The influence of healthcare work environment on patient safety outcomes in Ethiopian hospital settings

The influence of healthcare work environment on patient safety outcomes in Ethiopian hospital settings | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The influence of healthcare work environment on patient safety outcomes in Ethiopian hospital settings Ashagre Molla Assaye This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8098894/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Nurses’ work environment is a multidimensional concept and is defined as organizational characteristics of a work setting that facilitate or hinder professional nursing practice or nurses’ ability to practice skilfully and deliver high-quality care. Nurses’ work environment is one of many organizational factors that are associated with patient safety outcomes. It is also recognized as one of the important dimensions to maintain health and sustainable nursing workforce. A good work environment constitutes a factor for a better quality of care. Objectives: The main aim of this study is aimed at determining the level of nurses work environment and its relationship with patient safety outcomes in the acute care settings of Amhara Regional State, Ethiopia. Methods: Prospective observational study was conducted from July 2018 to March 2019. For phase one survey all 126 nurses who were working in the medical-surgical units of the study hospitals were invited to participate and 74 of them completed and returned the survey questionnaire. For phase two data collection, 80 nurses completed and returned the questionnaire. Regarding the patients’ record review, a sample of 528 patient records was planned to be reviewed. Data regarding nurses’ work environment were collected using the practice environment scale-nursing work index (PES-NWI). Data were entered into IBM SPSS 24.0 and descriptive statistics was done to describe the frequency and percentage of predictor and outcome variables. Chi-square test and Fischer exact test was calculated to see the relationship between the level of nurses’ work environment and patient safety outcomes. Results: The composite mean score of the subscales of the nurses’ work environment index during the first phase of the study for the public hospital was 2.3. The work environment of nurses in the public hospital during phase one of the study shows that none of the five subscales “nurse manager, ability, leadership and support” score was greater than 2.5. The score of the subscale for the nurses’ participation in hospital affairs is below 2.5 during both phases of study for all study units. At the unit level, the work environment of all the medical, surgical and orthopedics units of the public hospital was poor or unfavorable. Regarding the work environment of nurses in the private hospital, the score of two of the five subscales “nurse manager ability, leadership and support of nurses” and “nurse participation in hospital affairs” was greater than 2.5 which makes the category as mixed work environment. Conclusion: The Nurses work environment level in the public hospital is categorized as unfavourable while that of the private hospital was mixed during first phase of the study. Level of nurses’ participation in the hospital affairs is low in both hospitals. Work Environment Patient outcomes Nursing Hospitals Ethiopia Background Nurses’ work environment is a multidimensional concept and is defined as organizational characteristics of a work setting that facilitate or hinder professional nursing practice or nurses’ ability to practice skilfully and deliver high-quality care (1). It is one of the many organizational factors that are associated with patient safety outcomes (2-4). Nurses’ work environment is also recognized as one of the important dimensions to maintain health and sustainable nursing workforce. A good work environment constitutes a factor for a better quality of care (5). Unfavorable nurses’ work environment is considered as one of the factors causing nurses’ poor satisfaction, turnover, and poor patient outcomes. The influence of turnover on the cost of health care is high which include loss of productivity form loss of intellectual capital through experienced nurses. The multifaceted cost of nurse turnover highlights the need to have supportive work environment for nurses that enable less experienced nurses to gain knowledge and experience, and to assume the roles of seasoned nurses (6). Improving nurses’ work environment can be taken as a cost-effective intervention to decrease nurse turnover and improve both patient and nurse outcomes (6). There are different measuring tools for nurses’ work environment (2). One of the measuring scales is the Practice Environment Scale of the Nursing Work Index (PES_NWI) which was initially developed by Lake (7). The PES-NWI is widely used for international studies to measure the working condition of nurses (4, 8-10). The five facets of nurses’ work environment which are reflected by NWI include nurse manager ability, leadership and support of nurses, staffing and resource adequacy, colleagial nurse-physician relationship, nurses involvement in hospital affairs and nursing foundations for quality of care (6). A recent study on quality of care and work environment perceptions of nurses and physicians at the Saint Paul’s Hospital Millennium Medical College shows the nurses’ work environment was unfavorable to assure the quality of care (11). There is limited evidence that addresses the level of nurses’ work environment and its relationship with patient safety outcomes in acute care settings in Amhara region, Ethiopia. Therefore, this study is aimed at determining the level of nurses work environment and its relationship with patient safety outcomes in the acute care settings of Amhara Regional State, Ethiopia. Methods Study design and period: Prospective observational study was conducted from July 2018 to March 2019. Study participants Nurses who were working in the medical-surgical units of the study hospitals were participants of the self-administered survey. Patients’ medical records were also reviewed. For record review, medical records of patients aged 18 years or above, those who were admitted in the medical-surgical units and who stayed in the unit for more than two days were included in the study. Sample size and sampling technique All the nurses who were working in the medical-surgical units of the hospitals were invited to participate using the census sampling technique. During the pilot study, 30 nurses were invited to participate and 28 of them participated in the pilot nurses’ survey. For phase one survey all 126 nurses who were working in the medical-surgical units of the study hospitals were invited to participate and 74 of them completed and returned the survey questionnaire. For phase two data collection, 80 nurses completed and returned the questionnaire. Regarding the patients’ record review, a sample of 528 patient records was planned to be reviewed. The proportion of the number of patients who were admitted during the previous six months period was considered to allocate the samples proportionally to each study unit of the hospitals. A systematic sampling technique (K=12) was applied to select the records from the patients’ admission list in the units. The patients’ admission list in the unit was used as the sampling frame. The first record from the first 12 records was selected using lottery method. Data collection procedure Data were collected from nurses by inviting them to participate in the study using a recruitment flyer. The recruitment flyer contains the objectives of the project, inclusion criteria and contact details if they are interested in participating or if they want further information about the project. Following this self-administered Amharic version questionnaire was given to the participants. Participants were informed to fill in the questionnaire and return to the research coordinator within four weeks of the data collection period for each phase. Questionnaires which were not returned within four weeks of the study period were considered in the non-response rate. Data collection instrument The practice environment scale-nursing work index (PES-NWI) uses a 4-point likert scale ranging from one (Strongly disagree to 4 (strongly agree) using 31 items or statements that describe different aspects of the nurses work environment. Different studies recommend reporting the mean score of the item sub-scales or composite mean score of the scale. The five sub-scales of the NWI are nurse manager ability, leadership and support of nurses (eight items), nurse participation in the hospital affairs (eight items), nursing foundation for quality of care (seven items), staffing and resource adequacy (five items), and colleagial nurse-physician relations (three items). Each item was rated with a 4-point Likert scale ranging from 1=strongly disagree to 4=strongly agree. A higher score shows a more favourable work environment. We use the composite score and mean score of subscales to classify the work environment as a poor, mixed or good work environment (10). A mean score of 2.5 is the neutral midpoint for a four-point response set, above 2.5 indicate an agreement for the favourable work environment and below 2.5 is an agreement for the unfavourable environment (4, 12, 13). A favourable environment receives scores of >2.5 on all or four out of five subscales, mixed receives scores of >2.5 on two or three out of 5 subscales, and unfavourable receives scores of >2.5 on one or none of the 5 subscales (4). The reliability or Cronbach alpha score of NWI_R for the first phase and second phase nurses survey were 0.91 and 0.94 respectively. Data collectors Data collectors for patient records were nurses who have a bachelor’s degree qualification in nursing and who work in the respective hospitals, and who have access to the patients’ medical records in their respective working units. Data from nurses was collected by A.A. while unit-level data were collected by unit managers. Data quality control Study instruments were adapted from similar studies, and a pilot study was conducted to assess feasibility, face validity, and cultural validity. Following the pilot study, the necessary modification was made. Interrater reliability was assessed for the main study, and the kappa coefficient was 0.7. Training of the data collectors on how to use the record review checklist was conducted. Each data collector reviews three records as part of training and differences in the record review and other relevant issues were addressed. Continuous supportive supervision of the record review process was also conducted. All methods and reporting of this study were performed in accordance with the STROBE guideline for cohort studies (14). Data analysis Data were entered into IBM SPSS 24.0 and descriptive statistics was done to describe the frequency and percentage of predictor and outcome variables. Chi-square test and Fischer exact test was calculated to see the relationship between the level of nurses’ work environment and patient safety outcomes. Results Seventy-four and 83 nurses completed and returned the questionnaire for the first and second phase nurses’ survey making a response rate of 58.7% and 64% respectively. Twenty-nine (39.7%) respondents strongly agree for the statement “A nurse manager or immediate supervisor who is a good manager and leader” and 16 (21.6%) respondents strongly agree on the statement “A supervisory staff that is supportive of the nurses”. Only three (4.1%) respondents strongly agree for the statements “Opportunity for nurses to participate in policy decisions” and “Nurses are involved in the internal governance of the hospital”. Only four (5.5%) respondents also strongly agreed on the statement “An active quality improvement program” and “Adequate support services allow me to spend time with my patients” (Table 1). During phase two survey, 21 (26.6%) of respondents strongly agree for the statement “A nurse manager or immediate supervisor who is a good manager and leader”. Similarly, 16 (20.5%) respondents strongly agree on the statement on “A supervisory staff that is supportive of the nurses”. Only five (6.5%) respondents strongly agree on the statement “Opportunities for advancement” and only two (2.6%) strongly agreed on the statement “Active staff development or continuing education program for nurses”. Similarly, only three (3.8%) respondents strongly agree on the statement “Opportunity for nurses to participate in policy decisions” (Table 2). The top three items rated higher in the first phase study were “a nurse manager or immediate supervisor who is a good manager and leader” (mean 3.0), “working with nurses who are clinically competent” (mean=2.7) and “supervisory staff that is supportive of the nurses” (mean=2.7). The top two items rated higher in the second phase are “a nurse manager or immediate supervisor who is a good manager and leader” (mean=3.1) and “Supervisors use mistakes as learning opportunities, not criticism” (mean=2.9). The mean item score ranges from 1.85 to 3.0. The item which states “Opportunity for nurses to participate in policy decisions” scores the lowest mean (1.2 to 1.9 for) during both phases of the study and for both hospitals (Table 3). The composite mean score of the sub-scales of the nurses’ work environment index during the first phase of the study for the public hospital was 2.3. The work environment of nurses in the public hospital during phase one of the study shows that none of the five sub-scales “nurse manager, ability, leadership and support” score was greater than 2.5. The score of the sub-scale for the nurses’ participation in hospital affairs is below 2.5 during both phases of study for all study units. At the unit level, the work environment of all the medical, surgical and orthopedics units of the public hospital was poor or unfavorable. Regarding the work environment of nurses in the private hospital, the score of two of the five sub-scales “nurse manager ability, leadership and support of nurses” and “nurse participation in hospital affairs” was greater than 2.5 which makes the category as mixed work environment (Table 4). During the second phase of the study, the work environment of the medical-surgical unit of the private hospital was improving and categorized as a better work environment. However, the nurses’ participation in hospital affairs was very low (mean score=1.9). Similarly, the work environment of the surgical and orthopedics units of the public hospital was also improving with the score for two out of five sub-scales greater than 2.5. The mean score for nurse manager support and colleagial nurse-physician communications improved in all study units. The work environment for the medical unit in the hospital do not improve much and only the sub-scales for nurse manager ability, leadership and support of nurses scored greater than 2.5 (Table 4). Table 1: Item-by-item distribution of participants’ response on their work environment during phase one study. Work environment statement (Phase one) Strongly disagree Somewhat disagree Somewhat agree Strongly agree Mean A nurse manager or immediate supervisor who is a good manager and leader (n=73) 11(15.1) 7 (.6%) 26 (35.6) 29 (39.7) 3.00 A nurse manager who backs up the nursing staff in decision making, even if conflict is with a doctor (n=74) 12 (16.2) 18 (24.3) 28 (37.8) 16 (21.6) 2.65 A senior nursing administrator who is highly visible and accessible to staff (n=74) 16 (21.6) 22 (29.7) 21 (28.4) 15 (20.3) 2.47 Supervisors use mistakes as learning opportunities, not criticism (n=74) 12 (16.4) 16 (21.9) 35 (47.9) 10 (13.5) 2.59 A supervisory staff that is supportive of the nurses (n=74) 7 (9.5) 21 (28.4) 30 (40.5) 16 (21.6) 2.74 Administration to listens and responds to employee concerns (72) 21 (29.2) 33 (45.8) 12 (16.7) 6 (8.3) 2.04 Praise and recognition for a job well done (74) 22 (29.7) 25 (33.8) 21 (28.4) 6 (8.1) 2.15 Nursing administrators consult with staff on daily problems and procedures (74) 12 (16.2) 20 (27.0) 33 (44.6) 9 (12.2) 2.53 Career development/clinical ladder opportunity (72) 23 (31.1) 24 (32.4) 22 (29.7) 5 (6.8) 2.12 Opportunities for advancement (72) 25 (36.1) 28 (38.9) 14 (19.4) 5 (6.9) 1.99 Active staff development or continuing education program for nurses (n=72) 26 (36.1) 24 (33.3) 20 (27.8) 2 (2.8) 1.97 Nurses have opportunity to serve on hospital and nursing committees (n=74) 25 (33.8) 29 (39.2) 16 (21.6) 4 (5.4) 1.99 Opportunity for nurses to participate in policy decisions (n=74) 30 (40.5) 28 (37.8) 13 (17.6) 3 (4.1) 1.85 Nurses are involved in the internal governance of the hospital (n=73) 31 (42.5) 23 (31.5) 16 (21.6) 3 (4.1) 1.88 A preceptor program for newly hired registered nurses (n=73) 28 (38.4) 24 (32.9) 18 (24.7) 3 (4.1) 1.95 A senior nursing administration equal in power and authority to other top-level hospital executives (74) 27 (36.5) 27 (36.5) 18 (24.3) 2 (2.7) 1.93 Enough staff to get work done (n=74) 27 (36.5) 24 (32.4) 15 (20.3) 8 (10.8) 2.05 Enough registered nurses on staff to provide quality patient/client/resident care (n=73) 21 (28.8) 23 (31.5) 19 (26.0) 10 (13.7) 2.25 Adequate support services allow me to spend time with my patients (n=74) 15 (20.3) 35 (47.3) 20 (27.0) 4 (5.4) 2.18 Enough time and opportunity to discuss patient/client/resident care problems with other nurses (n=74) 17 (23) 32 (43.2) 21 (28.4) 4 (5.4) 2.16 Working with nurses who are clinically competent (74) 8 (10.8) 15 (20.3) 43 (58.1) 8 (10.8) 2.69 Written, up to date nursing care plans for all patients/clients/residents (n=74) 11 (15.1) 27 (37.0) 28 (38.4) 7 (9.6) 2.42 The use of Nursing diagnosis (n=73) 10 (13.7) 21 (28.8) 33 (45.2) 9 (12.3) 2.56 High standards of nursing care are expected by the administration (n=74) 16 (21.6) 30 (40.5) 21 (28.4) 7 (9.5) 2.26 Patients/clients/residents care assignments that foster continuity of care (n=73) 20 (27.4) 23 (31.5) 23 (31.5) 7 (9.6) 2.23 Nursing care is based on a nursing model, rather than a medical model (n=74) 15 (20.3) 25 (33.8) 27 (36.5) 7 (9.5) 2.35 A clear philosophy of nursing that pervades the patients/clients/residents care environment (n=72) 16 (22.2) 28 (38.9) 21 (29.2) 7 (9.7) 2.26 An active quality improvement program (n=73) 16 (21.9) 29 (39.7) 24 (32.9) 4 (5.5) 2.22 Physicians and nurses have good working relationships (n=72) 13 (18.1) 24 (33.3) 28 (38.9) 7 (9.7) 2.40 A lot of teamwork between nurses and physicians (n=73) 9 (12.3) 19 (26.0) 37 (50.7) 8 (11.0) 2.60 Collaboration between nurses and physicians (n=72) 10 (13.9) 18 (25.0) 36 (50.0) 8 (11.1) 2.58 Total mean 2.29 NB: The numbers presented in the table are as Number (Percent). Table 2: Item-by-item distribution of participants’ response on their work environment, phase two. Work environment statement (Phase two) Strongly disagree Somewhat disagree Somewhat agree Strongly agree Mean A nurse manager or immediate supervisor who is a good manager and leader (n=79) 4 (5.1%) 10 (12.7%) 44 (55.7%) 21 (26.6%) 3.0 A nurse manager who backs up the nursing staff in decision making, even if conflict is with a doctor (n=76) 7 (9.2%) 16 (20.0) 44 (57.9%) 9 (11.8%) 2.7 A senior nursing administrator who is highly visible and accessible to staff (n=79) 9 (11.4%) 19 (24.1%) 38 (48.1%) 13 (16.5) 2.7 Supervisors use mistakes as learning opportunities, not criticism (n=79) 6 (7.6%) 18 (22.8%) 43 (53.8%) 12 (15.2%) 2.8 A supervisory staff that is supportive of the nurses (n=78) 10 (12.8%) 15 (19.2%) 37 (47.4%) 16 (20.5%) 2.8 Administration listens and responds to employee concerns (77) 7 (9.1%) 25 (32.5%) 36 (46.8%) 9 (11.7%) 2.6 Praise and recognition for a job well done (76) 20 (26.3%) 30 (39.5%) 21 (27.6%) 5 (6.6%) 2.1 Nursing administrators consult with staff on daily problems and procedures (77) 13 (16.9%) 17 (22.1%) 39 (50.6%) 8 (10.4%) 2.6 Career development/clinical ladder opportunity (79) 27 (34.2%) 26 (32.9%) 22 (27.8%) 4 (5.1%) 2.0 Opportunities for advancement (77) 25 (32.5%) 28 (36.4%) 19 (24.7%) 5 (6.5%) 2.1 Active staff development or continuing education program for nurses (n=76) 25 (32.9%) 30 (39.5%) 19 (25.0%) 2 (2.6%) 2.0 Nurses have opportunity to serve on hospital and nursing committees (n=76) 15 (19.7%) 24 (31.6%) 32 (42.1%) 5 (6.6%) 2.4 Opportunity for nurses to participate in policy decisions (n=78) 23 (28.7%) 29 (37.2%) 23 (29.5%) 3 (3.8%) 2.1 Nurses are involved in the internal governance of the hospital (n=75) 21 (28%) 20 (26.7%) 29 (38.7%) 5 (6.7%) 2.2 A preceptor program for newly hired registered nurses (n=77) 25 (32.5%) 28 (36.4%) 21 (27.3%) 3 (3.9%) 2.0 A senior nursing administration equal in power and authority to other top-level hospital executives (77) 19 (24.7%) 26 (33.8%) 26 (33.8%) 6 (7.85) 2.2 Enough staff to get work done (n=77) 12 (15.6%) 17 (22.1%) 40 (51.9%) 8 (10.4%) 2.6 Enough registered nurses on staff to provide quality patient/client/resident care (n=76) 10 (13.2%) 22 (28.9%) 36 (47.4%) 8 (10.5%) 2.6 Adequate support services allow me to spend time with my patients (n=75) 10 (13.3%) 33 (44.0%) 28 (37.3%) 4 (5.3%) 2.3 Enough time and opportunity to discuss patient/client/resident care problems with other nurses (n=79) 12 (15.2%) 19 (24.1%) 41 (51.9%) 7 (8.9%) 2.5 Working with nurses who are clinically competent (77) 5 (6.5%) 17 (22.1%) 43 (55.8%) 12 (15.6%) 2.8 Written, up to date nursing care plans for all patients/clients/residents (n=78) 9 (11.5%) 25 (32.1%) 34 (43.6%) 10 (12.8%) 2.6 The use of Nursing diagnosis (n=79) 6 (7.6%) 16 (20.3%) 45 (57.0%) 12 (15.2%) 2.8 High standards of nursing care are expected by the administration (n=77) 7 (9.1%) 23 (29.9%) 40 (51.9%) 7 (9.1%) 2.6 Patients/clients/residents care assignments that foster continuity of care (n=78) 7 (9.0%) 23 (29.5%) 40 (51.3%) 8 (10.3%) 2.6 Nursing care is based on a nursing model, rather than a medical model (n=78) 9 (11.5%) 25 (32.15%) 37 (47.4%) 7 (9.0%) 2.5 A clear philosophy of nursing that pervades the patients/clients/residents care environment (n=77) 8 (10.4%) 24 (31.2%) 37 (48.1%) 8 (10.4%) 2.5 An active quality improvement program (n=76) 11 (14.5%) 24 (31.6%) 31 (40.8%) 10 (13.2%) 2.5 Physicians and nurses have good working relationships (n=76) 11 (14.5%) 20 (26.3%) 36 (47.4%) 9 (11.8%) 2.6 A lot of teamwork between nurses and physicians (n=78) 7 (8.8%) 17 (21.8%) 41 (52.6%) 13 (16.7%) 2.8 Collaboration between nurses and physicians (n=77) 5 (6.5%) 17 (22.1%) 42 (54.5%) 13 (16.9%) 2.8 Total mean 2.5 Table 3: Item-by-item distribution of mean score of participants’ response on their work environment in acute care settings, Amhara region, Ethiopia Work environment statement Mean score for phase one Mean score for phase two Public hospital Private hospital Public hospital Private hospital A nurse manager or immediate supervisor who is a good manager and leader 3.0 3.0 3.0 2.9 A nurse manager who backs up the nursing staff in decision making, even if conflict is with a doctor 2.7 2.3 2.8 2.4 A senior nursing administrator who is highly visible and accessible to staff 2.49 2.3 2.8 2.0 Supervisors use mistakes as learning opportunities, not criticism 2.6 2.2 2.8 2.5 A supervisory staff that is supportive of the nurses 2.7 3 2.8 2.6 Administration to listens and responds to employee concerns 1.98 2.5 2.6 2.8 Praise and recognition for a job well done 2.2 1.7 2.1 2.3 Nursing administrators consult with staff on daily problems and procedures 2.5 2.4 2.6 1.9 Career development/clinical ladder opportunity 2.2 1.9 2.1 16 Opportunities for advancement 2.1 1.4 2.1 1.6 Active staff development or continuing education program for nurses 2.0 1.7 2.0 1.9 Nurses have opportunity to serve on hospital and nursing committees 2.0 1.6 2.4 1.8 Opportunity for nurses to participate in policy decisions 1.9 1.2 2.1 1.4 Nurse are involved in the internal governance of the hospital 2.0 1.3 2.3 1.9 A preceptor program for newly hired registered nurses 2.0 1.8 2.0 1.6 A senior nursing administration equal in power and authority to other top-level hospital executives 1.9 1.9 2.3 2.3 Enough staff to get work done 1.9 3.2 2.5 3.4 Enough registered nurses on staff to provide quality patient/client/resident care 2.1 3.4 2.5 3.4 Adequate support services allow me to spend time with my patients 2.1 2.9 2.3 2.4 Enough time and opportunity to discuss patient/client/resident care problems with other nurses 2.1 2.7 2.6 2.5 Working with nurses who are clinically competent 2.6 3.2 2.8 2.9 Written, up to date nursing care plans for all patients/clients/residents 2.3 3.0 2.5 3.0 The use of Nursing diagnosis 2.6 2.3 2.8 2.8 High standards of nursing care are expected by the administration 2.2 3.0 2.6 2.9 Patients/clients/residents care assignments that foster continuity of care 2.2 2.7 2.6 2.9 Nursing care is based on a nursing model, rather than a medical model 2.4 2.3 2.5 2.8 A clear philosophy of nursing that pervades the patients/clients/residents care environment 2.2 2.8 2.6 2.9 An active quality improvement program 2.2 2.4 2.5 3.0 Physicians and nurses have good working relationships 2.4 2.7 2.5 2.7 A lot of teamwork between nurses and physicians 2.6 2.9 2.75 2.9 Collaboration between nurses and physicians 2.5 3.0 2.8 3.1 Table 4: mean score of subscales and composite score of the nurses work environment in acute care settings, Amhara region, Ethiopia. Unit/ hospital Subscales Mean score Phase one Phase two Medical Nurse Manager ability, leadership and support of nurses 2.5 2.7 Nurse participation in hospital affairs/workplace 1.8 1.9 Nursing Foundations for Quality of Care 2.2 2.4 Staffing and resource adequacy 2.4 2.5 Collegial Nurse-Physician relations 2.6 2.9 Surgical Nurse Manager ability, leadership and support of nurses 2.6 2.7 Nurse participation in hospital affairs/workplace 2.0 2.2 Nursing Foundations for Quality of Care 2.3 2.7 Staffing and resource adequacy 1.9 2.5 Collegial Nurse-Physician relations 2.45 2.7 Orthopedics Nurse Manager ability, leadership and support of nurses 2.48 2.5 Nurse participation in hospital affairs/workplace 2.2 2.2 Nursing Foundations for Quality of Care 2.4 2.6 Staffing and resource adequacy 2.4 2.6 Collegial Nurse-Physician relations 2.4 2.9 Medical-surgical or Private hospital Nurse Manager ability, leadership and support of nurses 2.4 2.6 Nurse participation in hospital affairs/workplace 1.6 1.9 Nursing Foundations for Quality of Care 2.6 2.8 Staffing and resource adequacy 3.0 2.8 Collegial Nurse-Physician relations 2.8 3.0 Composite score 2.5 2.6 Public hospital Nurse Manager ability, leadership and support of nurses 2.5 2.6 Nurse participation in hospital affairs/workplace 2.0 2.1 Nursing Foundations for Quality of Care 2.3 2.6 Staffing and resource adequacy 2.1 2.5 Collegial Nurse-Physician relations 2.5 2.7 Composite score 2.3 2.5 The effect of nurses work environment on patient safety outcomes This study shows the presence of relationship between the level of nurses work environment (Total score) with incidence of in-hospital mortality, pressure ulcer and hospital acquired pneumonia (Table 5). Table 5: Hospital level relationship between nurses work environment and patient safety outcomes. Phases of the study Patient outcomes Type of hospital X 2 and P-value Public Private Phase one NWI score 70 75 X 2 = 6.31, P=0.012 In-hospital mortality 11 2 Pressure ulcer 30 1 X 2 =24.5, P<0.001 HAP 75 3 X 2 =51.1, P<0.001 Phase two NWI score 78 75 X 2 = 9.01, P=0.003 In-hospital mortality 13 1 Pressure ulcer 20 1 X 2 = 14.7, P<0.001 HAP 54 3 X 2 =34.1, P<0.001 Discussion This study was conducted to determine the level of nurses work environment and its relationship with patient safety outcomes. The level of nurses’ work environment shows variation among the type of hospital and phase of the study within each hospital. The study shows that more than one-third of the respondents strongly agree on the presence of a nurse manager who is a good leader. However, less than five percent of the respondents strongly agree on participation of nurses on the internal governance of the hospital, the opportunity for nurses to participate in policy decisions, and the presence of active quality improvement program. The result of the later statement reflects that nurses are given a rare opportunity to be involved in decision making on hospital affairs. The level of nurses work environment in the public hospital was unfavorable. The level of nurses’ work environment shows improvement in the second phase than the first phase of the study in surgical, orthopedics and medical-surgical units. However, the level of nurses’ work environment in the orthopedics unit remains unfavorable. The level of nurses work environment in the current study is either poor or mixed in the public hospital and better in the private hospital. This is similar to the study conducted in Saint Paul hospital and millennium medical college (public hospital and college) in Addis Ababa, Ethiopia in which all the sub-scales of the NWI score less than 2.5 except staffing and resource adequacy (11). This might be due to higher patient load and higher patient acuity in public hospitals than that of private hospitals. The finding is has also similarity with the study conducted in south Africa in which nurses in public hospital were significantly more likely to rate the work environment as poor or fair compared to nurses in private hospital (15). Nurses’ participation in the hospital affairs remains low in both phases of the study. The level of nurses work environment is the public hospital was categorized as poor or unfavourable while that of the private hospital is categorized as better or favourable. The low level of the nurses’ participation in the hospital affairs in both hospitals indicates that nurses have low involvement in the hospital affairs. This might also reflect that the hospital management system based on traditional management system in which nurses have little control over practice instead of shared governance (16). Absence of shared governance will hinder the potential contribution of nurses in the improvement of the health services. The involvement of nurses at different governance level of healthcare is essential to improve quality of health care. A professional practice environment that incorporates shared governance may serve as a valuable intervention for organizations to promote optimal patient and nurse outcomes (17). This study shows that the level of nurses work environment has significant relationship with incidence of in-hospital mortality, pressure ulcers and hospital acquired pneumonia. This finding supports that better work environment improves the patient outcomes and highlight the importance of improving nurses work environment. However, this finding do not show the direction and strength of relationship. Previous studies show improved nurses work environment decrease negative patient safety outcomes such as mortality and pressure ulcer (18-20). Conclusion The Nurses work environment level in the public hospital is categorized as unfavourable while that of the private hospital was mixed during first phase of the study. Level of nurses’ participation in the hospital affairs is low in both hospitals. This study shows significant relationship between nurses’ work environment level and incidence of in-hospital mortality, hospital acquired pneumonia and pressure ulcers. Limitations of the study The study is conducted in only one public and one private hospital and might not be generalizable. Social desirability bias might affect the response by participants. Declarations ETHICS APPROVAL AND CONSENT TO PARTICIPATE This study was approved by the University of Adelaide Human Research Ethics Committee (H-2018-123) and the Amhara Regional Health Bureau Research and Technology Transfer Directorate (reference number 03/786/10). Informed consent was obtained from the participants to participate in the study. ACKNOWLEDGMENTS We would like to thank Adelaide Nursing School, the University of Adelaide and College of Medicine and Health Sciences, Bahir Dar University for financial support of this project, the managers of the study hospitals, data collectors and study participants for their cooperation for the project. AUTHORS CONTRIBUTIONS AA made substantial contributions to conception and design, analysis and interpretation of data, coordinates the data collection (acquisition) process and prepares the manuscript. CONFLICT OF INTEREST The authors declare that they have no conflict of interest. FUNDING Financial support was obtained from Adelaide Nursing School, the University of Adelaide and College of Medicine and Health sciences, Bahir Dar University. DATA AVAILABILITY Data can be obtained from the author through request. However, it cannot be shared publicly due to privacy and confidentiality of participants. CLINICAL TRIAL NUMBER Not applicable Consent to participate Informed consent was obtained from the participants, and consent was also implied by completing and returning the self-administered questionnaire by each study participant. Consent to publish Not applicable References Lee SE, Scott LD. Hospital Nurses’ Work Environment Characteristics and Patient Safety Outcomes: A Literature Review. Western Journal of Nursing Research. 2016;40(1):121-45. Norman RM, Sjetne IS. Measuring nurses’ perception of work environment: a scoping review of questionnaires. BMC Nursing. 2017;16(1):66. Lee SE, Scott LD. Hospital Nurses’ Work Environment Characteristics and Patient Safety Outcomes: A Literature Review. Western Journal of Nursing Research. 2018;40(1):121-45. Swiger PA, Patrician PA, Miltner RS, Raju D, Breckenridge-Sproat S, Loan LA. The Practice Environment Scale of the Nursing Work Index: An updated review and recommendations for use. International Journal of Nursing Studies. 2017;74:76-84. Copanitsanou P, Fotos N, Brokalaki H. Effects of work environment on patient and nurse outcomes. British Journal of Nursing. 2017;26(3):172-6. Smith JG. The nurse work environment: Current and future challenges. Journal of Applied Biobehavioral Research. 2018;23(1):e12126. Lake ET. Development of the practice environment scale of the nursing work index†‡. Research in nursing & health. 2002;25(3):176-88. Nantsupawat A, Kunaviktikul W, Nantsupawat R, Wichaikhum OA, Thienthong H, Poghosyan L. Effects of nurse work environment on job dissatisfaction, burnout, intention to leave. International Nursing Review. 2017;64(1):91-8. Aiken LH, Sloane DM, Clarke S, Poghosyan L, Cho E, You L, et al. Importance of work environments on hospital outcomes in nine countries. International Journal for Quality in Health Care. 2011;23(4):357-64. Warshawsky NE, Havens DS. Global use of the Practice Environment Scale of the Nursing Work Index. Nursing research. 2011;60(1):17-31. Weldetsadik AY, Gishu T, Tekleab AM, Mekonnen Asfaw Y, Girma Legesse T, Demas T. Quality of nursing care and nurses’ working environment in Ethiopia: Nurses’ and physicians’ perception. International Journal of Africa Nursing Sciences. 2019;10:131-5. Lake ET. Development of the practice environment scale of the Nursing Work Index. Research in nursing & health. 2002;25(3):176-88. Lake ET, Friese CR. Variations in nursing practice environments: relation to staffing and hospital characteristics. Nurs Res. 2006;55(1):1-9. Cuschieri S. The STROBE guidelines. Saudi journal of anaesthesia. 2019;13(Suppl 1):S31-s4. Coetzee SK, Klopper HC, Ellis SM, Aiken LH. A tale of two systems—Nurses practice environment, well being, perceived quality of care and patient safety in private and public hospitals in South Africa: A questionnaire survey. International Journal of Nursing Studies. 2013;50(2):162-73. Santos JLGd, Erdmann AL, Andrade SRd, Mello ALSFd, Lima SBSd, Pestana AL. Nursing governance: an integrative review of the literature. Revista da Escola de Enfermagem da USP. 2013;47(6):1417-25. Kutney-Lee A, Germack H, Hatfield L, Kelly S, Maguire P, Dierkes A, et al. Nurse Engagement in Shared Governance and Patient and Nurse Outcomes. JONA: The Journal of Nursing Administration. 2016;46(11):605-12. Olds DM, Aiken LH, Cimiotti JP, Lake ET. Association of nurse work environment and safety climate on patient mortality: A cross-sectional study. International Journal of Nursing Studies. 2017;74:155-61. Cho E, Sloane DM, Kim E-Y, Kim S, Choi M, Yoo IY, et al. Effects of nurse staffing, work environments, and education on patient mortality: An observational study. International Journal of Nursing Studies. 2015;52(2):535-42. Stalpers D, de Brouwer BJM, Kaljouw MJ, Schuurmans MJ. Associations between characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals: A systematic review of literature. International Journal of Nursing Studies. 2015;52(4):817-35. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8098894","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":568385082,"identity":"1a4aacca-c3a3-4866-a943-2c35c1ae0fb4","order_by":0,"name":"Ashagre Molla Assaye","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYFACHijNztzA8IGBIYEELcyMDYwzSNbCzEOMFv7+swc/ft1jE83PzNj42bbNLo+fvYHxw8cc3FokbuQlS8s8S8ud2czYLJ3bllws2XOAWXLmNjzW3OAxkJY4cDh3w2HGBqAW5sQNNxLYmHnxaJE/f8b4t8SB/yAtzb8t2+oJazE4kGMm+eHAAZCWNmnGtsOEtRjeyDGzZjiQDPJLm2XPueOJM3sONuP1ixzQYTd/HLDL7WdvPnzjR1l1IpBx8MNHfN4HAmZY1DAwsoHJBvzqQUp+wJl/CCoeBaNgFIyCEQgAO+hXObe0dlUAAAAASUVORK5CYII=","orcid":"","institution":"Bahir Dar University","correspondingAuthor":true,"prefix":"","firstName":"Ashagre","middleName":"Molla","lastName":"Assaye","suffix":""}],"badges":[],"createdAt":"2025-11-12 17:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8098894/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8098894/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":99501908,"identity":"5d945ef0-8d3d-471e-80af-af1faf0917ef","added_by":"auto","created_at":"2026-01-05 07:50:33","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":68922,"visible":true,"origin":"","legend":"","description":"","filename":"NWEmanuscript3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8098894/v1/547af8e50c5ef48f57a32153.docx"},{"id":99501910,"identity":"fdeba821-65e9-4027-9ffc-09ab4e83f935","added_by":"auto","created_at":"2026-01-05 07:50:33","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5211,"visible":true,"origin":"","legend":"","description":"","filename":"aa968151a5fd4290961419cddb29766e.json","url":"https://assets-eu.researchsquare.com/files/rs-8098894/v1/2eb5552ca8ae153a1c7a722b.json"},{"id":99790965,"identity":"e1eb73c5-80ba-45e2-b41e-edd6b2d26ee0","added_by":"auto","created_at":"2026-01-08 12:58:54","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":119185,"visible":true,"origin":"","legend":"","description":"","filename":"aa968151a5fd4290961419cddb29766e1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8098894/v1/256aa6c807aef5b8dd7bf64d.xml"},{"id":99501911,"identity":"0210328c-0ca2-4d0b-85d5-1c836d533e82","added_by":"auto","created_at":"2026-01-05 07:50:33","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":117507,"visible":true,"origin":"","legend":"","description":"","filename":"aa968151a5fd4290961419cddb29766e1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8098894/v1/a1b12c5a8c1b960d62827ebe.xml"},{"id":99501915,"identity":"33a5024d-6f16-4a82-ba61-506dd4cbc2d8","added_by":"auto","created_at":"2026-01-05 07:50:33","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":122947,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8098894/v1/59c3e9095c2ec9efd21e1362.html"},{"id":99802911,"identity":"0be3257c-2c35-4c17-bef2-d6b154c0696b","added_by":"auto","created_at":"2026-01-08 14:09:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":870643,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8098894/v1/2a8d2010-7917-4762-9c4a-44028cd7037a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The influence of healthcare work environment on patient safety outcomes in Ethiopian hospital settings","fulltext":[{"header":"Background","content":"\u003cp\u003eNurses\u0026rsquo; work environment is a multidimensional concept and is defined as organizational characteristics of a work setting that facilitate or hinder professional nursing practice or nurses\u0026rsquo; ability to practice skilfully and deliver high-quality care\u0026nbsp;(1). It is one of the many organizational factors that are associated with patient safety outcomes (2-4). Nurses\u0026rsquo; work environment is also recognized as one of the important dimensions to maintain health and sustainable nursing workforce. A good work environment constitutes a factor for a better quality of care (5).\u003c/p\u003e\n\u003cp\u003eUnfavorable nurses\u0026rsquo; work environment is considered as one of the factors causing nurses\u0026rsquo; poor satisfaction, turnover, and poor patient outcomes. The influence of turnover on the cost of health care is high which include loss of productivity form loss of intellectual capital through experienced nurses. The multifaceted cost of nurse turnover highlights the need to have supportive work environment for nurses that enable less experienced nurses to gain knowledge and experience, and to assume the roles of seasoned nurses (6). Improving nurses\u0026rsquo; work environment can be taken as a cost-effective intervention to decrease nurse turnover and improve both patient and nurse outcomes (6).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are different measuring tools for nurses\u0026rsquo; work environment (2). One of the measuring scales is the Practice Environment Scale of the Nursing Work Index (PES_NWI) which was initially developed by Lake (7). The PES-NWI is widely used for international studies to measure the working condition of nurses (4, 8-10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe five facets of nurses\u0026rsquo; work environment which are reflected by NWI include nurse manager ability, leadership and support of nurses, staffing and resource adequacy, colleagial nurse-physician relationship, nurses involvement in hospital affairs and nursing foundations for quality of care (6).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA recent study on quality of care and work environment perceptions of nurses and physicians at the Saint Paul\u0026rsquo;s Hospital Millennium Medical College shows the nurses\u0026rsquo; work environment was unfavorable to assure the quality of care (11). There is limited evidence that addresses the level of nurses\u0026rsquo; work environment and its relationship with patient safety outcomes in acute care settings in Amhara region, Ethiopia. Therefore, this study is aimed at determining the level of nurses work environment and its relationship with patient safety outcomes in the acute care settings of Amhara Regional State, Ethiopia.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and period:\u0026nbsp;\u003c/strong\u003eProspective observational study was conducted from July 2018 to March 2019.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses who were working in the medical-surgical units of the study hospitals were participants of the self-administered survey. Patients\u0026rsquo; medical records were also reviewed. For record review, medical records of patients aged 18 years or above, those who were admitted in the medical-surgical units and who stayed in the unit for more than two days were included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size and sampling technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the nurses who were working in the medical-surgical units of the hospitals were invited to participate using the census sampling technique. During the pilot study, 30 nurses were invited to participate and 28 of them participated in the pilot nurses\u0026rsquo; survey. For phase one survey all 126 nurses who were working in the medical-surgical units of the study hospitals were invited to participate and 74 of them completed and returned the survey questionnaire. For phase two data collection, 80 nurses completed and returned the questionnaire. Regarding the patients\u0026rsquo; record review, a sample of 528 patient records was planned to be reviewed. The proportion of the number of patients who were admitted during the previous six months period was considered to allocate the samples proportionally to each study unit of the hospitals. A systematic sampling technique (K=12) was applied to select the records from the patients\u0026rsquo; admission list in the units. The patients\u0026rsquo; admission list in the unit was used as the sampling frame. The first record from the first 12 records was selected using lottery method.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected from nurses by inviting them to participate in the study using a recruitment flyer. The recruitment flyer contains the objectives of the project, inclusion criteria and contact details if they are interested in participating or if they want further information about the project. Following this self-administered Amharic version questionnaire was given to the participants. Participants were informed to fill in the questionnaire and return to the research coordinator within four weeks of the data collection period for each phase. Questionnaires which were not returned within four weeks of the study period were considered in the non-response rate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection instrument\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe practice environment scale-nursing work index (PES-NWI) uses a 4-point likert scale ranging from one (Strongly disagree to 4 (strongly agree) using 31 items or statements that describe different aspects of the nurses work environment. Different studies recommend reporting the mean score of the item sub-scales or composite mean score of the scale. The five sub-scales of the NWI are nurse manager ability, leadership and support of nurses (eight items), nurse participation in the hospital affairs (eight items), nursing foundation for quality of care (seven items), staffing and resource adequacy (five items), and colleagial nurse-physician relations (three items). Each item was rated with a 4-point Likert scale ranging from 1=strongly disagree to 4=strongly agree.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA higher score shows a more favourable work environment. We use the composite score and mean score of subscales to classify the work environment as a poor, mixed or good work environment (10). A mean score of 2.5 is the neutral midpoint for a four-point response set, above 2.5 indicate an agreement for the favourable work environment and below 2.5 is an agreement for the unfavourable environment (4, 12, 13). A favourable environment receives scores of \u0026gt;2.5 on all or four out of five subscales, mixed receives scores of \u0026gt;2.5 on two or three out of 5 subscales, and unfavourable receives scores of \u0026gt;2.5 on one or none of the 5 subscales \u0026nbsp;(4). The reliability or Cronbach alpha score of NWI_R for the first phase and second phase nurses survey were 0.91 and 0.94 respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collectors\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collectors for patient records were nurses who have a bachelor\u0026rsquo;s degree qualification in nursing and who work in the respective hospitals, and who have access to the patients\u0026rsquo; medical records in their respective working units. Data from nurses was collected by A.A. while unit-level data were collected by unit managers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData quality control\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy instruments were adapted from similar studies, and a pilot study was conducted to assess feasibility, face validity, and cultural validity. Following the pilot study, the necessary modification was made. \u0026nbsp;Interrater reliability was assessed for the main study, and the kappa coefficient was 0.7. Training of the data collectors on how to use the record review checklist was conducted. Each data collector reviews three records as part of training and differences in the record review and other relevant issues were addressed. Continuous supportive supervision of the record review process was also conducted. All methods and reporting of this study were performed in accordance with the STROBE guideline for cohort studies\u0026nbsp;(14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were entered into IBM SPSS 24.0 and descriptive statistics was done to describe the frequency and percentage of predictor and outcome variables. Chi-square test and Fischer exact test was calculated to see the relationship between the level of nurses\u0026rsquo; work environment and patient safety outcomes.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSeventy-four and 83 nurses completed and returned the questionnaire for the first and second phase nurses\u0026rsquo; survey making a response rate of 58.7% and 64% respectively. Twenty-nine (39.7%) respondents strongly agree for the statement \u0026ldquo;A nurse manager or immediate supervisor who is a good manager and leader\u0026rdquo; and 16 (21.6%) respondents strongly agree on the statement \u0026ldquo;A supervisory staff that is supportive of the nurses\u0026rdquo;. Only three (4.1%) respondents strongly agree for the statements \u0026ldquo;Opportunity for nurses to participate in policy decisions\u0026rdquo; and \u0026ldquo;Nurses are involved in the internal governance of the hospital\u0026rdquo;. Only four (5.5%) respondents also strongly agreed on the statement \u0026ldquo;An active quality improvement program\u0026rdquo; and \u0026ldquo;Adequate support services allow me to spend time with my patients\u0026rdquo; (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring phase two survey, 21 (26.6%) of respondents strongly agree for the statement \u0026ldquo;A nurse manager or immediate supervisor who is a good manager and leader\u0026rdquo;. Similarly, 16 (20.5%) respondents strongly agree on the statement on \u0026ldquo;A supervisory staff that is supportive of the nurses\u0026rdquo;. Only five (6.5%) respondents strongly agree on the statement \u0026ldquo;Opportunities for advancement\u0026rdquo; and only two (2.6%) strongly agreed on the statement \u0026ldquo;Active staff development or continuing education program for nurses\u0026rdquo;. Similarly, only three (3.8%) respondents strongly agree on the statement \u0026ldquo;Opportunity for nurses to participate in policy decisions\u0026rdquo; (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The top three items rated higher in the first phase study were \u0026ldquo;a nurse manager or immediate supervisor who is a good manager and leader\u0026rdquo; (mean 3.0), \u0026ldquo;working with nurses who are clinically competent\u0026rdquo; (mean=2.7) and \u0026ldquo;supervisory staff that is supportive of the nurses\u0026rdquo; (mean=2.7). The top two items rated higher in the second phase are \u0026ldquo;a nurse manager or immediate supervisor who is a good manager and leader\u0026rdquo; (mean=3.1) and \u0026ldquo;Supervisors use mistakes as learning opportunities, not criticism\u0026rdquo; (mean=2.9). The mean item score ranges from 1.85 to 3.0. The item which states \u0026ldquo;Opportunity for nurses to participate in policy decisions\u0026rdquo; scores the lowest mean (1.2 to 1.9 for) during both phases of the study and for both hospitals (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe composite mean score of the sub-scales of the nurses\u0026rsquo; work environment index during the first phase of the study for the public hospital was 2.3. The work environment of nurses in the public hospital during phase one of the study shows that none of the five sub-scales \u0026ldquo;nurse manager, ability, leadership and support\u0026rdquo; score was greater than 2.5. The score of the sub-scale for the nurses\u0026rsquo; participation in hospital affairs is below 2.5 during both phases of study for all study units. At the unit level, the work environment of all the medical, surgical and orthopedics units of the public hospital was poor or unfavorable. Regarding the work environment of nurses in the private hospital, the score of two of the five sub-scales \u0026ldquo;nurse manager ability, leadership and support of nurses\u0026rdquo; and \u0026ldquo;nurse participation in hospital affairs\u0026rdquo; was greater than 2.5 which makes the category as mixed work environment (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the second phase of the study, the work environment of the medical-surgical unit of the private hospital was improving and categorized as a better work environment. However, the nurses\u0026rsquo; participation in hospital affairs was very low (mean score=1.9). Similarly, the work environment of the surgical and orthopedics units of the public hospital was also improving with the score for two out of five sub-scales greater than 2.5. The mean score for nurse manager support and colleagial nurse-physician communications improved in all study units. The work environment for the medical unit in the hospital do not improve much and only the sub-scales for nurse manager ability, leadership and support of nurses scored greater than 2.5 (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 1: Item-by-item distribution of participants\u0026rsquo; response on their work environment during phase one study.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"766\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eWork environment statement (Phase one)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStrongly disagree\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eSomewhat disagree \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eSomewhat agree \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eStrongly agree \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA nurse manager or immediate supervisor who is a good manager and leader (n=73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e11(15.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e7 (.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e26 (35.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e29 (39.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA nurse manager who backs up the nursing staff in decision making, even if conflict is with a doctor (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e12 (16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e18 (24.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e28 (37.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e16 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA senior nursing administrator who is highly visible and accessible to staff (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e16 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e22 (29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e21 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e15 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eSupervisors use mistakes as learning opportunities, not criticism (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e12 (16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e16 (21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e35 (47.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e10 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA supervisory staff that is supportive of the nurses (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e7 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e21 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e30 (40.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e16 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eAdministration to listens and responds to employee concerns (72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e21 (29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e33 (45.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e12 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e6 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003ePraise and recognition for a job well done (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e22 (29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e25 (33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e21 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e6 (8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eNursing administrators consult with staff on daily problems and procedures (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e12 (16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e20 (27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e33 (44.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e9 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eCareer development/clinical ladder opportunity (72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e23 (31.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e24 (32.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e22 (29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e5 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eOpportunities for advancement (72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e25 (36.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e28 (38.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e14 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e5 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e1.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eActive staff development or continuing education program for nurses (n=72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e26 (36.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e24 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e20 (27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e1.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eNurses have opportunity to serve on hospital and nursing committees (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e25 (33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e29 (39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e16 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e4 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e1.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eOpportunity for nurses to participate in policy decisions (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e30 (40.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e28 (37.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e13 (17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e1.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eNurses are involved in the internal governance of the hospital (n=73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e31 (42.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e23 (31.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e16 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e1.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA preceptor program for newly hired registered nurses (n=73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e28 (38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e24 (32.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e18 (24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3 (4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA senior nursing administration equal in power and authority to other top-level hospital executives (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e27 (36.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e27 (36.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e18 (24.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e1.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eEnough staff to get work done (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e27 (36.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e24 (32.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e15 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e8 (10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eEnough registered nurses on staff to provide quality patient/client/resident care (n=73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e21 (28.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e23 (31.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e19 (26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e10 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eAdequate support services allow me to spend time with my patients (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e15 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e35 (47.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e20 (27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e4 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eEnough time and opportunity to discuss patient/client/resident care problems with other nurses (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e17 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e32 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e21 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e4 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eWorking with nurses who are clinically competent (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e8 (10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e15 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e43 (58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e8 (10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eWritten, up to date nursing care plans for all patients/clients/residents (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e11 (15.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e27 (37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e28 (38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e7 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eThe use of Nursing diagnosis (n=73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e10 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e21 (28.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e33 (45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e9 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eHigh standards of nursing care are expected by the administration (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e16 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e30 (40.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e21 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e7 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003ePatients/clients/residents care assignments that foster continuity of care (n=73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e20 (27.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e23 (31.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e23 (31.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e7 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eNursing care is based on a nursing model, rather than a medical model (n=74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e15 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e25 (33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e27 (36.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e7 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA clear philosophy of nursing that pervades the patients/clients/residents care environment (n=72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e16 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e28 (38.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e21 (29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e7 (9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eAn active quality improvement program (n=73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e16 (21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e29 (39.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e24 (32.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e4 (5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003ePhysicians and nurses have good working relationships (n=72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e13 (18.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e24 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e28 (38.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e7 (9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA lot of teamwork between nurses and physicians (n=73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e9 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e19 (26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e37 (50.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e8 (11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eCollaboration between nurses and physicians (n=72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e10 (13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e18 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e36 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e8 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 717px;\"\u003e\n \u003cp\u003eTotal mean\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNB: The numbers presented in the table are as Number (Percent).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Item-by-item distribution of participants\u0026rsquo; response on their work environment, phase two.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"766\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eWork environment statement (Phase two)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eStrongly disagree\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eSomewhat disagree \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eSomewhat agree \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003eStrongly agree \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eA nurse manager or immediate supervisor who is a good manager and leader (n=79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e4 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e10 (12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e44 (55.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e21 (26.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eA nurse manager who backs up the nursing staff in decision making, even if conflict is with a doctor (n=76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e7 (9.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e16 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e44 (57.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e9 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eA senior nursing administrator who is highly visible and accessible to staff (n=79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e9 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e19 (24.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e38 (48.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e13 (16.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eSupervisors use mistakes as learning opportunities, not criticism (n=79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e6 (7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e18 (22.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e43 (53.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e12 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eA supervisory staff that is supportive of the nurses (n=78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e10 (12.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e15 (19.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e37 (47.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e16 (20.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eAdministration listens and responds to employee concerns (77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e7 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e25 (32.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e36 (46.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e9 (11.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003ePraise and recognition for a job well done (76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e20 (26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e30 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e21 (27.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e5 (6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eNursing administrators consult with staff on daily problems and procedures (77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e13 (16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e17 (22.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e39 (50.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e8 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eCareer development/clinical ladder opportunity (79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e27 (34.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e26 (32.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e22 (27.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e4 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eOpportunities for advancement (77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e25 (32.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e28 (36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e19 (24.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e5 (6.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eActive staff development or continuing education program for nurses (n=76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e25 (32.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e30 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e19 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2 (2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eNurses have opportunity to serve on hospital and nursing committees (n=76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e15 (19.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e24 (31.6%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e32 (42.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e5 (6.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eOpportunity for nurses to participate in policy decisions (n=78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e23 (28.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e29 (37.2%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e23 (29.5%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e3 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eNurses are involved in the internal governance of the hospital (n=75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e21 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e20 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e29 (38.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e5 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eA preceptor program for newly hired registered nurses (n=77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e25 (32.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e28 (36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e21 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e3 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eA senior nursing administration equal in power and authority to other top-level hospital executives (77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e19 (24.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e26 (33.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e26 (33.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e6 (7.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eEnough staff to get work done (n=77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e12 (15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e17 (22.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e40 (51.9%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e8 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eEnough registered nurses on staff to provide quality patient/client/resident care (n=76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e10 (13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e22 (28.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e36 (47.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e8 (10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eAdequate support services allow me to spend time with my patients (n=75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e10 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e33 (44.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e28 (37.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e4 (5.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eEnough time and opportunity to discuss patient/client/resident care problems with other nurses (n=79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e12 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e19 (24.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e41 (51.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e7 (8.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eWorking with nurses who are clinically competent (77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e5 (6.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e17 (22.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e43 (55.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e12 (15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eWritten, up to date nursing care plans for all patients/clients/residents (n=78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e9 (11.5%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e25 (32.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e34 (43.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e10 (12.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eThe use of Nursing diagnosis (n=79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e6 (7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e16 (20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e45 (57.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e12 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eHigh standards of nursing care are expected by the administration (n=77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e7 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e23 (29.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e40 (51.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e7 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003ePatients/clients/residents care assignments that foster continuity of care (n=78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e7 (9.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e23 (29.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e40 (51.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e8 (10.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eNursing care is based on a nursing model, rather than a medical model (n=78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e9 (11.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e25 (32.15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e37 (47.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e7 (9.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eA clear philosophy of nursing that pervades the patients/clients/residents care environment (n=77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e8 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e24 (31.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e37 (48.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e8 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eAn active quality improvement program (n=76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e11 (14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e24 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e31 (40.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e10 (13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003ePhysicians and nurses have good working relationships (n=76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e11 (14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e20 (26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e36 (47.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e9 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eA lot of teamwork between nurses and physicians (n=78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e7 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e17 (21.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e41 (52.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e13 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003eCollaboration between nurses and physicians (n=77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e5 (6.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e17 (22.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e42 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e13 (16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 726px;\"\u003e\n \u003cp\u003eTotal mean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3: Item-by-item distribution of mean score of participants\u0026rsquo; response on their work environment in acute care settings, Amhara region, Ethiopia\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"717\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eWork environment statement \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eMean score for phase one\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 145px;\"\u003e\n \u003cp\u003eMean score for phase two\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003ePublic hospital\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003ePrivate hospital\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003ePublic hospital\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003ePrivate hospital\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA nurse manager or immediate supervisor who is a good manager and leader\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA nurse manager who backs up the nursing staff in decision making, even if conflict is with a doctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA senior nursing administrator who is highly visible and accessible to staff\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eSupervisors use mistakes as learning opportunities, not criticism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA supervisory staff that is supportive of the nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eAdministration to listens and responds to employee concerns\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003ePraise and recognition for a job well done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eNursing administrators consult with staff on daily problems and procedures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eCareer development/clinical ladder opportunity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eOpportunities for advancement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eActive staff development or continuing education program for nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eNurses have opportunity to serve on hospital and nursing committees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eOpportunity for nurses to participate in policy decisions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eNurse are involved in the internal governance of the hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA preceptor program for newly hired registered nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA senior nursing administration equal in power and authority to other top-level hospital executives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eEnough staff to get work done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eEnough registered nurses on staff to provide quality patient/client/resident care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eAdequate support services allow me to spend time with my patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eEnough time and opportunity to discuss patient/client/resident care problems with other nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eWorking with nurses who are clinically competent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eWritten, up to date nursing care plans for all patients/clients/residents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eThe use of Nursing diagnosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eHigh standards of nursing care are expected by the administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003ePatients/clients/residents care assignments that foster continuity of care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eNursing care is based on a nursing model, rather than a medical model\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA clear philosophy of nursing that pervades the patients/clients/residents care environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eAn active quality improvement program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003ePhysicians and nurses have good working relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eA lot of teamwork between nurses and physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 430px;\"\u003e\n \u003cp\u003eCollaboration between nurses and physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4: mean score of subscales and composite score of the nurses work environment in acute care settings, Amhara region, Ethiopia.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eUnit/ hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eSubscales\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eMean score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003ePhase one\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003ePhase two\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eMedical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNurse Manager ability, leadership and support of nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNurse participation in hospital affairs/workplace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNursing Foundations for Quality of Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eStaffing and resource adequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eCollegial Nurse-Physician relations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSurgical\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNurse Manager ability, leadership and support of nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNurse participation in hospital affairs/workplace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNursing Foundations for Quality of Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eStaffing and resource adequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eCollegial Nurse-Physician relations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eOrthopedics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNurse Manager ability, leadership and support of nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNurse participation in hospital affairs/workplace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNursing Foundations for Quality of Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eStaffing and resource adequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eCollegial Nurse-Physician relations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eMedical-surgical or Private hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNurse Manager ability, leadership and support of nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNurse participation in hospital affairs/workplace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNursing Foundations for Quality of Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eStaffing and resource adequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eCollegial Nurse-Physician relations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eComposite score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePublic hospital\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNurse Manager ability, leadership and support of nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNurse participation in hospital affairs/workplace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eNursing Foundations for Quality of Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eStaffing and resource adequacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eCollegial Nurse-Physician relations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 382px;\"\u003e\n \u003cp\u003eComposite score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eThe effect of nurses work environment on patient safety outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study shows the presence of relationship between the level of nurses work environment (Total score) with incidence of in-hospital mortality, pressure ulcer and hospital acquired pneumonia (Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 5: Hospital level relationship between nurses work environment and patient safety outcomes.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePhases of the study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003ePatient outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eType of hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003eand P-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003ePublic\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePhase one\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNWI score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e70\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e75\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e= 6.31, P=0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eIn-hospital mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003ePressure ulcer\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=24.5, P\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHAP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=51.1, P\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePhase two\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNWI score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e78\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e75\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e= 9.01, P=0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eIn-hospital mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003ePressure ulcer\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e= 14.7, P\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHAP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=34.1, P\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was conducted to determine the level of nurses work environment and its relationship with patient safety outcomes. The level of nurses\u0026rsquo; work environment shows variation among the type of hospital and phase of the study within each hospital. The study shows that more than one-third of the respondents strongly agree on the presence of a nurse manager who is a good leader. However, less than five percent of the respondents strongly agree on participation of nurses on the internal governance of the hospital, the opportunity for nurses to participate in policy decisions, and the presence of active quality improvement program. The result of the later statement reflects that nurses are given a rare opportunity to be involved in decision making on hospital affairs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe level of nurses work environment in the public hospital was unfavorable. The level of nurses\u0026rsquo; work environment shows improvement in the second phase than the first phase of the study in surgical, orthopedics and medical-surgical units. However, the level of nurses\u0026rsquo; work environment in the orthopedics unit remains unfavorable. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe level of nurses work environment in the current study is either poor or mixed in the public hospital and better in the private hospital. This is similar to the study conducted in Saint Paul hospital and millennium medical college (public hospital and college) in Addis Ababa, Ethiopia in which all the sub-scales of the NWI score less than 2.5 except staffing and resource adequacy (11). This might be due to higher patient load and higher patient acuity in public hospitals than that of private hospitals. The finding is has also similarity with the study conducted in south Africa in which nurses in public hospital were significantly more likely to rate the work environment as poor or fair compared to nurses in private hospital (15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNurses\u0026rsquo; participation in the hospital affairs remains low in both phases of the study. The level of nurses work environment is the public hospital was categorized as poor or unfavourable while that of the private hospital is categorized as better or favourable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe low level of the nurses\u0026rsquo; participation in the hospital affairs in both hospitals indicates that nurses have low involvement in the hospital affairs. This might also reflect that the hospital management system based on traditional management system in which nurses have little control over practice instead of shared governance (16). Absence of shared governance will hinder the potential contribution of nurses in the improvement of the health services. The involvement of nurses at different governance level of healthcare is essential to improve quality of health care. A professional practice environment that incorporates shared governance may serve as a valuable intervention for organizations to promote optimal patient and nurse outcomes (17).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study shows that the level of nurses work environment has significant relationship with incidence of in-hospital mortality, pressure ulcers and hospital acquired pneumonia. This finding supports that better work environment improves the patient outcomes and highlight the importance of improving nurses work environment. However, this finding do not show the direction and strength of relationship. Previous studies show improved nurses work environment decrease negative patient safety outcomes such as mortality and pressure ulcer (18-20).\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe Nurses work environment level in the public hospital is categorized as unfavourable while that of the private hospital was mixed during first phase of the study. Level of nurses\u0026rsquo; participation in the hospital affairs is low in both hospitals. This study shows significant relationship between nurses\u0026rsquo; work environment level and incidence of in-hospital mortality, hospital acquired pneumonia and pressure ulcers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study is conducted in only one public and one private hospital and might not be generalizable. Social desirability bias might affect the response by participants.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eETHICS APPROVAL AND CONSENT TO PARTICIPATE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the University of Adelaide Human Research Ethics Committee (H-2018-123) and\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ethe Amhara Regional Health Bureau Research and Technology Transfer Directorate (reference number 03/786/10). Informed consent was obtained from the participants to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGMENTS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Adelaide Nursing School, the University of Adelaide and College of Medicine and Health Sciences, Bahir Dar University for financial support of this project, the managers of the study hospitals, data collectors and study participants for their cooperation for the project.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHORS CONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAA made substantial contributions to conception and design, analysis and interpretation of data, coordinates the data collection (acquisition) process and prepares the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinancial support was obtained from Adelaide Nursing School, the University of Adelaide and College of Medicine and Health sciences, Bahir Dar University.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData can be obtained from the author through request. However, it cannot be shared publicly due to privacy and confidentiality of participants. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCLINICAL TRIAL NUMBER\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the participants, and consent was also implied by completing and returning the self-administered questionnaire by each study participant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLee SE, Scott LD. Hospital Nurses\u0026rsquo; Work Environment Characteristics and Patient Safety Outcomes: A Literature Review. Western Journal of Nursing Research. 2016;40(1):121-45.\u003c/li\u003e\n\u003cli\u003eNorman RM, Sjetne IS. Measuring nurses\u0026rsquo; perception of work environment: a scoping review of questionnaires. BMC Nursing. 2017;16(1):66.\u003c/li\u003e\n\u003cli\u003eLee SE, Scott LD. Hospital Nurses\u0026rsquo; Work Environment Characteristics and Patient Safety Outcomes: A Literature Review. Western Journal of Nursing Research. 2018;40(1):121-45.\u003c/li\u003e\n\u003cli\u003eSwiger PA, Patrician PA, Miltner RS, Raju D, Breckenridge-Sproat S, Loan LA. The Practice Environment Scale of the Nursing Work Index: An updated review and recommendations for use. International Journal of Nursing Studies. 2017;74:76-84.\u003c/li\u003e\n\u003cli\u003eCopanitsanou P, Fotos N, Brokalaki H. Effects of work environment on patient and nurse outcomes. British Journal of Nursing. 2017;26(3):172-6.\u003c/li\u003e\n\u003cli\u003eSmith JG. The nurse work environment: Current and future challenges. Journal of Applied Biobehavioral Research. 2018;23(1):e12126.\u003c/li\u003e\n\u003cli\u003eLake ET. Development of the practice environment scale of the nursing work index\u0026dagger;\u0026Dagger;. Research in nursing \u0026amp; health. 2002;25(3):176-88.\u003c/li\u003e\n\u003cli\u003eNantsupawat A, Kunaviktikul W, Nantsupawat R, Wichaikhum OA, Thienthong H, Poghosyan L. Effects of nurse work environment on job dissatisfaction, burnout, intention to leave. International Nursing Review. 2017;64(1):91-8.\u003c/li\u003e\n\u003cli\u003eAiken LH, Sloane DM, Clarke S, Poghosyan L, Cho E, You L, et al. Importance of work environments on hospital outcomes in nine countries. International Journal for Quality in Health Care. 2011;23(4):357-64.\u003c/li\u003e\n\u003cli\u003eWarshawsky NE, Havens DS. Global use of the Practice Environment Scale of the Nursing Work Index. Nursing research. 2011;60(1):17-31.\u003c/li\u003e\n\u003cli\u003eWeldetsadik AY, Gishu T, Tekleab AM, Mekonnen Asfaw Y, Girma Legesse T, Demas T. Quality of nursing care and nurses\u0026rsquo; working environment in Ethiopia: Nurses\u0026rsquo; and physicians\u0026rsquo; perception. International Journal of Africa Nursing Sciences. 2019;10:131-5.\u003c/li\u003e\n\u003cli\u003eLake ET. Development of the practice environment scale of the Nursing Work Index. Research in nursing \u0026amp; health. 2002;25(3):176-88.\u003c/li\u003e\n\u003cli\u003eLake ET, Friese CR. Variations in nursing practice environments: relation to staffing and hospital characteristics. Nurs Res. 2006;55(1):1-9.\u003c/li\u003e\n\u003cli\u003eCuschieri S. The STROBE guidelines. Saudi journal of anaesthesia. 2019;13(Suppl 1):S31-s4.\u003c/li\u003e\n\u003cli\u003eCoetzee SK, Klopper HC, Ellis SM, Aiken LH. A tale of two systems\u0026mdash;Nurses practice environment, well being, perceived quality of care and patient safety in private and public hospitals in South Africa: A questionnaire survey. International Journal of Nursing Studies. 2013;50(2):162-73.\u003c/li\u003e\n\u003cli\u003eSantos JLGd, Erdmann AL, Andrade SRd, Mello ALSFd, Lima SBSd, Pestana AL. Nursing governance: an integrative review of the literature. Revista da Escola de Enfermagem da USP. 2013;47(6):1417-25.\u003c/li\u003e\n\u003cli\u003eKutney-Lee A, Germack H, Hatfield L, Kelly S, Maguire P, Dierkes A, et al. Nurse Engagement in Shared Governance and Patient and Nurse Outcomes. JONA: The Journal of Nursing Administration. 2016;46(11):605-12.\u003c/li\u003e\n\u003cli\u003eOlds DM, Aiken LH, Cimiotti JP, Lake ET. Association of nurse work environment and safety climate on patient mortality: A cross-sectional study. International Journal of Nursing Studies. 2017;74:155-61.\u003c/li\u003e\n\u003cli\u003eCho E, Sloane DM, Kim E-Y, Kim S, Choi M, Yoo IY, et al. Effects of nurse staffing, work environments, and education on patient mortality: An observational study. International Journal of Nursing Studies. 2015;52(2):535-42.\u003c/li\u003e\n\u003cli\u003eStalpers D, de Brouwer BJM, Kaljouw MJ, Schuurmans MJ. Associations between characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals: A systematic review of literature. International Journal of Nursing Studies. 2015;52(4):817-35.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Work Environment, Patient outcomes, Nursing, Hospitals, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-8098894/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8098894/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eNurses’ work environment is a multidimensional concept and is defined as organizational characteristics of a work setting that facilitate or hinder professional nursing practice or nurses’ ability to practice skilfully and deliver high-quality care. Nurses’ work environment is one of many organizational factors that are associated with patient safety outcomes. It is also recognized as one of the important dimensions to maintain health and sustainable nursing workforce. A good work environment constitutes a factor for a better quality of care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e The main aim of this study is aimed at determining the level of nurses work environment and its relationship with patient safety outcomes in the acute care settings of Amhara Regional State, Ethiopia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eProspective observational study was conducted from July 2018 to March 2019. For phase one survey all 126 nurses who were working in the medical-surgical units of the study hospitals were invited to participate and 74 of them completed and returned the survey questionnaire. For phase two data collection, 80 nurses completed and returned the questionnaire. Regarding the patients’ record review, a sample of 528 patient records was planned to be reviewed. Data regarding nurses’ work environment were collected using the practice environment scale-nursing work index (PES-NWI). Data were entered into IBM SPSS 24.0 and descriptive statistics was done to describe the frequency and percentage of predictor and outcome variables. Chi-square test and Fischer exact test was calculated to see the relationship between the level of nurses’ work environment and patient safety outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe composite mean score of the subscales of the nurses’ work environment index during the first phase of the study for the public hospital was 2.3. The work environment of nurses in the public hospital during phase one of the study shows that none of the five subscales “nurse manager, ability, leadership and support” score was greater than 2.5. The score of the subscale for the nurses’ participation in hospital affairs is below 2.5 during both phases of study for all study units. At the unit level, the work environment of all the medical, surgical and orthopedics units of the public hospital was poor or unfavorable. Regarding the work environment of nurses in the private hospital, the score of two of the five subscales “nurse manager ability, leadership and support of nurses” and “nurse participation in hospital affairs” was greater than 2.5 which makes the category as mixed work environment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe Nurses work environment level in the public hospital is categorized as unfavourable while that of the private hospital was mixed during first phase of the study. 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