Hrev_master [Healthcare in Low-resource Settings 2023; 11:10658] [page 1] A descriptive study on nursing practice environment among public sector nurses in Lahore Zunira Amir,1 Shama Maroof,2 Shahbaz Haider3 1Assistant Nursing Instructor, Lady Aitchison Hospital, Lahore, Pakistan; 2Superior College of Nursing, Lahore, Pakistan; 3Superior University, Lahore, Pakistan Abstract Pakistan is a country where the nursing profession still has to get a good working environment as it is directly related to improved patient care. The nursing practice environment is a key factor that contributes to retention. Bearing in mind the impor- tance of the issue the present study is designed to know the current state of the nursing practice environment. The data were collected from the nurses working in the medical wards and critical care units in the Pakistan Institute of Neurosciences, Lahore. Convenience sampling was used to select the respondents and collect the data. A total of 150 questionnaires were distribut- ed among the nurses and 110 questionnaires were used for the data analysis in Statistical Package for Social Sciences. Frequency, descriptive statistics, reliability, and validity analyses were performed. As per the results of the study, the questionnaire used in the study was reliable and valid. Additionally, the results of the study established that the nursing practice environment is poor asking for concrete steps to make it better for improved patient care delivery. Nurse lead- ers can dedicate their efforts to the improve- ment of the nursing practice environment to improve the nurse job outcomes. Further, they can also arrange the trainings for the professional development of the nurses to ensure the better healthcare services deliv- ery. The perceptions of the good nursing practice environment can be fostered among the nurses by having their active par- ticipation in the hospital matters and deci- sion making because they are also the key staff in the hospital environment. Introduction Environment exerts influence on the nurses, patients and organizational out- comes as well where healthcare services are provided to the patients. The authorized nurses in the hospital tend to increase a sense of responsibility among them. The resources availability in the hospital envi- ronment is necessary to deliver the patient care and address their needs related to the care provided. Additionally, the effective communication can be maintained in a good working environment in hospitals.1 Continuing on environment it is worthy to mention that the nursing practice envi- ronment is a key factor that contributes to the retention and recruitment of nurses, at the same time it has a significant impact on nurse missed nursing care and directly or indirectly influences the quality of nursing care.2 Shift work among nurses may reduce their well-being3 quality of sleep that caus- ing medication errors in nurses. Besides the shift work, previous research indicated that the conflict between nurses and physicians in the ward reduces the impact of quality of care and leads to negative patient outcomes.4 A study was conducted to find out the relationship between adequate staff and resources’ impact on patient satisfaction. The study finding reveals that increased workloads, inadequate nurse-patient ratios, long time for work, and increased documentation cause stress, fatigue, and disappointment in nurses and their levels of care. An adequate number of staff nurses and the availability of proper resources positively affect nurse performance and the quality of patient care.5 Accordingly, global shortages of nurses are the main reason for role over- load, job dissatisfaction, and poor nursing practice environment among nurses. Moreover, Wilson enlightened the fact that inadequate availability of health care professionals has been recognized as a global issue. Rivaz et al.5 suggested that an adequate number of staff nurses and the availability of proper resources positively affect nurses’ performance and quality of patient care. Wang et al.6 concluded that the negative perceptions of nursing practice environments were also significantly asso- ciated with intentions to leave their jobs. Bawakid et al.7 suggested that patients will satisfy and cure early if they patient is happy with the health services provided by health care providers. Rivaz et al.5 studied that due to poor management, work over- load, lack of time, and improper hospital strategies impact proper care delivery on the other hand adequate number of staff nurses and proper availability of resources positively affect nurse performance and quality of patient care. Nurse performance will be optimal in a better environment that contributes to giv- ing proper care to the patient which ulti- mately leads to patient satisfaction and nurse job satisfaction.6 The collaborative teamwork of nurses and physicians leads to proper patient care and a work environment that results in positive organizational out- comes.7 During the patient’s stay in the hos- pital nurse’s polite behavior, attitude, timely Healthcare in Low-resource Settings 2023; volume 11:10658 Correspondence: Shahbaz Haider, Superior University, Lahore, Pakistan. Tel.: +923086149902 E-mail: Shahbazhaider199@gmail.com Key words: Nursing practice environment; staffing adequacy; nurse leader; nurse training and development; nurse-physician collegial relationship. Acknowledgment: We acknowledge all the nurses who participated in the study voluntarily. Contributions: All the authors have equally contributed. Conflict of interest: The authors declare no conflict of interest. Funding: This research study is not funded by any institute/agency. Clinical trial registration: This does not apply to the present study as it is not an experimental study or clinical trial. Availability of data and materials: Data is available from the corresponding author on request. Ethics approval: The research study is approved by the research committee of Superior College of Nursing, Lahore (Ref. # SCN/RC/2021-RN08) Informed consent: This does not apply to the present study as data were not collected from the patients. Permission to reproduce material from other sources: All the materials have been cited and permissions obtained if necessary. Received for publication: 7 June 2022. Revision received: 8 January 2023. Accepted for publication: 12 January 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:10658 doi:10.4081/hls.2023.10658 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guar- anteed or endorsed by the publisher. No n- co mm er cia l u se on ly solving of the patient’s problem, and empa- thy toward the patient can build up trust in health care providers to improve the patient’s condition, and patient satisfaction.8 Nurse managers improve the clinical practice environment by proper bal- ancing of resources, bed allocation, positive attitude towards subordinates and teamwork leads to a positive practice environment which leads to the positive patient, nurse, and organizational outcomes. Nurse behav- ior toward patients is the key to positive patient outcomes and nurses will lead to compassion satisfaction.9 Therefore, the study has the objective to assess the state of nursing practice environ- ment in the public sector hospital in Lahore, Pakistan. The significance of this study lies in the fact that it has considered the nursing practice environment comprising of many factors including staff adequacy, resources, nurse-physician collegial relationship, qual- ity of care, and nurse perception that results in positive organizational outcomes such as quality of care. The study is also significant since it measures the perceptions of the nursing practice environment of nurses. It is argued that the nursing practice environ- ment denotes the surroundings in which a nurse works and influences the control of quality to deliver nursing care. It is also important for nurses to develop an aware- ness about their perception of the working environment that has a positive impact on their performance and enhances the patients’ satisfaction.1 Accordingly, it becomes necessary to know the current state of perceptions of the nurses regarding their nursing practice environment so that the administration may take necessary steps for its improvement ultimately aiming for a higher quality of patient care. Materials and Methods The study aims to assess the current state of the nursing practice environment. The current section describes the research methods adopted to complete the study. Population and sample size The current study is quantitative and follows the deductive approach. In this regard, the study was designed in the Tertiary care hospital of Lahore. All the nurses in the medical and critical care departments were the population of the study. Accordingly, nurses were selected from medical care and critical care depart- ments as a sample to represent the popula- tion of the study. Questionnaire and measurement Data were collected by using the previ- ously validated questionnaire of the nursing practice environment. There are different questionnaires for the assessment of the nursing practice environment, for instance, the Korean General Unit-Nursing Work Index,10 Revised Nursing Work Index,11 and Nursing Practice Environment.12 It is wor- thy to note that the nursing practice envi- ronment is one of the widely used scales and the present study adapted it for data col- lection. It has been previously used by dif- ferent studies in Pakistani nursing context as well.13 Lake13 developed a scale to measure the nursing practice environment containing the five dimensions. The nurse participation in hospital affairs was measured by five items (i.e., staff nurses are not involved in the internal governance of the hospital). The nursing foundation for quality of care was measured by adapting five items (i.e., nurs- ing care is not based on a nursing, rather a medical, model in this hospital). Nurse Manager Ability, leadership, and support of nurses were measured by adapting eight items (i.e., supervisors do not use mistakes as learning opportunities, rather as criti- cism). Staffing and resource adequacy was measured by adapting five items (i.e., there is not enough time and opportunity to dis- cuss patient care problems with other nurs- es), finally, three items were used to mea- sure the collegial nurse-physician relations (i.e., there is less functional collaboration, that is, joint practice, between nurses and physicians). After preparing the question- naire it was then sent to the academicians and practicing nurses to ensure the face validity of the questionnaire. After the review, necessary minor adjustments were made before distribution of the question- naire for data collection. Data collection Data were collected by using the ques- tionnaire. A total of 150 questionnaires were distributed among the nurses working in public hospital in Lahore. All the nurses voluntarily participated in the data collec- tion. A total of 110 valid questionnaires were used for data analysis. The partici- pants were selected by using convenience sampling for data collection. Every nurse that was readily available in the ward was approached and informed. The participants were all able to converse, read, write and speak English so the questionnaire was not translated into the Urdu language. The sam- ple size was sufficient for the study as it resulted in 73% response rate approximate- ly. The study adopted the questionnaire for data collection and previously studies reported that the response rate of the nurses as follows for the questionnaire mailed, e- mailed and handed out the response rate of nurses was 58%, 57.4% and 71.8% respec- tively.14 Ethical considerations For the study, a structured questionnaire was distributed to collect data. Prior permis- sions for conducting the study were obtained from the Superior College of Nursing. Participation in the study was vol- untary and no nurse was forced to partici- pate in the data collection procedure. No personal information was requested and respondents were made assured that their data would only be used for the academic study purpose with complete secrecy. Results First of all, the frequency analysis was performed to know the distribution of the different attributes of the respondents of the study. As per the findings reported in the table majority of the respondents belonged to the age group with having higher Post RN BSN qualifications. Additionally, the majority of the respondents were found to be working night shifts (Table 1). Data normality Once the attributes of the respondents (Nurses) were assessed then the descriptive statistics were performed to assess the data normality. In this regard, the Skewness and Kurtosis are reported in the following Table 2. The values of the Skewness and Kurtosis for all the measuring instrument items fall between the ranges of -2 to +2 indicating the data normality. Additionally, Table 3 shows the overall data normality for the computed variables. Reliability and validity Cronbach’s alpha was assessed to know the reliability of the data. As per the stan- dard, the value of Cronbach’s alpha should be greater than 0.7. As per the findings reported in table 4 all the values of Cronbach’s alpha are greater than 0.7 indi- cating the reliability. Additionally, Table 4 shows the validity of the constructs. KMO Bartlett’s test was performed. As per the parameters, the values of KMO for all the variables are greater than 0.5 and all the val- ues are significant. Hence, both reliability and validity are established. State of nursing practice environ- ment Since all the data collected is valid and reliable so the assessment of the nursing Article [page 2] [Healthcare in Low-resource Settings 2023; 11:10658] No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2023; 11:10658] [page 3] Article Table 1. Profile of respondents (nurses). Demographic variables Categories Frequency Percentage Age 21 to 30 39 35.5 31 to 40 45 40.9 41 to 50 25 22.7 51 to 60 1 .9 Qualification Diploma in Midwifery 21 19.1 Diploma in General Nursing 34 30.9 Post RN BSN 45 40.9 BSN Generic 10 9.1 Shift Morning 30 27.3 Evening 53 48.2 Night 27 24.5 Experience 1 to 3 year 19 17.3 4 to 6 year 29 26.4 7 to 9 year 35 31.8 10 t0 12 year 17 15.5 12+ year 10 9.1 Department Medical Ward 63 57.3 Critical Care 47 42.7 Table 2. Descriptive statistics (individual items of constructs). N Std. Skewness Kurtosis Deviation Statistic Statistic Statistic Std. Error Statistic Std. Error A nurse manager or immediate supervisor who is a good manager and leader 110 1.23505 0.158 0.230 -0.873 0.457 A nurse manager who backs up the nursing staff in decision making, even if a conflict is with a doctor 110 1.03145 0.292 0.230 -0.530 0.457 A senior nursing administrator who is highly visible and accessible to staff 110 1.05780 0.463 0.230 -0.715 0.457 Supervisors use mistakes as learning opportunities, not criticism 110 1.06897 0.055 0.230 -0.589 0.457 A supervisory staff that is supportive of the nurses 110 0.87291 -0.179 0.230 -0.409 0.457 Administration to listens and responds to employee concerns 110 1.02223 0.361 0.230 -0.593 0.457 Praise and recognition for a job well done 110 0.95154 0.352 0.230 -0.115 0.457 Nursing administrators consult with staff on daily problems and procedures 110 1.06428 0.147 0.230 -0.337 0.457 Career development/clinical ladder opportunity 110 1.08964 -0.016 0.230 -0.646 0.457 Opportunities for advancement 110 1.05040 -0.021 0.230 -0.528 0.457 Nurses have the opportunity to serve on hospital and nursing committees 110 0.98703 -0.084 0.230 -0.203 0.457 Opportunity for nurses to participate in policy decisions 110 0.85065 0.030 0.230 -0.328 0.457 A senior nursing administration equal in power and authority to other top level hospital executives 110 1.07609 0.057 0.230 -0.628 0.457 Enough staff to get work done 110 0.91799 0.000 0.230 -0.037 0.457 Enough registered nurses on staff to provide quality patient/client/resident care 110 1.02902 0.251 0.230 -0.587 0.457 Adequate support services allow me to spend time with my patients 110 1.01712 0.186 0.230 -0.514 0.457 Enough time and opportunity to discuss patient/client/resident care problems with other nurses 110 1.13217 -0.039 0.230 -0.856 0.457 Working with nurses who are clinically competent 110 1.12059 0.361 0.230 -0.616 0.457 Written, up to date nursing care plans for all patients/clients/residents 110 1.06381 -0.104 0.230 -0.777 0.457 High standards of nursing care are expected by the administration 110 1.14361 0.169 0.230 -0.788 0.457 Valid N (listwise) 110 - - - - - Patients/clients/residents care assignments that foster continuity of care 110 1.12300 0.197 0.230 -0.685 0.457 Nursing care is based on a nursing model, rather than a medical model 110 1.13878 0.385 0.230 -0.677 0.457 An active quality improvement program 110 1.21380 0.301 0.230 -0.937 0.457 Doctors and nurses have good working relationships 110 1.04670 0.269 0.230 -0.623 0.457 A lot of team work between nurses and doctors 110 1.10609 0.341 0.230 -0.600 0.457 Collaboration between nurses and doctors 110 1.07454 0.397 0.230 -0.501 0.457 No n- co mm er cia l u se on ly [page 4] [Healthcare in Low-resource Settings 2023; 11:10658] practice environment was done by catego- rizing it as poor, average, and good. As per the findings reported in Table 5, only 30% of nurses reported having a good nursing practice environment as compared to 70% of nurses who did not report having a good nursing practice environment. Additionally, cross-tabulation was per- formed to know the state of the nursing practice environment concerning the attributes of the respondents. As per Table 6, only a minor number of respondents regarded the nursing practice environment as good in both the medical wards (17) and critical care units (16). On the other hand, the majority of the nurses working the evening shift regarded the nursing practice as good as compared to the majority of the nurses working morning and night shifts who regarded the nursing practice environ- ment as average. There was a mixed response regarding the nursing practice environment when it comes to the experi- ence and only nurses having aged between 31 to 40 years reported it as a good. Discussion The purpose of the study was to exam- ine the current state of the nursing practice environment. In this regard, data were col- lected from the nurses working in the med- ical wards and critical care units. Data were subjected to the SPSS for data analysis. The results of the study revealed that the overall nurses do not consider the nurs- ing practice environment in which they are working as good. These findings are similar to the previous studies which have also reported the nursing working environment as poor. The results of the study revealed that nurses have less participation in deci- sion-making. Nurses with poor engagement tend to have poor experiences at work 15. Previously a study contended that nurses must participate in hospital activities to improve nurses’ practices and reduce the mistakes and improve nurses quality of care. Nurses discuss daily problems with leaders to improve clinical practices. Good nurse practices improve patient satisfaction.1 On the other hand, the nursing founda- tion for quality of care, nurse manager abil- ity, leadership, and support of nurses; staffing, and resource adequacy; and colle- gial nurse-physician relations were found to be poor as well. The results can be interpret- ed that the nurses are not satisfied with their nursing practice environment. For instance, the report does not have an appropriate sys- tem for their development to ensure the quality of care. They reported not having an appropriate system for learning and improv- ing practices related to patient care. Previously a study reported that hospital staffing and resource adequacy is perceived by nurse respondents as unsatisfactory. Severe shortages in resources and staffing in the public sector hospitals of Pakistan critically undermine the efforts of medical practitioners to ensure patient safety 13. Overall, the findings of the study revealed the perceptions of the nurses at the Pakistan Institute of Neurosciences (PINS). The present study carries several practi- cal implications for a better working envi- ronment at hospitals. First, the grievances Article Table 3. Descriptive statistics (computed variables). N Std. Skewness Kurtosis Deviation Statistic Statistic Statistic Std. Error Statistic Std. Error Nurse manager support 110 0.71188 0.064 0.230 -0.267 0.457 Nurse participation 110 0.70616 0.199 0.230 -0.118 0.457 Staffing resource adequacy 110 0.74914 0.235 0.230 -0.069 0.457 Nurse foundation care 110 0.85846 0.217 0.230 -0.462 0.457 Collegial nurse physician relationship 110 0.90063 0.545 0.230 0.021 0.457 Valid N (listwise) 110 - - - - - Table 4. Reliability and Validity. Reliability Validity Constructs Cronbach’s alpha Number of items KMO Significance NMLS 0.836 8 0.783 0.000 NP 0.734 5 0.718 0.000 SRA 0.762 5 0.683 0.000 NFQC 0.811 5 0.751 0.000 CNPR 0.786 3 0.665 0.000 Table 5. State of nursing practice environment. Rating Frequency Percent Valid Percent Cumulative Percent Poor 36 32.7 32.7 32.7 Average 41 37.3 37.3 70.0 Good 33 30.0 30.0 100.0 Total 110 100.0 100.0 - No n- co mm er cia l u se on ly of the nurses can be reduced by getting them engaged in the decision-making. By doing so they will feel like a part of the larg- er hospital environment where their sugges- tions are taken up to the table as they spend maximum time with the patients. Secondly, there should be appropriate training for the nurses so they can get hands-on experience for better patient care. To have better nurs- ing outcomes, a proper quality foundation should be established. Therefore, it is sug- gested that concerned government depart- ments and hospital management should work toward ensuring a suitable and safe working environment for nurses by improv- ing the accountability system. Authorities need to provide suitable opportunities for the professional development of the nurses to improve their competency. Thirdly, the literature identifies that most nurses are not satisfied with their nurse managers either he/she do not listen to them or are not able to take decisions in a critical situation. The nurse manager may lack the leadership abil- ity and can’t raise the voice of nurses at the hospital. Therefore, it is suggested that nurse managers should be trained enough in their leadership roles. Leadership develop- ment programs should be implemented to address the poor leadership concerns among the nurses. Fourthly, the study also identi- fied the nursing shortage as a serious con- cern so it is required that higher nursing authorities such as Pakistan Nursing Council should address this issue and find a possible solution. Based on the results of the study it is recommended that new nurs- ing colleges should be established to boost the availability of the new workforce for this sector to curb the pressure on the healthcare delivery services. There is dire need to address the issues highlighted in the study for the betterment of the nursing prac- tice environment so that the healthcare ser- vices delivery can be improved and patient satisfaction can be increased as well. Conclusions The descriptive research of the present study concluded that a better work environ- ment can be beneficial for nurses, patients, and organizations. And it is necessary to provide all resources that lead to a produc- tive work environment. The negative impact of the nursing practice environment can lead to patient death. So better nurse work environment leads to better patient care. It is worthy to note that a poor envi- ronment caused harmful effects on nurses and patients. Therefore, an organization must provide a productive environment for the betterment of patients and nurses as well as the institute. The environment is a key factor for patient quality of care and enhancing the professional quality of life. Poor nurse job outcomes are attributed to poor practice environments and high patient-to-nurse ratios. Leaders can focus their efforts on modifying these organiza- tional factors to improve job outcomes and increase nurse retention. Future directions The present study is descriptive and provided the results about the perceptions of nurses regarding the nursing practice environment. It is suggested that future studies may use the larger sample sizes from the multiple hospitals to have a com- parative analysis of the state of the nursing practice environment at both the private and public hospitals. Additionally, future studies are suggested to include the outcomes of the nursing practice environment that will enhance the understanding of the topic. References 1. Hameed S, Hussain M. Nurses percep- tion of practical environment relation- ship with patient satisfaction in Government Hospital Lahore. Int J Soc Sci Manag 2019;6:75-81. 2. Zeleníková R, Jarošová D, Plevová I, Janíková E. Nurses’ perceptions of pro- fessional practice environment and its relation to missed nursing care and nurse satisfaction. Int J Environ Res Public Health 2020;17:3805. 3. Algahtani FD, Hassan S-u-N, Alsaif B, Zrieq R. Assessment of the quality of life during COVID-19 pandemic: a cross-sectional survey from the Kingdom of Saudi Arabia. Int J Environ Res Public Health 2021;18:847. 4. 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