for some time. Indeed, a review of the relevant literature shows that the impact of nurse burnout has dominated healthcare research for some decades. However, the available empirical literature is not conclusive and is characterized by inconsistencies right from determining the cause of burnout among nurses, the role of hospital management and workforce on burnout to measures of addressing burnout and quality of healthcare.

Regarding the causes of burnout among nurses, research has noted inconsistencies. For example, a study by Starc (2018) stressed on the demand by patients for nursing care and a despise by doctors and physicians, coupled with their knowledge and skills are underestimated while they are nevertheless expected to provide compassionate, humane, competent, culturally sensitive, and ethical nursing care as the primary challenge experienced by nurses. Yao et al., (2018) while studying burnout concluded that stress, introvert unstable personality, and General Self Efficacy (GSE), are the primary factors of job-related burnout among nurses. GSE controls the effect of stress on burnout in nurses with neuroticism personality or extroversion. Increasing GSE, reducing stress, and increased social support may reduce job-related burnout among nurses. The author concluded that introvert nurses with an unstable personality need more social support to reduce stress and enhance their GSE.

Szczygiel and Mikolajczak, (2018) explain job burnout as a disorder resulting from exposure to high work demands whereas there are not enough resources to manage the demand. The researchers attributed exhaustion among nurses to exposure to a variety of occupational stressors. These include heavy workloads, time pressure, interpersonal conflicts at work,  and patient-related factors that include verbal aggression from patients and their caregivers.

In summary, there is evidence-based literature showing that burnout and significant impact on patients nursing care. Most of the research on the relationship between burnout and quality of care has used self-reported perceptions of quality of care an essential but relatively weak measure. Nevertheless, the available literature is not comprehensive that demands a systematic and comprehensive review of the literature concerning these elements to generalize the findings and develop a conclusion. At the time this research, this area of study had not been explicitly covered for England, an aspect that explains why there are variations in the literature available concerning nurses burnout and quality of care. The above-noted lack of England specific review addressing the objectives covered herein underscore the importance of conducting a comprehensive literature review and integration of the available evidence-based literature on the impact of nurses burnout in England and its impact on the quality of care.

1.4 Aim and Research Objectives

The general aim of the study was to understand the impact of burnout on care given by Accident and Emergency nurses in England. In particular, the study will seek to;

  1. To explore the epidemiology on burnout in hospital settings.
  2. To identify the factors which lead to burnout.
  3. To examine how the hospital workforce is planned to ensure the retainment of staff while ensuring efficiency.
  4. To investigate how the application of Working Time Regulation 1998 by the Royal College of Nursing (RCN) and how it hinders managers from identifying burnout amongst staff.
  5. To examine how absenteeism caused by burnout impact on quality of care.
  6. To identify changes hospitals can implement to minimize burnout amongst staff while maintaining quality care.

1.5 Literature Search Strategy

The search strategy used identified the key terms and concepts, select relevant database and resources, combine search terms with Boolean operators, review, and refine search results. The research data was collected on primary research articles using randomized control trials were electronically identified using the key terms and concepts, selecting relevant database and resources which included; PubMed, CINAHL, SciELO (Scientific Electronic Library Online), Scopus, LILACS, Science Direct (Elsevier), and the Proquest Platform (Proquest Health & Medical Complete). A total of 21 articles were critically examined and analyzed for this study.

1.6 Ethical Consideration

The study adhered to research ethics and respect for human rights. The guidelines of the Belmont report using human beings in research were taken into consideration ensuring respect, justice, and beneficence of the respondents. Considering that the study used secondary data, the researcher did not need to seek prior consent from primary respondents. The materials selected for the literature review were critically examined and analyzed with the aim of hiding sensitive personal information of the participants and avoiding plagiarism. Personal beliefs and reflections were only in the discussion, introduction and conclusion chapters to safeguard results from bias.

1.7 Structure and Outline of the Dissertation

The dissertation has six chapters. The introduction; It has a brief introduction, background of the study, rationale of study, aim, and objectives of the study, ethical considerations, project outline, and a summary. Chapter two is the theoretical framework; this covers; job and demands-resources model, the Maslach theory on burnout, conservation of resources, measurement, and diagnosis of burn out, burn out, and nursing. Chapter three it the methodology; this covers; data collection, inclusion, and exclusion criteria, and ethical considerations. Chapter four covers the finding and analysis. Chapter five is a discussion while the last chapter is the conclusion and recommendation.

1.8 Summary

This chapter gives an overview of the study. It also gives a background of the study that shows the review of the study, the information around it and previous scholars on the topic and relevant history of the study. The chapter also describes the rationale of the study, aims, and objectives of the research, how to search literature, and how to conduct ethically.


2.1 Introduction

There are several theories explaining burnout in the work environment. The study explored the Conservation of Resource model,  Job Demands-Resources model, and Maslach theory on burnout. These theories were selected because they are suitable to illuminate the concept of nurse burnout at the workplace. Measurement and diagnosis of burnout and a discussion on the effects of burnout on nurses.

2.2 Conservation of Resources

Conservation of resources (COR) model has for over the three decades become one of the most widely cited theories in organizational psychology and organizational behavior. It has been adopted burnout, and traumatic stress work environment (Hobfoll et al., 2018). Job resources and demands are the two critical sections of the model. Job demands are the physical, psychological, and social organizations features of the job which span from the workload, work pressures, time management, conflicts, and uncertainty.

Job resources formulate the physical or social structures of the company that are positioned to help the staff perform better at the workstation. It goes beyond explaining the impact of proper leadership, management, working tools, secure working environment, good working relationships, and prospects of promotion on burnout. In this model, when the demands increase and job resources decline, then an impact to both burnout and stress among workers will be evident (Bakker and Demereouti 2018).

However, when there is high job resource, and low job demands, more positive results are bound to happen. The model emphasizes the significance of creating an equilibrium between job demands and job resources. These two aspects depend on one another to form a thriving working environment. Job resources might reverse the adverse effect of job strains. For example, proper leadership, good supervision, and improved relationship with supervisors that can assist decrease work strain.

2.3 Job Demands-Resources Model

Since its development by Professor Arnold Bakker and Evangelia Demerouti in the early twenty-first century, the model has gained high popularity among researchers studying burnout and stress in the work environment. Currently, the JD-R model is referred to as one of the best models to explain job stress and burnout. It drew inspiration from earlier models such as the Effort-Reward Imbalance and Demand Control models. The theorists contended that the already existing models were not sufficient to explain numerous job situations and that they had an aspect of simplicity in them. The Effort-Reward Imbalance model emphasized on issues such as salary while the Job Demand-Control Model centered on autonomy. Majority of work organizations and jobs are complicated, and earlier research indicates a lack of resources and high job demands which require timely solutions. The theorists decided to come up with a model that would cover all persons, companies, and jobs thus backing up the physical and emotional welfare which delivers better results at the workplace. Schaufeli (2017) supports the model by noting that the model clarifies the phenomenon of burnout, mental distancing, and decreased personal efficacy.

The model has garnered considerable empirical support from various scholars. The model presumes that job resources and demands are alienated psychological processes. They attain the fundamental psychological needs while job demands require more efforts and consume many resources. In essence, job demands are likely contributors to health impairment process while job resources enable the attainment of set objectives and therefore raise the level of commitment and engagement via a motivational process. Latest examples have found a relationship between these resources where the resources of the occupation have demonstrated to buttress high demands of the job and therefore safeguard the individual from health issues (Corin and Björk 2016).

The JD-R model is applicable in all occupations; in this case nursing. Job demands are those mental, physical, social or authoritative qualities of the activity that require supported mental or physical aptitudes and this connected with specific physiological and psychological costs. Employment assets are those social, physical, psychological or hierarchical highlights of the occupation that are either operational in achieving work objectives. Reduced work requests and connected mental costs, animate individual development, learning, and improvement hence preventing burnout (Zito et al. 2016). Because the final results of contemporary work are diverse to a range of streamlining of web indexes to the conveyance of individual social insurance, obviously working condition fluctuate among organizations.

Notwithstanding the distinction, the JD-R display proposes that all activity qualities be ordered into two principle gatherings: occupation assets and requests. These elements appreciate remarkable properties and prescient esteem. Occupation requests are the components of work that costs vitality such as current obligations, the outstanding task at hand, and struggle. While unpredictability and the outstanding task at hand can be qualified as test requests that help to perform successfully, clashes are obstacles work requests that debilitate execution. Employment assets are the components of work that help the specialists to manage work requests and achieve their set objectives. For instance, social help and an assorted variety of aptitudes are persuasive occupations attributes that offer centrality to specialists and meet the vital mental necessities self-sufficiency and competency (Bakker and Demereouti, 2018).

2.4  The Maslach Theory on Burnout

The prior research by the scholar did not involve the data of an officially existing together hypothesis and underlined on burnout; essential intrigue had been to think about ’emotions’ which then later came about to enthusiasm for occupation burnout. The past examinations and research on burnout paid attention to giving consideration occupations whereby the individual legitimizing care and the individuals accepting consideration had a relationship. The investigation has expanded to comprise different professions other than human administration. Burnout occurs when there is a confusion between the individual chipping away at finishing the activity and the activity requests. The theory suggests that the individual carrying out the responsibility and the activity requests should coordinate each other to avert burnout. Moreover, burnout comprises three elements of negativity, passionate depletion, or depersonalization and inefficacy.

Emotional weariness is the most unmistakable and distinguishable among the three measurements. Most people encountering burnout experience fatigue. Burnout is related to enthusiastic enduring manifestations including disappointment, grouchiness, fomentation which manifest as inability to endure the passionate and physical attributes of the activity. In any case, the inadequacy of feelings adversely impacts physical skill. Such situations make people act in a way that does not line up with their work, and the victims are not ready to endure the activity requests. Cynicism and depersonalization is the second dimension of the theory. Depersonalization makes persons distant to each other and the job and results to negative emotions. Such situations are occasional, and occur when the person is incapable of associating himself with the job demands resulting to nonparticipation.

Emotional exhaustion influences the second dimension. Job dissatisfaction happens in this dimension and individuals are considered as objects rather than human beings. Lastly, inefficacy is the third dimension of the theory. This dimension is more sophisticated than emotional suffering and cynicism. In this dimension, a nurse experiences a general sense of incompetence and unworthiness after self-evaluation. Due to this, there is a decrease in individual attainments. This theory points out that burnout negatively influences the nurse’s performance, turnover, and the relationship among persons. In this regard, poor job person is a result of continued work after experiencing burnout. 

The Maslach theory of burnout articulates that prolonged reactions to chronic sensors on the occupation can nurture negative emotions of incompetence, distant and negative attitudes towards the job colleagues and the employer or management. Job burnout constitutes the dimensions of depersonalization, emotional exhaustion, and decreased individual attainments which can happen among staff who work with persons in some capacities. Depersonalization is the negative, detached and distinct attitude towards work and distancing of an individual from others in the organization and outside stakeholders. As illuminated, decreased individual accomplishment is the emotions of ineptitude and an observed lack of job productivity.

The theory acknowledges six risk factors that could cause a mismatch between the job and the individual: the lack of fairness, workload, control, community, reward, and values. It is remarkable to attribute that workload is the aftermath of this deed. There has to be an equilibrium between resources and demand to satisfy the demands. Time to complete the remaining task and accessibility of assets to empower the activity requests is vital. The absence of control might be affected by the absence of active contribution in the association which makes people feel less critical or underestimated. After some time sentiments of being ‘caught’ might happen which causes anxiety to rise causing burnout. Inadequate rewards, such as the absence of acknowledgment and appraisal for positive results. Positive prizes shape conduct and construct inspiration. Steady analysis prompts low spirit and withdrawal. Breakdown of the network, working associations, is seen as a network. Elements are vital. Setting up a decent association with coworkers is critical. The breakdown in the network can prompt the absence of help, no collaboration, uncertain clashes, and work environment harassing. Nonexistence of logic, justice, and decency are essential angles in working associations that cause burnout. If there is an occurrence of absence of decency or separation, criticism may happen. Conflicting with one’s qualities on account of occupation requests can produce pressure and sentiments of skepticism.

2.5 Measurement and Diagnosis of Burnout

Burnout is a condition of physical, emotional, and psychological fatigue that is a result of extreme and extended stress. It happens when an individual feels physically and emotionally drained unable to meet expectations at the workplace, and feels overwhelmed. When an individual has burnout, they lose interest and the motivation that led them to choose a career. Exhaustion saps an individual’s energy leaving them feeling helpless, skeptical, desperate, and bitter. Hence leads the person experiencing burnout to feel like they are no longer useful in their places of work (Maslach, 1997).

The process of diagnosis, management, and treatment of burnout begins with acknowledging the existence of the problem. The most common tool used to measure burnout is the Maslach Burnout Inventory (MBI) developed in 1983 by Jackson and Maslach (Appendix 1). This tool has subtypes such as Human Service Survey (MBI-HSS) which were designed primarily for human service-related occupation such as nursing (Maslach and Jackson, 1983).

MBI is used in the occupational institution to determine and measure the risk and prevalence of burnout in workplaces. Most of the material used in this research used MBI in estimating burnout among nurses. This assessment tool comprises three sections;  part A and B have seven questions each, while part C has eight issues. The first section uses physical symptoms to identify the presence of burnout. A score of 30 and above shows the presence of high burnout level, while a score between 18 and 29 indicates a moderate level of burnout. A score below 18 indicates low burnout level. In the second section, the tool measures a persons’ negative attitude towards the work environment; such as feelings towards the colleagues and the job. It also determines a person empathy level toward the patient’s or colleagues. The much the nurse withdraws and shows a sign of low involvement, the higher the level of burnout. A score of 5 and below shows a lower level; a score above 12 shows a high level while a score between 6 and 11 indicate a moderate burnout. The third section, section C, is determined by the first two parts of the tool.

Maslach burnout inventory is a useful instrument used globally as a tool for measuring the danger of burnout globally. In this section, when the score is 30 or below, it signifies a high level of exhaustion. At this point, a person is at a ‘low point.’ At such level, the burnout is high enough to hinder the employee’s performance.  The nurse may show emotional distress characterized by low self-esteem. The score above 40 is indicating low levels of burnout while a score of 34 and 39 shows a moderate level of burnout (Jeremy et al., 2015).

2.6 Burnout and Nursing

The prevalence of stress and burnout among nurses is a common phenomenon. It is caused by a demanding and stressing work environment. The high cases of burnout in nursing are a threat to the health care system and the well-being of the patients. Many studies reveal that there is a high rate of burnout among nurses, and particularly in those serving in hospitals; Europe, Asia, and North America report a high incidence of burnout. A study done in Finland with a sample of 723 nurses, nearly half of the nurses indicated that they experienced burnout, frustration, and job dissatisfaction. Elderly, secondary level nurses and those working in psychiatric departments experienced the highest level of burnout (Jeremy et al., 2015).

A survey conducted by Zahiri et al. (2014) on a sample of 61 revealed that 24.5% of the sampled nurses experienced burnout and that only 8.19% of the participants had worked for 15 years or more which means that most nurses opt for early retirement when they can no longer handle stress at work. The levels of emotional fatigue were at 45.9%, depersonalization 40.9%, and personal inefficacy at 70.4% for nurses in this study.

There exist a link between a shortage of nurses and job dissatisfaction, burnout, and stress. In a systematic review, the findings disclosed a positive bidirectional association between the shortage of nurses and burnout among nurses working in accident and emergency section. There are two types of burnouts,  the nurses who are absent from work and those that are at work but not efficiently providing quality care. The degree of the stress, job dissatisfaction, and burnout encountered by the oncology registered nurses and their view of recruiting inadequacy varied based on their work settings and demography. Nurses who hold high positions in the sector and those who worked inpatient environment and non-Magnet hospitals were more probable to attribute insufficiency of staffs as one of the key contributing aspects of their stress, burnout, and job dissatisfaction. In essence, the burnout caused many accidents and emergency nurses to quit (Fiona et al., 2016).

2.6.1 Causes of Burnout on Nurses

According to Jeremy et al. (2015), the leading cause of burn out is the conditions in the work environment, where personal risk factors vary depending on individual vulnerability where the personal risk factors include personality traits and demographic variables. The work environment that causes burnout includes; work overload, poor interpersonal relationships with other nurses, insufficient reward, unfair treatment of nurses, conflict in value and job description, and inefficiency in job performance. Personal risk factors resulting in burnout include; family status, age, education background, gender, race, and personal traits. The workload is the primary cause of burnout caused by inadequate staffing in medical care organizations a study of 665 hospitals indicated that 20% had a patient-to-nurse ratio of seven or more, while 25% had a ratio of four or less. High patients nurse ratio consumes nurses time for innovation, research, and interact with the patients. The research shows that the patient-to-nurse ratio in England high; hence nurses work for many hours causing fatigue and stress.

            Low salary and poor management demotivate nurses and reduce performance and quality of patient care. These factors lead to high turnover, and most nurses intend to change career. Salary is a drive to motivation leading to performance. Poor management is a factor that causes nurse burnouts. Management plays an essential role in the control of health care institutions. It provides enough resources for the nurses to deliver quality care an innovation (Zvauya et al., 2017)

 According to Leiter and Maslach (2009), poor communication and collaboration increases chances of nurse burnout. If the nurses do not collaborate with others, it becomes hard for them to deliver quality care. Communication is also a factor that leads to chances of burnout. The nurses and management should take communication as a crucial factor that contributes to the running of a hospital. Without proper communication, the management cannot give clear instructions to nurses. Most nurses do not get opportunities to advance their studies due to work related commitment caused by low nurse-patient-ratio. Inability to acquire higher credentials hinders career progression.

2.6.2 Impact of Burnout on Patients

According to Hayley et al. (2015), nurse burnout contributes to infections in hospitals. Studying nurse staffing, burnout, and healthcare-associated infection, the researcher, found that there was a statistically significant difference between urinary tract infection and patient to nurse ratio (0.86; P = .02) and surgical site infection (0.93; P = .04). In a multivariate model for regulating patient severity and hospital and nurse features, only nurse burnout remained statistically significant to urinary tract infection (0.82; P = .03) and surgical site infection (1.56; P < .01). Arguably, hospitals, whereby burnout was decreased by 0.3, had a total of 6,239 fewer infections in a year. Consequently, the survey offered a plausible illumination for the link between nurse staffing and health care linked infection.

Burnout has personal, professional, and organizational consequences to the nurses (Net CE, 2018). Some of the personal consequences burnout have on nurses are poor physical and mental health as a result of stressors, low job control, work overload, minimal teamwork among nurses and other health assistants, high job demands, and job dissatisfaction. Other severe cases resulted in high rates of musculoskeletal injuries and musculoskeletal disorders were among the nurses with job dissatisfaction, poor work scheduling, poor interpersonal relationships, and decision making. 

The professional and organizational consequences caused by burnout are cases of decreased productivity during their shifts, absenteeism and in extreme situations; some leave their jobs which is a result of decreased confidence, morale and motivation. Such situations create an unsympathetic attitude, causing careless decision making, lack of innovation and fresh ideas since they do the bare minimum. Consequently, it lowers the nurse-patient ratio and raises the job turnover among nurses resulting due to job dissatisfaction, and burnout. Burnout also leads to nursing errors resulting in poor patient care where in extreme situations, patients are administered the wrong medication, or given at the wrong time. Mortality levels increase where burnout is high since, with the low nurse-patient ratio, one nurse has more than six patients. In a study done in England by Net CE, (2018), if one nurse had to attend to one or two patients, nurses would have saved an estimate of 25 lives per 1,000 hospitalized patients and 15 lives per 1,000 surgical patients.

2.6.3 Effects of Burnout among Nurses

The consequences of burnout among nurses are alarming. Leiter and Maslach, (2009) report that there are three dimensions of burnout. These are emotional suffering, depersonalization, and efficacy. When nurses encounter at least one of the aspects, then the overall job productivity reduces. The condition has resulted in daring consequences in welfare, the safety of patients, quality of life, and quality of care offered. Moreover, according to (Klein et al., 2018), burnout causes depression among nurses leading to high job turnover. A survey that involved 68, 000 registered nurses in 2007 registered inpatient nurses, nearly 43% of the nurses had a great extent of emotional suffering. The study documented that 37%, of nursing home nurses, 35% of hospital nurses, and 22%  of nurses working in other environments encountered high levels of emotional suffering.

Burnout lowers the levels of patient satisfaction in the hospital. According to Dall’ Ora et al., (2015), the patients nursed in units with sufficient employees, proper management of nursing care, and functional relationship between the nurses and physicians were more than twice likely to record high contentment with care. Also, nurses in such environment showed significantly lower exhaustion and burnout. In essence, the higher the levels of job burnout, the lower the patient satisfaction.

Burnout influences the level of job turnover among nurses. Leiter and Maslach, (2009), studied 667 Canadian nurses to understand the relationship between burnout and nurses turnover. The result showed that the working environment and social-economic factors played a significant role in job turnover. The turnover trend is a threat to both the welfare of patients and nurses. It is evident that high turnover would lower nurse-patient ratio further worsening the already bad situation. It is essential to understand the relationship between stress, job satisfaction, and burnout. Khamisa et al., (2017) conducted a study with a sample of 895. The study showed that stress is a better predictor of burnout and general health than the level of job satisfaction. The study recommended urgent measures to address personal and occupational stress in the workplace.

According to Nantsupawat et al., (2016), the emotional state of nurses is significant in determining the quality of care provided to patients. The study disclosed that 32% of nurses documented immense emotional suffering, 35% low personal attainment and 18% high depersonalization. Nonetheless, 16% of the nurses considered the quality of care on the departments as poor or fair, 14% documented infections, 11% reported medication errors, and 5% reported patient letdowns. The study linked the three subscales of the MBI to rising reporting of poor or fair quality of care, medication mistakes, infections, and a decline in patients visit. Each unit of augmenting emotional exhaustion score linked with 2.63 times increase in documenting the poor or fair quality of care, a 30% increase in patient falls, a 32% rise in infection, and 47% rise in medication errors. The finding of the study is that nurse burnout linked to the increased odds of documenting negative patient results. In essence, enforcing interventions to decrease burnout among nurses is essential in enhancing patient care.

2.6.4 Management of Burnout among Nurses

Based on available literature, the work environment is a significant factor that causes burnout and stress; modifying it has the potential to reduce burnout. Some of the ways of managing burnout is improving personal lifestyle, professional lifestyle, and organizational levels. Personal lifestyle includes; obtaining adequate sleep, proper nutrition, regular physical activities and meditation, self-reflection, identifying and maintaining priorities, recognizing own limitation, and seeking emotional assistance when necessary. Professional lifestyle includes; varying work routine, setting achievable goals, interpersonal support from other nurses, and practical communication skills. Organizational level includes; creating a good work environment, providing access to training where necessary, maintaining strong leadership roles, and participation in decision making that concern providing quality patient care. It is important to note that, it is cheaper and easier to prevent burnout that resolving it once it has occurred, thus, essential to prevent accumulation of stress.

Referring to Fryer et al., (2016), assessing the confidence of nurses and other health practitioners have and its effect on the provision of quality care. The patient’s perception showed that the level of confidence among nurses influenced the quality of services provided. Poor hospital work environment and lack of teamwork and social support affect the confidence, morale, and motivation of nurses.

2.7 Summary

Burnout affects both the emotional, social, and physical state of the nurse, as well as the provision of quality care to the patients and patient safety. Organizations and institutions should focus on creating a good work environment for nurses so that they can feel included among their colleagues and their supervisors.  Such measures ensure that nursing patterns organized for effective delivery of patient care.


3.1 Introduction

The researcher carried out a literature review for this dissertation. The databases consulted were Proquest Health & Medical Complete. The terminology ‘Literature’ is a gathering of academic, scholarly writings which are non-restricted to scientific articles, books, dissertations, and conference proceedings. Literature reviews formulate an incessant evolving network of scholarly works that are interrelated. A proper literature review is developed and elongated on already coexisting earlier research and studies on related topics. The description of a literature review constitutes six conceptions which are: List, knowledge enhancer, search, survey, a report, and a guideline.

3.2 Research Design and Quality Assessment

Based on the nature of the set research aim, this study is Argumentative since it involves critically reviewing the literature in order to support or disagree with its findings the causes of burnout of nurses in England.

3.3 Data Collection and Analysis

It is essential to note that the data collected and the research papers used are to the topic and the aim of the study. Through the latest library guide page, the study used the following to search research article: Cinahl (EBSCO), Academic Search Elite (EBSCO), The Cochrane Library, Nursing Collection 1 (OVID), PubMed, Sage and Science Direct. The initial step entailed searching for the article through the entire databases using various keywords ‘nurses,’ ‘burnout,’ England,’ and ‘patients care.’ Science Direct, EBSCO, and PubMed generated the most detailed and relevant results based on the keywords. The above keyword generated a total of 9567 findings.

The author also compiled data from secondary databases including PubMed, CINAHL, SciELO (Scientific Electronic Library Online), Scopus, LILACS, Science Direct (Elsevier), and the Proquest Platform (Proquest Health & Medical Complete). Other sources used were journals and periodicals among other authentic sources. Therefore, the conclusions made in this study are regarding the impacts of burnout amongst nurses and how it affects the quality of care based on the reviews of past data on how other authors have written about the impacts of burnout as well as personal reasoning or rational deduction of the researcher.

3.4 Inclusion and Exclusion Criteria

The study used the following inclusion criteria: the study was a primary study published in an internationally recognized journal with an editorial board and peer review. Also, included primary quantitative studies that used the Maslach Burnout Inventory for burnout assessment in primary care nurses. The study included only after 2012.

The study excluded studies of non-working populations like trained nurses that did not enter into the profession after their studies. This decision was important as these nurses would not provide accurate experiences compared to the working population. However, the study included other findings published in England including editorials, letters to editors, commentaries, trials, literature reviews, abstracts, qualitative studies, studies that reported only a cross-sectional analysis, studies that reported instrument validation or research method, and follow-up studies with a comparison group or treated had burnout as a dependent variable. The final sample for the study was n=21 studies.

3.5 Ethical Considerations

Before the writing of the thesis, the author derived the principles of good scientific practices through a detailed study of scientific research guidelines. Important element noted include acknowledgment of research used, fabrication of data, and ethical carelessness (Pliva et al. 2014). The importance of using Arcada library to access educational websites such as Science Direct and EBSCO to avoid illegal retrieval and use of data was also noted. The materials selected for the literature review did not require to be critically examined and analyzed with the aim of hiding sensitive personal information of the participants since this was a secondary research. Also, the study considered the guidelines of the Belmont report using human beings in research. The report gives three ethical principles of research that used people as the subject of the study. These principles are respect, justice, and beneficence. Other critical ethical practices used were the importance of avoiding plagiarism.

3.6  Summary

This chapter details out a systematic review how different primary studies and secondary data sources were used to assess, impacts of burnout on the quality of care including a detailed description of various steps followed by the researcher.  


4.1 Introduction

The findings of this research will be used to conclude the causes of burnout to all the nurses including the A&E nurses. This is an analysis of the research findings from the analysis of the literature used. Data were examined using thematic analysis and constant comparative methods. Findings and analysis focused on answering the research objectives of the report.

4.2 Explore The Epidemiology On Burnout In Hospital Settings

According toJeremy Dale et al., (2015), there is a high rate of early retirement, and the nurses tend to reduce working hours. In a sample of 1192 working A&E nurses, 978 (82%) intend to quit the general practice, go on a career break or reduce working hours in the next five years. This involved 488 (41.9%) who intend to quit the work and about a quarter 279 (23.2%) indicated that they need a career break while 67 (5.6%) planned to add their clinical working hours. The respondents who intended to leave the GP stated that the reason was the volume and intensity of workload, time wasted on unnecessary tasks, the introduction of seven working days, and no job satisfaction. The main objectives were the impact of work pressure, the diverse nature of workload, and the continuous stress. Reduction of workload intensity, the volume of work, administrative activities, increased the duration of patient care, no out of hour commitments, flexible working conditions, and clinical autonomy were the crucial requirements to reduce the workforce crisis.  However, it is essential to increase their pay, giving incentives, and time for education and training.

Nurses are affected by long working hours in most hospitals, nurses work in 12 hours shifts, and this affects job satisfaction, employee well-being, and they tend to quit work.  According to Chiara Dall’Ora et al., (2015), working for more than 12 hours were recorded higher than the nurses working 8 hours or less. In a sample of 8606 nurses (27%) reported working overtime on their last shift. Distribution of shift length on a personal level and in most hospitals, nurses taking 12 hours shifts were less than 15%. Nurses working 8 hours or less recorded fewer cases of burnouts than 12 hours or more shifts.

A study conducted through online questioners on work-related pressure, job autonomy, anxiety symptoms, depression, emotional exhaustion and depersonalization using Maslach Burnout Inventory model,  Atir et al., (2018) revealed that burnout led to high prevalence rates in all poor health measures: depersonalization (20.7%), emotional exhaustion (38.7%), symptoms of depression (36.1%), and anxiety symptoms (43.1%). The analysis indicated that job autonomy has significantly reduced burnout. The study used a sample of 593, which was evenly distributed among England (32.5%), Scotland (35.4%), and Wales (32%). The majority of the participants were male (63.1%) aged between 41-50 years (45.5%) and 51-60 years (31%). There were eight groups represented in total with the majority being A&E nurses working under physicians (28.8%), under surgeons (18.2%), under anesthesiologist (14%) and others (15.7%). Four out of 10 consultancy firms reported a high number of anxiety symptoms and a third of the respondents were having high symptoms of depression, and (38.7%) were emotionally exhausted, and (20.74%) depersonalization. The study shows the importance of preventing burnout. If the hospital management addressed the documented issues, hospitals will not experience high nurses’ burnout.

4.3 Factors that Lead to Burnout

Research have identified several factors that lead to nurses’ burnout; inadequate nursing staffs in hospitals, overtime, fear of not completing tasks, job demand, job complexity, lack of professional recognition, respect, or reward, conflicts, ineffective managers. The survey also outlined themes contrasting management and staff care perspectives. The research realized that many staff care is not known as persons in their rights by their employing institutions. The general lack of acknowledgment on the job is done, caring within regular duties in the hospital leads to employee burnout. They further stated that maintaining nurse’s wellbeing have significant effects on the care of residents. Higher job satisfaction is related to lower burnouts, raised global empowerment, organization support, increased psychological empowerment, the cohesion of work groups, and personal achievements.

Kerasidou at al. (2019) studied austerity measures and the transforming role of accident and emergency(A&E) professionals in a weakening welfare system. There is an increasing need for services and resources, the change of A&E patients changing the meaning of A&E from ‘Accidents and Emergencies’ to ‘Anything and Everything.’ The study also shows that harsh policies tend to change the behavior of healthcare in A&E. The policies focus on the processes, time-keeping, and the operation. Healthcare is considered to withdraw from values such as empathy in interactions with patients. The policies also hinder the morale and motivations of nurses. The concepts of moral danger and burnout analyses the experiences and feelings of being devalued. The study concluded that harsh policies cause a change in practice and functions in the A & E professionals leading to burnout.   

Referring to Lori (2015), the factors that lead to burnout include; workload: if the nurses are overworked they get demotivated; self control: nurses are not able to perform their tasks as supposed; insufficient reward: lack of recognition of nurses contributions in the hospital leading to no chances to advance; absence of community: poor work relationships and poor leadership and insufficient supervisory support; absence of fairness: poor salaries that does not comensulare the workload; and conflict in values: disagreements on job requirements and nurses personal principles. Also the study found that the level of burnout is affected by age, race, family status, educational status, personality traits, and gender.

4.4 How Hospital Workforce is Planned to Ensure the Retainment of Staff While Ensuring Efficiency

Previous research have established that patients liked nurses who worked as a team, treated them individually, and collaborated in work helping them to recover. Himanshu et al. (2015), indicated that inpatient wards in mental health department is a stressful unit to work, and concerns have been raised to cater for the quality of nurse wellbeing and patients care in the wards. Recent research shows that nurses use professional autonomy to perform their clinical work and improved staff morale. Nurses like being recognized and be valued in their hospitals. More interactions between nurses and patients in the wards reduce violent situations. Participating patients said they observed staff closely and were concerned about their well-being. The patients helped the nurses work together reducing nurse stress and unfortunate incidents in the wards. Some patients modified their behaviors to support staff well-being.

According to Erhabor (2014), the National Health Service (NHS) is a public delivery system offering quality health services in England and the United Kingdom. Medical laboratory provide quality care for patients including quality medicine where over 70% diagnosis are done by nurses. The research gave information on working conditions of a nurses of NHS in England. Reducing pressure in the working environment reduces human error and results to quality patient care. Negotiation of better pay and career structure should be responsive to the needs of an individual, professional group, training curriculum, and nature of work done that support attainment of individual goals. The data alsoshowed that there is a high rate of early retirement and the nurses tend to reduce working hours. In a sample of 1192 general practice nurses participants indicated that 978 (82%) intend to quit the general practice, go on a career break or reduce working hours in the next five years. This involved 488 (41.9%) who intend to quit the work and about a quarter 279. Approximately 23.2% indicated that they need a career break. The respondents who intended to leave the GP stated that the reason was the volume and intensity of workload, time wasted on unnecessary tasks, the introduction of seven working days and no job satisfaction. The main objectives were the impact of work pressure, the diverse nature of workload, and the continuous stress. Reduction of workload intensity, the volume of work, administrative activities, increased the duration of patient care, no out of hour commitments, flexible working conditions, and clinical autonomy were the crucial requirements to reduce the workforce crisis.  However, it is essential to increase their pay, giving incentives, and time for education and training.

4.5 The Working Time Regulation 1998 in (RCN) and How it Hinders Managers from Identifying Burnout.

Health boards have improved the monitoring processes to ensure managers adhere to set working hours for nurses. The working hours range from 8 hours to 12 hours which should have a break in between.  In a study done in England by Royal College of Nursing (2015), 71% of the nurses working in England, work beyond their contracted working hours, where they work one to five hours unpaid each week. 13% work an extra six to ten hours per week. While 16% work an extra ten hours each week. It implys that the nurses do not have adequate breaks in between the working hours causing burnout which affects their quality of service provision. The long working hours do not provide the nurses with a platform for open communication with their managers which is caused by problems at the organizational level. Consequently, it creates a frustrating work environment and routine eventually leading to job frustration. Such work environment hinders managers’ from identifying stress, depression, and burnout among nurses, affecting the institutions quality of health care provision.

Working Time Directive (WTD) has implemented new guidelines, changing working hours for nurses from 48 hours per week form 56 hours per week. The change in working hours reported an improvement in quality of care and a rise in the standards of the quality of patient care. A&E, ICU, and surgical nurses are among the specialist areas for which the royal college of Nursing (RCN) recommends minimum work hours. Such directives is intended have breaks in between shifts; however, is not the case. Currenly, they work for 10 to 12 hours, reducing the concentration levels they give to patients and affecting the quality of patients care. With long hours, nurses are not able to have team building activities, which reduces the time they have to refresh and engage work with their managers and supervisors.  Such work environment hinders managers from identifying early cases of burnout, and it is until there is a substantial reduction in quality of work that they see the challenge affecting the workplace (Fernandez and Williams, 2018).

The RCN guidance on shift working (RCN, 2013), identified that there had been a debate on the pros and cons of 8-hour shifts and 12-hour shifts. This is an indication that there is a difference in the quality of patient care and the emotional and physical state of nurses. The survey stated that 30% of the nurse preferred the 12-hour shifts since they would have fewer shifts per week and have more time to take days off. However, the long hours and minimal rest between the breaks have caused burnout affecting services offered to the patients. This has been associated with an increased risk of errors compared to the ones who took 8-hour shifts. Most companies provide clinical psychologists to help out patients with stress, depression, burnout, and trauma. With the long working hours, nurses do not hold regular meetings with psychologists, hindering the managers and supervisors from identifying nurses who are being affected.

4.6 Effects of  Absenteeism on Quality of Care.

A study was done in England DAK-Gesundheit health insurance, 1267 nurses were used. The data was in regards to sick leaves and absenteeism in a twelve months duration. Negative and Positive Predictive Values (NPV and PPV) for a 12-month duration for absenteeism and sick leave were calculated. To assess the association between absenteeism and sick leave during follow-up, a multiple ordinal logistic models (proportional odds model) was applied. Of the respondents, 719 reported a high number of absenteeism and sick leaves while 548 had less absenteeism and sick leaves during the follow-up period (Klein et al., 2018). This means that there are more cases of absenteeism and sick leaves in England. The data obtained from the health insurer was combined with secondary data to ensure that it was feasible.

According to Yasuhiro et al. (2018) I a study addressing the availability of nurses at work and the emotional state for the nurses who are available at work. The depression anxiety and stress scale (DASS), was used to assess the respondent’s stress and anxiety levels. The phrases “I felt that I had nothing to look forward to,” “I felt I was close to panic,” and “I found it difficult to relax” were used to measure depression, anxiety, and stress respectively. The values obtained ranged from 40-60% for depression, 30-40% for anxiety, and 40-65% for stress. This scores indicated that nurses in England had severe depression and anxiety which led to burnout and affected the quality of patient care and attendance at work.

Currently, nurses have 12-hour shifts. However, there is growing concern that these long working hours are affecting the mental and psychological health of nurses leading to absenteeism, and intentions to leave their current jobs. Referring to Dall’ Ora et al., (2015), in a study to assess absenteeism and intention to leave the job, as a result of rigid work schedules, burnout, depression, and job dissatisfaction. A survey conducted on 31,627 registered nurses in 488 hospitals across 12 Europe, including England. Nurses working shifts of 12 hours, were more likely to be absent from work regularly, owing to emotional exhaustion, burnout, and depression. They were more likely to have high job dissatisfaction

According to Dale et al. (2018), a study was done assessing whether nurses wanted to maintain their careers in the next five years. Using a random sample of 978 nurses in England, 82 % had the intentions of either reducing working hours or took a break. Those with intentions of leaving the practice, 66% were male, and 34% were female aging between 40 to 59 years. Stepwise logistic regression analysis (SLRA), identified; work experience, gender, age, and monotony at the workplace as the main reasons why the respondents wanted to leave work or reduce their working hours within five years. The results indicate that most nurses are not happy with their current careers which affect the nurse-patient ratios alternatively affecting the quality of patient care.

4.7 Management of Burnout to Maintain Quality Care

According to William and Sonia (2015), the quality of interpersonal relationships among A&E nurses and patients is at the core of good management in a hospital. The study reported that nurses spend only 40% of their time in direct contact with patients. This affects the quality of services provided and job satisfaction. In England, initiatives have been put in place to allow nurses and patients to interact more consequently improving patient and staff morale. Increasing the time spent among the patients for nurses and improving communication skills also supports positive patient engagement. If successful, such ideas would have a positive influence on producing favorable results for staff morale and the patient experience.

Fryer et al., (2016), conducted a study done in England, to assess the confidence of nurses and other health practitioners and its effect on the provision of quality care. A cross-sectional survey on 66,348 hospital patients in 61 hospitals across England. The patients were asked to rate the confidence of the nurses that attended to them, and how it affected the quality of care. Results of the patient’s perception showed that the level of confidence the nurses had significantly affected the quality of services they delivered to the patients. Poor hospital work environment also affects the nurses’ confidence. This means that there is a need to mentor, motivate and increase the morale of nurses, to maintain and increase the quality of care.

According to Fiona et al., (2018), protected engagement time (PET) is an essential aspect for managing staff time to ensure their attention is focused on patient care and quality of service provision. This ensures that there is an acceptable nurse-patient ratio by increasing staff and patient interaction. The study involved the administration of questionnaires, consistent collection of clinical data, observation tools with questions addressing the issues of managing burn out to ensure quality service. The researcher assessed the interaction-observation checklist (IOC) and the Camden staff-patient activity record (CaSPAR) in England. The study used 28 observations, with a maximum of 10 observations per week to develop a conclusion. The study concluded that nurses should not be overworked. All departments should have an acceptable nurse to patient ratio. The hospital should be able to hire more nurses and allocate sufficient nurses where needed.  

Nursing demands critical care to the patients in the intensive care unit (ICU), which can be a significant cause of stress, depression, and burnout. A study conducted on 58 doctors and 38 Nurses in England to assess ICU-related causes of stress, depression, burnout, and risk of work-related ruminations. The results showed that 80% of the health care professionals had varying cases of depression, affective rumination, and burnout. Long working hours and the intensity of the work environment, were considered as the leading causes of burnout. It is important to often screen nurses working within the ICUs, Wards, A&E and other intense departments to ensure that signs and symptoms of burnout are identified early to ensure that high standards of patient care are maintained (Vandevala et al., 2017).  

4.8 Summary

Factors that contribute to the burnout of nurses including the A&E nurses are inadequate nurses to convenience the maximum time a nurse is required to work in a day, job demands, lack of rewards and motivation, conflicts, and incompetent management. These conditions force nurses to withdraw their service in early retirement or migrate to other professions leaving inadequate A&E nurses in the profession. The small number of nurses will eventually overwork to meet the expectations of the patients leading to serious burnout.


5.1 Introduction

This is an in-depth explanation of the findings and analysis done in chapter four. Burnout on A&E nurses is synonymous to the usual burnout on general nurses. Therefore, the findings of the general nurses can be used to conclude the causes and effect of burnout on A&E nurses. The chapter provides a discussion of each objective of the study. It provides a discussion of the results analyzed in the earlier chapter.

5.2 Discussion on main  objectives of the study

The study shows that nurses are working 8-hours or less recorded a few cases of burnouts than 12-hours; this indicates that nurses get overworked leading to fatigue. The GPs experience a high level of stress emotional exhaustion, feelings of depersonalization. There is a need to deal with these issues to prevent burnout and encourage GPs to develop interests of working promoting job satisfaction retaining the workforce.

The study gives evidence of how GPs across the career path is going through; work overload, lack of control, insufficient reward and conflict leading. Such factors lead to nurse burnout.  Job satisfaction is related to lower burnouts, raised global empowerment, organization support, increased psychological empowerment, the cohesion of work groups, and personal achievements poor relationships and work leadership and inadequate supervisory support increase burnout among nurse. This is applicable to the A&E nurses and we conclude that fatigue is one of the causes of burnout affecting them.

Policies that affect nurses negatively in hospitals should be implemented to ensure professional satisfaction and reduce nurses burnout. There is a need for adequate staffing in all departments, fair pay of nurses, implementation of corrective actions, and identifying potential sources of turnover. Giving 8-hours shifts gives the nurses time to rest avoiding errors that would have been caused. To prevent burnout and to encourage GPs nurses, hospitals should develop strategies and protect interests that may affect health care, promoting job satisfaction, and morale to retain the current workforce. Also, the A&E nurses requires to be well remunerated, work less hours following short schedules to ensure that they have sometime to do their duties and rejuvenate their energy.

The answer on whether working hours should be 12 or 8 is still not clear. New structures for professionalism and organization at the workplace are being put in place to ensure that managers and supervisors identify stress, depression, and burnout in nurses early. To identify the signs of burnout, managers should provide clinical psychology for the nurses, open communication medium between the management and nurses, provision of team building and retreats, and work compensations for extra work shifts. This is because nurses and other health professionals in England are becoming more significant both in the short term and long term, to ensure quality provision of services to patients.

Sick leaves, absenteeism, and resignation for nurses are attributed to depression, burnout, and job dissatisfaction. Nurses should have enough rest between work schedules, flexible work schedules, reducing workload intensity and volume, out-of-hour commitments, frequent work motivation, and incentive payments. This will ensure that nurses are confident and comfortable at work, leading to job satisfaction.

Improved models for professionalism and organization in management are being implemented, reducing the worsening workforce crisis in England. This can be done by improving the work environment, patient and staff morale. Increasing the time spent among the A&E nurses and improving communication skills supports management of burnout. Psychological distress and trauma among nurses can be managed by providing clinical psychiatrists.

5.3 Summary

Improving the physical, psychological and mental state of the A&E nurses raises the standards of quality of patient care.


6.1 Introduction

This chapter entails the conclusion and recommendation of the study on the impacts of burnout on A&E nurses and how this affects the standards of patient care.

6.2 Conclusions

Burnout is prevalence among nurses in England and the adverse effect on the quality of care. To achieve this, primary data was sourced from leading databases such as; PubMed, CINAHL, SciELO (Scientific Electronic Library Online), Scopus, LILACS, Science Direct (Elsevier), and the Proquest Platform (Proquest Health & Medical Complete). The study addressed the diagnosis of burnout, where the nurse tends to lose interest and the motivation that led them to choose the career. Exhaustion saps an individual’s energy leaving them feeling helpless, skeptical, desperate, and bitter. Hence leads the person experiencing burnout to feel like they are no longer useful in their places of work.

The study addressed burn out, the causes, impacts, effects, and management of burnout, in the main objectives which were as follows; To explore the epidemiology on burnout in hospital settings. To identify the factors which lead to burnout. To examine how the hospital workforce is planned to ensure the retainment of staff while ensuring efficiency. To investigate how the Working Time Regulation 1998 is applied by the Royal College of Nursing (RCN) and hinders managers from identifying burnout amongst staff. To examine how absenteeism inflicted by burnout impact on quality of care. To identify changes hospitals can implement to minimize burnout amongst staff while maintaining quality care.

Long working hours with minimal rest in between, leads to burnout, reducing the quality of patient care. Flexibility in work schedule, adequate supervisory, open communication and team building, reduces the chances of burnout among the staff. The nurses who already experience burnout cases require clinical psychologists o help through the trauma, improving their condition and reducing absenteeism, sick leaves, and nurses turnover. There is a need for adequate staffing in all departments, fair pay for nurses, implementation of corrective actions, and identifying potential sources of burnout.

Based on systematic review, this study concludes that, A&E nurses should not have long work hours, flexible work schedule to reduce monotony, have adequate break in between the shifts, have the support of clinical psychologists, open communication with the managers and supervisors, team building to raise the levels of morale, motivation, and confidence. These measures will improve the physical, psychological and mental state of the nurses raises the standards of quality of patient care.

6.3 Recommendations

Nurses who work in accidents and emergency, ICUs and other intense departments have high cases of burnout. This is because these departments are characterized by overcrowding, confrontations, unpredictability, a wide range of infectious diseases, traumatic events and injuries. The job demand is very high, with a high level of stress and emotional exhaustion, job depersonalization, minimal job controls, and social support. Managers and supervisors need to pay more attention to these departments to prevent turnover, illnesses, and burnout.

At an individual level, nurses should identify the primary source of stress at the workplace, use teamwork as a support network, practice self-care, find a hobby or interest to distract them during work breaks, and have open communication with the managers and supervisors. To reduce the chances of burnout for the A&E nurses at the hospital, managers and supervisors should reduce the chances of conflict at work. This will ensure job satisfaction, raise global empowerment, organization support, increased psychological empowerment, the cohesion of work groups, and personal achievements. 

Adequate staffing in all departments, fair pay of nurses both for work done during their shifts and those who prefer to add some extra shifts. This ensures that they have adequate workload ensuring efficiency, implementation of corrective actions, and identifying potential sources of turnover. Hospitals should create a nurses burnout advisory council led by the hospital management. Frequent surveys should also be done in departments that need critical attention from the nurses; for example; A &E, ICU, and surgical nurses. The hospital should have respect for all the nurses and other health representatives, empower workers in various departments, solve the problem immediately when they arise and have clear goals and alignment of the hospital`s goals, and objectives. This will ensure the provision of quality patient care.

New structures for professionalism and organization at the workplace, including clear work schedules and workloads, ought to be put in place to ensure quality provision of patient care. The managers and supervisors should also identify stress, depression, and burnout in nurses on time. To identify the signs of burnout on time, managers should provide frequent clinical psychology for the nurses, create an open platform for communication between the management and nurses, providing team building and retreats, work compensations for extra work shifts. This ensures that the nurses identified with cases of burnout are assisted, thus, improving work outputs.

Promoting job satisfaction, confidence and morale will help to retain the current workforce, by ensuring that the cases of sick leaves, absenteeism, and reduce nurses turnover. Ensuring that the nurses have enough rest between work schedules, flexible work schedules, reducing workload intensity and volume, out-of-hour commitments, frequent work motivation, and incentive payments. This will reduce stress, depression, burnout and job dissatisfaction, ensuring that the nurses comfortable at work, providing high-quality provision of patient care.

6.4  Summary

Adequate workload and clear work schedules ensure that nurses have proper attention in service provision. Nurses need to have some down time, in between work shifts, to avoid burnout. This ensures that they provide quality and standard patient care.


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