Burnout Syndrome In Professionals Research Articles

ТРЕНИНГ РАЗВИТИЯ САМООБЛАДАНИЯ КАК ЛИЧНОСТНОГО РЕСУРСА ПРЕОДОЛЕНИЯ ПРОФЕССИОНАЛЬНОГО ВЫГОРАНИЯ

The stressfulness of the performance of district police officers causes the occurrence of a syndrome of professional burnout of employees. In this regard, special measures of psychological and pedagogical support for the development of self-control are required as one of the main personal resources for the prevention and overcoming of professional burnout by district police officers. An effective method aimed at developing the self-control of district police officers is a specially organized training designed to promote the psychological recovery of employees and, ultimately, increase satisfaction with their professional activities, increase psychological well-being at work and reduce professional burnout.
 The article proposes a training program for the development of self-control as a personal resource for overcoming professional burnout.

ПРОФЕССИОНАЛЬНОЕ ВЫГОРАНИЕ СОТРУДНИКОВ ОВД КАК СЛЕДСТВИЕ ПСИХОТРАВМИРУЮЩЕГО ВОЗДЕЙСТВИЯ ПРОФЕССИОНАЛЬНОЙ ДЕЯТЕЛЬНОСТИ: ОСНОВНЫЕ ПРОЯВЛЕНИЯ И СЛЕДСТВИЯ

The article attempts to study the features of the manifestation of professional burnout of police officers and the factors influencing its occurrence and course. Based on the analysis of scientific papers on the problem of burnout, the main directions in the study of this phenomenon, as well as problematic issues that require further research, are identified. Conclusions are drawn about the need for a more detailed study of the determinants of professional burnout, due both to the extreme conditions of the professional activity of the subjects, and their individual characteristics associated with manifestations of neuropsychic stability, adaptive potential and the development of typological personality characteristics. To conduct the study, a set of diagnostic methods was selected and tested, aimed at identifying professional burnout and describing its symptoms, as well as factors influencing the occurrence/absence of burnout in the activities of employees of the organization. The respondents were 80 employees of the internal affairs bodies of the Main Directorate of the Ministry of Internal Affairs of Russia for the Stavropol Territory. Based on the analysis of the empirical data obtained in the course of the study, conclusions were drawn about the relationship between the manifestation of the syndrome of professional burnout and the individual typological properties of the personality, as well as with the subjects' subjective perception of their professional activity as psychotraumatic, associated both with personal achievements and with opportunities for professional growth and leading to a decrease in adaptive potential and serious personal changes. The results obtained during the study were used to build a program of psychological measures aimed at reducing the level of professional burnout and increasing the adaptive capacity of police officers

Use of the Maslach Burnout Inventory Among Public Health Care Professionals: Scoping Review.

Work can be considered a source of living, well-being, and socioeconomic development. When the work environment negatively influences individuals, it may trigger emotional disturbances, behavioral problems, chronic stress conditions, and illnesses such as burnout syndrome (BS). Recently, studies on BS have increased and placed a special focus on health care professionals. The prevalence of BS among health professionals is associated with their chronic exposure to human hardship and long working hours without proper rest. These factors have contributed to greater stress and high physical and emotional exhaustion levels. This study aims to identify and map studies using the Maslach Burnout Inventory (MBI) scale to identify burnout syndrome in health professionals working in public health services. This scoping review was developed based on the Joanna Briggs Institute (JBI) Reviewers Manual and reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A total of 6 databases were searched to identify relevant studies: Embase, LILACS, MEDLINE or PubMed, PsycInfo, Scopus, and Web of Science. Gray literature was consulted on ProQuest Dissertations and Theses Global, Google Scholar, Brazilian Digital Library of Theses and Dissertations, and Open Access Theses and Dissertations. Additionally, the reference lists were searched to retrieve studies not previously selected. The steps followed in this study were proposed by Arskey and O'Malley and Levac, Colquhoun, and O'Brien: identification of research questions, identification of potential studies, study selection, data extraction and imputation, data analyses and interpretation, and consultation with stakeholders. The detailed methodology was published in a protocol. A total of 55 articles were identified after screening for eligibility criteria, published between 1999 and 2021 in 32 countries. Most reports were published in Brazil, Spain, and China. A total of 22 versions of the MBI were identified, presenting different items, scores, and cutoff points. The included studies had recommendations and implications for clinical practice. The consultation with stakeholders allowed knowledge translation for those interested in BS. Studies mostly included physicians (34/55, 61.8%) and nurses (24/55, 43.6%), and the original version of MBI was predominantly used. Divergences in BS classification were highlighted, which may be related to MBI cross-cultural adaptations and applications in other countries. This study contributes to the advancement of research regarding burnout syndrome as an occupational illness since it has harmful consequences for workers, health care services, and the quality of care provided to the population.

ОПЕРАЦИОНАЛИЗАЦИЯ ПРОФЕССИОНАЛЬНОГО ВЫГОРАНИЯ ПЕРСОНАЛА В УСЛОВИЯХ УДАЛЕННОЙ РАБОТЫ И ГИБРИДНОГО ОФИСА

The article presents the results of the author’s research on the risks of staff burnout in a remote and hybrid office. The object of the study is professional burnout in the conditions of remote work and hybrid office. The subject of the study is recommendations for the prevention of professional burnout in conditions of remote work and a hybrid office. The goal is to carry out the operationalization of professional burnout in the conditions of remote work and a hybrid office for the subsequent development of a software application for the prevention of professional burnout. The authors present a theoretical analysis of the problem under study based on the results of modern research. The risks of remote work are identified. The main markers of professional burnout are presented. Several groups of factors are considered, which determine the likelihood of an employee developing a syndrome of professional burnout: socio-demographic, personal, organizational and socio-psychological. To obtain information that a subordinate is prone to burnout, the authors suggest using special techniques. The author’s operationalization of professional burnout is presented. In the author’s operationalization, the authors tried to consider the structural components of professional burnout based on the symptoms, stage of development, and factors on which the likelihood of burnout development depends.

Модель профилактики синдрома профессионального выгорания у педагогических работников

The aim of the study is to develop a holistic methodologically sound model that will allow timely forecasting and managing the process of preventing professional burnout among modern teachers in the context of changing labour activity formats such as online interaction, distant and hybrid learning, emergency self-education and the transition to developing new technologies in digitalizing different aspects of education, etc. Studying the symptoms and phases of school teachers’ professional burnout is carried out, and negative trends associated with a number of factors and causes are identified. The main ones are the following: depersonalization, exhaustion, reduction of professional achievements. The model development is based on a personality-oriented approach and the principles arising from it. The model includes theoretical-target, diagnostic, preventive, reflective-evaluative and advisory blocks. It reflects the relationship of the leading symptoms, phases, causes of burnout with the main areas of preventive work, namely socio-psychological, personal, professional and used technologies. Testing the model shows positive changes in the studied indicators, confirmed by statistically significant differences. This model can be used by school administration staff to predict and manage the process of preventing professional burnout syndrome among teachers.

Professional burnout syndrome among nurses and midwives depending on the place of work

Professional burnout is a common problem occurring among employees whose job is related to other people, and additionally involves providing them with assistance. Therefore, one of such risk groups is the medical personnel, especially nurses and midwives. Scientific research shows that various factors have a different effect on the occurrence of professional burnout. The aim of the study was to review Polish and foreign scientific literature on the syndrome of professional burnout among nurses and midwives. On the basis of the literature review, it has been shown that the occurrence of professional burnout depends not only on education, seniority and salary, but also on human interactions at the workplace, level of social competence, and methods of coping with stress. It would not be possible to identify these factors if it wasn’t for the use of research tools in form of various types of questionnaires, e.g. Maslach Burnout Inventory (MBI) and Copenhagen Burnout Inventory (CBI). It is extremely important to undertake preventive and prophylactic activities to protect the medical personnel against this phenomenon.

Burnout Syndrome in Primary Health Care professionals during the COVID-19 pandemic

Workers in Primary Health Care (PHC) play a key role in coping with COVID-19, which required personal and work-flow changes, causing physical and emotional overload and stress, which could lead to Burnout Syndrome (BS). The objective of this study was to check the prevalence of BS in health professionals working in PHC in the municipality of Curitibanos, state of Santa Catarina, Brazil. The research was carried out between November 2020 and May 2021, a sociodemographic questionnaire, and the Brazilian version of the Maslach Burnout Inventory - Human Services Survey (MBI-HSS), which contains 22 questions and three dimensions - Emotional Exhaustion (EE), Depersonalization (DP) and Personal Fulfillment (PF), were applied. Data were collected and analyzed descriptively with subsequent statistical comparison. Participants were50 volunteers aged 40.1 ± 9.5 years, time in the profession of 10.8 ± 7.9 years. Results of the MBI-HSS showed the prevalence of risk was moderate for EE and high for DP and PF. However, no significant difference was detected between the MBI-HSS dimensions and sociodemographic variables. In conclusion, the prevalence of risk was 17.6+11.4 points in EE (moderate); 6.6+5.0 points in DP (moderate) and 36.8+6.6 points in RP (high), indicating that the evaluated population already demands some need for contingency or preventive care because it has a clear predisposition to BS. However, there was no statistical association with sociodemographic variables.

SINDROM PROFESIONALNOG SAGOREVANJA KOD SOCIJALNIH RADNIKA I ZNAČAJ MENTALNOG ZDRAVLJA POMAGAČA

This paper deals with the problem of professional burnout syndrome among social workers, the factors that contribute to the occurrence of this phenomenon and the importance of prevention and care for the mental health of professional helpers. In addition to the theoretical analysis of this phenomena and risk factors associated with the nature of the social worker’s professional role, the paper also presents the results of research on the existence of professional burnout syndrome among social workers on the territory of Serbia. The presence of parameters that indicate the occurrence of burnout syndrome among professional workers within the social protection system was established. Elevated levels of stress, tension and emotional exhaustion were noted, as well as the presence of apathy, lack of connection with clients and reduced self-care. Competencies for working with clients and self-image remained preserved. Finally, the paper presents possible ways to prevent the occurrence of burnout syndrome.

Professional burnout syndrome in a group of nursing staff employed in a psychiatric hospital

Nurses are one of the occupational groups most exposed to stress in the health care system. In their daily work, the staff of a psychiatric ward often encounters threats, aggression or unpredictability of patients' behavior. Employees, including nurses, often feel discomfort related to the treatment of patients admitted against their will, the need to use direct coercion. In psychiatry, it is also burdensome to participate in family matters of patients, to solve their problems. The group of factors recognized as stressful and causing psychological burden for nurses includes a large number of patients under their care, their serious condition as well as physical and verbal aggression of the patient and violence. The aim of the study was to present the problem of occupational burnout in a group of nursing staff employed in a psychiatric hospital Material and methods 203 nurses participated in the study. The research tool was a proprietary questionnaire and a standardized tool, the Ch. Maslach. The level of statistical significance in this study was p<0.05. Results The average occupational burnout rate was 34.9% ± 20.9%. Emotional exhaustion was assessed at 32.5% ± 28.5%, the level of depersonalization at 23.1% ± 26.1%. The main motivators in the work of nurses are earnings (57.3%), willingness to help others (54.4%) and a good atmosphere at work (35%). Conclusions: Mental burden in the work of a psychiatric nurse results in the development of occupational stress leading to occupational burnout. Actions are recommended to counteract the professional burnout syndrome

ПРОФЕССИОНАЛЬНОЕ ВЫГОРАНИЕ ВРАЧЕЙ И СРЕДНЕГО ПЕРСОНАЛА КАК АКТУАЛЬНАЯ МЕДИЦИНСКАЯ ПРОБЛЕМА (ОБЗОР ЛИТЕРАТУРЫ)

This article is dedicated to the literature review of professional (emotional) burnout syndrome (PBS) among physicians and nursing staff with various specializations and experience. It contains information on the occurrence of the syndrome, how long the issue has been explored in the world so far, and the factors that have led to the syndrome development. PBS is the reaction of the body to continuous professional stressors. The main factor is mental exhaustion. PBS is a type of psychological defense in the form of the partial or total suppression of emotions in response to psycho-trauma. As a result, a common emotional behavior emerges among physicians, where emotional burnout starts having adverse effects on professional activity and increases frequency of medical errors. In this regard, not only does the PBS affect the lives of medical staff, but it also has a direct impact on the quality of medical services. The PBS prevention measures on individual, interpersonal and organizational levels lead to increased professional motivation, decreased tension at work, optimized psychophysiological condition, an equilibrium of physical and psycho-emotional costs, and increased level of professional satisfaction.

Professional burnout, quality of life issues and psychological burden in anesthesiologists and intensive care specialists in contemporary conditions аfter COVID-19 pandemic: results of an internet-based survey

INTRODUCTION: Anesthesiologists and intensive care specialists are considered to be an extremely vulnerable group of medical specialists, more susceptible to professional stress in the context of the COVID-19 pandemic. OBJECTIVE: We aimed to study the severity of professional burnout syndrome (PB), quality of life (QoL) issues and psychological burben in anesthesiologists and intensive care specialists working in a multi-field hospital, as well as to determine the risk factors for PB in these specialists. MATERIALS AND METHODS: Physicians completed the online survey questionnaire including MBI, WHOQOL-BREF and HADS for assessment of PB, QoL and anxiety and depression, respectively, as well as the checklist with general questions related to COVID-19. Pairwise or multiple comparisons as well as correlation and regression analyses were performed within the statistical analysis. RESULTS: The online survey involved 101 physicians (mean age 38.3 ± 9.8 years, 54.5 % — females). During the pandemic, 68.3 % of specialists worked in the red zone. It was demonstrated that the PB syndrome or its signs were observed 2 years after the start of the pandemic in 75 % of specialists — in 27 % it was formed, and in 48 % its signs were revealed. Decreased levels of the main QoL domains, physical, psychological and social well-being, were observed in 1/3 of physicians. About one third of specialists had borderline or increased levels of anxiety/depression. Working in the red zone during pandemic and elevated levels of depression increase the probability of PB, and a high level of social well-being decreases it. CONCLUSIONS: For the prevention of the PB development of screening examinations are recommended on the regular basis to reveal those specialists who are at high risk of PB. The results obtained may be used to develop evidence-based practical recommendations for the prevention of PB syndrome and psychosocial disorders in anesthesiologists and intensive care specialists.

The Emergence of Professional-Emotional Burnout Syndrome in Teachers of Preschool Education Institutions: Factors, Symptoms, Stages, and Prevention

The article is devoted to the problem of the syndrome of professional and emotional burnout of teachers. The authors analyzed the main factors, indicated the symptoms of professional burnout, and established methods and means of prevention of emotional burnout in the teaching profession. The article describes the content of key concepts, the essence of the categories «emotional burnout», «stress», and «emotional exhaustion», and the emergence and understanding of related concepts in the scientific research of foreign scientists (A. Griffiths, S. Jackson, T. Kox, K. Maslach, H. Selye, H. Freudenberg, etc.). The results of the analysis of scientific works proved that stress has three stages of development: anxiety, resistance, and exhaustion, which can cause professional and emotional burnout in specialists in various fields. The basic symptoms are emotional exhaustion, depersonalization, and reduction of personal achievements. T. Cox and A. Griffiths (about 150) provided a more detailed analysis of the symptoms of professional and emotional burnout and distinguished three groups of symptoms – affective, cognitive, and motivational. The peculiarities of the raised problem in our country are revealed, taking into account the specifics of the teaching profession. The factors of professional burnout of preschool teachers are singled out, namely: high responsibility, daily mental overload, the excessive number of duties, high emotional inclusion, strict control of the administration, etc. Measures to prevent emotional burnout were presented in three aspects: professional and administrative (psycho-training, role-playing, business games, mentoring, a favorable psychological climate in the team, etc.), non-professional (a rational division of work and rest, healthy nutrition, physical exercises, self-regulation, establishing short-term and long-term goals, etc.). It has been established that a comprehensive approach to the prevention of professional burnout in preschool teachers should include correction of the mental, physical, and spiritual components of the individual’s health.

Most frequent risk factors for the development of burnout syndrome in health professionals

A Síndrome de Burnout (SB) é caracterizada por sintomas emocionais diretamente relacionados com o trabalho. Profissionais da saúde possuem altas demandas diárias e enfrentam longas jornadas de trabalho, tendo a pandemia de COVID-19 intensificado o problema. Este estudo objetivou avaliar os principais fatores de risco envolvidos no desenvolvimento da SB entre os profissionais de saúde. A triagem dos artigos foi realizada através do método PRISMA. Foi identificado que locais que não incentivavam o companheirismo, que não realizavam capacitações regulares ou o treinamento emocional da equipe apresentavam maiores índices de SB. Fatores psicológicos intrínsecos à personalidade dos trabalhadores e transtornos psicológicos prévios também influenciaram nos riscos de SB. O “lockdown” dissociou redes de apoio psicológico. O colapso do sistema de saúde e o risco constante de contágio desencadearam a “coronafobia”. A dificuldade em tratar a COVID-19 e as mortes de muitos pacientes aumentaram a condição de estresse dos profissionais. Além disso, a falta de equipamentos de proteção individual, insumos medicamentosos e leitos de unidades de terapia intensiva agravaram o quadro psíquico dos profissionais.

Professional Burnout Syndrome in Health Personnel and Social Workers: a Comparative Questionnaire-Based Survey

AIM. To perform the comparative assessment of the prevalence of professional burnout symptoms in health personnel and social workers providing services to persons with pronounced disabilities. MATERIAL AND METHODS. We conducted a survey of employees in two medical institutions (healthcare workers, Group 1, n = 86) and employees in a social service institution (social workers, Group 2, n = 89). The presence of professional burnout was established using Maslach Burnout Questionnaire adapted by N. Vodopyanova. RESULTS AND DISCUSSION. Signs of professional burnout of different severity were found in 96,6 % of the respondents. High and extremely high levels of psychoemotional exhaustion, depersonalization, reduction of personal achievements were more frequent among health personnel than among social workers: 1,9 times (p = 0,012), 1,6 times (p = 0,033), 2,9 times (p = 0,029) respectively. At the same time, 31.4 % of Group 1 and 7.9 % of Group 2 respondents indicated overwork due to understaffing; 29.1 % and 10.1 %, respectively, indicated frequent need for additional work due to the temporary absence of colleagues. It explains higher levels of professional burnout among employees of medical institutions. At the same time, Group 2 was characterized by a younger age (by 6.5 years on average, p = 0.006) and a shorter work experience in the institution (by 10 years on average, p < 0.001) compared to Group 1, which may indicate both «staff turnover» among social workers and the appearance of conditions in the social service sphere attractive for younger age specialists. CONCLUSION. Health personnel have higher levels of the professional burnout symptoms more often than social workers, that is probably connected with an increased intensity of labour and overwork.

Профілактика професійного вигорання медичних сестер при наданні паліативної і хоспісної допомоги

The risk of burnout syndrome ranks one of the leading places among nurses, especially at the primary care level and in palliative and hospice care units. In the article are reflected results of the study of emotional resources, «organizational precursors of burnout», also are discussed clinical manifestations and methods of prevention of professional burnout syndrome in nurses. As a part of the educational process for the prevention of this condition, the primary task is to train students and medical personnel, help in organizing work in specific institutions in order to carry out preventive or corrective measures. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Professional burnout syndrome in specialist surgeons: Prevalence and risk factors

Professional burnout syndrome in specialist surgeons: Prevalence and risk factors

SÍNDROME DE BURNOUT EM PROFESSORES: um olhar para literatura com ênfase na necessidade de intervenção

Work considered as a source of survival is also linked to the formation of identity and the individual is related not only to pleasure but also to illness. The wear and tear related to working conditions can generate stress that is prolonged, originating the Burnout Syndrome in professionals. The teaching professional is one of the categories that is most exposed to the occurrence of this syndrome and this fact can harm both the professional and the school community they serve. Faced with this reality, the present study sought to briefly describe aspects of the relationship between health and work; discuss the risk factors associated with stress in the teaching profession; reporting on the Burnout Syndrome in teachers began its consequences and the need for actions aimed at the prevention and treatment of those affected. It is characterized as a narrative review of the literature that used the Google Scholar platform as a database, the search being carried out using the following words: “burnout” and “teachers”. Works in the Portuguese language were used preferably in the period from 2002 to 2022, counting for the composition of the corpus of this review a total of 56 works that include articles, books, TCCs, dissertations and theses. The study showed that work according to its organization and demands can have consequences for both physical and mental health. In the second case, one of the conditions that has been highlighted is Burnout. In the specific case of teachers, the profession is considered a complex task with many demands, often double shifts and direct contact not only with students but also with parents and other social actors in the school, which can lead to physical and mental exhaustion. , behavioral changes in the relationship with colleagues, low appreciation of their profession and consequently brought numerous consequences preventing the well-being of teachers. The investigated literature indicated some paths that can help to change this situation and alert to the urgency of rethinking working conditions through urgent actions to be adopted.

Рrofessional burnout syndrome as a manifestation of stress in naval specialists of different age groups

OBJECTIVE: To assess the symptom severity and formation of professional burnout syndrome (PBS) in naval experts of different age groups.MATERIALS AND METHODS: 849 naval experts, aged 25–45 were examined. Based on generally accepted methods, there was the evaluation of professional burnout and stress, considering clinical-psychophysiological features of the respondents with a different severity level of symptom manifestation. Moreover, to assess the dynamics of professional burnout in naval experts, performing military service as part of Arctic division, subgroups by age were identified out of the total sample (N=127): the group of persons, performing military service as part of Arctic division aged 25–30 included 21 people (n1=21), aged 31–40–72 people (n2=72), aged 41–45–34 people (n3=34). Statistics: Statistic analysis of the data was conducted using the application package «STATISTICA 6.0» and spreadsheet Microsoft Excel-2010.RESULTS: The formation nature of PB syndrome in naval experts of different age showed that the persons, performing military service as part of Arctic division, aged 25–30, experienced a high rate of stress phase (68,1±7,9 points), indicating its formation, and 39,8±7,5 points in the resistance phase, indicating the process of this phase formation; yet there were normative values (28,4±5,1 points) on the exhaustion phase in this group of people. The naval experts, performing military service as part of Arctic division, aged 31–40, experienced a high rate of stress phase (72,8±7,9 points) and resistance phase (73,4±11,5 points), indicating their formation in the examined individuals; at the same time the indicators on the exhaustion phase did not overcome the normative values of 26,7±7,2 points. The naval experts, performing military service as part of Arctic division, aged 41–45, experienced average normative values on stress phase (25,9±3,8 points), resistance phase (23,9±3,9 points); yet there was formation of exhaustion phase (39,1±6,9 points).DISCUSSION: The analysis allowed to reveal age-sensitive formation of professional burnout syndrome. It is shown that individual manifestations of the syndrome form clear modal symptoms among different age groups. The specifics of neuropsychic disorders in naval experts of different age groups were identified.CONCLUSION: The data analysis allowed to conclude that prevention of PBS formation and its successful overcoming could largely be achieved by naval experts’ implementation of optimal strategies for coping with stress and using constructive and mature psychological defenses in their behavior.

Professional burnout of medical workers in the era of the COVID-19 pandemic as a risk factor for mental health

The paper presents an analysis of the literature on the problem of professional burnout syndrome in medical workers, presented in the Scientific Electronic Library (eLibrary), as well as in the English-language text database of medical and biological publications PubMed.
 The novel coronavirus infection pandemic is associated with many factors contributing to formation and development of professional burnout in medical workers. The risk factors are: high workload, lack of PPE, threat and risk of contracting a new coronavirus infection, social isolation, insufficiency (at the first stage) of accumulated knowledge about the new little-studied disease.

Assessment of The Effect of Stress, Sociodemographic Variables and Work-Related Factors on Rationing of Nursing Care.

(1) Rationing of nursing care is withholding, limiting or not fulfilling the necessary nursing activities for patients. It may have a negative effect on patient safety and the quality of care. The aim of the present paper is the assessment of the effect of stress on the rationing of nursing care. (2) The current research has a cross-sectional, observational design. The study sample comprised 567 nurses. The following questionnaires were used in the study PIRNCA and PSS-10. (3) It was demonstrated that nurses with a high level of perceived stress rationed nursing care to a greater extent and showed lower assessment of nursing care and lower job satisfaction in comparison with nurses with average and low levels of perceived stress. (4) 1. Stress in nurses has a negative effect on rationing of nursing care and job satisfaction. It is recommended that actions aimed at developing effective stress coping skills be implemented as early as at the stage of training to become a nurse. 2. Factors such as marital status, sex, form of employment, place of employment and the level of professional burnout syndrome may have an influence on the level of experienced stress. In turn, the level of experienced stress, marital status, education, place of work as well as the place of residence may have an effect on rationing of nursing care and, consequently, affect the quality of care.