International Journal of Africa Nursing Sciences 7 (2017) 24–30
Contents lists available at ScienceDirect
International Journal of Africa Nursing Sciences
journal homepage: www.elsevier.com/locate/ijans
Quality of nursing care: The influence of work conditions, nurse
characteristics and burnout
Rola H. Mudallal a,⇑, Mohammad Y.N. Saleh b, Hanan M. Al-Modallal a, Rania Y Abdel-Rahman c
a
Community and Mental Health Department, Hashemite University, Zarqa, Jordan
b
Clinical Nursing Department, The University of Jordan, Amman, Jordan
c
Maternal, Child, and Family Department, Hashemite University, Zarqa, Jordan
a r t i c l e i n f o a b s t r a c t
Article history:
Received 17 January 2017 Ó 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
Received in revised form 8 June 2017
Accepted 13 June 2017
Available online 17 June 2017
1. Introduction
Providing quality health care is one of the most challenging
issues for health care systems all over the world. Increasing
demand on health care services associated with shortage of health
care professionals and massive advances in health sciences and
technology has created an overload of work and job stress, which
lead to an increase in errors and a decrease in work quality (The
Institute of Medicine [IOM], 1999, 2001, 2013).
Prompt changes in the health care system, a work overload,
consistent interaction with suffering patients and continuously
unmet psychological needs will lead to burnout; which is a state
of emotional, intellectual and physical exhaustion (Azeem, Nazir,
Zaidi, & Akhtar, 2014; Maslach, Schaufeli, & Leiter, 2001; Patrick
& Lavery, 2007). Sever burnout is manifested by fatigue, job dissat-
isfaction, low self esteem, poor concentration and reasoning, as a
result, this may lead to emotional depletion, uncaring perception
of the clients, negative self evaluation and quitting job (Maslach
& Jackson, 1981; Maslach et al., 2001). Nurses burnout reduces
their work productivity, increases the potential of health related
errors (Montgomery, Panagopoulou, Kehoe, & Valkanos, 2011),
rises turnover rate and directly affects the quality of nursing care
(Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Leiter & Maslach,
2009). In a study that aimed to investigate the influence of burnout
on some work related variables, researchers found that emotional
exhaustion was associated with absenteeism, intention to leave
profession, personal and family deterioration, also, depersonaliza-
tion was linked to the perception of having made errors (Su~ner-
Soler et al., 2014). Therefore, it is a key to recognize the factors
in nurse burnout that may affect the quality of nursing care.
⇑ Corresponding author at: The Hashemite University, School of Nursing, P.O.
Box 150459, Zarqa 13115, Jordan.
E-mail address: rula@hu.edu.jo (R.H. Mudallal).
http://dx.doi.org/10.1016/j.ijans.2017.06.002
2214-1391/Ó 2017 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Quality is a health care services level that is consistent with
updated professional knowledge and allows desired outcomes to
be obtained (IOM, 1990). Several studies explored and examined
the different environmental factors that are related to the quality
of nursing care and required improvement at health care systems.
Laschinger, Shamian, and Thomson (2001) studied the effects of
magnet hospital characteristics on nurses’ job satisfaction, trust,
perceived quality of care, and burnout among nurses. Authors
reported the organizational traits of autonomy, control, and collab-
oration were negatively correlated with burnout, which in turn is
associated negatively with the perceived quality of care, although
trust in management was positively correlated with nurses’ per-
ceived quality of care. In a recent study, Van Bogaert, Van
Heusden, Timmermans, and Franck (2014) suggested that nurse
work environment such as ‘‘nurse-physician collaboration” and
‘‘nurse management” at both unit and hospital levels are influen-
tial to nurse-assessed quality of care as mediated by nurse-work
characteristics. In addition, effective leadership styles have an
influential role in providing quality nursing care, nurses in depart-
ments with effective leadership styles reported lower rates of med-
ication errors, patient falls, pneumonia, urinary tract infections,
brain hemorrhage and patient mortality (Houser, 2003). Similarly,
in Jordan, factors related to work environment, competent man-
agement, and nurses’ job satisfaction; specifically satisfaction with
psychological rewards, rotating work shifts and daily census, were
reported as significant indicators of quality of nursing care
(Mudallal, 2013). Furthermore, quality of nursing care in Jordanian
hospitals was significantly dependent on nature (type) of the hos-
pital (Mrayyan, 2008; Mudallal, 2013).
In addition, nurse burnout reflected a unique role in the quality
of nursing care provided through different studies. Vahey, Aiken,
Sloane, Clarke, and Vargas (2004)-study revealed that quality of
nursing care indicator ‘‘patient satisfaction” was negatively
associated with nurse burnout. A substantial relationship between
 R.H. Mudallal et al. / International Journal of Africa Nursing Sciences 7 (2017) 24–30
burnout and quality of nursing care was evident in a secondary
analysis of a cross-national data from six countries in which the
investigators found that high level of nurse burnout was signifi-
cantly associated with low or fair level of quality nursing care
(Poghosya, Clarke, Finlayson, & Aiken, 2010). On the same extreme
of understanding, a Belgian study included 546 registered nurses
from 42 units demonstrated that emotional exhaustion is a signif-
icant predictor of job satisfaction, turnover and quality of nursing
care (Van Bogaert, Clarke, Roelant, Meulemans, & Van de
Heyning, 2010). Similarly, a recent cross-sectional survey, using a
multilevel modelling technique to analyze data of 709 nurses from
different levels and were working in 25 residential aged care ser-
vices demonstarted that emotional exhaustion and depersonaliza-
tion were substantial indicators of the quality of nursing care (Van
Bogaert, Dilles, Wouters, & Van Rompaey, 2014).
Although a limited number of studies highlighted the influence
of burnout on the quality of nursing care, burnout has been found a
mediator of the pathway between some organizational traits or
interventions and the quality of nursing care. For example, burnout
played a mediator role in the relationship between nursing work
environment and patient’s safety (Laschinger & Leiter, 2006), influ-
enced nursing work environment on job outcomes (Van Bogaert,
Meulemans, Clarke, Vermeyen, & Van de Heyning, 2009) and qual-
ity of nursing care (Spanu, Baban, Bria, Lucacel, & Dumitrascu,
2013). Of the aspects of burnout, emotional exhaustion besides
workload have mediated the relationship between work environ-
ment in terms of ‘‘nurse-physician relationship”, ‘‘hospital and
nurse management” and ‘‘organisational support” and the quality
of nursing care; all of which were found to have predictive perfor-
mance of the quality of nursing care (Van Bogaert, Kowalski,
Weeks, Van Heusden, & Clarke, 2013).
Based on previous evidences, environmental factors and nurse
characteristics have influenced both burnout and the quality of
nursing care (Aiken et al., 2002; Houser, 2003; Laschinger et al.,
2001; Mrayyan, 2008; Mudallal, 2013; Van Bogaert, Van
Heusden, Timmermans, & Franck, 2014) and substantiate the
mediation role of burnout in relation to the quality of nusring care
(Laschinger & Leiter, 2006; Spanu et al., 2013;Van Bogaert et al.,
2009; Van Bogaert et al., 2013). Limited number of studies demon-
started the influence of burnout on the quality of nursing care
(Poghosya et al., 2010; Van Bogaert et al., 2010; Van Bogaert,
Dilles et al., 2014), although the influence of workers’ stress level
on productivity has been addressed. Therefore, the aim of this
study is to investigate the influence of nurse burnout, general work
conditions, nurse and patient characteristics on the quality of nurs-
ing care.
2. Methods
2.1. Design
Cross-sectional, correlational designs were employed to explore
the influence of nurse burnout on the quality of nursing care.
2.2. Sample and setting
The data of this study was collected from both: nurses and
patients. The sample size was estimated using statistical power
procedures. the estimated sample size was 178 particeipants for
each group (nurses and patients).
A convenience sample of 270 registered nurses and 270 hospi-
talized patients from 24 units of eight hospitals in Jordan was
recruited. Only registered nurses with a minimum experience of
at least one year in a clinical area and adult patients who were
25
conscious, oriented, free of pain and able to speak and communi-
cate were included in the study.
The selected hospitals for this study were from three major
Jordanian governorates. The health care system in Jordan has three
major sectors: Public (Ministry of Health (MOH), Royal Medical
Services (RMS) and educational hospitals), private and donors.
For this study, the data were collected from nurses in (MOH),
private and educational hospitals.
2.3. Ethical considerations
The human rights and ethical considerations were protected all
over the study. The researchers obtained the ethical approval to
use the study instruments. Institute Review Board (IRB) approval
for each hospital was also guaranteed. Participants were informed
of the purpose of the study, and their right to withdraw without
penalty at any time. To keep anonymity, the questionnaires did
not include any information regarding the participant identity.
Return of completed questionnaires by nurses and patients was
considered as a signed agreement to participate in this study. After
filling the questionnaire by the participant it was coded by a num-
ber and kept in secure place; no one has an access to the data
except the researcher.
2.4. Measurement
The data in this study was collected through the following
tools:
2.4.1. Service quality scale (SERVQUAL)
This instrument was originally developed by Zeithaml, Parasur-
aman and Berryin 1985 to measure service quality. It is a reliable
and valid scale that can be used by researchers, managers and pro-
fessionals to assess service quality (Clark & Clark, 2007;
Parasuraman, Zeithaml, & Berry, 1988; Scardina, 1994). Service
quality is the difference between what the consumer expects from
the service and what he or she perceives the service to be in the
experienced situation. According to this instrument, service quality
has the following five dimensions: tangibility, reliability, respon-
siveness, assurance and empathy (Parasuraman et al., 1988;
Scardina, 1994). The scale was completed by adult patients in dif-
ferent hospital departments. The Arabic version of the instrument
was used by the researchers to facilitate the understanding of
items by Jordanian patients. The arabic version of SERVQUAL has
been used and studied in different research through which it was
valid, and demonstrated high reliability-Cronbach alpha was more
than 0.90 for the total scale (Al-Borie & Damanhouri, 2013). In this
study, Cronbach alpha for the total SERVQUAL is 0.93.
The SERVQUAL consists of 22-Likert-type items with five points
(1 = very much below my expectations, 2 = below my expectations,
3 = meet my expectations, 4 = above my expectations, 5 = very
much above my expectations). The responses for the whole scale
were summed into 110. Higher scores reflect higher levels of qual-
ity of nursing care services.
2.4.2. Maslach burnout inventory (MBI)
The MBI-human services survey instrument consists of
22-items designed to address three dimensions of burnout for
professionals in human services. Nine items measure Emotional
Exhaustion (EE); the feeling of being overstressed in addition to
emotional and physical resources depletion. Five items measure
depersonalization (DP) which is unfeeling and negative attitude
about clients. Eight items measure personal accomplishment (PA)
the feelings of competence, achievement and productive at work
(Maslach et al., 2001).
26 R.H. Mudallal et al. / International Journal of Africa Nursing Sciences 7 (2017) 24–30
The nurses responses for each item ranged from 0 ‘‘never” to, 6
‘‘every day.” The responses for each sub-scale were summed. High
EE and DP scores reflect high levels of burnout, while low PA scores
reflect high levels of burnout (Maslach & Jackson, 1981).
The nurses completed the English version of the questionnaire;
because they were familiar with English terms in nursing more
than Arabic ones, since English is the teaching language in nursing
schools in Jordan. The instrument was found to be highly reliable
and valid in many studies when it was used to measure burnout.
For this study, Cronbach alpha for the three subscales ranged from
0.779–0.906.
2.4.3. Nurses, patients and work characteristics
The demographic data of the nurses involved in this study
included: gender, marital status, working shift (fixed shift or rotat-
ing (A, B, C or day, night)), educational level (Bachler or master),
age and years of experience as a registered nurse. General work
conditions included: department type (medical, surgical, maternal
and child care, intensive care units), daily census (the average
number of inpatients or occupied beds in the department), the
model of nursing care provision (functional, team, or total patient
care), and the leadership style of the direct supervisor (autocratic,
democratic, permissive, or situational).
The demographic data for the patients included: gender, marital
status, educational level, age and length of stay in hospital.
2.5. Data collection
The data of the present study was collected by trained research
assistants. The research assistants were available to answer any
questions. The data were collected from both nurses and patients.
Nurses reported their level of burnout through the MBI. Because
burnout is expected to affect nurses’ ability to judge quality
(Maslach & Jackson, 1981), quality nursing care was measured
through patients’ responses on the SERVQUAL. Completed MBIs
were matched to SERVQUAL questionnaires which were completed
by patient participants who received care by those nurses who
completed MBIs during hospitalization. The pair of surveys was
then given a code for analysis. Research assistants used the assign-
ment sheet to decide on matched pairs. Assignment sheet is a doc-
ument used by department manager to design the job and
distribute workload on nurses each shift; this document provided
research assistants with information regarding patient care assign-
ment, to recognise the nurse who had the most contact with the
patient, which helped in maching process.
2.6. Analysis
Univariate descriptive statistics were used to assess means (M)
and standard deviation (SD) for continuous variables. Frequencies
were used to describe the categorical demographic characteristics
of the sample.
Before running stepwise multiple regression model, two infer-
ential tests were used to determine the factors that may influence
the quality of nursing care: 1) Pearson Correlation Coefficient
(Pearson r) to assess the relationship between continuous variables
including nurse burnout, census, nurses’ and patients’ age, experi-
ence, length of stay and quality of nursing care. 2) One way analy-
sis of variance (ANOVA) to determine factors may influence the
quality of nursing care including categorical variables of demo-
graphics and departmental characteristics.
Stepwise regression analysis was used to determine the predic-
tive performance of those factors that had a statistically significant
correlation with the quality of nursing care. The researchers exam-
ined the normality of the outcome variable, linearity of predictors,
homogeneity of variance and independence of variables before
running the regression analysis (Warner, 2008).
3. Results
3.1. Descriptive analysis
A total of 300 registered nurses were approached. Two hundred
seventy registered nurses completed the questionnaires, with a
response rate of 90%. Approximately 45% (n = 121) of the partici-
pants were males, and 55% (n = 149) were females. The mean age
of the nurse participants was 29.40 years (SD = 6.29), ranging from
23 to 47 years. Nurse participants had mean years of experience of
6.71 years (SD = 5.75). Approximately half of the nurse participants
were married (n = 141, 52.20%), 121 (44.80%) of nurse participants
were single, and some were divorced or widowed (8, 3%). Most of
the nurse participants (n = 242, 89.70%) had a baccalaureate
degree; the residue had a Master degree. Results revealed that
most nurse participants (n = 204, 75.6%) rotated on either A, B, C
or day and night shifts and 66 (24.4%) were fixed on A shift.
The patient participants response rate was 96%. Most of the par-
ticipants were females (n = 168, 62.20%) and married (n = 170,
63%). The mean age of patient participants was 36.42 years
(SD = 16.83), and their educational level ranged from primary
school to graduate studies. The length of stay ranged from 2 to
37 days (M = 3.99, SD = 3.95). For most patients, 211 (78%) were
experienced hospitalization for the first time.
In regard to the work environment; approximately 158 (58.52%)
nurse participants worked in general medical and surgical depart-
ments, 65 (24.7%) in intensive care units and the remanent were in
obstetric or maternity departments. In terms of the model of nurs-
ing care, 116 (43%) nurse participants were assigned to total
patient care, while 102 (37.8%) were assigned in teams. According
to the results, 109 (40.40%) managers adopted a democratic leader-
ship style, 63 (23.30%) were autocratic and 51 (18.90%) managers
had a permissive leadership style. The average daily census was
(M = 21.39, SD = 15.88) patients in different departments. The data
were collected from three types of hospitals: MOH (n = 118,
43.70%), private (n = 105, 38.89%) and educational (n = 47, 17.41%).
3.2. Preliminary analysis
Results revealed that nurse participants conveyed a relatively
moderate level of burnout in terms of EE (M = 27.02, SD = 12.02),
DP (M = 13.37, SD = 6.18) and PA (M = 34.95, SD = 9.14). Moreover,
the patients reported that the quality of nursing care was congru-
ent with their expectations (M = 65.16, SD = 15.70).
To measure the strength and direction of the linear relationship
between nurse burnout, demographics and departmental charac-
teristics and the quality of nursing care, ANOVA used for categori-
cal variables (Table 1) and Pearson r for continuous variables
(Table 2). The results showed a significant negative correlation
(a = 0.01) between the total scores of the quality of nursing care
and the total EE and DP scores and a positive correlation with PA
(Table 2). The highest correlation was found between the total
scores of the quality of nursing care and PA (r = 0.440). A significant
relationship was detected between the quality of nursing care and
nurses’ characteristics including gender, working shift, and level of
education (Table 1), age and experience (Table 2). Regarding work
environment, the daily census had a significant negative correla-
tion with the quality of nursing care (r = 0.226) (Table 2). In addi-
tion, quality of nursing care was significantly varies among the
three types of studied hospitals (Table 1).
Unexpectedly, patient participants evaluated the quality of
nursing care that was provided by male nurses (M = 70.56,
 R.H. Mudallal et al. / International Journal of Africa Nursing Sciences 7 (2017) 24–30 27

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

Characteristics n % Quality of Nursing Care

Mean SD F P-Value
Nurse participants
Gender 3.97 <0.001*
Male 121 44.80 70.66 20.48
Female 149 55.20 60.77 19.90
Marital Status 1.32 0.07
Single 121 44.80 71.18 19.90
Married 141 52.20 61.13 20.25
Divorced/Separated 5 1.90 40.20 2.17
Widowed 3 1.10 53.33 9.50
Shift Worked 23.72 <0.001*
Fixed A (8 hours) 66 24.40 54.80 19.64
Rotating 204 75.60 68.51 19.96
Level of Education 2.07 0.04*
Baccalaureate 242 89.70 64.73 21.03
Master 28 10.30 73.39 19.26
Patient participants
Gender 0.98 0.53
Male 102 37.80 62.84 21.62
Female 168 62.20 66.57 20.10
Marital Status 0.78 0.90
Single 66 24.40 66.95 21.16
Married 170 63.00 65.44 19.93
Divorced/Separated 18 6.70 57.94 22.83
Widowed 16 5.90 63.00 24.43
Level of Education 0.91 0.67
Elementary 55 20.30 61.73 21.85
High School 76 28.10 60.95 19.40
Diploma 60 22.20 61.88 21.02
Baccalaureate 61 22.60 72.74 18.64
Post Graduate 18 6.70 78.78 16.90
Presence of Chronic Illness 0.95 0.57
Yes 58 21.50 63.59 20.75
No 212 78.50 65.60 20.77
General work conditions
Department type 1.09 0.31
Medical & Surgical 158 58.52 61.77 22.03
Obstetric/Maternity 47 17.41 70.06 18.32
Intensive Care Units 65 24.07 66.24 19.91
Nursing Care Model 1.04 0.42
Total patient care 116 43.00 66.32 20.31
Team 102 37.80 66.22 21.88
Functional 49 18.10 61.80 18.60
Unclear 3 1.10 39.33 6.66
Leadership Style 0.75 0.92
Autocratic 63 23.30 61.30 21.40
Democratic 109 40.40 65.88 20.71
Permissive 51 18.90 66.16 18.18
Situational 47 17.40 68.17 22.14
Hospital Type 232.45 <0.001*
MOH 118 43.70 46.48 9.42
Private 105 38.89 80.24 16.26
Educational 47 17.41 78.38 9.55
*
ANOVA is significant at a = 0.05, 2-tailed test.

Table 2 SD = 20.48) better than the quality of nursing care that was pro-
Correlations between quality of nursing care, nurse burnout, demographics and vided by female nurses (M = 60.78, SD = 19.90). Moreover, results
department characteristics among registered nurses in jordanian hospitals (n = 270). revealed that better quality of nursing care was provided by young,
Study Variables Quality of Nursing Care single nurses (M = 71.18, SD = 19.90), who were working on differ-
Mean SD Pearson r ent rotating shifts (M = 68.5, SD = 20.80) and primarily in obstetric
Nurse Age 29.40 6.29 0.367** and maternity departments (M = 70.06, SD = 18.32).
Nurse Experience 6.71 5.75 0.362**
Daily Census Rate 21.39 15.88 0.226**
Patient Age 36.42 16.83 0.052 3.3. Predictors of quality of nursing care
Length of Stay 3.99 3.95 0.007
Burnout Stepwise regression analysis was used to identify predictors of
EE 27.02 12.02 0.439**
quality of nursing care. All factors that were found to have a signif-
DP 13.37 6.18 0.278**
PA 34.95 9.14 0.440** icant relationship with quality of nursing care were entered in step
one regression analysis; except nurses’ age as it is correlated with
**
Correlation is significant at a = 0.01, 2-tailed test.
nurses’ experience (increase in the nurse’s years of experience
28 R.H. Mudallal et al. / International Journal of Africa Nursing Sciences 7 (2017) 24–30
Table 3
Predictors of quality nursing care as perceived by jordanian nurses (n = 270).
Variables B Adjusted R2
Hospital Type (P) 16.48 0.558
Census rate 0.16 0.572
Nursing shift work (Rotating) 3.47 0.577
Predictors of quality of nursing care final model produced at a = 0.05; Excluded variables are: EE, DP, PA, Nurse age, Nurse experience, Nurse gender, Nurse level of education.
means increase in nurse’s age). The data was screened for multi-
collinearity. Dummy variables were created for all categorical vari-
ables before performing the regression analysis (Warner, 2008).
The stepwise regression analysis revealed a significant overall
model of three predictors: Hospital type, census rate, and rotating
shift worked. These predictors were accounted for approximately
58% of the variance of the quality of nursing care.
Hospital type was the dominant predictor of the quality of nurs-
ing care; it was responsible for 55.9% of the variance. Burnout vari-
ables (EE, PA and DP) were excluded from the model when other
predictors were statistically superior (Table 3). Furthermore, two
factors related to work conditions were significant: census rate
(1.6%) and working on rotating shifts (A, B and C or day and night)
(0.7%) (Table 3).
4. Discussion
The present study demonstrates work conditions in terms of
hospital type, census rate, and rotating shift as significant predic-
tors of the patients’ reported quality of nursing care. Hospital type
was the dominant variable predicting quality of nursing care. Jor-
danian hospitals are different in their nature of work environment,
departmental characteristics, climates, polices and level of technol-
ogy used (Mrayyan, 2008; Mrayyan, Mudallal, & Hamaideh, 2010;
Mudallal, 2013). Indeed, Private and educational hospitals have a
favorable environment for both patients and nurses in terms of
better nurse-patient ratio, low daily census rate, collaborative
nurse-physician relationship, higher standards of quality of nurs-
ing care, advanced technology in use, leadership support, nurses’
autonomy and adequate health care professionals (Mrayyan
et al., 2010; Mudallal, 2013). Moreover, private and educational
hospitals in Jordan were pioneers in generating national and inter-
national accreditation and quality assurance programs.
On the other hand, MOH hospitals -the largest health care sec-
tor in Jordan which covers most Jordanian governorates- are facing
different challenges starting with insufficient funding, increasing
demand on health care services, shortage of health care profession-
als; this means nurses perform nursing and non-nursing duties,
limited quality improvement programs, centralized management
practices, and lack of staff development programs (Halasa, 2008),
all of which reflected negative impact on nurses’ and patients’ sat-
isfaction. However, health care system in Jordan is undergoing a
huge reform and development that is focusing on improvement
of health care management and clinical practices, and in order to
improve the quality of nursing care; technology, informatics and
national competencies for registered nurses and nurse managers
are being introduced.
Daily census was an additional factor predicting the quality of
nursing care. This finding was congruent with a previous investiga-
tion conducted in Jordan (Mudallal, 2013). An increase in daily cen-
sus was found to reduce the quality of care. An increased census
means an increase in patients’ number in the department, which
decreases the time spent on caring for each patient, this conse-
quently increases job stress and reduces the quality of care
(Sochalski, 2001; Williams, 1998).
R2-Change F-Change df p
0.559 340.10 1/268 0.00
0.016 9.86 1/267 0.00
0.007 4.42 1/266 0.03
Nursing shift work was considered a good indicator of the qual-
ity of nursing care. Patients reported higher-quality nursing care is
provided by nurses on rotating shifts. Quality of nursing care pro-
cesses differs according to the situation elements; most of the time,
nurses on the A-shift are overloaded with direct and indirect
patient care activities which negatively impacts the quality of
nursing care and creates higher job stress (Williams, 1998).
Compared to work conditions, nurse burnout and nurse charac-
teristics had lower influence on the quality of nursing care. The
correlation results of this study revealed that high level of nurse
burnout, as defined by high EE, DP and low PA, was associated with
the patients’ report of poor quality of nursing care. This result is
consistent with that of Vahey and colleagues (2004) study; nurses
feeling EE and lack of PA significantly affected patient satisfaction.
Additionally, the results of this study are similar to Poghosya et al.
(2010), Van Bogaert et al. (2010), and Van Bogaert et al. (2014), all
of which found a significant negative relationship between nurse
burnout and the quality of nursing care. But, unexpectedly and
despite a moderate correlation between nurse burnout and quality
of nursing care, nurse burnout was not showing a prediction per-
formance of the quality of nursing care. This may explain that
burnout is a common problem in most Jordanian hospitals and it
may play a mediator role between nursing work environment
and quality of nursing care. This result supports the findings of
Van Bogaert and colleagues and Laschinger and Leiter (2006).
However, further studies are needed to assess the burnout phe-
nomenon and the mediator role of burnout and nurse characteris-
tics in Jordan. In addition to burnout, nurse gender, age, experience
and educational level were also not having a prediction perfor-
mance in relation to quality of nursing care.
Surprisingly, the results of this study revealed that the quality
of nursing care was negatively associated with nurse experience;
an increase in years of experience was associated with a decrease
in the quality of nursing care level. The nurses’ role in patient care,
direct contact with patients’ suffering, work overload, difficult
work conditions and increased use of technology may lead to burn-
out, especially if these factors are associated with social responsi-
bilities (home and family) (Azeem et al., 2014; Gandi, Paul,
Haruna, & Zubaira, 2011; Jacobs, Hill, Tope, & O’Brien, 2016). Pro-
gression in nurses’ age and experience in nursing profession leads
to further exposure to work environment related factors, add to
this, older nurses in Jordan are less familiar with technology and
informatics which creates a bigger burden. Furthermore, one of
the most common challenges facing women work in the Arab
world, is the community perception regarding the roles for both
women and men that women have more social responsibilities
regarding home and family beside profession, and are more
dependable than men (Dajani, 2012), which leads to an increasing
load on married, female nurses. This may explain why the quality
of nursing care was better when provided by male, single, young
and less experienced nurses in this study.
In addition to predictive elements of quality of nursing care, this
study found that the highest patients’ perception of the quality of
nursing care was more often found in maternity departments com-
pared to other departments. These findings are consistent with
Sochalski (2001) and Boyle, Miller, Gajewski, Hart, and Dunton
 R.H. Mudallal et al. / International Journal of Africa Nursing Sciences 7 (2017) 24–30
(2006). This result may be explained in that although the quality of
nursing care usually implemented in terms of hospital standards
similarly at all departments of the same hospital; patients’ past
experiences and psychological status affect their perception of
quality nursing care provided. Patients in wards other than mater-
nity department suffer the consequences of their diseases while
feel happy most of the time in the maternity wards.
This study also, revealed that department type, nursing care
model and leadership style do not have a significant influence on
the quality of nursing care. However, these factors were relevant
to quality of nursing care in previous studies (Houser, 2003;
Laschinger & Leiter, 2006; Mudallal, 2013; Van Bogaert et al.,
2010; Van Bogaert et al., 2013; Van Bogaert, Dilles et al., 2014
and Van Bogaert, Van Heusden et al., 2014). This may be explained
in a way related to unclear systems for nurses as a result of health
care system reform. However, further studies are needed to
explore this arena.
4.1. Limitations, implications and recommendations
This study suggested that ‘‘work conditions” is the main influ-
ential factor of the quality of nursing care, whereas burnout and
nurses characteristics have lower impact. The results of this study
are unique because the quality of nursing care was measured using
a comprehensive tool rather than using one or two items and was
completed by patients to avoid self-evaluation bias. On the other
hand, this study used non-probability sampling procedure and
the data was limited to eight hospitals in Jordan, hence, the gener-
alizability of these results may be limited. Further studies are rec-
ommended using random sampling procedure and involvement of
other health care settings to improve the generalizability of these
findings.
The results of this study are important for developing nursing
practice, education, and research. Nurse managers may consider
changes in nursing work environment to reduce nurses’ stress level
and improve nurses’ and patients’ satisfaction such as improving in
nurse to patient ratio, nursing mix, opportunity for staff develop-
ment, boost multidisciplinary collaboration, support the work
environment with enough and advanced equipment, and using
transformational leadership style to inspire, empower and moti-
vate nurses and to enhance effective change.
Although the results showed that young nurses provide rela-
tively better quality of care, which reflects a recent improvement
in nursing education; it is recommended to teach caring concepts
with a focus on the quality dimensions, informatics and stress
management. Further staff development programs are required
in hospital settings to followup nurses development.
Additional outcome studies are needed to assess the unique
influence of different factors on the quality of nursing care. In addi-
tion, more interventional studies are recommended to evaluate the
effects of different programs designed to reduce work stress as
means to improve the quality of nursing care worldwide.
5. Conclusion
The purpose of this study was to examine the influence of nurse
burnout, nurse characteristics and work conditions on the quality
of nursing care. This study illustrated that ‘‘work conditions” vari-
able has the most impact on the quality of nursing care. Mediation
effect is expected for nurse burnout and nurse characteristics; thus,
various studies are required to investigate these phenomena. Con-
sequently, it is important for nurse mangers and policy makers to
improve nursing work conditions in a way that improves nurses’
competencies and decrease stress level among nurses which will
reflect positively on the quality of nursing care. Activities such as
29
increasing nurses’ autonomy over their practice, improving nurses’
leadership abilities, providing sufficient staffing and resources, and
supporting nurses with continuous educational programs can
improve nurses’ work conditions, competencies and enhance the
quality of care.
Competing interests statement
The authors declare that there is no conflict of interests regard-
ing the publication of this paper.
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