Predictors of burnout, work engagement and nurse reported job outcomes and quality of care: a mixed method study
© The Author(s). 2017
Received: 7 May 2016
Accepted: 30 December 2016
Published: 18 January 2017
High levels of work-related stress, burnout, job dissatisfaction, and poor health are common within the nursing profession. A comprehensive understanding of nurses’ psychosocial work environment is necessary to respond to complex patients’ needs. The aims of this study were threefold: (1) To retest and confirm two structural equation models exploring associations between practice environment and work characteristics as predictors of burnout (model 1) and engagement (model 2) as well as nurse-reported job outcome and quality of care; (2) To study staff nurses’ and nurse managers’ perceptions and experiences of staff nurses’ workload; (3) To explain and interpret the two models by using the qualitative study findings.
This mixed method study is based on an explanatory sequential study design. We first performed a cross-sectional survey design in two large acute care university hospitals. Secondly, we conducted individual semi-structured interviews with staff nurses and nurse managers assigned to medical or surgical units in one of the study hospitals. Study data was collected between September 2014 and June 2015. Finally, qualitative study results assisted in explaining and interpreting the findings of the two models.
The two models with burnout and engagement as mediating outcome variables fitted sufficiently to the data. Nurse-reported job outcomes and quality of care explained variances between 52 and 62%. Nurse management at the unit level and workload had a direct impact on outcome variables with explained variances between 23 and 36% and between 12 and 17%, respectively. Personal accomplishment and depersonalization had an explained variance on job outcomes of 23% and vigor of 20%. Burnout and engagement had a less relevant direct impact on quality of care (≤5%). The qualitative study revealed various themes such as organisation of daily practice and work conditions; interdisciplinary collaboration, communication and teamwork; staff nurse personal characteristics and competencies; patient centeredness, quality and patient safety. Respondents’ statements corresponded closely to the models’ associations.
A deep understanding of various associations and impacts on studied outcome variables such as risk factors and protective factors was gained through the retested models and the interviews with the study participants. Besides the softer work characteristics — such as decision latitude, social capital and team cohesion — more insight and knowledge of the hard work characteristic workload is essential.
KeywordsBurnout Work engagement Job satisfaction Turnover intentions Quality of care Structural equation model Sensitizing concepts
Thirty years of research on burnout and on nurse work environment provide a body of knowledge about occupational stress and well-being and insight in the psychosocial work environment of nurses, one of the largest workforce in healthcare. Both research domains started empirically with a lack of theoretical frameworks. Research on burnout and psychosocial work environment has predominantly been conducted using the Maslach Burnout Inventory-Human Service Survey . The primary themes in burnout research fit readily into the six areas of worklife such as workload, control, community, fairness, reward and value congruence . Engagement as the positive pole of a continuum and the opposite of burnout became an additional and interesting research domain to feature the person-job fit . In line with Maslachs’ primary themes, Karasek and Theorell  have developed the job demand-control-support model that consists of three main dimensions: job demands, job decision latitude and job social support. This model provides insights about the mechanism of job related characteristics within specific nurse work environments such as emergency nursing, oncology nursing, mental health nursing and nurse unit managers [1, 2, 11, 16, 51]. Research on nurse work environment started with the observation that some hospitals in the US were more successful in attracting and retaining nurses compared to other hospitals. In addition, these researchers have been focused on to what extent certain relevant aspects were generalizable and transferable to other hospitals . A substantial number of studies identified and linked aspects of a balanced, healthy and supportive psychosocial work environment ([20, 27, 30, 32]) with quality and patient safety indicators such as patient satisfaction, mortality, co-morbidity and adverse events [5, 6, 18]. Furthermore, intervention studies were conducted to evaluate quality improvement projects aiming practice environments that support highly motivated and skilled nurses answering accurately complex patient needs. In the US implementations of ANCC Magnet Hospital key components including transformational leadership, structural empowerment, exemplary professional practice and new knowledge, innovations and improvements [7, 56]. In the UK and other European countries implementations of or the Productive Ward – Releasing Time to Care™ program [35, 49, 54, 55].
Our research program was initiated more than 10 years ago, adapting these research insights and knowledge in the Belgian context and meanwhile aiming better understanding of the associations between nurse practice environment and nurse work characteristics such as workload, decision latitude and social capital and outcome variables such as feelings of burnout and engagement, nurse reported job outcomes and quality of care [42, 43, 45, 46, 50]. Our research initiatives have been contributing to a clear understanding of nurses their practice environment that could support and guide the practice community. Therefore, this study based on an explanatory sequential design, was a next step in a series of studies that developed comprehensive models providing a deep understanding of various associations and impacts on studied outcome variables. The study aims were threefold: (1) To retest and confirm two structural equation models exploring associations between practice environment and work characteristics as predictors of burnout (model 1) and engagement (model 2) as well as nurse-reported job outcome and quality of care; (2) To study staff nurses’ and nurse managers’ perceptions and experiences of staff nurses’ workload; (3) To explain and interpret the two models by using the qualitative study findings.
This mixed method study was based on an explanatory sequential study design . The study started in a first phase with a quantitative approach collecting and analysing of quantitative data with the aim to retest and confirm two previous developed models. The second phase, a qualitative study, existed of collecting and analysing qualitative data based on semi-structured interviews. Both study phases were conducted independently. Finally, in a third phase qualitative study results assisted in explaining and interpreting the findings of the two model.
Quantitative data set
The study was conducted in two acute care university hospitals, one in the Dutch- and one in the French-speaking part of Belgium, with 600 and 850 beds respectively. All participants were staff nurses working in direct care in either medical, surgical, obstetric, geriatric or intensive care units and operating theatres including adult and paediatric care units. Participants were invited by one of the investigators to participate in the study on a voluntary basis. Data collection took place between September 2014 and May 2015. Respondents could complete the self-report questionnaires electronically either at home and/or in the hospital.
Qualitative data set
The purpose of the qualitative study was to investigate staff nurses’ and nurse managers’ perceptions and experiences of staff nurses’ workload. To understand the complexity of staff nurses workload we included for this study a purposive sample with typical cases of staff nurses as well as nurse managers practicing on medical or surgical units. Assuming that medical and surgical nursing units are relatively comparable in terms of staff nurse practice environment and nurse work characteristics such as workload, we might expect similar perceptions and experiences. Each staff nurse and nurse manager of the participating units were invited by two study investigators, respectively. Data were collected until sufficiency was obtained on the research topics (staff nurses = 9; nurse managers = 10). The semi-structured interviews were organized only in the Dutch-speaking university hospital between January 2015 and March 2015 and performed in a dedicated room. The hospital had recently implemented the Productive Ward programme and became involved in an accreditation process (JCI - Joint Commission International) as a part of a larger national hospital accountability process.
The institutional review board of each study hospital approved the qualitative study. In addition, a qualified ethics review committee (Antwerp University Hospital – University of Antwerp Belgium) approved the qualitative study.
Procedure and data analyses
Quantitative study: model retesting and confirmation
The two models were carefully developed and fitted sufficiently to a cross-sectional dataset based on survey design. Moreover, we used a set of measurement instruments such as the Revised Nursing Work Index (NWI-R) , the Maslach Burnout Inventory-Human Service Survey (MBI-HSS) , the Utrecht Work Engagement Scale (UWES) , the Intensity of Labour Scale , Social Capital [17, 36] and Nurse reported job outcomes and quality of care [3, 42]. These measures were thoroughly tested with various study populations as well as in the present study regarding validity, reliability and consistency [42–48]. All measures used a 4-point Likert-type scale (strongly disagree, disagree, agree, strongly agree), where nurses were asked to rate their agreement, except for the MBI-HSS and UWES, where respondents rated frequencies on a 7-point scale ranging from never to every day.
In SEM, a ratio of at least 5 subjects for each variable, including error measurements, observed variables (indicators) and latent variables (dimensions), is recommended . A total of 85 and 80 variables (error measurements, observed and latent variables) were included in model 1 (burnout) and model 2 (work engagement) respectively and analysed in this study with a convenient sample of 751 respondents. Cronbach’s alpha coefficients of measures ranged from .639 to .913 (see Tables 4 and 5). However, job outcomes’ Cronbach’s alpha coefficient was in our studies low. Inter-item correlations, an alternative measurement technique assessing internal consistency , for the indicators of the job outcome dimension ranged from fair to moderate with values between .15 and .21 [45–48].
AMOS software was used to conduct model retesting and confirmation on the full database incorporating imputation of incomplete data, maximum likelihood estimation, and estimation of means and intercepts . In our previous studies as well as in this study various fit measures were calculated and compared against accepted criterion levels (CFI and IFI ≥ .90; RMSEA < .080) to verify models plausibility.
The Statistical Package for the Social Science (SPSS) version 22.0 and AMOS version 22.0 software (SPSS Inc, Chicago) were used for descriptive analyses and computation of Cronbach’s alphas and correlation coefficients.
Qualitative study: semi-structured interviews
Staff nurses’ semi-structured interview: topics and items
Last experience with perceived workload
Describe the conditions and your actions?
Could you handle the situation?
What was the reaction of your team?
Aspects that influence perceived workload
What are the circumstances that you perceive workload?
How do these circumstances occur? Do certain colleagues (nurses, physicians, physiotherapist, …) have a particular role in such a situation?
In your opinion what is acceptable workload and what is not acceptable workload?
Are there circumstances that you experience workload less fierce although there is lots to do? Why was that so?
Impact of workload
What is the impact of workload on yourself, physically and mentally?
How do you deal after very busy workdays?
Did you experience aversion to go to work caused by perceived workload?
Do you have sometimes the intention to leave the nursing profession through your perceived workload?
What is the impact of workload on your patients and on patient care
Nurse managers’ semi-structured interview: topics and items
Last experience with perceived workload
Describe the conditions?
What was in your opinion the reasons that your staff nurses perceived workload? How did they cope?
How did you have faced this situation and what were your particular actions?
Aspects that influence perceived workload
What are the circumstances when your staff nurses experience workload?
How does these circumstances occur?
In your opinion what is the impact of staff nurses’ competence, nurse - patient ratios and patient acuity on perceive workload?
In your opinion what is acceptable workload and what is not acceptable workload?
In your opinion can you and how do you adjust situations when your staff nurses perceive workload?
Impact of workload
What is the impact of workload on your staff nurses, physically and mentally?
How do you deal with colleagues who experience difficulties with perceive workload?
What is the impact on perceive workload on patients, patient care and safety?
Model analysis using the qualitative study findings
We performed a new analysis of the two models by using the qualitative findings. These findings could provide a deep understanding of the various associations and impacts on studied outcomes. The use of the qualitative data might have an additional value to strengthen models.
Quantitative study: model retesting and confirmation
Characteristics of study population and distribution of nurse reported job outcomes and nurse-reported quality of care (n = 751)
Age in years
Years in nursing
Years on present unit
Baccalaureate degree in nursing or midwifery
Master degree in nursing and midwifery sciences
Working regime 50% or more of a full-time position
Working regime 75% or more of a full-time position
Dissatisfied or very dissatisfied with the current job
Intention to leave the current hospital within one year
Intention to leave nursing
The quality of care on the unit is fair or poor
The quality of care at the last shift is fair or poor
The quality of care in hospital the last year has deteriorated or definitely deteriorated
Observed (a) and latent variables (b) of the retested models (n = 751)
Nurse practice environment:
loading model 1
loading model 2
Nurse-physician relationship (b) (Cronbach’s alpha: .83)
Physicians and nurses have good working relationships (a).
Much teamwork between nurses and doctors (a).
Collaboration (joint practice) between nurses and physicians (a).
Nurse management at the unit level (b) (Cronbach’s alpha: .77
Working with nurses who are clinically competent (a).
Nurse managers consult with staff on daily problems and procedures (a).
Standardized policies, procedures and ways of doing things (a).
Hospital management and organizational support (b) (Cronbach’s alpha: .83)
A chief nursing officer is highly visible and accessible to staff (a).
An administration that listens and responds to employee concerns (a).
Staff nurses are involved in the internal governance of the hospital (e.g., practice and policy committees) (a).
Workload (b) (Cronbach’s alpha: .86)
Many times I have to do a lot of work
Tasks that I have to solve are often very difficult
Normally time is short, so often I am pressed for time at work
Decision latitude (b) (Cronbach’s alpha: .68)
To learn continuously is necessary in my work (a)a.
I can fully practice what I have learned in my training (a)a.
In my work I have to take a lot of decisions independently (a).
Social capital (b) (Cronbach’s alpha: .91)
In our unit there is trust between nurses
In our unit there is favourable work climate
In our unit nurses shared values
Observed (a) and latent variables (b) of the retested model (n = 751)
Loading model 1
Loading model 2
Emotional exhaustion (b) (Cronbach’s alpha:. 90)
I feel emotionally drained from my work (a).
I feel used up at the end of the workday (a).
I feel I’m working too hard on my job (a).
Depersonalisation (b) (Cronbach’s alpha:. 66)
I’ve become more callous toward people since I took this job (a)
I worry that this job hardening me emotionally (a)
I feel patients blame me for some of their problems (a)
Personal accomplishment (b) (Cronbach’s alpha: .69)
I can easily create a relaxed atmosphere with my patients (a).
I feel exhilarated after working closely with my patients (a).
I have accomplished many worthwhile things in this job (a).
Vigor (b) (Cronbach’s alpha: .86)
At my job, I feel strong and vigorous (a).
When I get up in the morning, I feel like going to work (a).
Dedication (b): (Cronbach’s alpha: .82)
I am enthusiastic about my job (a).
My job inspires me (a).
Absorption (b) (Cronbach’s alpha:. 64)
I feel happy when I am working intensely (a)a.
I am immersed in my work (a).
Job outcomes: (b) (Cronbach’s alpha: .32)b
Job satisfaction (a).
Intention to stay in the hospital (a).
Intention to stay in nursing (a).
Nurse – assessed quality of care (b) (Cronbach’s alpha: .73)
At the current unit (a).
At the last shift (a).
In the hospital the last year (a).
Superior fit indices were established by replacing two items of the decision latitude dimension and one item of the absorption dimension. All pathways of the two models were significant except one pathway between absorption and quality of care (model 2) was not confirmed (p = .076). Nurse reported job outcomes and quality of care explained variances of model 1 (burnout) were 63 and 53% and of model 2 (work engagement) 59 and 53%, respectively. Hospital management/organizational support and nurse – physician relations had an indirect impact and nurse management at the unit level had a strong direct impact on outcome variables with explained variances of 25 and 36% in model 1 and 23 and 37% in model 2, respectively. Workload had an impact on outcome variables with explained variances of 15 and 13% in model 1 and 17 and 12% model 2, respectively. Personal accomplishment and depersonalization showed an explained variance on job outcomes of 23% and vigor of 20%. Personal accomplishment and absorption had less relevant direct impact on quality of care (≤5%).
Qualitative study: semi-structured interviews
Study population demographic characteristics qualitative study (n = 9; n = 10)
Years in nursing
Years on present unit
Years as nure managers
Baccalaureate degree in nursing
Master degree in nursing
Additional management and leadership training
Organisation of daily practice and work conditions
“Our management expects good patient care quality but with a decrease of care personal … not easy (staff nurse interviewee 2).”
“A lot of admissions during the day have an important effect on your workload (staff nurses interviewee 2).”
“A common thread are unexpected events, it affect us, additionally to our daily activities and require immediately our attention … our usual specialities unpredictability’s and then … and on top of that, Murphy’s law (Nurse manager interviewee 8).”
“You have to learn to deal with workload; in the beginning of your career it is very overwhelming (staff nurses interviewee 4).”
“Even experienced teams have difficulties to deal with al these changes. Young staff nurses are more open to changes but we had one young staff nurse, she left us after only 4 months assigned to our unit because of too many changes (Nurse manager interviewee 10).”
“A huge obstacle is our patient record system, it is changing all the time and very comprehensive … it is a burden (Nurse manager interviewee 5).”
“Hospital management is trying hard to meet targets within the hospital vision and JCI – requirements but that does not always reflect our daily practice (staff nurses interviewee 2).”
“JCI goes too fast within a tight time schedule, staff nurses have not the reasonable time to change their routines properly (Nurse manager interviewee 3).”
“JCI stimulates awareness how things are going in daily practice and how to improve (staff nurse interviewee 7).”
“Lean is very positive, there is a clear return of investment (staff nurses interviewee 2).”
“I heard many positive comments on bedside nursing handover from staff nurses and patients. An example of a successful changes that impacts workload positively (Nurse manager interviewee 9).”
“Maybe little things like to organize better our wound care trolley can be helpful to support staff nurses workload (Nurse manager interviewee 5).”
Interdisciplinary collaboration, communication and teamwork
“Often experience and competent physicians have more clear schedules and communication (staff nurse interviewee 9).”
“We are a team and together as a team we will deal with workload (staff nurse interviewee 5).”
“Sometimes workload is so overwhelming that you have to express your opinion so badly, but meanwhile it is a loss of your energy too (staff nurse interviewee 3).”
“We try to avoid irritations (staff nurse interviewee 6).”
“Often mistakes and flaws will be explained through high workloads and regular swept under the carpet (staff nurses interviewee 5).”
“Management communication is often focused to data and numbers (staff nurses interviewee 3).”
“A call for help must be answered, I never complain but when I call for help I need someone that listens (Nurse manager interviewee 10).”
Staff nurses personal characteristics and competencies
“When you work hard focussed on good patient care you can learn every day (staff nurse interviewee 1).”
“More then half of our time we experience unacceptable workload (staff nurse interviewee 3).”
“Instead of that we constantly look for and use new coping mechanisms … something must be done … otherwise the hospital will do badly (staff nurse interviewee 3).”
“Workload is not the only factor of staff nurses ‘ absenteeism (Nurse managers interviewee 2.).”
“A good team can balance workload (staff nurses interviewee 1).”
“I try to motivate staff nurses in every situation also when it is about a decision that I as a nurse manager don’t really support (Nurse managers interviewee 7.).”
“ I try to listen and let staff nurses to speak up … an important aspect of our job as a nurse manager (Nurse manager interviewee 2.).”
“I support and help staff nurses when we have a lot of work by making telephone calls or arrangements around unplanned patient admissions such as patients from intensive care, … to lower the stress, I try to avoid that my unit will crash (Nurse managers interviewee 10.).”
“Sometimes I have to decide about matters the team don’t like but we have to (Nurse managers interviewee 1.).”
Nurse managers reported that staff nurses turnover in their unit were low. Some agreed that there were nurses who left their unit or the hospital because of unit workload as well as health problems.
Patient centeredness, quality and patient safety
“Often you are focussed not enough to your patients and overlook important changes; often we overlook early clinical signs (staff nurses interviewee 6).”
“Our staff nurses have to work fast and are afraid to make mistakes, … sometimes they have the feeling that they deliver unsafe patient care … (Nurse manager interviewee 3.).
“I admit to evaluate patients’ pain scores regularly is important but I prefer that staff nurses administer pain medication 4 times a day (Nurse manager interviewee 3.).”
“You have to set priorities and the first thing you loose are the opportunities for social interaction with patients (staff nurses interviewee 6).”
“Quality of care equals listen to patients (staff nurses interviewee 8).”
“Lack of time for patients’ mental and emotional well-being is a source of staff nurses’ frustration (Nurse managers interviewee 6.).”
“As a nurse you have the impression that you fall short more then patients’ impression of our shortcoming (staff nurses interviewee 9).”
Models explaining and interpreting using qualitative study findings
Study participants addressed a bundle of factors that influenced workload. These factors described how daily practice was organized and certain conditions were in place (nurse management at the unit level) largely determined by management decisions and policy (hospital management & organizational support). In turn, workload clearly was a risk factor for staff nurses’ symptoms such as fatigue, headaches and vulnerability for diseases (emotional exhaustion), for negative feelings such as frustration and negativism and behaviours such as letting go, being less accessible and approachable (depersonalisation) as well as thoughts of failure and inefficacies (personal accomplishment) to patients needs and demands (quality of care items). Good interdisciplinary collaboration and communication (nurse – physician relations) that supported nursing practice (decision latitude) as well as supportive collaboration between colleagues such as good teamwork, opportunities to speak up and express opinions (social capital) were protective factors to balance workload; to deal with stressful work conditions, to be engaged for patients total patient care (vigor and dedication) and to stay in the nursing profession (job outcome items: intention to stay in the profession). Study participants expressed their concerns about the impact of high and prolonged workload on quality and patient safety (quality of care items) through nurses’ mistakes, which often were not reported. Participants were concerned that they might overlook relevant patients’ vital and other clinical signs as well as neglect patients’ mental and emotional needs. Both staff nurses and nurse managers reported staff nurses’ feelings of sadness and querulousness (job outcome items: satisfaction with the current job). Predictions of favourable hospital management & organizational support as well as nurse management at the unit on workload and study outcomes were confirmed: study participants reported supportive work conditions through successful innovations that engaged staff and improved patients’ care and well-being. Moreover, nurse unit managers showed that they have a pivotal position between management decisions and daily practice and work conditions supporting and protecting their team and teamwork.
In the quantitative study the two retested models with burnout and engagement as mediating outcome variables were largely confirmed with a convenient study sample in two acute care university hospitals. Our study results are in line with previous studies about hospital Magnet status showing the relevance of hospital-level and unit-specific strategies to achieve an excellent nursing practice environment [14, 22, 24]. Moreover, in additional analysis of models the qualitative study findings confirmed associations described in both quantitative studied models. Study participants explained the important impact of management and policy decisions on their daily practice as well as the role of their peers and nurse manager and good interdisciplinary relationship with physicians. Laschinger et al.  showed that nurse managers’ authentic leadership behaviour such as self-awareness and transparency, moral-ethical behaviour and supporting balanced processes plays an important role in creating positive working conditions. In addition, this behaviour strengthening new nurses’ confidence that helps them to cope with increased job demands and protect them from feelings of burnout and poor mental health. The models as well as what staff nurses’ and nurse managers’ expressed in the qualitative study identified and confirmed risk factors as well as protective factors related to favourable job outcomes and nurses’ assessed quality of care. Social capital and decision latitude are nurse work characteristics that are strongly predicted by nurse management at the unit level. In turn, social capital has a protective and stimulating impact on emotional exhaustion and vigor. Furthermore, decision latitude has a stimulating impact on personal accomplishment and dedication. In an empowered work environment nurses have access to relevant information, opportunities for learning and personal development and supportive relationships with peers, supervisors and interdisciplinary to achieve their goals. Moreover, professional discretion and visibility, strong commitment, engagement, work effectiveness and quality of care were identified [28, 52, 53, 57]. Instead, workload showed to be a relevant risk factor predicted by hospital management and organizational support with a highly negative impact on emotional exhaustion and vigor as well as on both outcome variables. The qualitative study revealed clearly the differences between acceptable and unacceptable workload as the capacity nurses have to sufficiently meet patients’ physical as well as emotional needs. In addition, when staff nurses were able to consider patients’ status and clinical signs timely providing quality and patient safety that also resulted in acceptable workload perception. High and prolonged workloads were related to nurses’ decreased adequacy and efficacy, complains of fatigue, headache and vulnerability for diseases as well as affects nurses’ feelings of frustration, negativity and sadness. These feelings could affect not only the individual nurse but also the whole team [44, 50]. A study investigating nursing performance under high workload revealed that certain mechanisms such as selection, optimization and compensation strategies (SOC model) support nurses’ individual decision-making and ability to perform well . The SOC model implicates that nurses use their individual resources more efficiently and adaptively by setting priorities and focus on fewer but most relevant goals, pursue these goals in an optimized way and flexibly apply compensatory means . More research on staff nurses’ cognitive and physical workloads and work demands  within an supportive and empowered psychosocial work environment will offer better insights in achieving a healthy nurse workforce and excellent quality and safety of care. However, personality characteristics in nurses vulnerable to develop burnout are identified and require sufficient and appropriate attention .
Certain limitations of the study are recognized. Firstly, although retested and confirmed, the models were based on a cross-sectional study design and should be interpret with caution. A longitudinal study design could confirm and/or extent our study results. Secondly, the qualitative study was performed independently of the model retesting and confirmation and gave additional insights about the studied variables and pathways between variables through additional model analysis. However, the study was conducted with staff nurses and nurse managers of medical and surgical wards of one study hospital. Other wards and the second hospital were not involved. Future qualitative research with other wards such as obstetric, geriatric and/or intensive care units or services such as operation theatre could confirm and extent study results. Thirdly, both study methods were based on nurses’ perceptions and experiences. Additional study method involving objective nurse and patient related variables could extent confirmation of our study results. Finally, replication in different socio-economic conditions is necessary to support generalizability.
This mixed method study based on an explanatory sequential study design provides a deep understanding of various associations and impacts on studied outcome variables. Risk factors and protective factors were identified through the retested and confirmed models and corresponded closely what study participants revealed. Besides the more softer work characteristics such as decision latitude and social capital and team cohesion more insight and knowledge of the hard work characteristic workload is essential.
Analysis of Moment Structures
American Nurses Credentialing Center
Comparative Fit Index
Incremental Fit Index
Joint Commission International
Maslach Burnout Inventory-Human Service Survey
National Health system
Qualitative data analysis computer software
Revised Nursing Work Index
Root Mean Square Error of Approximation
Statistical Package for the Social Science
Utrecht Work Engagement Scale
The study obtained no funding.
Availability of data and materials
Additional supporting files such as the database of the quantitative study (XLSX) and codebooks and themes of the qualitative study in the Dutch language (DOCX) are available as well as by request to the corresponding author.
PVB LP DVH MV VK ZVDC EF conceived and designed the experiments; DVH and VK ZVDC performed the experiments quantitative and qualitative, respectively; PVB DVH MV and LP VK ZVDC analyzed the quantitative data and qualitative data, respectively; PVB LP DVH MV EF wrote the paper. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
Every potential respondent received an invitational letter, containing information on the study and a written informed consent form. The institutional review board of each study hospital approved the quantitative study and qualitative study. In addition, a qualified ethics review committee (Antwerp University Hospital – University of Antwerp Belgium) approved the qualitative study.
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