Workload and quality of nursing care: the mediating role of implicit rationing of nursing care, job satisfaction and emotional exhaustion by using structural equations modeling approach – BMC Nursing

The results of this study supported the proposed hypothesized model. The findings shown in this structural equation model provided strong support for the study hypotheses.

Based on the findings, implicit rationing of nursing care played a mediating role in the relationship between workload and the quality of nursing care. Therefore, the H1 hypothesis was supported. When the nurses’ workload is high and they are responsible for caring for a large number of patients, they are inevitably forced to ration some important interventions which, in turn, can reduce the quality of nursing care [12, 13]. An earlier study showed that implicit rationing of nursing care functions as a mediator between predictive variables such as workload and patient-related outcomes such as medication error and patients’ falling. These adverse events can reduce the quality of nursing care [20]. In other words, workload has an indirect effect on patient-related outcomes through care rationing and affecting the ability of nurses in completing their main tasks. In another study, nurse-to-patient ratio, as an important indicator in the workload of nurses, affected the quality of care and the incidence of adverse events through rationing of care. In other words, poor nurse staffing levels leads to the rationing of nursing care and, thereby, hinders the provision of high quality care [14]. Some other studies also referred to the mediating role of rationing of nursing care in the relationship between workload and patient safety [46] as well as in the relationship between workload and patients’ falling [47]. Accordingly, implicit rationing of nursing care seems to play a key role in the relationship between workload and the quality of nursing care.

In the present study, nurses’ job satisfaction was the second variable that mediated the relationship between workload and quality of nursing care. Hence, the H2 hypothesis was supported. When the workload is increased, nurses cannot meet some of the needs of patients despite the effort they make. So, nurses do not have a positive attitude toward their performances, leading to less job satisfaction [23, 48]. In these circumstances, nurses do not have the necessary peace of mind and precision in the workplace which may negatively affect their efficiency and performance, decreasing the quality of the provided care [49]. Job satisfaction is an important variable that mediates the relationship between workload and other variables such as intention to leave the job and position [50, 51]. Therefore, this is affecting the quality of nursing care indirectly. However, more research is required to investigate the mediating role of job satisfaction.

Emotional exhaustion was another mediating variable in the relationship between workload and quality of nursing care in this study. Therefore, the H3 hypothesis was supported. Emotional exhaustion is considered to be the most important component of job burnout and nurses who experience high levels of emotional exhaustion will suffer from job burnout and have a lower ability and tendency to provide high-quality care [39, 52]. According to Van Bogaert et al. (2009), emotional exhaustion plays a mediating role in the relationship between nurses’ workplace conditions and the quality of nursing care [53]. Liu et al. (2018) also indicated that emotional exhaustion mediates the relationship between workload and patient safety. When nurses are constantly exposed to stressful work environments, their reactions become more chronic and serious, and they need more time to recover [46]. Additionally, because of high workload and regular attendance at the hospital, nurses do not have much opportunity to rest and regain their energy and, thus, will experience a perpetual emotional exhaustion [54].

It is noticed from this study that there was no significant correlation between workload and quality of nursing care. This finding is interesting and in line with an earlier study in which despite the high levels of workload and insufficiency of human resources and equipment, the quality of nursing care was at a high level [6]. Considering that both the nurse’s workload and the quality of nursing care have been investigated from the nurse’s point of view, more reliable results have been obtained in this study. It should be noted that the final model in this study is a full mediation model, as the three variables (rationing of nursing care, job satisfaction, and emotional exhaustion) fully mediate the effect of workload on the quality of nursing care. So, after controlling for this mediation effect, there is no direct effect of workload on quality of nursing care [55].

Also, it seems that experience of high levels of workload for a long period of time and fall into the habit of these conditions lead to nurses can manage difficult situations. According to this finding, it is suggested that temporary or permanent high nursing workload should be taken into consideration in the next researches. Also, social desirability bias which is the tendency to respond in a pleasing way, in answering the questions related to quality of nursing care may also have been influential.

Study limitations

This study has several limitations: a) the present study was confined to frontline nurses in four selected governmental hospitals in a small city in the country; so, generalization of the findings may be limited; b) given the limited number of available participants, the convenience sampling method was used to provide the minimum sample size. It is suggested that future studies be conducted in different cities of the country and private and public hospitals with more participants, to be able to compare the findings; c) the use of self-report questionnaires and nurses’ perceptions to obtain data on the study variables may be a potential limitation because of social desirability bias [56, 57]. It is recommended that future studies use more precise data collection strategies with observation or retrospective methodology; d) because the questionnaires filled out by the participants based on their work performance in the past month, recall bias may be another limitation of this study; e) although SEM approach was used in this study, causation cannot be established with the cross-sectional study design.

Implication for clinical practice

Nurse managers have a prominent position related to issues such as nursing workload, rationing of nursing care, job satisfaction and emotional exhaustion. Providing any intervention in these fields, will ultimately effect on the quality of nursing care. Nursing workload, which was at high level, is a major concern in this study. Some strategies such as staffing and resource adequacy assessment and hiring more nurses to increase staffing levels can be useful [58]. Moderate levels of job satisfaction and emotional exhaustion were another important finding of this study. Administering flexible work schedules, increasing monthly salary, suggesting some mental health resources, and modification of work environment may be improving nurses’ job satisfaction and decrease their emotional exhaustion. Regular supervision of clinical nursing care activities and provision of continuous feedback are important to ensure that essential nursing care tasks are provided and prevent any compromise of nursing care [59].