The relationship between the nurses' work environment and the quality and safe nursing care: Slovenian study using the RN4CAST questionnaire.

INTRODUCTION: The safety and quality of patient care are basic guidelines in finding new and improved solutions in nursing. Important and influential factors shape the nurses' work environment in hospitals.
PURPOSE: With the study, we intended to investigate whether the perception of nurses' work environment is related to the safety culture and the quality of patient care and whether it differs according to nurses' level of education. METHODS OF WORK: The study with a quantitative research method was conducted at the six clinical departments of the University Medical Centre, Ljubljana in 2019. We used a survey questionnaire from the European survey Nurse forecasting in Europe (RN4CAST).
RESULTS: 270 nurses were included in the study. The response rate was 54%. The study confirmed that there is a correlation between the assessment of the nurses' work environment and the general assessment of patient safety (r = 0.36; p <0.001), the general assessment of the quality of nursing care (r = 0.32; p <0.001), the confidence in patient self-care at discharge (r = 0.29; p <0.001) and the quality of patient care in the previous year (r = 0.27; p = 0.001). The results showed frequent verbal abuse of nurses, in 44.9% by patients and their relatives and in 35.4% by staff. Graduate nurses rated the work environment more negatively than healthcare technicians (p = 0.003). DISCUSSION AND
CONCLUSION: We confirmed the correlation between the assessment of nurses' work environment and patient safety and the quality of health care, and that employees' education influences the assessment and perception of the work environment.

Introduction

In assessing the work and organisation of public health at all levels, the work environment and, in a broader sense, the culture of the work environment, which is largely composed and co-created by nurses, are extremely important. The work environment in hospitals can increase or decrease the abilities and competencies of nurses to provide quality nursing care. Research in different health systems and different cultural settings has confirmed that factors in the work environment significantly influence the quality of nursing care and consequently the treatment outcomes of patients during hospital treatment [1-7]. Researchers [5-13] have published the results of an international study on the impact of factors in the work environment on the quality of nursing care in hospitals. This study, in which Slovenia was not included, was conducted from 2009 to 2011 in twelve European countries.

In 2018, according to the National Institute of Public Health, only 34.7% of all nursing staff in the country (21644) had a bachelor’s degree [14]. Analysis of data on the Slovenian categorization of the intensity of hospital nursing shows shortage of nursing staff since 2007, and the share of the deficit of Slovenian nursing staff in hospitals has been increasing over the years (in 2013—the deficit 21.78%; in 2016—the deficit 25.40%) [15]. Analysis of data of the above-mentioned categorisation of the sample in 2011 proves that the nursing providers in Slovenian hospitals are overburdened, and there is a trend towards increasing complexity of hospital nursing [16]. Dissatisfaction with work among Slovenian nurses stems mainly from the organisation of work, non-compliance with personnel standards and norms and unregulated conditions in the field of competencies between individual professional profiles [17]. The International Organization of Nurses draws attention to the fact that an unsustainable heavy workload is also associated with increased absenteeism and employee turnover, which in turn compromises the quality of patient care [18]. In Slovenia, nurses also change to less demanding healthcare jobs, to healthcare jobs abroad or even leave the profession.

According to the presented situation in nursing, we intended to find out how nurses perceive the current situation in their work environment. The main goal of the study was to determine whether the results confirm the correlation of the work environment to the culture of patient safety in the hospital, and consequently to the quality of care. Due to the different educated hospital nursing providers, we investigated whether the perception is influenced by the level of education achieved.

Methods

The study was based on a quantitative research method using a questionnaire for nurses (requested from the author) from the international cross-sectional study Nurse forecasting in Europe (acronym: RN4CAST). We coordinated the work methodology with the protocol of the European project [19].

Preparation and description of the research instrument

The survey questionnaire for nurses contained 118 questions or statements, which were divided into four sections: Your workplace, Quality and safety, Your last shift at the hospital, Your data [19]. The Slovenian translation of the instrument was performed using the standard forward-backward translation [20].

The clarity of the Slovenian translation and the uniformity of the statements and questions as regards the social environment was assessed with the assistance of a group of twenty nurses employed on the hospital department, who added comments and possible ambiguities while completing the questionnaire.

Measures and validation of the Slovenian version of the questionnaire

The construct validity of the questionnaire was assessed by an exploratory factor analysis to determine whether similar statements measured the same latent variable as proposed by several authors [21, 22]. The set of statements in the first part of the questionnaire is designed to measure elements of the work environment based on the practice environment scale of the nursing work index (PES-NWI) [8]. All items were measured on a four-point Likert agreement scale. Four factors were extracted using the principal axis factoring method and orthogonal rotation, namely: interpersonal relationships and teamwork (16.4% of variance explained), nurses’ co-decision-making and development prospects (10.3% of variance explained), organisational priorities regarding the quality of patient care (9.1% of variance explained) and support of the nursing management (8.9% of variance explained) (S1 Table). The first factor, interpersonal relationships and teamwork, included seven items. An exemplary item is “Doctors respect nurses as professionals.” The second factor, nurses’ co-decision-making and development prospects included five items with an exemplary item being “Registered nurses participate in the hospital’s internal management”. The third factor, organisational priorities regarding the quality of care included five items. The item with the highest factor weight is “There is an active quality assurance program”. The fourth factor, organisational priorities regarding support of the nursing management included five items. An exemplary item is “The supervising nurse manages and leads the department well”. One item “There are written, up-to-date nursing care plans for all patients.”had high factor weights on two factors, and seven items did not have high factor weight on any of the factors. These items were excluded from the calculation of composite score (an average of items with high weights on a single factor). Cronbach’s alpha coefficient indicated good measurement reliability for all factors (range 0.74 to 0.92) (S1 Table).

In statements about patient safety culture (measured on the five-point Likert agreement scale), two latent variables (factors) were extracted using factor analysis, namely: mutual trust (23.9% of variance explained) and the importance of patient safety and feedback (19.7% of variance explained) (S2 Table). Mutual trust included four items, which were reverse coded for the analysis. An exemplary item (reversed coded for the analysis) is “When changing shifts important information about patient care is often lost”. The importance of safety included two items, which were reverse coded for the analysis. An exemplary item is “The hospital management’s actions show that patient safety is one of the most important tasks”. One item did not have a high factor weight on any of the factors and was excluded from the calculation of the composite score (an average of items with high weights on each factor). In this case, Cronbach’s alpha coefficient also demonstrated good reliability of the measurement (0.71 and 0.72) (S2 Table).

Work environment and quality of nursing care were evaluated by a single item on a four-point scale (from poor to excellent), while patient safety was evaluated on a five-point Likert type item (from unsatisfactory to excellent). The frequency of eight adverse events (quality indicators of healthcare) was assessed on a six-point frequency scale (never to every day).

Sampling, inclusion and exclusion criteria

University Medical Centre Ljubljana (UMC Ljubljana) is the largest Slovenian hospital with 2150 beds. Simple random sampling of six out of ten Departments of the Division of Internal Medicine and from the nine Departments of the Division of Surgery at the UMC Ljubljana was performed using the “Simple Random Sampling Applet” computer programme [23]. Randomization was done at the department level. This is one of the probability sampling methods that yields a representative sample if the response is large and the non-response is by the chance.

By following the RN4CAST methodology and work protocol, only adult medical-surgical care nursing units were included in the study. The data of different elements of nursing practice environment to patient safety and clinical outcomes are best researched and documented within these work domains [20], thus enabling a more reliable comparison. Specialized nursing units, such as the Departments of Paediatrics, Intensive Care Units, Long-Term Care Units, Emergency Departments, Department of Anaesthetics Care and Operating Theatres were not included in the selection process of our research.

Study and data analysis

Consent to use the questionnaire for nurses from European research was obtained in August 2018 by the European coordinator of the EU-FP7 RN4CAST-project, Full Professor Walter Sermeus, provided that we conduct a study in one hospital. Therefore we decided to conduct a study among graduate nurses and healthcare technicians at the UMC Ljubljana. In early 2019, 1721 nurses were employed in hospital departments of UMC Ljubljana, of which 47.3% were nurses with a bachelor’s degree [24]. Ethical approval for the pilot study was granted by the Committee for Medical Ethics of the Republic of Slovenia (Reference no. KME RS.0120-490/2018/5). Before the start of the research work, we addressed a request for a pilot study to the head nurse of UMC Ljubljana. We also previously obtained consent for research from the hospital research group in nursing and all other necessary permits (Leadership team of the Division of Internal Medicine, Leadership team of the Division of Surgery).

The study was conducted from January 16th, 2019, to March 1st, 2019. We previously notified the head nurses and heads of selected departments by e-mail of their random selection and requested their cooperation. We presented the purpose of the study and how it would be conducted to all participating nurses in the selected departments in advance and informed them of the voluntary basis of their decision and the anonymity of participation. The survey questionnaires were handed out to participants in a sealed envelope, and a new envelope with the title of the submission was enclosed for its return. Envelopes with the completed questionnaires were sent daily from the administrative offices of individual departments with the rest of the internal mail to the one selected administrative office at the Division of Surgery. The time limit for completing and returning the questionnaires was a maximum of three weeks.

Statistical analysis

In the study, we used the original questionnaire with all-encompassing scales, although only results of the part of the questionnaire are presented in this paper. The mean number of patients per nurse during their last shift was calculated based on self-assessment provided by nurses. Items relating to nurses’ work environment, safety culture, overall assessment of nurses’ work environment (a single item), overall assessment of patient safety in the department (a single item), overall quality of nursing care in the department (a single item) and adverse events were described by percentages. Composite scores per dimension of nurses’ work environment and patient safety culture (as evaluated by factor analysis) were calculated and used in multiple linear regression analysis. Two multiple regression models were built to examine the relationship between nurses’ work environment and patient safety culture. Four dimensions of nurses’ work environment were included as independent variables and each dimension of patient safety culture (mutual trust, importance of safety culture) was included a dependent variable in the regression model. Comparison between nurses with and without bachelor’s degree in the overall assessment of the work environment was done by Mann-Whitney U test. Spearman correlation coefficient was calculated between each dimension of patient safety culture or nurses’ work environment and frequency of each adverse event. Statistical testing was performed at the 0.05 significance level. No correction for multiple testing was applied. Statistical analysis was performed using SPSS software, v. 26.

No a priori sample size was determined, however post-hoc sample size calculation indicates that for achieving 80% power of the multiple linear regression model with four predictors at significance level α equal to 0.05 and effect size as determined by R2 equal to 0.17, the sample size of 85 would suffice.

Results

Of the 384 nursing staff in the selected departments, 270 nurses (70%) were present at the workplace at the time of the survey. The questionnaire was sent to all present nurses in the selected departments and 147 questionnaires (54%) were completed and returned. The majority (90.5%) of the participants were female and full-time employees (94.6%). Their average (standard deviation) age was 40 (SD = 10.9) years, and 63.3% of the nurses had a bachelor’s degree. A comparison of the structure of the sample, according to the level of nurses’ education, shows (Table 1) that the structure of the sample statistically significantly differs from that in the population (p < 0.001). The nursers with bachelor’s degrees are overrepresented in the sample. The gender structure, however, does not statistically significantly differ from that in the population (p = 0.063). In our study, the calculated ratio was 9.94 patients per nurse per work shift. We obtained this ratio based on the data from the question: “How many patients were you directly responsible for during your most recent job?” All forms of work shifts were included.

Table 1

Sample description.

	Sample (n = 147)	Population (n = 1393)	P
Female sex f (%)	133 (90.5)	1184 (85)	0.063
Mean (SD) age in years	40 (10.9)	-
Bachelor’s degree	93 (63.3)	600 (43.1)	< 0.001

Nurses gave the highest rating to the statements that “management expects high standards of nursing care” (47.6% of respondents completely agreed and 41.5% of them agreed with the statement) and that “they work with clinically qualified nurses” (43.5% of respondents completely agreed and 44.9% of them agreed with the statement). They gave the lowest rating to the statements that “assigning patient care tasks promotes continuity of care” (24.5% of respondents completely disagreed and 29.9% of them disagreed with the statement) and that “there is enough staff to get the job done” (35.4% of respondents completely disagreed and 33.3% of them disagreed with the statement) (S1 Fig).

A comparison of the percentage of nurses’ responses regarding the general assessment of the work environment, patient safety and the quality of nursing care is summarized in Fig 1.

Fig 1

Evaluation responses regarding the overall assessment of the work environment in the department, patient safety in the department and the quality of nursing care (N = 147).

A3 –How would you rate the working conditions in your current job at this hospital (e.g., suitable equipment, relations with coworkers, support from superiors); B1—How would you rate the overall quality of nursing care that patients receive in your department/unit; B4—Rate the overall safety of patients in your department/unit.

From the statements measuring the patient safety culture, nurses agreed and most with the statement “in the department, they work on preventing mistakes being repeated” (68.5% of them agreed or strongly agreed with the statement). The agreement with the reversely coded statement that “others resent their mistakes” was the lowest (34% of them agreed or strongly agreed with the statement) (Fig 2). The lowest share of strongly agree responses was regarding “the receiving of feedback on changes made in response to report events”.

Fig 2

Patient safety culture by statements (n = 147).

Among the 8 quality indicators of healthcare listed in the questionnaire as adverse events occurring to patients or employees, verbal abuse of nurses by patients and/or their relatives as well as by staff stood out. About one-fifth (19%) of the surveyed nurses perceived weekly verbal abuse by patients and/or their relatives. The share of responses confirming the occurrence of verbal abuse of nurses by patients or their relatives once to several times a month was even higher (44.9%). The occurrence of verbal abuse of nurses by staff was perceived by 12.2% of the respondents on a weekly basis, and once to several times a month by 35.4% of nurses.

The incidence of pressure sores after admission once or more per month was confirmed by nurses by 29.9%. Similarly, complaints of patients or their relatives were detected among nurses once or more per month by 29.3%. Work-related physical injuries occurred to nurses once or more per month in 20.4%. (Fig 3).

Fig 3

Frequency of adverse events occurring to patients or staff (quality indicators of healthcare) (n = 147).

Determining the relationship between the perception of the work environment and patient safety culture and the quality of patient care

Using multiple linear regression with the four dimensions of nurses’ work environment as independent and mutual trust as one of the two dimensions of patient safety culture as dependent variable (Table 2). We found that two dimensions of nurses’ work environment were related to mutual trust, namely organisational priorities regarding the quality of care (B = 0.30; p = 0.016) and management support of nursing care (B = 0.35; p = 0.003). Both regression coefficients are positive indicating that higher organisational priorities regarding the quality of patient care and higher management support of nursing care are reflected in higher mutual trust between healthcare staff.

Table 2

Relationship between perception of the dimensions of the work environment and the mutual trust, the first dimension of the patient safety culture (result of multiple linear regression).

	Regression coefficient	P
Intercept	1.78	<0.001
Interpersonal relationships and teamwork	-0.06	0.609
Nurses’ co-decision-making and the opportunity for development	-0.05	0.693
Organisational priorities regarding the quality of patient care	0.30	0.016
Management support nursing care	0.35	0.003

R2 = 0.17

The second multiple regression model included the four dimensions of nurses’ work environment as independent and the second dimension of patient safety culture, namely the importance of patient safety, as a dependent variable (Table 3). Results indicate that the importance of patient safety is positively related to the nurses’ co-decision-making and the opportunity for development (B = 0.31; p = 0.048) and with organisational priorities regarding the quality of patient care (B = 0.49; p = 0.001). Higher importance of patient safety is present when nurses have the opportunity for professional development and cooperate in decision making. The importance of patient safety goes hand in hand with firmly set priorities regarding the quality of patient care.

Table 3

Relationship between perception of the dimensions of the work environment and the importance of patient safety, the second dimension of the patient safety culture (results of multiple linear regression).

	Regression coefficient	P
Intercept	1.05	0.006
Interpersonal relationships and teamwork	-0.01	0.939
Nurses’ co-decision-making and the opportunity for development	0.31	0.048
Organisational priorities regarding the quality of patient care	0.49	0.001
Management support nursing care	-0.02	0.907

R2 = 0.20

We found a positive correlation between all dimensions of the work environment and nurses’ certainty that patients can care for themselves at discharge (S3 Table). We also confirmed a positive correlation between most dimensions of the work environment and the general assessment of the quality of nursing care in the department as well as the overall assessment of the quality of hospital care of patients in the past year (S3 Table).

Adverse events involving patients or nurses showed a negative correlation with at least two of the dimensions of the nurses’ perception of the work environment (Table 4). The correlation coefficients, however, indicate a weak relationship between variables. The highest, but still moderate, negative correlation exists between verbal abuse of nurses by staff and management support of nursing care (r = 0.38; p < 0.001) and the former and overall assessment of the work environment in the hospital (r = - 0.37; p < 0.001).

Table 4

Spearman’s correlation coefficient between adverse events and perception of the work environment.

	Pressure ulcers after admission		Patients’ falls leading to injuries		Healthcare- associated urinary tract infections		Verbal abuse of nurses by patients and/or their families		Verbal abuse of nurses by staff
	r	P	r	P	r	P	r	P	r	P
Interpersonal relationships and teamwork	-0.24	0.003	-0.18	0.031	-0.21	0.009	-0.07	0.423	-0.11	0.192
Nurses’ co-decision-making and the opportunity for development	-0.19	0.024	-0.24	0.004	-0.17	0.042	-0.25	0.003	-0.30	<0.001
Organisational priorities according to quality of care	-0.11	0.173	-0.23	0.005	-0.19	0.023	-0.20	0.018	-0.25	0.002
Management supports nursing care	-0.04	0.654	-0.07	0.417	-0.15	0.070	-0.25	0.002	-0.38	<0.001
Overall assessment of the work environment in the hospital	-0.14	0.097	-0.16	0.051	-0.21	0.010	-0.33	<0.001	-0.37	<0.001

r = Spearman’s correlation coefficient

Perception of the work environment and nurses’ education

We then investigated whether there is a difference in the perception of the work environment according to nurses’ acquired education (with a bachelor’s degree/ without a bachelor’s degree). The study involved 63.3% graduate nurses (at the time of the study, their proportion at the hospital’s departments was 43.1%). Nurses with a bachelor’s degree gave a lower overall assessment of the work environment (U-value = 1821.5, p = 0.003). Also nurses without a bachelor’s degree rated the dimension organizational priorities regarding the quality of patient care more positively than nurses with bachelor’s degrees (S4 Table).

In Slovenia, nursing education takes place in two stages, in accordance with the standards of the European Directive 2013/55/EU. The professional competencies of the graduate nurse as a healthcare provider in the healthcare team comply with the competencies of the above-mentioned directive after completing 3-years of the first cycle of Bologna higher education. After completing four years of education, the healthcare technician is qualified to observe and monitor the patient’s state of health, perform tasks as directed by a graduate nurse or medical doctor, report in the team, assist in patient activities of daily living, provide first aid, and care for the dying and deceased. His/her professional competencies enable him/her to carry out part of the nursing activities and diagnostic-therapeutic program independently, and part as a co-worker in a team led by a graduate nurse [25].

Discussion

In this study, we used the RN4CAST questionnaire to determine the correlation between nurses’ perception of the work environment and patient safety and the quality of nursing care. Our findings showed that two-third of nurses (68%) rated the patient safety culture as “good” or “excellent”. The result is surprising, as it is 24 percentage points lower than the European average (92%) [5]. The evidence from a European survey supports the fact that patient safety is a key indicator of the quality of medical treatment and nursing care [5, 10, 12].

Various U.S. researchers have shown that a poorer safety culture of the hospital increased the 30-day mortality rate among patients with acute myocardial infarction [26] and that in patients with heart failure, the possibility of readmission within 30 days after discharge from hospital increased by 2–8% if certain nursing care activities were not performed [27]. Nursing activities left undone can pose a high risk to quality and safe patient care [28].

Among the statements about the patient safety culture, the lowest-rated statement that “employees receive feedback on changes made in response to reports on events” was alarming. To eliminate the shortcomings of existing work systems and processes, it is important that reporting and analysis of adverse events allow for timely corrective action [29] while considering interprofessional differences in perception of patient safety culture as well as certain influential factors (sufficient staff, lack of time) [30].

In our study, we demonstrated a correlation between the assessment of nurses’ perception of the work environment and the overall assessment of patient safety. Almost one-third of the respondents rated patient safety as poor or satisfactory. Similarly, the results of a survey in twelve Slovenian hospitals in 2013 showed an overall low patient safety culture. The following elements of the safety culture were rated the worst: teamwork across hospital units, non-punitive response to errors, hospital management support for patient safety, and staffing [31]. Foreign researchers have reached conclusions that a better hospital work environment for nurses increases the chance of survival of patients with cardiac arrest by 16% [32]. In another study, it was shown that there is an 11% increased chance of 30-day survival in elderly patients on mechanical ventilation in better work environments, and if more graduate nurses are present [33].

The general assessment of the work environment showed that half of the nurses (49%) assessed the work environment as “poor” or “satisfactory”. The result of the assessment of the work environment correlated with the percentage of nurses who would leave their current job in the next year due to dissatisfaction with the work environment (51%). Sermeus et al. [8] found that nurses in all participating countries had a negative perception of their work environment and expressed their intention to leave their current job in one year, the percentage varying from country to country (20% to 50%), with an average of 35.6% [9]. When looking for measures to retain nurses, the major Slovenian hospital identified the factors influencing nurses’ leaving: inadequate pay (for less work in nursing or for easier work outside of nursing), lack of professional affiliation and the futility of performing a demanding profession in nursing care, poor interpersonal relationships and communication in health care, inadequate mentoring, desire to work in another field, insufficient staff, the rapid development of the profession and innovations, physical demands [34]. The increased turnover of nursing staff is a global and long-standing social problem, the causes of which are multifaceted, often similar and comparable regardless of the diversity of the geographical and cultural environment.

Compared to the overall assessment of patient safety, the quality of nursing care in the hospital was rated high in the study. The individual dimensions of the work environment, as well as its general assessment, showed a positive correlation with the general assessment of the quality of nursing care, with the nurses’ confidence in patient self-care after discharge, and with a better assessment of the quality of patient care in the last year.

Quality indicators of healthcare as adverse events that occurred to patients or staff confirmed a negative correlation with nurses’ perception of the work environment. Some associate the occurrence of adverse events with poor communication and poor cooperation in interdisciplinary teams, resulting in inappropriate handover protocols and a lack of recognition of and respect for the role of the individual [35], while at the same time attributing an important role to the leaders of nursing care teams [36]. A poor work environment as well as a high ratio of patient to nurse certainly increases the possibility of adverse events [37, 38]. The high ratio of the number of patients per nurse calculated in our study corresponds with the lowest assessment of agreement of the participating nurses that “there are not enough staff on the department to get the job done”. According to European researchers [8], the number of nurses in individual countries is not a true indicator of the adequacy of the number of nursing staff. When there is a shortage of nursing staff, employers strive to make the most efficient use of the workforce, but research shows the correlation between long shifts or overtime work and nursing activities not carried out, which results in a poorer quality of care [11, 12]. The recent study in Slovenian hospitals also confirms the workload as the most stressful factor among nurses, which consequently reduces the quality of care [39]. Objectively measured personnel data based on the Slovenian categorization of the intensity of hospital nursing also prove the correlation of the long-term shortage of nursing staff with some national quality indicators of healthcare [40].

The most pronounced negative impact on the quality of nursing care in the study was the perceived verbal abuse of nurses by patients and/or their relatives on a monthly basis (44.9%), which was almost twice as high as the average in the European study (26%), and abuse by staff (35.4%), which was four times higher than the European average (8%) [13]. Unstable conditions in the work environment (insufficient number of graduate nurses, increased workloads, reduced support from management, poor team relations, etc.) have been shown to promote abuse of nurses and to have a greater impact than the patient population itself [41]. We have previously presented the findings of our study on the poor assessment of the work environment by almost half of the respondents. In 2018, a survey was conducted in three Slovenian healthcare institutions in various places on the prevalence of violence among healthcare employees. Employees expressed the opinion that they had experienced verbal violence from patients or their relatives more than ten times in one year in 24.1% of cases, while 10% confirmed they had experienced violence from co-workers or superiors [42]. A previous Slovenian survey among nurses on workplace violence revealed that the most frequent perpetrators of verbal abuse were patients (39.3% of respondents) and co-workers (39.6% of respondents) [43].

European research has confirmed, among other things, that the level of nurses’ education is important for reducing adverse events [10]. In our study, regarding the link between nurses’ level of education and their perception of the work environment, we established a worse, negative general assessment of the work environment as well as a poorer assessment of dimension of the work environment on organizational priorities regarding the quality of care among graduate nurses. The percentage of graduate nurses who expressed a poor assessment of the work environment was almost one-third higher than healthcare technicians. Certainly, acquired knowledge, experience and professional competencies encourage responsible judgment, decision support, and high-level practice within the framework of nursing care regarding safe and quality patient care, as well as enabling critical evaluation of individual events and situations [7, 44]. In our study, nurses expressed a desire for greater educational opportunities as well as more prospects for advancement. On the other hand, 57% of respondents thought that there are enough graduate nurses on the department for quality patient care (answers “I partially agree” and “strongly agree”), which is contrary to the results of the European study, where, on average, almost 70% of the respondents expressed an opinion on the shortage of graduate nurses on the department [10].

Strengths and limitations

The limitation of the research is that no correction was made for multiple testing, hence some false positive statistically significant associations might have been discovered. For more rigorous interpretation of results only those with p ≤ 0.001 could be interpreted as statistically significant.

Respondents’ perceptions expressed their view on probabilities and predictions, which may differ from actual situations. Further research would be needed to clarify the more exposed results of our research.

As mentioned earlier, we conducted the research to investigate the relationship between the perception of the nurses’ work environment and selected variables. The innovative European RN4CAST project is still relevant. It is important to research and discern how to create a positive work environment for nurses and other staff, that impacts sick leave and the recruitment and retention rates. Our research was carried out ten years after the European project, which may be a partial limitation.The data presented in the introduction confirm the deterioration of the situation in Slovenian nursing care. No decisive or substantive changes have been made in the past ten years, nor systematic improvements that could limit the conclusions of direct comparison of our results with the European project. However, in some cases, our results were more comparable to those of individual countries than to the overall average.

Our study is a good starting point for a wider study in all Slovenian hospitals to identify and predict the needs for nursing care providers in light of the current situation and all characteristics of nurses’ work environment.

Conclusion

The results of the study showed that there is a correlation between the assessment of nurses’ work environment and patient safety culture and the quality of care in the hospital environment. The assessment of the work environment differed between nurses with a degree in nursing and healthcare technicians, as the latter gave a more positive assessment.

The results of the study reveal a discrepancy between the overall assessment of the quality of nursing care and the assessment of patient safety. The findings show that despite the high assessment of the quality of nursing care in the department the indicators of quality of care confirmed a negative correlation with all dimensions of the work environment and the general assessment. Verbal abuse of nurses by patients and their relatives, as well as by staff, was the most notable.

Average degree of agreement (M–arithmetic mean) and standard deviation (SD) for statements relating to the perception of the work environment.

(DOCX)

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Factor weights (>0.40) obtained by factor analysis (principal axis factoring method and orthogonal rotation) on statements regarding work environment.

(DOCX)

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Factor weights (>0.40) obtained by factor analysis (principal axis factoring method and orthogonal rotation) on statements regarding patient safety culture.

(DOCX)

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Spearman’s correlation coefficient between the general assessment of the quality of care, the assessment of self-care and the assessment of the quality of care in the previous year and the perception of the work environment.

(DOCX)

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Perception of the work environment and nurses’ education.

(DOCX)

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16 Jun 2021

PONE-D-21-15371

THE RELATIONSHIP BETWEEN THE NURSES’ WORK ENVIRONMENT AND THE QUALITY AND SAFE NURSING CARE: SLOVENIAN STUDY USING THE RN4CAST QUESTIONNAIRE

PLOS ONE

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for asking me to review this paper which addresses and important area of research.

The abstract provides a balanced summary of what was done and the key findings.

The introduction could be strengthened as it does not provide a strong rationale for the study question and why it is important. The reasons for exploring the education of nurses should also be clear in the introduction. Appropriate permissions for the study appear to have been granted.

The technique for validation of the questionnaire (principal axis factor method with orthogonal rotation) should be referenced. The validation of this tool and factor weights take up a lot of space in this paper and could be presented in supplementary material instead (Tables 1 and 2). It could be clearer how the factors were used in the analysis.

The methods section should define all the key outcome variables and how these were measured. For example, it does not state that adverse events will be collected. The methods section should also describe exactly how patient safety and quality of nursing care were measured, as it is not clear for the reader. Methods should also explain how job satisfaction was measured as it is mentioned first on line 193. It is not clear how the sample size was determined.

I found the result section difficult to understand without referring to the original RN4CAST questionnaire. It needs to be clearer for the reader to understand all the variables being measured and presented. Many of the measures appear to have come from single questions on the RN4CAST (A3, B4 and B1) which could be made clearer to the reader. If possible, the authors should present effect sizes/absolute values as well as p values for correlation, as it is difficult to judge whether findings would be clinically important.

The discussion should have a section on study limitations and potential sources of bias. The discussion relates well to previous literature however the conclusion on line 243 that poor patient safety arises from a poor working environment is not substantiated from the data. The direction of effect has not been ascertained as this is a cross sectional study. The generalisability of findings could have been considered. The conclusion is succinct and based on the evidence presented.

Overall, I believe that the research has been conducted in a rigorous way using a defined population and it adds to new knowledge. However, the paper itself could be improved so that the methods and results sections are more clearly linked. The introduction and discussion sections could be strengthened as highlighted above.

Reviewer #2: This study applied the RN4CAST questionnaire to assess the perception of nurses’ work environment, safety culture, and quality of patient care in 6 clinical departments at one hospital in Slovenia. The authors also stratified results by nurses’ level of education. The data presented in this manuscript has good potential and is of interest to the discipline; however, the statistical analysis conducted by the authors needs revising. My main concern is that the authors treated ordinal categorical variables as continuous, which might be appropriate in some cases when using Linkert scales but should be checked to make sure the estimates are not considerably different. This is particularly relevant for modelling; I would suggest running an ordinal logistic regression in parallel to the multiple linear regression models in order to confirm the results presented in the manuscript. The manuscript would also benefit from revising the English and language used, as I found it difficult to follow at various points.

Introduction:

1) The authors state that they aimed to compare the results of their study with the international benchmark, derived from the study conducted by Aiken et al. However, they do not provide direct comparisons in the results section but rather contrast the two studies in the discussion section. I would therefore advise revising the aim of the study to not include this statement.

2) The number of beds, nurses and percentage of graduate nurses seem like results from the study as opposed to based on literature. If this is the case, please move these to the results section and add details on data source in the methods section. However, if based in published literature, please add a reference for these data.

3) Lines 72 to 74: Needs clarifying/rewording. My understanding is that the classification of hospital nursing intensity in hospitals across Slovenia was derived from data in 2016 that showed a deficit of nursing care providers in health care institutions. What are the implications of this?

Methods:

4) Were there any changes made to the original translation after the cognitive assessment was completed?

5) Were there any changes made to the questionnaire as described in lines 95-103 or were these changes applied on the data analysis stage? The authors mention in line 144 that they used the original questionnaire in its entirety. Please clarify to the readers.

6) Should add “data not shown” when mentioning the comparison of the structure of the sample to the population; however, might be worth adding it to supplementary as a table so that the readers can see the direct comparison. Also, please add the significance level (95% confidence intervals or p-value).

7) Exclusion criteria: why were these department excluded? Please provide justification.

Results:

8) How was the patient-per-nurse ratio calculated? What was the source for number of patients? What was defined as a work shift (e.g. 12 hours shifts, 8 hours shift, mix of both patterns)? Were these data from the same study period and averaged across all departments included? Need more details on how these were calculated.

9) The authors mention that assessment of nurses’ work environment was assessed by a 4-point agreement scale but results are presented as a 5-point scale. Could you please clarify this in the manuscript?

10) As the 5-point scale are ordered categorical data, might not be appropriate to express results as mean and standard deviation. It would be best to present the proportion of respondents that selected each category, perhaps easier to represent as a horizontal stacked bar figure. Similarly, table 3 could be reproduced as a horizontal bar figure, as this would provide more information to the readers (the proportion of each response for each question). You can then group 1-2 and 4-5 to comment on results in the text.

11) Table 3. Why was satisfactory/acceptable (score 3) grouped with scores 1 and 2? What was the rational for creating these two distinct groups (i.e. 1-3 and 4-5)? Were the differences observed statistically significant?

12) Table 5. What was the outcome variable in this regression? Mutual trust? I would suggest modelling this using an ordinal logistic regression as opposed to multiple linear regression. Also, “regression coefficient” can be used as header instead of “B”. The test statistic is unnecessary, as is the intercept.

13) Table 8. Not needed, the results of this comparison could be summarised in the text by simply adding the p-value. Would be helpful to reminder the reader the % for each education level from the study sample at this point.

What are the main differences between graduate nurses and licensed practical nurses? Which tasks are each of them responsible? These could affect their perceptions of the work environment and therefore it would be useful for the reader to know how these are classified/defined in Slovenia, as it could vary from country to country.

Discussion:

14) Not sure the authors can state that a poor work environment increases the ratio of the number of patients per nurse. It might, if morale is low enough to the point that it increases absenteeism but the opposite could also be true (i.e. high numbers of patients per nurse could lead to a poor work environment – or even constitute a poor work environment - due to increase workload on the limited staff).

15) Comparisons between the average European findings and those from this study are interesting but the authors should acknowledge the potential limitation that these surveys were conducted decades apart (2009 vs 2019) and therefore direct comparisons might not be appropriate (or might reflect changes that occurred throughout the years as opposed to actual differences between countries). Would also be helpful if the authors provided additional context to try to explain these differences – any other literature showing higher abuse by Slovenian healthcare staff?

16) Which dimensions were scored worse by graduate nurses compared to licensed practical nurses? What is the definition of these terms and how do they differ in terms of types of tasks performed and level of education?

It seems like some of the study findings discussed were not reported on the results section. Presenting stacked bar figures for each of the domains might help the reader follow the manuscript narrative and visualise all the results in a clear and concise manner.

17) I suggest that the authors add a strengths and limitation section. These could include the strength of having applied a standardised questionnaire that has been used Europe-wide. However, in the limitations section they should acknowledge that the European survey was conducted in 2009 to 2011 while this study took place in 2019, therefore contextual/external changes could have happened in the meantime, limiting conclusions from direct comparisons.

Minor comments:

Lines 82-84: This seems like the aim of the study and should be moved to the end of the introduction.

Line 87: Are these the domains referred to later in the manuscript? If so, the manuscript would benefit from standardising the nomenclature as either questionnaire sections or domains.

Lines 91-93 could be merged with the previous section, without the need of a subheading for this particular paragraph.

Line 97: spell out PES-NWI and use the abbreviation between brackets.

Table 1. Convention is to use dots for decimal places as opposed to comma. Need to explain text highlighted in red and add footnote detailing what F1-F4 stands for. These also apply to table 2.

Line 120: “This’s” should not be contracted, substitute for “This is” instead.

Line 184 to 187: Please rephrase these as I could not follow what the authors are trying to state.

Line 187 to 189: the authors joined very different concepts/responses in one sentence. I suggest splitting these into short clear sentences.

Lines 207 to 211 – Needs to be re-worded, I could not understand the comparisons that were made, and the results detailed. Would be useful to break down the paragraph into smaller sentences so that it is clear to the readers what is being compared to what, and results for each comparison.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

11 Sep 2021

Dear Editor-in-Chief and Editorial Board!

Thank you for the opportunity to correct the manuscript, thank you for instructions of editorial board and reviewers ’comments.

We have submitted all required items for resubmission. We edited the ORCID iD for the corresponding author. Prior to submission, the files in the PACE program were reviewed to meet the PLOS ONE technical requirements. The official translator proofread the manuscript.

We have thoroughly corrected the manuscript and we hope that this version will be suitable according to all the criteria for publication in PLOS ONE.

With kind regards

Submitted filename: Reply to reviewer 1.docx

Click here for additional data file.

10 Nov 2021

PONE-D-21-15371R1The relationship between the nurses' work environment and the quality and safe nursing care: Slovenian study using the RN4CAST questionnairePLOS ONE

Dear Dr. Grosek,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Dec 25 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

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Barbara Schouten

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have been extremely careful to address all the points I have raised and I believe this revised paper is very much better for your readers. The methods and discussion sections have undergone substantial revisions and I now believe this paper should be published as it adds to the evidence in this area and has been conducted in a rigorous way. Thank you for the opportunity to review it. Good luck to your authors.

The introduction could be strengthened as it does not provide a strong rationale for the study question and why it is important. THIS IS MUCH IMPROVED

The reasons for exploring the education of nurses should also be clear in the introduction. INCLUDED

The technique for validation of the questionnaire should be referenced. MUCH CLEARER NOW

The validation of this tool and factor weights take up a lot of space in this paper and could be presented in supplementary material instead (Tables 1 and 2). NOW MOVED WHICH IMPROVES THE PAPER

The methods section should define all the key outcome variables and how these were measured. For example, it does not state that adverse events will be collected. EXPLAINED IN MORE DETAIL NOW

Methods should also explain how job satisfaction was measured as it is mentioned first on line 193. INCLUDED NOW

It is not clear how the sample size was determined. NEW SECTION ADDED

I found the result section difficult to understand without referring to the original RN4CAST questionnaire. It needs to be clearer for the reader to understand all the variables being measured and presented. Many of the measures appear to have come from single questions on the RN4CAST (A3, B4 and B1) which could be made clearer to the reader. MUCH EASIER TO UNDERSTAND NOW

If possible, the authors should present effect sizes/absolute values as well as p values for correlation, as it is difficult to judge whether findings would be clinically important. EFFECT SIZES ADDED, READS SO MUCH BETTER NOW

The discussion should have a section on study limitations and potential sources of bias. STRENGTHS AND LIMITATIONS ADDED

The conclusion on line 243 that poor patient safety arises from a poor working environment is not substantiated from the data. REMOVED

The generalisability of findings could have been considered. NOW ADDED

I am not sure whether the authors have made all data underlying the findings in their manuscript fully available. They may have done this for the publishing team as a supplementary paper.

Reviewer #2: Thank you for revising the manuscript according to the suggestions and for providing a point-by-point reply to all comments. The manuscript is very much improved and reads well in my opinion. The added figures provide additional data and highlight the main findings from the study. The authors have successfully clarified all issues/points I made.

Please see below my suggestions for (very) minor revision:

I would suggest moving the last paragraph of the introduction to the methods section, as it describes the setting and the approvals obtained to conduct the study (e.g. could be moved to ‘study and data analysis’).

Similarly, some of the findings were presented in the methods section. I would suggest moving lines 144-155 to the results section.

Line 216 – Should this be “From the statements measuring the patient safety culture, nurses agreed most with the statement (…)”?

Lines 217 and 219 – When you say “68.5% agree and strongly agree responses” do you mean that 68.5% agree or strongly agree with the statement? Same for line 219. This is what I gather from figure 2, please reword if correct.

Lines 282-284 – I would suggest spelling out M and SD.

Line 312 – Should contain a comma instead of a full stop i.e. “In our study, we demonstrated (…)”.

Line 217 – Delete comma “Foreign researchers have reached conclusions,”

Lines 323-324 seem to repeat the same information reported in lines 321-322. If so, I would suggest deleting lines 321-322.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

30 Nov 2021

Dear Editors.

Responses to both reviewers regarding minor corrections are submitted under Response to Reviewer 1 and Response to Reviewer 2

Submitted filename: Response to reviewer 2.docx

Click here for additional data file.

3 Dec 2021

The relationship between the nurses' work environment and the quality and safe nursing care: Slovenian study using the RN4CAST questionnaire

PONE-D-21-15371R2

Dear Dr. Grosek,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Barbara Schouten

Academic Editor

PLOS ONE

10 Dec 2021

PONE-D-21-15371R2

The relationship between the nurses' work environment and the quality and safe nursing care: Slovenian study using the RN4CAST questionnaire

Dear Dr. Grosek:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

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PLOS ONE Editorial Office Staff

on behalf of

Dr. Barbara Schouten

Academic Editor

PLOS ONE