Burnout and Stress in Healthcare Professionals

This assignment delves into the critical issue of burnout and stress experienced by healthcare professionals. It examines various contributing factors, including long working hours, high patient demand, and challenging work environments. The assignment analyzes relevant research studies that explore the consequences of burnout on mental well-being, job satisfaction, and patient safety. Furthermore, it investigates coping mechanisms and potential interventions aimed at mitigating burnout among healthcare professionals.

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Dissertation
Name of student:
Name of university:
Author note:

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Table of Contents
I. Introduction.........................................................................................................................3
1.1 Introduction......................................................................................................................3
1.2 Background......................................................................................................................3
1.3 Research problem.............................................................................................................4
1.4 Justification of research....................................................................................................5
1.5 Significance of research...................................................................................................6
1.6 Aims and Objectives........................................................................................................6
1.7 Research aims and objectives...........................................................................................6
1.8 Research question.............................................................................................................7
1.9 Research Hypotheses.......................................................................................................7
2. Methodology..........................................................................................................................8
2.1 Introduction......................................................................................................................8
2.2 Literature search...............................................................................................................8
2.3 Bibliographic aids............................................................................................................9
2.4 Inclusion and Exclusion Criteria and the Search Strategy...............................................9
2.5 Search staretegy.............................................................................................................10
2.6 Search outcomes.............................................................................................................11
2.7 Summary........................................................................................................................12
3. Review of Literature............................................................................................................13
4. Results and Discussion.........................................................................................................27

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5. Research limitations.............................................................................................................31
6. Future Scopes of Research...................................................................................................31
References................................................................................................................................32

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Research title: The impact of behaviour of healthcare workers on patient outcomes and
strategies for improving behaviours: a systematic review
I. Introduction
1.1 Introduction
Health care professionals have principal contribution towards the overall health and
well-being of the patients. Health care professionals like nurses and doctors are liable towards
ensuring maximum benefit to the patient’s well being via delivering holistic care
management. However, the skills, competencies and behaviour of the healthcare
professionals have a significant impact upon their mental and physical well being of the
patient along with their length of hospital stay (Bodner et al. 2015). The present chapter of
the dissertation sets the stage for value research on analyzing the impact of the behaviour of
the healthcare workers patients outcomes. This chapter will begin va setting the scene and the
context around the impact of the behaviour of healthcare professionals. A robust rationale for
the choice of the topic will be presented. The next section of this chapter represents the
significance of the study followd by the clear description of the how the question will be
formulated along with aims and objective of the research.
1.2 Background
Against the evolving healthcare sector across the globe, the behaviour of
healthcare professionals has drawn significant attention in context of delivering high quality
care. The key aspects of behaviour of healthcare professionals include ability to communicate
effectively, maintin patient dignity and confidentiality, engage in learning behaviour,
demonstrate leaderhsip skills, combat burnout and tension, and fulfil personal responsibility
and integrity. Research indicates that behaviours of healthcare professionals in different care
organisations are different, and the reason for this difference is multidimensional (Strachan

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et al. 2015). The four key aspects related to healthcare professional’s practice are knowledge,
attitude, behaviour and quality of care. Knowledge of healthcare professionals is central to
the issue of professional accountability. It is defined as the means by which the whole
purpose of caring for patients is achieved. Attitude is the persistent disposition to consistently
respond to the patients in a given manner. It is the most indespinsible concept in healthcare.
Behaviour refers to the natural conduct of a professional in a setting directed by internal and
external influences. The behaviour of a professional directly and indirectly influences patient
care. Quality of care is the degree to hich healthcare professionals increase the chances of
desired health outcomes for the patients being cared for, and is consistent with professional
knowledge. It is determined by outcomes, patient perceptions, and organizational structure
and systems (Baum 2016).
1.3 Research problem
Due to the drastic rise in demand for high standard healthcare centres in the UK, focus
has been shifted to the nature of behaviour of care professionals since this is the main factor
behind care quality. Finding the cause of inappropriate behaviour and implementing
strategies has proved to be a major challenge in the recent past. Voluminous literature
indicates that behaviour of professionals vary from one care setting to another and this
difference is clearly evident from the feedback of the service users. While one care setting
might have care workers capable of demonstrating required skills and competencies, another
care setting might not have the same condition (Folland, Goodman and Stano 2016).
There are numerous evidences highlighting the negative attitude of the healthcare
professionals towards the patients which decreases the total health and well-being while
increasing their length of hospital stay (Davison et al. 2016). There are numerous contexts
where negative attitudes of the healthcare professionals are higher and the reasons behind this
is both internal and external like organisational factors (Davison et al. 2016). However, it is

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difficult to undertake deeper investigation on the attitudes of the healthcare professionals
towards their oatients. Several factors like long working hours, lack of proper training and
education, irritating behaviour of the patients and lack of proper training skills are highlighted
as the factors affecting the behaviour of the healthcare professionals towards their patients
(Chen et al. 2016). However, there are no definite plan analyszing how this factors are
influencing their behaviours or what are exact mechanisms via which the impact of these
factors an be minimalised.
Hence, in this research key focus will be to explore these factors which are
contributing towards the negative or challenging behaviour of the healthcare professionals
towards the elderly patients. The research will try to explore the impact of this challenging
and negative behaviour of the healthcare professionals over the patient along with the
possible strategy to overcome this scenario.
1.4 Justification of research
Attitudes and behaviours of healthcare workers have a deep infleucne on the health
outcomes of the service users, as well as on the working conditions of fellow professionals.
Challenging behaviour is a serious concern since it can cause major danger and distress to the
patients as well as to the other professionals working in the mutlidiscplinary team. For
successfuly managing the unaccepted behaviour, it is necessary to understand the manner in
which care professionals empty their skills, demonstrate their knowledge and display their
attitude (George 2015). Comparison of the above stated factors between two care units was
thought to be valuable since key information derived from one organsition can act as a set of
recomemdnation for the other organisation, and vice versa.

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1.5 Significance of research
This dissertation paper is focused on the challenging behaviour of the healthcare
professionals upon the patients. At present it has become one of the alrmaing issue in the
healthcare organisations (Hynninen et al. 2015). Therefore from the present study aims
towards the indentification of the major factors responsible for the negative or challenging
behaviour of the healhtcare professionals toward the patients. The study will be helpful
because, based on the findings of the research, policies can be outlined by the respective care
settings for improving the working conditions of the professionals. Appropriate strategies can
be taken by the care settings that can address the concerns of the professionals on the basis of
the valuable insights taken from the research (Baum 2016).
1.6 Aims and Objectives
The of the research is to explore the of behaviour of healthcare workers on patient
outcomes and strategies for improving behaviours.
1.7 Research aims and objectives
1. To analyze the impact of the various factors that leads to change in the attitude of the
healthcare professionals towards the patients
2. To investigate how these factors affects the health and wellbeing of the patients
3. To recommend the ebst possible ways to improve the attitude of the healthcare
professionals towards their patients.
1.8 Research question
 What are the resoans behind the negative attitude of the health care professionals
towards the patients
 What are impacts of the negative attitudes of the healthcare professionals over their
patients

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 What are the nurses or other healthcare professionals doing regarding to overcome
their challenging behaviour?
1.9 Research Hypotheses
Hypotheses of objective 1
H0: Factors like verbal and physical aggression of the patients and conflict with the
patient’s family members, long working hours, lack of proper nursing training and shortage
of staffs do not lead to challenging behavior of the nurses.
H1: Factors like verbal and physical aggression of the patients and conflict with the
patient’s family members, long working hours, lack of proper nursing training and shortage
of staffs lead to challenging behavior of the nurses.
Hypotheses of objective 1
H0: Factors like verbal and physical aggression of the patients and conflict with the
patient’s family members, long working hours, lack of proper nursing training and shortage
of staffs do not affect the well being of the elderly persons in a health care
H1: Factors like verbal and physical aggression of the patients and conflict with the
patient’s family members, long working hours, lack of proper nursing training and shortage
of staffs affect the well being of the elderly persons in a health care

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2. Methodology
2.1 Introduction
The aim of this chapter is to elaborate the steps which are use while conducting
systematic literature review and other process that are ued for narrowing down the evidences
into order to accrued towards the final selection of the article. The approach that will be
undertaken will be examined critically while discussing the strengths and limitations of the
bibliographic aids.
2.2 Literature search
Before starting systematic literature review, proper identification of the keywords are
mandatory (Polict and Beck 2014). The keywords should be selected in such a manner that it
covers the principal concepts of the research questions. The principla keywords used in the
literature search are discussed in Table 1. All these keywords are used for the search of the
literary articles in the electronic databases.
Keywords
Keywords Thesaurus terms Subject Headings
Health care professionals Healthcare employees, doctors,
nurses
Health care professionals
Challenging behaviours Negative attitude Challenging behaviours
Nursing action Duty of nurse Nursing care
Patient impact Patient outcome Patient impact
Table : 1
Source: Created by author

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2.3 Bibliographic aids
A proper search of literature is crucial in order to gain access of the breadth of the
information available. Electronic sources enable huge access of relevant and authentic articles
which are available online and hence are regarded as a good approach for initiation of the
literature search for the systematic review (Parahoo 2014). The main online electronic
databases which are used for search for the literary articles include Medline, Internurse, Ovid
Nursing Full Text Plus, Psych Info, British Nursing Index and normal university library
search.
According to Parahoo (2014), before starting any review of literature, a through
search analysis of the the available reviews which are already being published online is
necessary. This is because, it will help to reduce the chances of duplicate work while framing
of the research questions which are already being used in previous research. Moreover,
Holloway and Wheeler (2010) is of the opinion that the through analysis of the previous
published aritlce that fall within the scope of the research helps in finding of the proper
research gap and thereby helping to restructure the themes for the systematic literature
review.
2.4 Inclusion and Exclusion Criteria and the Search Strategy
According to Coughlan et al. (2013) the formulation of the clear inclusion and exlusion
criteria is curcial in order to eliminate the irrelevant information which do not fall under the
scope of the research. Polit and Beck (2014) further opined that the proper selection of the
inclusion and exlcuison criteria helps in setting the proper boundaries of the literature review
and thus helping to shorten the scholarly articles which are available online. However,
selection of the inclusion and exclusion criteria should be justified enough in order
adequately validate the online search of bibliographic articles. For example, Parahoo (2014)

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stated that the exclusion criteria that are too specific may overlook some revelant yet
important information.
Inclusion and Exclusion Criteria
Inclusion Exclusion
Primary research and Secondary research
Language: English
Year of publication: 2012 to 2018 Older than 2012
Peer reviewed journal article
Research methods: Qualitative
Table 2: List of the Initial inclusion and exclusion criteria
Source: Created by author
Both primary and secondary research were chosen in order to incorporate as much as
data possible in the systematic review and thereby making it more refined (Parahoo 2014).
Articles which are published before 2012 were not included ithe stdy in roder to focus on the
most recent and updated findings (Polit and Beck 2014).
2.5 Search staretegy
Accoridng to Robb and Shellenbarger, 2014, use of the Boolean operators used to
narrow down the search or to broaden the results. Here the Boolean operetors like AND/OR
were utilised in order to combine and contrast the key words as highlighted in the above table
(table 1). The keyword search strategy that was utilised for the literature search include,
healthcare professionals OR nurses OR physicians and negative attitude OR challenging
behaviour, Nurses OR physicans AND negative behaviour AND patient impact. After
adjusting the number of publication year, the google Boolean search lead to the generation of

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145,000 articles. This search number showed that there is a wide variety of authentic yet
relevant literature which is available online surrounding the particular research questions.
Accoridng to Siu and Comerasamy (2013), the search which huge hits via employing birad
key-words reveale that that there is huge amount of grey literature available online. Grey
literature also encompassed governmet publications and other guidance literature wich are
released to the general public for increase in the awareness and for education. Since goofle
search lead to the evolution of the huge articles, it was difficult to scrutinize. So other search
enegines where employed for the authethic search of the data. The evolved searches were firt
talied on the basis of the title of the research and then shortlisted articles were scrutinised on
the basis of the abstract to highlighted the revelancy and then the final articles were chosen
for the literature review.
The search of the literature was continued until when the searcher of the keywords
within the estimated time-frame lead to the generation of the duplicate searches with no new
hits for the literature review. According to the research findings of Saumure and Given
(2008), this process of the generation of the duplicate searches is known as “data saturation”.
Saumure and Given (2008) have opined that this is the ideal time is discontinue the research
in order to generate a rounded perspective of the research. The search of the literature helped
in the identification of numerous articles (details of which is given in the search outcomes)
and out of them 25 articles were shortlisted for the generation of the systematic reviews.
2.6 Search outcomes
Search Outcomes
Resource Search Terms Number of articles
returned
Number of relevant
articles

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Crochrane Database of
Systematic Review
As per table 1 20 0
Google Scholar Health care
professionals,
behaviour, impact on
patients
17200 Time consuming to
reduce the article
numbers
Library Search Health care
professionals,
behaviour, impact on
patients
25 5
Ovid Full Text Nursing
Plus
As per table 1 10 2
Psych Info As per table 1 5 1
Joanaa Briggs Institute
EBP Database
As per table 1 25 0
Medline As per table 1 44 7
British Nursing Index As per table 1 50 8
Internurse As per table 1 30 2
2.7 Summary
Thus in the research summary, it can be stated that in order to carry out the data-
analysis in a systematic review format, qualitative research approach was chosen. In order to
carry out systematic analysis, the literary articles were used which were retrieved from the
electronic databases based on the keyword search and within the limited time-frame. Baased
on the through analysis of the title and abstract, 25 articles were selected for the systematic
review.

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3. Review of Literature
Theme 1: Long working hours and shortage of the nursing staffs
One consistent theme that has been identified while exploring research literature
related to the impact of health care behaviour on patient outcome, long working hours and
shortage of staffs emerged as a common theme. These two issues were the reason for
inappropriate health care professionals and poor patient related outcome. The issues of
burnout and job dissatisfaction were linked to long working hours and all these issues were
affected performance of nursing staffs, mental health care professionals, physicians and other
health care staffs. Scanlan and Still (2013) showed the impact of long working hours on
well-being and performance of mental health staffs. By means of survey method with
occupational therapist working in mental health care services, it was found that job
challenges resulted in poor employee well-being (high burnout and job dissatisfaction) and
poor patient outcome too. The strength of the research was that it covered all important
outcomes related to impact of long working hours such as job satisfaction, turnover intention,
burnout, job demand and job resources. However, the study outcome is not generalisable as
the survey was done only in one mental health services and causal factors were not explored.
Despite this limitation, the finding has implication for mental service manager to promote
resilience skills in staffs and provide them with the right flexibility to overcome job stress and
enhance performance (Morse et al. 2012).
Although level of stress is high for mental health care professionals, however
evidence related to impact of long working hours and stress on staff performance were found
for general physician too. Passalacqua and Segrin (2012) conducted research with resident
physician and explained that long-call shift increases the number of stressors for physicians

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resulting in poor quality of care. The study proved changes in physician’s attitude towards
patient due to burnout and perceived stress. By means of comparison of self-reported
measures on stress in physician before the start and end of shift, it was found that the
attribute of empathy declined in physicians by the end of the shift. Since empathy is
significant aspect of patient-centred care, this had an impact on patient-centred
communication process (Epner and Baile 2012.). Hence, burnout contributes to deterioration
in empathy which impairs high quality interaction with patient and the study gives the
implication for implementing stress management intervention for health care professional and
strengthening their behavioural skills to promote empathy and optimal communication with
patient. The credibility of the study is understood from its research methodology as important
parameters like stress, burnout and empathy were measured by means of validated tools and
the relation between stress and empathy is consistent with other research literature (Williams
et al. 2017). However, the only limitation that affects the transferability of the work is that no
patient related response to get the complete picture related to long workings hours on
physician-patient communication process.
Stimpfel, Sloane and Aiken (2012) showed that level of burnout among hospital
nurses increased with the increase in work shift and this resulted in patient’s dissatisfaction
with care. Hospital nurses need to work for 12 hours and this limits work-life balance and
flexibility that is desired by nurses in practice. This situation increases the risk for fatigue and
burnout among nurses which ultimately comprise patient care. The study aimed to investigate
about the relationship between shift length and nursing outcome of burnout, dissatisfaction
and intention to leave the job. By means of secondary analysis of cross-sectional data
obtained from survey, the study proved that long shift hours increase the likelihood of poor
nursing performance. The study outcome also revealed that patients were dissatisfied with
the care received in hospital setting where nurses had work shift of more than thirteen hours.

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This findings gives the implication that institutional factors like long working hours is the
reason for inappropriate performance of nursing staffs and the increase in patient safety
issues in care. This finding is consistent with the work of Wu et al. (2013) too as the study
showed that patient safety grade deteriorated in hospitals where nurses had to work for ling
working hours. However, the limitation of the work is the use of cross-sectional secondary
analysis method. It limited scope for causal inferences of nurse’s long working hours on
patient outcome. There was a need for primary research method to obtain causal inferences
related to the issue.
Theme 2: Aggression and conflict with patient and their family members
The above result gave idea about institutional and management barrier resulting in
poor health staff outcome and behaviour. However, as this research focused on reviewing
health care professional’s attitude and its impact on patient, the theme of aggression and
conflict with patient and family members also emerged as a major theme. In health care
setting, there are many patient with symptom of aggression and poor skills and attitude of
health care staffs in handling aggressive patients results in issues of stigmatization and
conflict with patient and family members (Catthoor et al. 2015).
The issue of aggression and violence is highly prevalent in inpatient settings with
mental health problems. As staff’s attitude and beliefs towards aggressive patient can have an
impact on the management strategies they adapt, analysis of staff attitude is important.
Pulsford et al. (2013) focused on evaluating the attitude of both staffs and patients about ways
to manage aggression and participant’s response were collected by the use of MAVAS
(Management of Aggression and Violence scale), a questionnaire tool covering the topic of
aggression and violence and agreement on statements related to aggression management.
Some differences were found regarding the staff and patient’s views on patient aggression

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and violence as patients agree that modification of physical environment can lessen
aggression; however staffs were unaware about it. In the area of statements related to
management of aggression, both staffs and patient agreed on use of medication for
management of aggression, however their disagreed on use of restraint and seclusion method
to handle such patient. Negotiation was also regarded as a favourable strategy for both patient
and family members. The strength of this evidence is that it proved that staffs and patient’s
view on cause of aggression and aggression management are similar and the value of non-
physical strategies for management of aggressive patient became eminent. However, since
the research was restricted to one setting, it cannot be generalized for all hospitals. The study
by McCann, Baird and Muir-Cochrane (2014) also showed very similar outcome, however it
explored attitude of clinical staffs only.
Another research study that was found suitable to address the research question
included the study by Kowalczuk and Krajewska-Kułak, (2017) which aimed to assess the
exposure of difference types of health care workers to patient aggressions. It also explored
potential determinants of such kind of exposure. As per the research aim, a total of 1,624
workers were selected which was appropriate sample size to evaluate attitude of different
health care professionals. The researcher also classified aggression exposure to eight types
such as raised voice, threats, blackmail, threatening attitude, striking attempts, aggression in
front of health care staffs, aggression in front of others and physical violence. The review of
study findings revealed that all health care professional groups regarded raised voice as the
most common form of patient aggression and physical violence as less frequent form of
aggression. In addition, the frequency of raised voice was most commonly observed during
communication with nurses and other staffs. Another important finding was that aggression
exposure is high in outpatient healthcare unit particularly for medical rescue workers. The
strength of the study is that it proved that exposure to aggression decreases with age and

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nurse is the medical staff who is most exposed to patient aggression. Hence, the study brings
forward the need to evaluate skill of nursing staffs in managing aggressive patient.
Based on the above finding, it was necessary to evaluate research literature exploring
nurse’s attitudes and perception towards management of aggressive behaviour in patients.
This resulted in inclusion of three studies that evaluated nurse’s attitude towards aggression
and its impact on patient. By the use of cross-sectional survey design, Angland, Dowling and
Casey (2014) showed that nurse’s perception towards cause and management of aggression
are complex and most of the response contradicts with one another. In addition, the response
of nurses had correlation with the type of training course taken by the nurse and their
experience at work. Negative attitude towards aggression were also found. This correlation
suggests that educational programs are vital for improving nurse’s competence in handling
patients with aggression and violence. The study gives the implication that as psychiatric
practice looks at care of patients with complex mental illness, only registered nurse with
required knowledge and skills for mental health practice should work in mental care setting.
The limitation found in the work is that it had a small size and the sampling strategy affected
the credibility of the evidence.
The review of another research presented contrasting view point regarding nurse’s
skill in managing aggressive patient compared to the work by Angland, Dowling and Casey
(2014). By conducting a quantitative research with professional nurses working at a
psychiatric hospital in Western Cape, South Africa, Bekelepi (2015) showed that nurses
encounter verbal aggression frequently compared to sexual aggression. However, one
surprising finding in the study was that nurses with less year of experience had more
knowledge about aggression. Overall nurse had fair knowledge about ways to manage
aggressive patient. This research finding may differ from the findings given by Angland,
Dowling and Casey (2014) because of individual hospital setting in which the research was

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done. Bekelepi (2015) work might have yielded positive results regarding nurse’s knowledge
related to controlling aggression because of participation of newly graduate registered nurse
in aggression minimisation training as part of their orientation program. Hence, such training
program may differ in different setting resulting in different outcome. Therefore, conducting
the research work in only one psychiatric hospital is the major limitation of the study. It give
the implications for health managers to conduct needs analysis to determine the skills of
nurse and deliver proper training to enhance their competencies in aggression management
(Gerdtz et al. 2013).
Apart from skills and knowledge base of health care professionals in dealing with
aggression in health care setting, the emotional and feelings related to such issue also
determines individual staff’s capability to professionally overcome such issue in practice.
This aspect was covered by Camuccio et al. (2012) which focused on exploring the thoughts
and feelings of Italian psychiatric nurse while caring for distressed and aggressive patient.
Focus group approach was taken to collect research data and analysed transcribed data of
nurses revealed that fear was an overwhelming emotion experienced by nurse and these was
found due to team safety issues, familiarity or non-familiarity with the patient and patient
physique. Fear was a dominant feeling among nurses indicating that complying with the
principle of non-maleficence became a challenge for nurse because of risk to their own
safety. Secondly, the results also showed that the overall team’s emotion and feelings also
had an impact on nurse’s ability to balance their emotion and impulsive reactions. The
unpredictability of aggression in different patient was also one major challenge for the nurse.
This is also described by (Ward 2013.). The study is limited by its small size and
homogenous population, however the significance of this research is that apart from
individual skills, the research pointed to the fact that better collaboration with clinical team is
also essential to manage aggressive patient in mental care setting. It also gives the implication

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to manage feelings and behaviour of nurse to effective handle distressed and aggressive
patient.
Theme 3: Lack of proper training and skills
The level of experience and nurse’s participation in training program to enhance their
professional skills also determines the quality of care provided by health care professionals.
As patient aggression is one factor that affects health care professional’s attitude and feeling
towards patient, Gerdtz et al. (2013) evaluated the outcome of rapid training programs on
nurse’s attitude towards preventing aggression in emergency department. The training
program aimed to promote the use of de-escalation strategy to control aggression in patient.
The MAVAS tool was used to collect data for pre-test post-test survey. The reviewing of
research study revealed moderate changes in attitude about prevention and management of
aggression, however changes were found in the way staffs interacted with patient. This
finding indicate that to improve staff’s attitude towards aggressive patient, there is a need for
developing effective and sustainable prevention program.
Poor knowledge and skills of staffs towards management of patient also results in
patient safety issues and poor quality of care. Due to incidence of high rate of patient safety
issues in clinical setting, the level of training on patient safety education also determines the
ability of health care professionals in promoting health and well-being of patient. Patient
safety education is an emerging demand in health care, however it has received little
attention. Lack of patient safety education and training among health care professional
increases risk of adverse event Lack of attentions to patient safety details has been found
because of poor recognition by health educators regarding acquiring patient safety training.
Secondly, the focus on treatment of disease instead of prevention of illness also results in
many preventable adverse events in health care setting (Leotsakos et al. 2014). Due to the

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prevalence of such issues, the study by Brasaitė et al. (2016) is considered significant as it
looked to explore the skills of health care professionals in patient safety. By the use of Patient
Safety Attitude, Skills and Knowledge tool, the researcher evaluated the skills of physicians,
head nurse and nurse assistants. The review of findings indicated that health care
professionals were competent regarding their safety skills. The patient safety skills of health
care professionals varied depending work related and demographic factors too. Hence, this
finding can be applied only for the country in which the research was done and the outcome
cannot be applied in other setting.
One of the common experienced by health care professionals in practice is related to
dealing with stress and complex issues in patient. The stress level of health care staffs
increase due to workplace demand, long workings hours and poor capability to handle
patients with complex health problem. From this perspective, it can be said that level of staff
training in stress management also determines the quality of care given by staffs and their
attitude towards diverse patient group. Mindfulness based training is most commonly taken
up by health care professionals to improve their stress management skills (Manotas et al.
(2014). Hence, nurse’s capability for stress management can determine psychological well-
being of staffs. Nursing staff is the one member of the health care team who are constantly
involved in care patient, hence Pahlevani et al., (2015) investigated about the effectiveness of
stress management training on psychological well-being of nurses. The research was done
with intervention and a control group. The intervention group completed 10 sessions on stress
management whereas the control group received no intervention. The analysis of pre-test and
post tested data revealed that stress management training significantly improved
psychological well-being in nurses. It enhances the skills needed by nurse to cope with stress
and the outcome was consistent with other research too. By taking of control and intervention
group, the credibility of the research was also enhanced as this helped in proper analysis of

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the effectiveness of training on well-being of health care professionals. However, one
element that is missing is the impact of training on professional competency of nurse or other
health care professionals. Hence, it can be concluded that different forms of professional and
non-professional training are essential for health care professionals to manage challenges in
work and influence relationship with patient.
Theme 4: Poor work environment
Patient safety and the attitude of health care professionals towards patient safety is a
topic of interest in health care field due to the rise in number of patient safety incidents.
However, the review of studies on attitude of staffs towards patient safety has revealed that
the job or working environment of health care professionals affected their ability to provide
high quality care (Berry et al. 2016). For example, the study by Brasaite et al. (2016) did not
investigated about workplace environment, however the impact of workplace environment of
patient safety was identified by the investigation of health care professional’s attitude towards
patient safety. The study was conducted in three hospitals of Lithuania and the main research
participants were physicians, nurses and head assistants. The data was collected by means of
questionnaire on and tools on patient safety attitude. The review of research outcome
revealed that majority of health care staff has positive safety attitudes. Another important
finding was that the patient safety attitudes of staffs were influenced by working environment
factors like safety culture, working condition and job satisfaction level. In addition,
physicians were found to have higher safety attitude related to teamwork climate compared to
other groups. The research also differentiated study results on the basis of working unit and
by this approach, it was found that psychiatric unit staffs had lowest safety attitude.
The above research had many strengths and advantages. Firstly, by the approach taken
for data analysis, the study was successful in highlighting about the factors that influence

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patient safety attitude of worker. Secondly, it showed clear link between impact of work
climate on patient safety and differences in attitudes based on different professional groups
and their work in different health department. It also gave the indication those mental health
care professionals at high risk of poor patient safety attitudes because of patient related
factors such as exposure to physical violence and stress. The study finding is also reliable
because it was done in different setting (Brasaite et al. 2016). Review of this evidence gives
the implication that health care leaders must consider the need to provide appropriate work
environment to promote positive patient safety attitudes among health care professionals.
Improved safety and teamwork culture has contributed to decrease in patient harm related
cases in hospital setting (Berry et al. 2016).
Another study also evaluated the impact of work environment on health care workers,
however in this case the focus was to establish its link with mental-emotional health instead
of patient safety attitude. Analyzing mental and emotional well-being was also essential to
assess their capability to cope with stress in work. The study was done with 200 health care
professionals and the ‘Coping Strategies for Stressful Events (CSSE)’ instrument was used to
evaluate coping skills of the research participant. Research rigor is also evident as validity of
the tool was also considered by the researcher. The review of overall findings of the study
revealed that there was lack of stress management skills among health care workers and this
was because of high level of stress in work (Koinis et al. 2015). Hence, the study gave the
idea that stressful event is the one work environment related factors that affects the mental
and emotional health of health care professional. Such stressful and hazardous work
environment influences their decision to quit the job too. This research has important
implications to develop strategies to provide right psychological and counselling support to
staffs to strengthen their skills in effectively dealing with stressful situations at work (Howlett
et al. 2015).

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Theme 5: Impact over the physical and mental wellbeing of the patients
According to Hazelhof et al. (2016), challenging behaviour of the nursing staffs and
othe health care professionals at present is a common process. This is because, shortage of
the staffs has increases the pressure on the nursing professionals causing long working hours,
reduction in the work-life balance along with reducing the rate of satisfaction. This results in
the generation of the challenging or negative behaviour among the patients especially aming
the mentall ill patients and elderly patients. Hazelhof et al. (2016) is of the opinion that it
hampers overall mental and physical well-being of the patnts. Vandecasteele et al. (2017)
revealed that elderly patients who are suffering from chronic disease or are terminally ill are
the main victims of the negative behaviour of the nurses and other healthcare professionals.
This negative behaviour or an act of neglect in treating this patients increase the chance of
getting affected with the hospital acquired infections like bed scores. Vandecasteele et al.
(2017) further opined that the level and the type of behaviour is the key determinant of the
impact upon the mental and physical well-being. Vandecasteele et al. (2017) have opined that
high level of violation or negative behaviour leads to fatal outcomes. Hynninen et al (2015),
further stated that negative behaviour from the healthcare professionals, especially among the
nursing staffs results in the generation of complex psychological issues among the nurses and
this lead to the generation of a sense of isolation, ancoety, depression and other physical
issues like hypertension, low rate of self-esteem and a suuden disgust towards the overall
medical treatment. This fear or disgust over the medical treatment withdraws all the hope of
the patients towards the effective recovery thereby negatively affecting the health outcome of
the patients along with the increase in the tenure of the hospital stay. In this context Hynninen
et al. (2015) have also stated that patients who suffers from islation like the mentally ill
patients or the eldelty patients generally seeks a companion or spiritual assictance which
increases the rate of recovery. However, this kind of negative attitudes of the nurses towards

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the patients further creates a gap in the spiritual assictance. It can alternatively said that the
lack of support and positive regards or assiatance in the daily life further increases their
susceptibility of developing mental health complications which again have adverse physical
health outcomes.
Recommendations for improvement
Accoridng to Shaban et al. (2015), the main recommendation that can be sited for the
improvement of the begative attitude of the healthcare professionals over the patients include
proper training. Accoridng to the research reports published by Shaban et al. (2015), nursing
students ofter go through certain experience of high level of stress during the process of their
training and this leads to the generation of psychological along with emotional impairment
during their professional life. According to Shaban et al. (2015), impairment in their
professional life affects the quality of the patient care theyr provide. Need support coming
from the clinical instructors along with proper guidance of these students help to relieve
stress while promoting positive clinical experience. The descriptive cross-sectional study,
conducted over the nursing students by Shaban et al. (2015), concluded that source of stress
for these students are mainly coming from the pressure of their assignmen work and the
surrounding clinical environment. The common coping strategy highlighted by Shaban et al.
(2015) through this study inclide problem solving behaviour along with staying optimistic.
Study also stress over transference attention from the stressfull situations over other soothing
things. However, avoidance of the situation can never be regarded as method for coping
strageies used for stress reduction. Swan and Hamilton (2016) also vouched in the favour of
optismistic environment. According to Swan and Hamilton (2016), positive attitude and
having optimism towards the surrounding life, provides a person develop better tolerance to
stress. The positive thoughts induce the release of endorphins, dopamine and serotonin which
keeps the person in general happy, this will reflect on the positive behavior towards the

26
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patient and achieve better patient outcome. The positive mindset controls the neurological
response to stress and provide less negative resistance (Swan and Hamilton 2016). Pulido‐
Martos, Augusto‐Landa and Lopez‐Zafra (2012) proposed recuirtment of more experienced
and trained healthcare professionals in order to reduce the negative impact of the healthcare
professionals attitudes towards the patients. Pulido‐Martos, Augusto‐Landa and Lopez‐Zafra
(2012) is of the opinion that the experienced healthcare professioansl are required to be
appointed to each and every wards along with the novice healthcare professionals. This will
help to maintain the pairity among the staffs while decrease in the limit of the adverse
incidences like negative attitude in the Moreover, Pulido‐Martos, Augusto‐Landa and Lopez‐
Zafra (2012) also opinion that the healthcare professionals who are experience in this field
have excellent communication and intrapersonal skills which help them to interact with the
patients and their family members in a decent manner while withstanding the work ressure.
Appointing experience professionals against the novice staffs also helps to reduces the
workload or the stress factor among the nurses and there by helping to cope up with stress.
According to the comprehensive review conducted by Morse et al. (2012), development of
rigorus testing of interventions along other approaches in the ciritcal area helps in reducing
stress. Morse et al. (2012) stated stress reduction can be achieved via proper time
management. Morse et al. (2012) stated that healthcare professionals should have a good
sense of time management; this will help them achieve more output in a given time frame.
The pressure of time can be proportional to the amount of the work that has to be done.
Organizing the plan of work helps achieving this goal, without having to succumb to the
physiological stress of work overload. Prioritizing the plan of work also helps developing
better sense of time management and leave room for emergency responsibilities, which is
common in healthcare settings. Ventola (2014) opined that maintaining organizational charts
and binders, help constantly study the work that needs to be done. It is important that

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healthcare professionals maintain a organizer since they have multiple patients and
responsibilities to attend to.

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4. Results and Discussion
Impact of the various factors that leads to change in the attitude of the healthcare
professionals towards the patients
Systematic review of literature let to the identification of several factors that lead to
the generation negative attitudes of the healthcare professionals towards the patients. One of
the prime factor that is highlighted in the systematic review of literature is high level of burn
out and job dissatisfaction. Accoridng to Scanlan and Still (2013), long hours of working has
caused increase in the level of job stress and performance. Scanlan and Still (2013) further
stated that it affected the mental well-being of the heatlcare proessionals and thereby leading
to the generation of burnout which gets expressed as negative attitude towards the nurses.
This reports goes in sync with the data highlighted by the reports published in The Guardian
(2017). Accoridng to the reports published in The Guradian (2017), the workforce which are
working for the National Health Service (NHS) are under more work-pressure than ever. The
reason highlighted by the BBC news is that more people are now using the NHS both in the
physical health care domain and in the mental health care domain and this lead to the cause
longer working hours along with incrrase in the level of job stress. Accoridng to Passalacqua
and Segrin (2012), long working hours increases the level of stressor element among the
healthcare professionals and this decreases the sense of empathy among the health care
professionals especially among the nurses and this cast a negative impact on the behaviour.
Moreover, lack of empathy among the nurses lead to the decrease in the quality of the
patient-centred care and thereby reducing the overall quality of care. Another factor which is
highlighted in the systematic review is the aggression and conflict with the patients and their
family members lead to the generation of negative attitude of the healthcare professionals
over their patients. This kind of aggression or conflict affect the management strategies

29
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adapted by the healthcare professionals and thereby reducing the quality of care. Kowalczuk
and Krajewska-Kułak, (2017) have further highlighted that physical violence and verbal
violence are two main pillar of the aggression of that exists between the relationship of the
healthcare professioanal. Constant exposure of the verbal violence from the patient’s family
members or physical violence from the patients decreases the sence of sympathy among the
healthcare professionals and thereby reducing the level of quality of care or generation of
negative attitudes towards the patients. According to the reports published by NICE (2014),
in between the financial year of 2011 and 2012, there are 60,000 reported cases of both verbal
and physical aggression against the NHS staffs in englans. Out of these highest amount is
recorded with the metal health staffs or learning disability staffs (69%) and then there were
ambulance staff (3%) primary care and acute care staffs (26%). NICE (2014) stated that this
physical or verbal aggression affects the behaviour of the carers and thereby casting a adverse
impact on the care procred.
Affect on the health and wellbeing of the patients
Accoridng to the analysis done by the Hynninen, Saarnio and Isola (2015), the
negative attitude of the health crae professionals increases the length of the hospital stay of
the patients and thereby reducing the quality of care. This findings as highlighted in the
systematic review holds promising significance under the context of the reports published by
The Guardian (2017). Accorinding to this report, the lenghth of hospital stay is increases in
both the public and privately funded hospitals in Englans. This increase in the length of the
hospital stay is increases the detah tool among the critically ill patients aor patients admitted
in the aged care sections. However, some contradicting facts are also highlighted by the
reports published by The Guardian (2017). As per the contradicting facts, unnecessary delay
in the discaharge is increasing the length of the hospital stay among the patients in England.
Accoridng to Vandecasteele et al. (2017) as highlighted in the systematic review section, the

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DISSERTATION
neglegiance in the work field, or increases in the job pressure is increasing the stress factor
among the healthcare professionals. This is due to the stress factor that the healthcare
professionals are loosing theor proficiency and excellency in viewing the specific results and
the promising outcomes of the patients upon the implementation of the therapy plan. This
neglect to reviewing the patuents progressive vital statistics is increasing the length of the
hospital stay among the patients of England and thereby decreasing the overall quality of care
along with increase in the mortality rate (Vandecasteele et al. 2017). Moroever, it can also be
said form the systematic review of literature that the well being of the nurse and the
healthcare professionals affects the health can wellbeing of the heatl care professional. The
research reports highlighted by Vandecasteele et al. (2017) showed that nurses who are
suffering from job stress are more likely to treat their patients negatively. Analysis of the
report published by Peters et al. (2013) provided a different view of this altogether.
According to them, patients are less likely to ask direct questions to the healcare
professionals about their poor care and poor caring behaviours and this lead to the overall
deterioration of the quality of care and thereby impact on their physical well-being.
Moreover, Peters et al. (2013) have further opined that getting a negtaove vibes from the
attending healthcare professionals genetated a sense of negetavity among the patients and this
increases the mental pressure on the patients and thereby ecplaining the reason behind their
imbalance in the mental wellbeing.
Initiatives of the nursing and healthcare professionals to overcome the challenge
From the systematic review, it can be said that proper training is an effective means
towards overcoming the stress and thereby reducing the negative attitude of he healthcare
professioanls over the patients. Studies of Shaban et al. (2015) conlcuded that if proper
training system framed then it will be easier to decrease the challenging or negative
behaviour of the healthcare professioanls in the workplace. The work related stress of the

31
DISSERTATION
nurses can be reduced via increasing the appointment of the new and trained nurses in the
hospitals (Lopez‐Zafra 2012). Lopez‐Zafra (2012) further opined that healthcare orgaisations
are now using workload of the healthcare professionals via increasing the number of strength
of the healthcare professinals, both doctors and nurses and thereby increasing the service
quality. Lopez‐Zafra (2012) further opined that this will help to reduce the conflict in
between the nurses with the patients and their family members.
Thus from the above discussion it can be concluded that Factors like verbal and
physical aggression of the patients and conflict with the patient’s family members, long
working hours, lack of proper nursing training and shortage of staffs lead to challenging
behavior of the nurses and this challenging behaviour of the nurses cast a huge impact on the
mental and physical well-being of the patients thereby increasing their length of stay in
hospital.

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5. Research limitations
The researcher has stringent budget along with limited time frame that restricted the
research domain. The researcher failed to access few of the articles and journals, which have
restricted access because it needs to be bought. Thus, the researcher failed to implement more
relevant data in the research work. The time was extremely limited, which restricted the
overall searching procedure as well. The limitation of the budget plan and along with time is
the biggest issue in case of the research work.
6. Future Scopes of Research
There is gamut future scope for this researcher. The researcher failed to access some
of important journals and articles, which were associated with the research work. Hence, the
future researchers have high scope to use those data in their field of research work, which can
make the research more refine and authentic. The researcher could have used more literature
support if he had ample time along with budget plan. Moreover, the future scope of the
research will be directed towards how the recommendation can be used to frame the policy
for the reduction in the negative attitudes of healthcare professionals and thereby reducing the
impact on the patients.

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DISSERTATION
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