Providing quality services is a priority activity for healthcare units, since good quality translates into health, trust and safety in terms of the patient’s life. The quality of care is considered mainly through the qualifications and competence of medical personnel, infrastructure and equipment base, as well as through the degree of patient satisfaction (1). Nurses, by virtue of their professional function, are in the closest contact with the patient. They are the ones who create the image of the facility and influence the climate of treatment (2, 3).

The concept of care overlooking is a fairly new phenomenon. It first appeared in 2006 introduced by Beatrice J. Kalisch and can be considered in any field of nursing. It refers to errors associated with the omission of all or part of a particular aspect of care (4, 5). The definition of care rationing in nursing refers to the deliberate failure to perform tasks resulting from patient care due to lack of time. Available publications prove that skipping care is directly related to the failure to ensure patient safety (6–9). The reasons for this phenomenon can be staff shortages, increased demand for care, new technologies and treatment methods, as well as greater patient awareness (10, 11). The totality of the aforementioned aspects translates into increased expenditures of time and labor incurred by nursing staff (12–14). The concept of care rationing according to Schubert et al. assumes that all nursing activities are equivalent, so that it is possible to achieve not only the desired activities, but also those expected by patients and the nursing diagnosis made, has a very strong impact on care rationing (15, 16).

Job satisfaction is understood as a higher level of job fulfillment. A satisfied employee has a higher sense of self-esteem and satisfaction of needs. In addition, work should be a place of self-fulfillment for employees; one in which they feel satisfied with their professional development and intellectual challenges. This, in turn, creates a sense of identification with the organization’s goals. Satisfaction, including job satisfaction, is also understood as an individual’s ability to realize their needs, goals, values, and beliefs (17).

Job satisfaction has been the subject of many studies on organizational behavior. Lu et al. (18) demonstrate that satisfaction on job satisfaction consists of several of various elements, including working conditions, communication, nature of work, organizational policies and procedures, pay and conditions, promotion opportunities, recognition, appreciation, safety, supervision and relationships. Although the description of job satisfaction varies, several common factors emerge in various studies, which include working conditions, organizational environment and perceived stress, role conflict and ambiguity, role perception and content, and organizational and professional commitment (19). Job satisfaction is considered a global problem; however, it is also necessary to improve the quality of care provided and the work environment in healthcare organizations, as lack of job satisfaction among nurses can affect their practice, which in turn can directly or indirectly affect patient satisfaction (20).

The nursing profession is associated with many stressful situations and a heavy workload. Contact with patients and their loved ones, lack of support from superiors often leads to psychotic symptoms, depression, sleep and wakefulness disorders in this professional group (21, 22). The causes of burnout can be traced to three areas: individual interpersonal and organizational. The above conditions may or may not promote occupational burnout (23). Occupational burnout syndrome usually begins unnoticed and the person affected often does not recognize the first symptoms. A common definition of the process is that it is a prolonged reaction to interpersonal and emotional stressors operating at work. Initially there is fatigue, irritability, tension, hyperactivity associated with symptoms of psychophysical exhaustion. As a result of the stress associated with the state of tension in the next phase, there is a loss of energy, discouragement and there are signs of depression related solely to the work situation (24). While studying the phenomenon of burnout, Maslach and Jackson distinguished two groups of variables: factors that can promote burnout and behaviors that help effectively combat burnout. The result of the study was the clarification of a characteristic picture for occupational burnout among nurses. This phenomenon increases with an increase in assigned tasks or a decrease in decision-making opportunities at work. These factors result in feelings of emotional exhaustion and a tendency to depersonalize patients. Depersonalization increases when feedback from patients decreases. According to Jackson and Schuler’s study, the risk of occupational burnout increases with the inability to control the environment. This finding was based on the premise that a rewarding environment for an employee is one that he or she can influence, while an unfavorable environment is one in which the ability to control is limited (25).

The work of the anesthesia nurse is one of the most difficult and responsible specialties in the profession due to its nature. Nurses working in intensive care units are particularly vulnerable to occupational burnout syndrome and belong to high-risk groups. The work, the essence of which is the care and nursing of a person in a life-threatening condition, such as after an accident, after surgery, in an advanced stage of illness or in a terminal state, exhausts psychologically primarily by constantly moving around final, critical issues, exhausts by its intensity (26).

Rationing of nursing care has a significant impact on the quality of services provided (22). Therefore, the authors set the aim of this study to investigate the relationship between occupational burnout, job satisfaction and rationing of care by anesthesia nurses employed in intensive care units. Analysis of such correlations will answer the question of whether the number of skipped activities by anesthesia nurses is lower in a psychosocially friendly work environment.

The survey was conducted among 477 selected anesthesia nurses employed in intensive care units in Poland. 4.0% of the respondents were under 25 years old, 60.2% between 25 and 35 years old, 19.9% between 36 and 45 years old, and 14.9% were between 46 and 55 years old. Only 1.0% of respondents were over 56 years old. Respondents’ length of service as anesthesia nurses from 1 to 10 years was declared by 63.5% of respondents, from 11 to 20 years by 20.1% of respondents, 21 to 30 years by 12.6% and over 31 years by 3.8% of respondents. Detailed results are presented in Table 1.

Nurses participating in the study worked 12-h shifts. According to the Polish Labor Code, there is a two-and three-month reference period (decided by the employer). As a rule of thumb, during the indicated period, the number of night and holiday duties for each nurse should be comparable.

The aim of this paper was to determine the relationship between occupational burnout, job satisfaction and rationing of care among anesthesia nurses employed in intensive care units. This is an innovative study of a group of nurses providing services to patients in life-threatening conditions requiring intensive treatment, supervision, and enhanced care. The results of our study showed that the mean total score of the degree of nursing rationing assessed by the BERNCA-R questionnaire was 1.65 ± 0.82 (below average), which may mean that the surveyed group is aware of the fact of responsibility for the health of patients. In studies by other authors conducted in a professional group of nurses, the mean BERNCA-R score was 1.55 ± 0.15, indicating that the frequency of care rationing ranged from “never” to “rarely” (30) and was similar to the results in the own research. Other studies have shown a higher frequency of nursing rationing among nurses working on surgical wards, with a mean score of 2.72 ± 0.86, and nurses working on conservative wards (2.08 ± 0.86) (22) and were similar to the own research.

In the Schubert et al. study, the mean BERNCA score was 57 (1.69 ± 0.571) and, according to the authors, meant that nurses had to ration at least one of the 32 tasks indicated in the questionnaire during the last 7 days of work, which is confirmed by our own study and those of other authors (22, 30, 31). A slightly lower level of rationing (1.38 ± 0.62) was shown by Uchmanowicz et al. study (32).

The mean overall burnout score among the anesthesia nurses surveyed was 60.82 ± 10.46, which indicates the presence of burnout in the study group. The mean score of emotional exhaustion, which significantly affects the level of professional burnout was 26.39 ± 6.07, depersonalization was at 14.14 ± 3.21 and lack of personal achievement was at 20.29 ± 4.70. This was presumably due to too much mental stress, responsibility for human lives and working under constant stress. A study by other authors conducted in a group of professional nurses showed that the mean score of occupational burnout was at 49.27 ± 19.76, exhaustion 63.56, depersonalization 37.2, lack of achievement 47.07 (30). In another study, the total MBI score was 38.14 ± 22.93. The individual components of occupational burnout yielded values of emotional exhaustion equal to 44.8, lack of personal achievement equal to 40.66, depersonalization equal to 28.95 (33) and differed from the results of the own research.

In the own research, the level of job satisfaction of the nurses surveyed was above average at 23.00 ± 5.2, which means that most nurses were satisfied with their jobs at a level above average. In the Uchmanowicz et al. study, the average score obtained by respondents was 11.71 ± 5.97, suggesting that respondents’ answers indicate a state between “dissatisfied” and “rather dissatisfied” with their work. Scores ranged from 7 to 18, with a median score of 11 (34), which has been confirmed by other studies (30, 35).

In the own research, there are statistically significant correlations between occupational burnout and rationing of nursing care, which are characterized by insignificant strengths of association. Greater inability to perform certain activities is associated with lower job satisfaction. The correlation is statistically significant (p < 0.001) but the strength of the association was found to be insignificant (Spearman’s rho = −0.202).

A study by other authors observed a statistically significant positive correlation between the BERNCA-R scale and MBI (p < 0.05), and a negative correlation between the BERNCA-R scale and JSS (p < 0.05). Independent predictors of the BERNCA-R scale were the emotional exhaustion of the MBI scale and the assessment of the impact of independence on job satisfaction (p < 0.05) (34). Similarly, Radosz-Kanwa et al. proved that BERNCA-R scale scores correlated statistically significantly and positively (r > 0) with two (of three) subscales of the MBI questionnaire: emotional exhaustion and depersonalization (p < 0.001) (31), which was confirmed by our own research. Rascu et al. (36) showed that bedside rationing of care refers to the use of clinical judgment by nurses to prioritize how they allocate their time and skills in providing health care to patients due to major time and staffing constraints or other organizational issues. The study by Tamayo et al. (37) found that nurses most often rationed care, support and supervision tasks. It was less common to omit other aspects of care. Identifying factors influencing rationing can help identify starting points for hospital policy reforms, as evidenced by our own research. Studies by many authors have found an overall increase in rationing of care activities, with documentation and social support being the most rationed (22, 38, 39).

Jaworski et al. (8) demonstrate that higher job satisfaction can reduce the risk of rationing nursing care, which is supported by other studies (40). White et al. found that some respondents often reported not being able to provide necessary care to patients (41). Other research suggests that workplace atmosphere and relationships partially mediate the link between organizational climate and occupational burnout (42). A nurse’s job satisfaction is related to the level of nursing care provided; higher levels of rationed care mean higher levels of occupational burnout and lower job satisfaction, resulting in general dissatisfaction among this professional group (43). There were other studies conducted that identified lack of time, inadequacy of staff, lack of team dynamics as possible factors that affect rationing of nursing care (44).

The results proved that there is a statistically significant, although with a weak strength of association, correlation between occupational burnout and rationing of care by anesthesia nurses employed in intensive care units. As the limitation of anesthesia nurses’ ability to perform certain activities increases, their job satisfaction decreases. Therefore, it is important to ensure that intensive care units are adequately staffed with nurses, as there are fewer job responsibilities that are unfulfilled in the work environment that is conducive to nurses.

The results of the survey have a solid basis; however, the study may have some limitations. The study involved a professional group of anesthesia nurses employed in intensive care units of different ages and job seniority. The sample size was non-representative of the situation in Poland, also due to bias in the selection of respondents, which may limit the generalizability of the results. The sample size was not large enough, which may limit the generalizability of the results. Further multi-center surveys are needed to generalize the results and implement recommendations for management.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by the Bioethics Committee of the State Academy of Applied Sciences in Przemyśl. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

KT: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – original draft, Writing – review & editing. KK: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – original draft, Writing – review & editing. BM: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – original draft, Writing – review & editing.