Results Nursing Dissertation


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.

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