Worldwide, nursing staff has been suffered from increasing workload and reductions in feelings of enjoyment and motivation in their work and personal achievement. Consequently, they tend to be absent from their work, and distance themselves from their patients as well as they will exhibit burnout. These factors may an important mediating role to increase shortage of nurses, increase patient adverse events and reduce quality of care and patient safety in healthcare settings.(22-24) The International Council of Nurses (ICN) encourages positive work environments to attract nurses and improve nurse job outcomes, enhance retention, and improve patient outcomes (ICN, 2007).(25) The present study considered an essential step toward understanding and applying delivery of patient care model in Egyptian healthcare settings. Therefore, it spotlighted on connecting structure ( work characteristics and structural empowerment) and process ( practice environment) of nurse work environment to nurse job outcomes of enjoyment, motivation , absenteeism and burnout and nursing sensitive patient outcomes of medication administration errors, patient falls, pressure ulcers, pulmonary infections , bloodstream infections and urinary tract infections .
Structure and process of work environment are very important especially in critical care and toxicology units. The present study highlights nurses fairly rated nurses’ work characteristics and its dimensions namely job significant, job variety, job identity, and autonomy and job feedback. Job significant and job variety yields high mean scores than others three nurses’ work characteristics dimensions. According to the definition of task significance, the nurses in the study units emphasis on the value of their professional role and important of their practices to treat critical ill patients and return patients to ordinary life. They also mentioned that they should have a variety of nurses’ skills to meet high burden of critical ill patients’ demands for safeguarding their life. Nurses in this study perceived low job feedback in their work. They did not receive a clear and enough information about their performance and effectiveness in their work. Insufficient feedback has direct impact on quality of work, and influences on nurses’ job outcomes. Job characteristics can be used to redesign job in order to improving quality of care and enhancing nurse job outcomes.(26)
The lowest rating of task identity and autonomy in the present study indicated that nurses in the study units had a less freedom, independence and involvement in clinical and work decisions to carry out requirements of their job. Nurse- physician relationship is a “Boss subordinate” relationship. Physician gives the medical orders to nurses and the nurses are forced to follow directive orders without asking for a rationale for these directives. They did not participate in decision making about patient care and did not respect their ideas in nursing care. Thereby, nursing practice in study units carried out by individually manner rather than collaborative team manner. The role of autonomy needs to be assessed at the team level, not at the individual level. Nursing practice requires nurses to work in a team and carry out the work in a collective manner instead of doing it individually.(30) The findings of the current study was disagreement with study in China(2011) where revealed that overall job characteristics as perceived by professional nurses was at a enough level (95) but similar to those found in two Egyptian University hospitals in 2004 and 2012 (88,87) where showed that nurses’ job characteristics was at insufficient level (87)
Katrinli et al.,(2009)(27) and Tonges,(2005)(28) argued that job dimensions of task identity and autonomy play significant roles in nurses’ job involvement. When nurses have opportunities to make independent decisions related to interventions that they use with patients, they develop emotional ties with patients and their work. If nurses involved in their job decisions and increase their autonomy, they feel personal responsibilities and accountability towards their work outcomes. Varjus et al.,(2011)(29) also suggested some factors enhance the autonomy of nurses in clinical practice such as collaborative manner, supportive management, education, experience, lower workload , and empowerment.
Structured work environment is very critical to facilitate the movement toward a more organized atmosphere and to establish better staff empowerment in healthcare settings. Employees who work in an environment that provides good opportunities, ample resources, useful information, and great support will have the capacity to be effective in their job and achieve their goals.(35,36,37) Nurses need a work environment that is structured to provide them with tools to effectively carry out this important role. (35) The present study found that nurses perceived deficiency in structured empowered environment and its components as opportunity, support, formal and informal power, information and resources. These results indicated that work environment in critical and toxicology units had insufficient structural empowerment to promote and improve nurses’ professional roles.
The study findings may be attributed to working environment for nurses had many obstacles that hinder nurses’ abilities and performance to respond to patients’ requirements. These obstacles included nurses unable to access to enough information and resources to make their clinical decision making ; they inadequately receive helpful feedback about their performance, they substantially felt interrupted relationships with their colleagues and physicians ; their supervisor provided a little support regarding their professional practices , they had a little opportunity to improve their job and career through educational and training programs , they received fewer rewards and incentive , and they significantly had fear from criticism when errors occurred. These results of present study were asserted by the two studies in Egypt in 2017 and 2013 (44,48), where found that nurses were expressed that strongly disagreement regarding to present of access to empowerment structures in nurse practice environment . in the same time , the findings were incongruent with three Canada studies.( 38,46,47) and two USA Studies(91,82) where nurses reported their structured working environment to be Satisfying.( 82, 38,46,47,91)
The present study shed a light on unfavorable nurse practice environment in critical and toxicology units. The overall mean scores of nurse practice environment and its dimensions appears to be fair. Nurse physician relations and nurse manager ability, leadership and support yields as the two top mean scores. Nursing foundation for quality, nursing participation in hospital affairs and staffing and resources adequacy rated as the lowest mean scores in nurse practice environment. These findings may be related to nurses felt interrupted relationship, collaboration and communication with other health care providers and isolated from their councils and hospital committees. They did not participate in important unit-level and hospital-level policy making decisions. Their supervisor did not provide them with enough supportive measures during their work and sufficient clinical information to carry out their roles. Nurses had lower level of autonomy over their practice, policies, procedures and standards. So, patients’ problems were solved by slowly nurses’ actions. Also, there was lacking of managerial commitment to quality of care and patient safety programs in their units that might predispose to deficiencies of human and financial resources. These findings may be also contributed to the study units provide free health care services with low financial and human resources, there are high burden of hospitalized patients and high population demand that consume resources. Also, these units did not pass the national accreditation. These results were articulated by the Egyptian Study in 2017 and in 2010 (44,57) but contention with those found in Saudi , USA, Switzerland, Brazil, and Belgium studies where found that the nurses perceived favorable practice environment in their work.(89, 81,39,90, 91,94)
The nurses in the study units reported that they will feel more enjoyment in their work, when nursing leadership will divert their efforts to improve structure and process of their work environment. Thereby, they will be pleasant when attending their work, motivated to improve their performance and able to enhance quality and safety of patient care. They will have less stress and frustration which could lead to eventual less burnout. The current study enlightened the nurses who worked in fairly structure and process work environment might predispose to high burnout and absent from their work. Burnout and absenteeism may be contributed to less nurses’ enjoyment and slight nurses’ motivation of their work. Findings from this study were consistent with others studies in different countries where concluded that nurses around the world face similar negative nurse job outcomes despite differences in work environment and organizational factors of health care settings.( 97,92,82,85,89,60)
Aiken et al. has argued that “adverse nurse job outcomes are low among staff nurses when hospitals are consistently better work environments”. (45) Structure and process of nurse work environment in study units had both direct and indirect effect on nurse job outcomes. These findings can be verified by a moderate significant negative association between the overall nurses’ work characteristics, work empowerment and practice environment and two nurses’ job outcomes (absenteeism and burnout). These results were also proved by a moderate significant positive correlation between structure elements of work characteristics and empowerment, process elements of practice environment and nurses’ enjoyment and nurses’ motivation. the findings of this study were supported by other studies in different countries from 2004 to 2017 where found that work environment have relationships with nursing outcomes.(60,38,39,82,83,85,86,89,91,92,93,94)
The present study was also evident that nurses’ work characteristics, work empowerment and practice environment were independent and dependant predictors of patient outcomes in the critical and toxicology units. They had a statistically significant impact on lower incidences of adverse events such as medication administration errors, patient falls, pressure ulcers, pulmonary infections, bloodstream infections and urinary tract infections. The reduction of adverse events can be achieved by creating more structurally empowering environments and enhancing work characteristics and practice environment. Similarly, Grindel (2005) (53) and Welker-Hood (2006) (54) found that creating and maintaining a healthy work environment for nurses go hand-in-hand with quality of care and patient safety. Workplaces that promote work effectiveness by increasing the nurses’ access to resources, support and guidance, information and opportunities to develop skills can thereby enable nurses to interact with patients with sufficient frequency and skill to prevent the occurrence of risk (38) These findings were demonstrated by moderate negative relationships between structure (work characteristics and empowerment), process ( practice environment) of work environment and patient outcomes (medication administration errors, patient falls, pressure ulcers, pulmonary infections, bloodstream infections and urinary tract infections). These findings were congruent with other studies in developed countries from 2001 to 2015 where found that that work environment have an association with nursing-sensitive patient outcomes. (52, 73,38, 76-81,39,82,84,86,94 )
The present study proved that structure and process of nurse working environment were responsible to increasing patient risks, adverse patient outcomes and deteriorating quality of care and patient safety in the study units. They were a statistically significant direct effect on decreasing nurses’ perceived quality of care and patient safety. These results can be explained by moderate significant positive correlation between structure elements of work characteristics and empowerment, process elements of practice environment and perceived quality of care and patient safety among nurses in their units. This finding was matched with Hinno et al. (2011) (49) , Purdy (2011)(38) and Van Bogaert et al. (2009)(50,92) who revealed that there was statistically significant influence of nurses work environments on perceptions of the quality of care among nurses .
The Agency for Health Care Research and Quality (AHRQ, 2000) has reported that “development of innovative approaches to measuring quality, including the perspectives of providers, patients, and consumers”.(40) Nurses play a definite role in the improvement of quality and promoting patient safety at the unit level. The nurses in the study units evaluated and judged effectiveness of their work performance to be inadequate in quality of care and patient safety. This finding was incongruent with other studies by Mahran and Ibrahim in 2016(51), Mahran in 2017 (44) , Purdy (2011)(38) , Van Bogaert1 (2014) (94) who found that nurses perceived high quality of care and patient safety culture in their units. Patient safety and quality of care are important components to reflect degree to which the nursing care being provided to meet clinical patient needs. Nurse-sensitive indicators are widely used to evaluate the quality of nursing care.(42) The present study was evident that nursing sensitive indicators of medication administration errors, pressure ulcers and nosocomial infections (pulmonary, bloodstream and urinary tract infections) tends to be higher than nursing sensitive indicator of patient falls. Patient falls was low documented in this study. It may be due to underreported of falls conditions among nurses and most of critical ill patients were sedated ventilated and immobile.
The results of current study were agreement with some studies and disagreement with other studies in adverse events rates. The findings of this study was lesser than that found in Assuit University hospital where an medication administration error rate was of 86.6% , but greater to those found in Tertiary hospital in Western New York (9.7%) (39) . Similarly , findings of other studies in teaching hospital in Egypt and in Paris (France) .(66-68, 70) Pressure ulcers rate in this study was larger than that that found in the Main University hospital study (10.0%)(57) and El-Minya University (7.36%)(60) , and Tertiary hospital in Western New York (12.1%) (39) but smaller to those found in Brazil (35.2%)(71) and in Jordan (30 %) .(59) This could be explained by what Al-Dugiem has said “Patients in critical care units are more at risk of forming pressure ulcer because of their impaired mental, nutritional, and mobility capacities in addition inadequate resources and nurse staffing to providing preventive care as turn patient from side to side every 2 hours” . (57) Pressure ulcer prevention includes increasing mobility of the patient and superior nursing care.(39) Additionally, falls rate in the present study was equivalent to those found in Ontario and Canada study in 2011 ( 4. 91%) (38) but grater to those found in other studies in United States in 2004(75) and Switzerland in 2008.(74) This rate was also less than that found in Tertiary hospital in Western New York (16.2%) (39)
The results of pulmonary infections rates were lower than that found in some of Egyptian University Hospitals such as the Tanat (73.17%), Ain Sham (37.5 %) and Cairo (66.7%) , but greater to those found in the Main university hospital (16.3%) in 2010 and in Alexandria University Students Hospital(11%). (62,63,65,69) Similarly, a study in 2011 in tertiary hospital in Western New York where found pulmonary infections was 21 % and in Greece university hospital was 25 % .(39,58 ) Concerning, bloodstream infections rate was greater than that found in University hospitals in Egypt as the Main University hospital ( 3.1%) , Alexandria University Students Hospital (2%), and Tertiary hospital in Western New York (4.5%) but comparable to those found in Cairo University hospital(11.1%), and Beni-Suef University Hospitals ( 10.7) . (57, 64, 65,39) Urinary tract infections was minor than that found in the other studies in Some Egyptian University hospitals.(57,61,62,63,65 ,72 from where urinary tract infection rate ranged from 15 % to 47.5 and in France hospitals in 2011. (56) Similarly, one study in Iranian hospitals in 2009 revealed that urinary tract infection was 10 %.( 55)
This finding was not surprising considering that insertion of ventilator device; central lines and urinary catheter were common in all critical care units due to acuity conditions of patient populations. The majority of patients in critical care tended to be bedridden and vulnerable group. They also received multiple medications and complexity nursing care. The risk of adverse events became greater with these groups of patients who received multiple medications and complexity of nursing care. Risk factors associated with development adverse events in the study unit were patient frequently transferred within the hospital for diagnostic and treatment procedures; they had previous admission to hospital and they had high length of stay in hospital.
Structure and process of nursing work environment are the most important determinants for developed patient adverse events in critical care units. Structure elements including : 1) Limited resources and funds result in inadequate supplies leading to reuse of single- use supplies, and insufficient of nursing staff. Inadequacy of staffing was associated with heavy workload and nurses had insufficient time to provide patient care and spend with their patients; 2) the majority of critical care nurses had earned a diploma’s qualifications. competences of nurses while care deliver were influenced by educational level of nurse; 3) deficient of nursing policies and procedures and disseminations of them among nurses; 4) shortcoming of infection and quality programs to help nursing staff to use of aseptic techniques; 5) Nurses worked rotated shifts and irregular working hours; and 6 ) commitment of hospital manager to infection and quality program was lacking which result in limited fund and resources to support implementation of quality and safety measures. Nurses of this study complain from insufficient time and resources to provide appropriate nursing care. If the nurse does not have the time to provide efficient nursing practices and maintain aseptic technique during their care, the patients are liable to adverse events. This finding was confirmed by the results of Ahmed et al. (2009) study in Egypt.(96)
Developed of patient adverse events may be also related to process elements of nursing work environment. Process elements involving non compliance with aseptic technique and infection control precautions during insertion and maintenance of device , improper nursing practices during routine daily care , the number of insertions of the same device at the same time, and duration and high utilization of invasive device in the same place. Special contributing factors to the incidence of pulmonary infections rates in the study units were inappropriate reprocessing of respiratory care tubing,; frequency and duration of endotracheal tube use ; insertion of a nasogastric tube, frequently suction, inadequate experience of some operators in weaning process of ventilator, substantial underlying factors of chronic lung disease; coma and supine position.
The present study provides strong evidence to support patient care delivery model in creating better structure and process work environment for nurses which considered as a significant predictors of nurse and patient outcomes. This study also highlights the importance of assuring structure and process nurse work environment are designed to support nursing practices in critical and toxicology units. These may result in achieving high quality of care and patient safety while at the same time improve nurse job and nurse sensitive patient outcomes.
These results were verified by synergistic negative effect of structure and process work environment on nurse job outcomes (levels of burnout and absenteeism) and nurse sensitive patient outcomes rates of medication administration errors, pressure ulcers , patient falls and noscomial infections ( pulmonary infections , bloodstream infections and urinary tract infections). These were also ensured by the direct positive impact of structure and process work environment on nurses’ enjoyment and motivation, and perceived quality of care and patient safety among nurses.
In this respect, the study findings shed a light on deteriorating nurse and patient outcomes in the study units. Deterioration of outcomes was attributed to deficiency of structure (work characteristics and empowered environment) and process nurses’ work environment (practice environment) in the study units.
Recommendations: The present study suggests key strategies that are essential to support nurses to carry out their practices. These strategies also help to improve nurse job and patient outcomes. Nursing managers must:
Revise and redesign nurses’ work role
Develop quality and patient safety policies and procedure to guide nurses’ performance and improve quality of nursing care
Develop a consistent approach that allows monitoring, reporting, examining, and reviewing patient and nurse outcomes in a supportive atmosphere
Encourage teamwork to facilitate interaction, communication, cooperation and collaborative among health care providers and ensure continuity of patient care.
Develop training program to update nurses’ knowledge, learn nurses new skills and solving work problems
Share information among health care providers for clinical decision making
Provide regular feedback to nurses about their performance
Consider resources whether staff , time, equipment and supplies are necessary to support nursing practice and achieve better patient outcome
Support nurse to participate in their decision making , unit councils and hospital committees
Provide their support and commitment to nursing practice for achieving optimal quality of care.
Provide rewards and recognition to nurses for increasing enjoyment and motivation among nurses.
Divert their efforts to create positive environment for nursing practices.
Create nursing care standards and indicators for determining quality of nursing care and patient care.
Developing and implementing intervention programs to eliminate causes and reduce negative nurse job and patient outcomes
Quickly respond to correct patient care problems
Build good working relationships and trusting among healthcare providers
Attend staff development programs to learn how integrate nurses in their decision making and respect new ideas of nurses