Nursing Work Environment and Clinical Nurses’ Perceptions During the COVID-19 Pandemic in South Korea: A Mixed-Method Study

Nursing Work Environment and Clinical Nurses’ Perceptions During the COVID-19 Pandemic in South Korea: A Mixed-Method Study | 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 Nursing Work Environment and Clinical Nurses’ Perceptions During the COVID-19 Pandemic in South Korea: A Mixed-Method Study SuJung Jung, Yeji Seo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6249692/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background The COVID-19 pandemic significantly impacted the nursing work environment, highlighting critical gaps in staffing, managerial support, and infection control. This study aims to investigate the nursing work environment and clinical nurses’ perceptions during the COVID-19 pandemic in South Korea. Methods A mixed-methods study with an explanatory sequential design was conducted. Quantitative data were collected using the Korean version of the Practice Environment Scale-Nursing Work Index (PES-NWI) and analyzed using descriptive statistics. Qualitative data were obtained through interviews and analyzed using traditional content analysis. Results The overall PES-NWI score was 2.31 (SD = 0.38), indicating an unfavorable work environment. Nurses reported inadequate staffing, limited participation in decision-making, and inconsistent infection control practices. The lowest-rated item was “Enough registered nurses to provide quality patient care” (M = 1.79), reflecting severe staffing shortages. Nurses emphasized the need for greater managerial support, structured communication, and targeted infection control training. Conclusions Improving staffing levels, enhancing managerial support, and developing comprehensive infection control protocols are essential to strengthen the nursing work environment and improve nurse satisfaction and care quality during future public health emergencies. nurses work environment working conditions pandemics Figures Figure 1 Figure 2 BACKGROUDN The nursing work environment refers to the characteristics of a healthcare organization that support nurses in providing high-quality professional care to patients (1). It includes factors such as nurses’ involvement in hospital policies, the adequacy of staffing and resources for professional nursing, the establishment of a foundation for delivering excellent care, and fostering collaborative relationships between nurses and doctors to address patients’ health needs (2). Previous studies have shown that when nurses perceive their hospital’s work environment positively, patient mortality rates decrease, and nursing performance improves (3–5). The COVID-19 pandemic, caused by the novel coronavirus that emerged in 2019, has profoundly disrupted healthcare systems worldwide (6). In South Korea, the country demonstrated an exemplary response by implementing early detection and isolation measures through extensive testing to prevent the spread of infection (7). However, as the number of confirmed cases increased due to community transmission and the global spread of the virus, the burden on healthcare personnel, including nurses, gradually intensified. This escalating pressure has led to significant changes in the nursing work environment (8). Nurses, as frontline healthcare providers, played a crucial role in improving patient outcomes through their nursing practice (9) However, numerous studies have reported that nurses faced an increased risk of infection, limitations in decision-making, and had to work under challenging conditions, often going beyond their usual duties in emergency situations during the pandemic (10,11). In addition, nurses experienced high levels of burnout during the COVID-19 pandemic, with emotional exhaustion, depersonalization, and lack of personal accomplishment being prevalent, and identified risk factors such as younger age, low social support, increased workload, and inadequate resources (12–14). In South Korea, nurses were already dealing with significant challenges in their work environments, including high patient loads and limited resources compared to their counterparts in other countries. Korean nurses reported caring for an average of 12 patients per shift, which is double the number managed by nurses in the United States and some European countries (15,16). This high workload, coupled with insufficient staffing and resources, has been linked to adverse outcomes such as burnout, job dissatisfaction, and high turnover rates. (17,18). Given these pre-existing challenges, it is essential to explore how the COVID-19 pandemic further impacted the nursing work environment in South Korea. Understanding these dynamics is critical for identifying areas of improvement and developing strategies to address systemic issues. Enhancing the work environment is key to improving nurses’ well-being and retention, ensuring better patient outcomes, and preparing the healthcare system for future health crises. This study aims to investigate the work environment of clinical nurses in South Korea during the COVID-19 pandemic. Specifically, the study seeks to: 1. Examine clinical nurses’ perceptions of the impacts of the COVID-19 pandemic on their work environment. 2. Identify the challenges clinical nurses faced and the strategies they employed to improve the work environment during and beyond the pandemic. METHODS Study design This study is designed to use a mixed-methods approach to better understand changes in the nursing work environment from the perspective of clinical nurses during the COVID-19 pandemic, as well as to gain a deeper understanding of strategies for improving the nursing work environment. The explanatory sequential design means that the purpose of the second qualitative phase is to explain the results discovered in the first quantitative phase, and sometimes to explore outliers that are not entirely consistent with the collected data. Since qualitative data analysis is used to explain the quantitative phase’s results, the term ‘explanatory’ is used ( 19 ). In this study, the primary goal was to understand the work environment of clinical nurses during the pandemic using a quantitative approach. The qualitative phase was then used to gather more detailed insights and perspectives from nurses through in-depth exploration. The explanatory sequential design is one of the six methodologies of mixed methods research ( 19 ) (Fig. 1 ). Quantitative data collection and analysis were conducted in the first stage. In the second stage, qualitative data collection and analysis were carried out to integrate the findings from both phases. Quantitative phase Participants and procedure The quantitative phase of the research involved clinical Korean nurses (n = 28). Convenience sampling was used to recruit nurses using a secure electronic online survey platform for quantitative data from June 2023 to July 2023. The inclusion criteria were clinical nurses who had more than one year of clinical experience both before and after the onset of the COVID-19 pandemic and were currently employed in medical institutions at or above the hospital level at the time of their research participation, having volunteered to take part in this survey. Measures The self-administered questionnaire consisted of three parts. To assess the nursing practice environment during the COVID-19 pandemic the Korean version of the Practice Environment Scale Nursing Work Index (PES-NWI) (Cronbach’s alpha = .901) was used. The scale consisted of five dimensions and 29 items: (a) PES_P = nurse participation in hospital affairs (9 items); (b) PES_F = nursing foundations for quality of care (9 items); (c) PES_M = nurse manager ability, leadership, and support of nurses (4 items); (d) PES_S = staffing and resource adequacy (4 items); (e) PES_R = collegial nurse–physician relations (3 items). Each item is scored on a scale of 4-point Likert scale, ranging between 1 (strongly disagree) and 4 (strongly agree) with a score range from 29 to 116. A higher score indicates a better nursing work environment ( 20 ). The scoring method for PES-NWI involves calculating the average value of all items, and the scores fall within a range of 1 to 4 points. Lake and Friese (2006) considered a score of 2.5 or higher as an indication that nurses agree that their work environment is good, while a score below 2.5 was judged as otherwise ( 2 ). At the end of the PES-NWI survey, three open-ended questions were included to collect more experiences and thoughts about the working environment during the COVID-19 pandemic. These questions were adapted from a previously published study ( 21 ): (a) “In the context of the COVID-19 situation, how do you think your nursing work environment has changed?” (Q1) (b) “In the context of the COVID-19 situation, what specific positive and negative changes do you believe have occurred in your nursing work environment, including examples such as nurse-patient ratios and direct nursing activity hours?” (Q2) (c) “As a nurse in the COVID-19 situation, what do you think are the ways you can enhance your nursing work environment?” (Q3). Lastly, demographic and occupational information collected from participants. Data analysis Frequency distributions were adopted to describe categorical variables of demographic and occupational characteristics. Means with standard deviations (SD) were used to describe continues variables and scores of PES-NWI. All statistical analyses were conducted with SPSS 28.0. For qualitative data, traditional content analysis methods were used. Qualitative phase Participants and procedure Qualitative data collection was performed to explore further details about the changes in the nursing practice environment during the pandemic in Korea. Among the subjects who participated in the survey of quantitative research, those who expressed their intention to participate in qualitative research, those who understood the purpose of the research and agreed to participate in qualitative research. Qualitative data was collected by a research assistant and a professor at the School of Nursing, from 11th to August 25th August 2023. The participants in the qualitative research interview were contacted directly by the research assistant to the subjects who expressed their intention to participate in the qualitative research among the questionnaires of the research, and the interview schedule of the participants was confirmed, and 10 people were secured. In consideration of the social distancing situation due to the pandemic and the work of the research participant in the COVID-19 ward, the interview was conducted through Kakao Talk open chat so that the participants could talk comfortably. Based on previous research related to the care of COVID-19 patients, the research team asked questions with a pre-composed interview questionnaire, which has been modified from a previously published study ( 21 ). A semi-structured interview was conducted by adding a variety of questions about each person's response. The main interview question is, "How do you think your nursing environment has been affected during the COVID-19 pandemic?", "What specific positive and negative impacts do you think there are in your nursing environment during the COVID-19 pandemic, including the examples? (e.g., nurse-patient ratio, hours of direct nursing activities, etc.)", "As a nurse in the corona situation, what do you think can be done to improve your nursing work environment during the COVID-19 pandemic?", "In addition, do you have any final words about the nursing work environment in relation to this study?" Data analysis The content analysis method is a systematic and objective analysis method that analyzes explicit or potential content by classifying and evaluating the content of the material in order to determine the meaning and effect of the main symbol or theme ( 22 ). Traditional content analysis is a dynamic analysis method that inductively derives results from research data ( 23 ). First, the researcher repeatedly read the transcription and field notes to try to understand the interview as a whole. Meaningful phrases related to the nursing work environment in the context of the COVID-19 pandemic were identified and displayed, and they were named and coded to better represent the inherent meaning and context of the displayed phrases. Afterwards, the process of categorizing and comparing the extracted code according to meaning was repeated, Finally, the research question, 'How has the nursing work environment in Korea evolved during the COVID-19 pandemic, and what specific changes have occurred?' the contents of were categorized into five domains of the nursing work environment, The code and key keywords were derived. In addition, in order to reveal the importance and degree of interest perceived by the participants, the frequency and percentage of the code according to the quantitative analysis method of the content analysis method were described according to the order of the frequency and percentage of the code ( 22 ). Ensuring the validity of this study In order to ensure the validity of qualitative research, we tried to meet the criteria of credibility, auditability, fittingness, and conformability proposed by ( 24 ). First, in order to meet reliability, nurses who are currently directly caring for COVID-19 patients in hospitals who are willing to voluntarily participate in the study were introduced and recruited participants, by asking open-ended questions during the interview, we wanted to allow the participants to freely state their nursing experience without restriction, thus obtaining a sufficient data. In addition, two researchers gathered to discuss until they agreed and analyzed the data to improve the reliability of the interpretation. In an effort to ensure auditability, participant statements have been presented in the results of the study so that readers and subsequent researchers can track the analysis of this study, we tried to meet the suitability by collecting the general characteristics of the study participants, such as gender, educational background, clinical experience, and hospital size. Finally, in order to establish the possibility of confirmation, two of the study participants were selected to provide the contents of the interview and the results of the analysis to see if their experiences were well reflected, the results of the analysis confirmed that there was no distortion. All the authors of this study have experience in conducting and publishing qualitative research and have tried to equip them with the readiness and competence to conduct qualitative research. We attended conferences related to qualitative research and devoured books and papers related to qualitative research methodology. Ethical Considerations Before collecting the data, this study was approved by the author's university Institutional Review Board (IRB No. XXX-XXXX). During the data collection process, the subjects were explained the purpose of the study and the confidentiality and anonymity of the collected data. Informed consent to participate was obtained from all participants, and electronic and written consent forms were filled out, and certain rewards were provided. The researcher explained that the participant could withdraw from the study at any time, and that there was no disadvantage to doing so. It was explained that the statements were recorded, and the interview was conducted with consent. The recorded contents will be used for research purposes only, in accordance with the law, the research data will be kept and then discard data. When transcribing, personal information was deleted and anonymized so that the identity of the research participant was not revealed. In addition, in principle, the collected data will be stored for 3 years at the end of the study and then discarded, it was explained that if there are any inconveniences or inquiries when participating in the study, they can be contacted at any time through the contact information written in the description. The electronic consent form and questionnaire were kept by the researcher in a locked place, Computer-generated data was locked to take into account the ethical aspects of the research participants, such as restricting access to anyone other than the researcher. RESULTS Quantitative phase Participants Table 1 presents the demographic and professional characteristics of the study’s 28 participants. The average age of the participants was 35.17 years (SD = 6.4), with the majority being female. Educational backgrounds varied, and participants had an average of 140.75 months (approximately 11.7 years) of clinical experience, though variability was significant. Additionally, participants were employed in different hospital settings, held various positions, and most had experience caring for COVID-19 patients. Table 1 Descriptive Information of the Participants (N = 28) Characteristics Age, y, mean (SD) 35.71 (8.30) Women, N 27 Education, N High school graduation 1 Some college 2 4 years college 16 Master’s degree or higher 9 Total clinical experience (months), mean (SD) 140.75 (103.47) Size of the hospital † , N Tertiary general hospital 16 Hospital with over 300 beds 10 Hospital with fewer than 300 beds 2 Position/Title † , N Nurse 22 Charge nurse 3 Ward manager 3 Monthly income (KRW), mean 3,773,214 Experience in caring for COVID-19 patients, N Yes 26 † where you are currently working Nursing Work Environment Table 2 and Fig. 2 present the scores for various subscales of the Practice Environment Scale of Nursing Work Index (PES-NWI). The overall score for the nursing work environment was 2.31 (SD = 0.38), indicating that the work environment was generally perceived as unfavorable. A detailed analysis of the various subscales of the PES-NWI revealed key areas of concern and aspects of the work environment that were rated more positively. In terms of nurse participation in hospital affairs (PES_P), the average score was notably low, with the lowest-rated item being “Administration that listens and responds to employee concerns” (M = 1.75, SD = 0.65). This suggests that nurses felt their concerns were not adequately addressed by hospital administration. Other items in this subscale, such as “Staff nurses have the opportunity to serve on hospital and nursing committees” (M = 1.89, SD = 0.83) and “Nurse managers equal in power and authority to other top-level hospital executives” (M = 2.14, SD = 0.97), further highlighted a lack of involvement and empowerment in hospital governance. Table 2 Practice Environment Scale of Nursing Work Index (PES-NWI) Subscales Subscales Statements M SD PES_P Administration that listens and responds to employee concerns 1.75 0.65 Staff nurses have the opportunity to serve on hospital and nursing committees. 1.89 0.83 Career development/clinical ladder opportunity 2.25 0.70 Staff nurses are involved in the internal governance of the hospital (e.g., practice and policy committees) 2.11 0.83 Nurse managers consult with staff on daily problems and procedures 2.57 0.57 Opportunity for staff nurses to participate in policy decisions 1.79 0.74 Opportunities for advancement 2.18 0.77 Nurse managers equal in power and authority to other top level hospital executives 2.14 0.97 A chief nursing officer who is highly visible and accessible to staff 1.93 0.90 PES_F An active quality assurance program 2.32 0.72 A clear philosophy of nursing that pervades the patient care environment 2.18 0.82 Written, up-to-date nursing care plans for all patients 2.54 0.74 Active staff development or continuing education programs for nurses 2.29 0.66 Nursing care is based on a nursing, rather than a medical model 2.75 0.70 Patient care assignments that foster continuity of care, i.g., the same nurse cares for the patient from one day to the next 2.61 0.83 Working with nurses who are clinically competent 2.82 0.61 A preceptor program for newly hired RNs 3.46 0.79 High standards of nursing care are expected by the administration 3.11 0.88 PES_M A nurse manager who is a good manager and leader 2.39 0.83 A supervisory staff that is supportive of the nurses 2.61 0.63 A nurse manager who backs up the nursing staff in decision making, even if the conflict is with a physician 2.36 0.73 Praise and recognition for a job well done 2.25 0.70 PES_S Enough registered nurses to provide quality patient care 1.79 0.63 Enough staff to get the work done 1.89 0.57 Adequate support services allow me to spend time with my patients 1.82 0.55 Enough time and opportunity to discuss patient care problems with other nurses 2.21 0.42 PES_R A lot of teamwork between nurses and physicians 2.21 0.74 Collaboration (joint practice) between nurses and physicians 2.46 0.84 Physicians and nurses have good working relationships 2.32 0.67 PES-NWI 2.31 0.38 M, mean; SD, standard deviations; PES_P, nurse participation in hospital affairs; PES_F, nursing foundations for quality of care; PES_M, nurse manager ability, leadership, and support of nurses; PES_S, staffing and resource adequacy; PES_R, collegial nurse–physician relations; PES-NWI, Practice Environment Scale Nursing Work Index. The nursing foundations for quality of care (PES_F) subscale received the highest rating, with a mean score of 2.67 (SD = 0.44), suggesting that nurses generally perceived the foundations for providing quality care to be in place. Notably, the item “A preceptor program for newly hired RNs” scored the highest within this subscale (M = 3.46, SD = 0.79), indicating strong support for new nurses. However, the item “A clear philosophy of nursing that pervades the patient care environment” received a lower rating (M = 2.18, SD = 0.82), suggesting that the overarching nursing philosophy was not consistently present throughout the work environment. The nurse manager ability and leadership (PES_M) subscale revealed a moderate level of support, with the item “A nurse manager who is a good manager and leader” scoring 2.39 (SD = 0.83). However, other items in this subscale, such as “A nurse manager who backs up the nursing staff in decision-making, even if the conflict is with a physician” (M = 2.36, SD = 0.73) and “Praise and recognition for a job well done” (M = 2.25, SD = 0.70), indicate that while nurse managers are generally supportive, recognition and support for nurses in decision-making were areas of concern. The staffing and resource adequacy (PES_S) subscale had the lowest overall score (M = 1.93, SD = 0.40), underscoring the critical issue of inadequate staffing. The item “Enough registered nurses to provide quality patient care” received the lowest score within this subscale (M = 1.79, SD = 0.63), pointing to significant concerns over staffing levels and their impact on patient care. Lastly, the nurse-physician relationships and teamwork (PES_R) subscale indicated moderate collaboration between nurses and physicians, with items such as “Collaboration (joint practice) between nurses and physicians” (M = 2.46, SD = 0.84) and “Physicians and nurses have good working relationships” (M = 2.32, SD = 0.67), suggesting that although teamwork was generally reported, there was room for improvement in collaboration and communication between the two groups. Overall, the findings highlight significant areas of dissatisfaction, particularly in staffing, nurse participation in decision-making, and administrative support. However, aspects such as the quality of care and nurse-physician relationships were perceived more positively, suggesting areas of strength in the work environment. Qualitative Phase Qualitative data were collected through three open-ended questions included at the end of the quantitative survey. A total of 28 nurses provided responses, and 10 participants agreed to participate in follow-up in-depth interviews. The analysis revealed key themes and subthemes, organized according to the research questions. Perceived Changes in the Nursing Work Environment During the COVID-19 Pandemic Two major themes emerged regarding changes in the nursing work environment during the COVID-19 pandemic: Increased Workload and Task Complexity Participants described how additional responsibilities related to COVID-19 screening and management led to an increased workload. “After COVID-19, we had to check the infection status and symptoms of patients and caregivers before admission and surgery, which increased our workload significantly.” (Participant 1) “Putting on and taking off protective equipment takes a lot of time, making the nursing process more exhausting.” (Participant 10) Challenges in Infection Control Participants reported confusion and stress caused by rapidly changing infection control guidelines. “In the early days of the pandemic, infection control guidelines were unclear and constantly changing.” (Participant 3) “We had to monitor not only patient symptoms but also the health status of staff members, which added to our workload.” (Participant 6) Positive and Negative Changes in the Work Environment Participants identified both positive and negative changes in the work environment during the pandemic: Positive Changes Despite the overall challenges, participants noted improvements in teamwork and infection control practices: “The creation of infection control protocols helped us respond more effectively to high-risk virus outbreaks.” (Participant 3) “The crisis strengthened the teamwork among nurses. We helped each other more.” (Participant 10) Negative Changes Participants reported challenges related to staffing and resource shortages, as well as increased pressure from patients and caregivers: “The nurse-to-patient ratio remained the same, but direct care time increased, leading to overtime work.” (Participant 10) “Patients and caregivers expected nearly perfect care, which added pressure.” (Participant 9) “Administration was not responsive to our concerns, and we were left to figure things out on our own.” (Participant 5) Strategies to Improve the Nursing Work Environment Three main strategies were proposed by participants to improve the nursing work environment: Improved Staffing and Nurse-to-Patient Ratios “We need more nursing staff to reduce the workload and increase direct care time per patient.” (Participant 10) Increased Support from Nurse Managers and Institutions “Nurse managers should advocate for nurses’ needs and ensure that guidelines and resources are consistently provided.” (Participant 5) Enhanced Training and Infection Control Programs “We need more specialized training on infection control and emergency response.” (Participant 7) “Administrative support and increased staffing would allow us to focus more on direct patient care.” (Participant 9) Integrated Interpretation of Quantitative and Qualitative Findings The mixed-methods analysis provided a comprehensive understanding of how nurses in South Korea perceived their work environment during the COVID-19 pandemic, revealing alignment between the quantitative and qualitative findings. By integrating both data sets, key areas of consistency and divergence were highlighted, offering deeper insights into the factors influencing the nursing work environment and potential strategies for improvement. In terms of work environment perceptions, the overall PES-NWI score of 2.31 indicated unfavorable perceptions of the work environment. This was consistent with qualitative findings, which identified increased workload due to screening, testing, and infection control measures as a central challenge. Nurses reported being overwhelmed by the added responsibilities, which further contributed to stress and burnout during the pandemic. Staffing and resource allocation were major concerns, as reflected in the lowest PES-S score of 1.93. Qualitative data further emphasized the need for improved staffing levels and better administrative support. Nurses highlighted the strain caused by insufficient resources and personnel, particularly during peak periods of the pandemic, which impacted their ability to provide optimal care. Despite these challenges, several positive outcomes were identified. Infection control protocols were generally viewed as beneficial, helping to maintain patient safety during the pandemic. Additionally, improved teamwork was acknowledged as a key factor that allowed nursing staff to navigate the heightened demands of the crisis more effectively. Nurses expressed appreciation for collaborative efforts within teams, which contributed to better problem-solving and mutual support. To address the identified challenges, several recommendations for improvement emerged. These included the need for increased staffing, stronger managerial support, and structured training programs to equip nurses with the necessary skills to manage future crises. Enhanced infection control measures were also highlighted as critical to improving the work environment and ensuring the safety of both nurses and patients in similar situations in the future. DISCUSSION The COVID-19 pandemic placed unprecedented strain on healthcare systems globally, with clinical nurses on the frontlines facing unique challenges. This study explored the nursing work environment among South Korean clinical nurses during this global health crisis using a mixed-methods approach. The findings highlight significant areas of concern related to staffing, administrative support, and workload, while also identifying strengths in infection control and teamwork. Nursing Work Environment The overall score of the Korean version of the Practice Environment Scale-Nursing Work Index (PES-NWI) was 2.31, indicating a generally unfavorable work environment. This score is notably lower than those reported in other settings. For example, Magnet hospitals in the U.S. reported an average score of 2.95 ( 20 ), and studies from China during the COVID-19 pandemic showed an average of 3.44 ( 21 ). Given that a score below 2.5 indicates an unfavorable work environment ( 2 ), the findings suggest that Korean clinical nurses perceived their work environment as unsatisfactory during the pandemic. This result was significantly lower than the score of nurses in general hospitals (2.2 points) ( 25 ) and nurses in small to medium-sized hospitals (2.01 points) ( 26 ) from the pre-COVID era in Korea. This suggests that the nursing work environment in Korean hospitals worsened during the pandemic, further highlighting the strain imposed by increased workload and resource shortages. Furthermore, even in the analysis of 46 studies from 28 countries measuring the nursing work environment with PES-NWI from 1999 to 2014, staffing and resource adequacy consistently remained the lowest-rated subscale ( 27 ). This aligns with the findings of this study, where staffing and resource adequacy received the lowest score, emphasizing the persistent global challenge of insufficient staffing and resources in nursing work environments. Nurses reported significant challenges due to insufficient staffing and heavy workload, which were consistent with the qualitative findings. Participants described having to manage additional responsibilities such as COVID-19 screening and infection control, which further strained existing resources. Addressing staffing shortages through increased hiring and strategic workforce allocation should be a priority for improving work environments and ensuring high-quality patient care. Conversely, the highest-rated subscale was nursing foundations for quality of care (PES_F). This suggests that despite the overall challenges, nurses perceived that the foundational elements for providing quality care were in place. The highest-rated item within this subscale was the presence of a preceptor program for newly hired nurses (mean = 3.46), highlighting the importance of structured support for new staff. However, the relatively low score for “A clear philosophy of nursing that pervades the patient care environment” (mean = 2.18) indicates that the overarching nursing philosophy was not consistently reflected in practice. Enhancing the consistency of nursing philosophy through staff training and policy reinforcement could further strengthen the quality of care. Nurses also highlighted the need for an infection control education program, particularly for COVID-19, aligning with previous research showing that educational needs vary based on clinical characteristics ( 28 ). The increased demand for critical care nurses during the pandemic further underscores the need for targeted education and support. A previous study emphasized the importance of improving nursing students’ learning flow through systematic support and strategies at the university level, which could help bridge the gap between education and clinical practice ( 29 ). Strengthening preceptor programs, reinforcing nursing philosophy, and expanding systematic training from the university level could improve nursing quality and preparedness. Leadership and Administrative Support The subscale for nurse manager ability and leadership (PES_M) received a moderate score of 2.39, reflecting mixed perceptions of leadership quality. While nurses acknowledged the presence of supportive managers, they also expressed frustration over the lack of recognition and decision-making support. For instance, the item “A nurse manager who backs up the nursing staff in decision-making, even if the conflict is with a physician” scored relatively low. This finding underscores the importance of empowering nurse managers to support staff effectively during high-stress situations. Previous studies have highlighted that strong leadership and decision-making support are critical in managing healthcare crises ( 30 ). Developing targeted leadership training programs focused on crisis management and staff advocacy may enhance the work environment and improve nurse retention. A key concern raised by participants was the lack of responsiveness from hospital administration. The lowest-rated item within the nurse participation in hospital affairs (PES_P) subscale was “Administration that listens and responds to employee concerns”. This reflects a significant gap in communication and decision-making processes. Qualitative findings further supported this, with nurses reporting that they often had to “figure things out on their own” due to inconsistent or delayed guidance from hospital leadership. Strengthening communication channels and establishing mechanisms for nurses to provide input on hospital policies and practices could improve overall satisfaction and engagement. Staffing and Resource Adequacy Staffing and resource adequacy emerged as the most critical issue, consistent across both the quantitative and qualitative phases. Nurses reported that the nurse-to-patient ratio remained unchanged despite the increased workload caused by COVID-19 screening, patient monitoring, and infection control. The lowest-rated item in the staffing subscale, “Enough registered nurses to provide quality patient care”, reflects the acute staffing shortages faced by nurses during the pandemic. Qualitative data emphasized the strain caused by overwork and overtime requirements, which contributed to burnout and reduced job satisfaction. These findings align with previous studies reporting similar challenges during health crises ( 21 ). Increasing staffing levels and introducing workload management strategies, such as task delegation and shift adjustments, could mitigate these challenges and improve the work environment. Teamwork and Interprofessional Collaboration The nurse-physician relationships and teamwork (PES_R) subscale scored moderate perceptions of collaboration. While nurses reported generally positive working relationships with physicians, there was room for improvement in joint decision-making and communication. The qualitative findings supported this, with nurses describing increased teamwork during the pandemic as a positive change. The crisis created opportunities for enhanced collaboration and problem-solving within nursing teams. Strengthening interprofessional training and establishing structured communication protocols may further enhance teamwork and improve patient care outcomes. The integrated findings from this study highlight several key recommendations to improve the nursing work environment. Increasing staffing and resource allocation through enhanced hiring and workload management is essential to reduce stress and improve care quality. Strengthening leadership and managerial support by providing targeted training for nurse managers on crisis management and staff advocacy can empower leaders to support frontline nurses more effectively. Enhancing communication and decision-making processes by establishing structured communication channels and involving nurses in hospital decision-making can improve responsiveness and staff engagement. Developing comprehensive training programs on infection control, emergency response, and crisis management will better prepare nurses for future public health emergencies. Finally, fostering a consistent nursing philosophy by strengthening the alignment between nursing practice and institutional values can create a more cohesive and supportive work environment. Limitations While this study provides valuable insights into the nursing work environment during the COVID-19 pandemic, several limitations should be acknowledged. First, the sample size was relatively small (n = 28), which may limit the generalizability of the findings. Second, the study focused on a specific geographic and healthcare context in South Korea, which may reduce the applicability of the results to other settings. Additionally, the cross-sectional design limited the ability to assess changes over time, and the absence of longitudinal data prevents understanding how work environment perceptions evolved throughout the pandemic. Future research should explore longitudinal changes in the nursing work environment and examine the long-term impact of COVID-19 on nurse job satisfaction and retention. CONCLUSIONS This study contributes valuable data on the nursing work environment in South Korea during the COVID-19 pandemic. In light of these findings, it is essential for healthcare institutions to prioritize the development of educational programs for nurses and nurse managers to improve coping skills for future pandemic scenarios. Moreover, addressing staffing shortages, enhancing administrative support, and investing in leadership development are critical strategies for improving the nursing work environment. The implications of this study highlight the importance of adapting nursing work environments to better support staff during crises, promoting their well-being and resilience. By addressing these challenges proactively, healthcare institutions can ensure that nurses are better equipped to handle future global health emergencies. Abbreviations M, mean; SD, standard deviations; PES_P, nurse participation in hospital affairs; PES_F, nursing foundations for quality of care; PES_M, nurse manager ability, leadership, and support of nurses; PES_S, staffing and resource adequacy; PES_R, collegial nurse–physician relations; PES-NWI, Practice Environment Scale Nursing Work Index. Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Semyung University (IRB No. SMU-2022-11-002-02). Informed consent to participate was obtained from all participants. The study adhered to the principles outlined in the Declaration of Helsinki. Consent for publication The authors obtained written consent for publication from all participants involved in the study. Availability of data and materials The data supporting the findings of this study are available upon reasonable request from the corresponding author. Due to ethical considerations and participant confidentiality, the full interview transcripts cannot be publicly shared. Competing Interests The authors declare no conflicts interest. Funding This research received no external funding. Authors' contributions Study design: Yeji, SuJung. Data collection: Yeji , SuJung. Data analysis: Yeji , SuJung. Study supervision: Yeji , SuJung. Manuscript writing: Yeji , SuJung. Critical revisions for important intellectual content: SuJung. All authors have read and approved the manuscript. Acknowledgements Not applicable. References Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes. J Nurs Adm. 2008;38(5):223–9. Lake ET, Friese CR. Variations in nursing practice environments: relation to staffing and hospital characteristics. Nurs Res. 2006;55(1):1–9. Copanitsanou P, Fotos N, Brokalaki H. Effects of work environment on patient and nurse outcomes. Br J Nurs Mark Allen Publ. 2017;26(3):172–6. Rivaz M, Tavakolinia M, Momennasab M. Nursing professional practice environment and its relationship with nursing outcomes in intensive care units: a test of the structural equation model. Scand J Caring Sci. 2021;35(2):609–15. Malinowska-Lipień I, Put D, Maluchnik M, Gabryś T, Kózka M, Gajda K, et al. Influence of the work environment of nurses on the 30-day mortality of patients hospitalized in Polish hospitals. cross-sectional studies. BMC Nurs. 2024;23(1):117. Han SH, Kim SR, Cha KS, Son HJ, Shin MJ, Choi JR et al. Infection control during surgery for patients with confirmed or suspected coronavirus disease-19. 2020. Arora AS, Rajput H, Changotra R. Current perspective of COVID-19 spread across South Korea: Exploratory data analysis and containment of the pandemic. Environ Dev Sustain. 2021;23:6553–63. Pimenta Lopes Ribeiro OM, de Lima Trindade L, Silva Fassarella C, de Abreu Pereira SC, Figueiredo Cabral Teles PJ, Gomes, da Rocha C et al. Impact of COVID-19 on professional nursing practice environments and patient safety culture. J Nurs Manag. 2022;30(5):1105–14. Schroeder K, Norful AA, Travers J, Aliyu S. Nursing perspectives on care delivery during the early stages of the covid-19 pandemic: A qualitative study. Int J Nurs Stud Adv. 2020;2:100006. Kim HR, Yang HM. Nursing experience during COVID-19 pandemic in Korea: a qualitative analysis based on critical components of the professional practice models. BMC Nurs. 2022;21(1):288. Santos JLGD, Balsanelli AP, Freitas E, de O, Menegon FHA, Carneiro IA, Lazzari DD, et al. Work environment of hospital nurses during the COVID-19 pandemic in Brazil. Int Nurs Rev. 2021;68(2):228–37. Galanis P, Vraka I, Fragkou D, Bilali A, Kaitelidou D. Nurses’ burnout and associated risk factors during the COVID-19 pandemic: A systematic review and meta‐analysis. J Adv Nurs. 2021;77(8):3286–302. Martin B, Kaminski-Ozturk N, O’Hara C, Smiley R. Examining the Impact of the COVID-19 Pandemic on Burnout and Stress Among U.S. Nurses. J Nurs Regul. 2023;14(1):4–12. Ge MW, Hu FH, Jia YJ, Tang W, Zhang WQ, Zhao DY, et al. COVID-19 pandemic increases the occurrence of nursing burnout syndrome: an interrupted time-series analysis of preliminary data from 38 countries. Nurse Educ Pract. 2023;69:103643. Cho E, Sloane DM, Kim EY, Kim S, Choi M, Yoo IY, et al. Effects of nurse staffing, work environments, and education on patient mortality: An observational study. Int J Nurs Stud. 2015;52(2):535–42. Cho E, Lee NJ, Kim EY, Kim S, Lee K, Park KO, et al. Nurse staffing level and overtime associated with patient safety, quality of care, and care left undone in hospitals: A cross-sectional study. Int J Nurs Stud. 2016;60:263–71. Aiken LH, Sloane DM, Clarke S, Poghosyan L, Cho E, You L, et al. Importance of work environments on hospital outcomes in nine countries. Int J Qual Health Care. 2011;23(4):357–64. Ha DJ, Park JH, Jung SE, Lee B, Kim MS, Sim KL, et al. The Experience of Emotional Labor and Its Related Factors among Nurses in General Hospital Settings in Republic of Korea: A Systematic Review and Meta-Analysis. Sustainability. 2021;13(21):11634. Creswell JW, Klassen AC, Plano Clark VL, Smith KC. Best practices for mixed methods research in the health sciences. Bethesda Md Natl Inst Health. 2011;2013:541–5. Lake ET. Development of the practice environment scale of the Nursing Work Index. Res Nurs Health. 2002;25(3):176–88. Jingxia C, Longling Z, Qiantao Z, Weixue P, Xiaolian J. The changes in the nursing practice environment brought by COVID-19 and improvement recommendations from the nurses’ perspective: a cross-sectional study. BMC Health Serv Res. 2022;22:754. Krippendorff K. Content Analysis: An Introduction to Its Methodology. SAGE; 2018. p. 473. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88. Sandelowski M. The problem of rigor in qualitative research. Adv Nurs Sci. 1986;8(3):27. Cho E, Choi M, Kim EY, Yoo IY, Nam-Ju L. Construct Validity and Reliability of the Korean Version of the Practice Environment Scale of Nursing Work Index for Korean Nurses. J Korean Acad Nurs. 2011;41(3):325–32. Kang KN. Factors Influencing Turnover Intention of Nurses in Small-medium sized Hospitals. J Korean Acad Nurs Adm. 2012;18(2):155–65. Swiger PA, Patrician PA, Miltner RSS, Raju D, Breckenridge-Sproat S, Loan LA. The Practice Environment Scale of the Nursing Work Index: An updated review and recommendations for use. Int J Nurs Stud. 2017;74:76–84. Kang H, Im J, Kang HY. Priority Analysis of Needs for COVID-19 Infection Control Education for Nurses at a Medium-Sized Hospital. J Korean Acad Fundam Nurs. 2022;29(4):472–83. Raso R, Fitzpatrick JJ, Masick K, Giordano-Mulligan M, Sweeney CD. Perceptions of authentic nurse leadership and work environment and the pandemic impact for nurse leaders and clinical nurses. JONA J Nurs Adm. 2021;51(5):257–63. Park J, Seo M. Influencing Factors on Nursing Students’ Learning Flow during the COVID-19 Pandemic: A Mixed Method Research. Asian Nurs Res. 2022;16(1):35–44. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 15 Jun, 2025 Reviewers agreed at journal 15 Jun, 2025 Reviewers invited by journal 29 Apr, 2025 Editor assigned by journal 24 Apr, 2025 Editor invited by journal 26 Mar, 2025 Submission checks completed at journal 25 Mar, 2025 First submitted to journal 25 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-6249692","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":449985551,"identity":"a05d1b3d-6329-469b-bae1-613869c5c957","order_by":0,"name":"SuJung Jung","email":"","orcid":"","institution":"California State University, Long Beach","correspondingAuthor":false,"prefix":"","firstName":"SuJung","middleName":"","lastName":"Jung","suffix":""},{"id":449985552,"identity":"38abdacf-f86f-4f9f-99fa-9b949abcafc3","order_by":1,"name":"Yeji Seo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIie3OPUvDQBjA8ecMpMuT3ppCQT9CQMgk6Ve5cnBTh07ON2UKdK3ghwh0dYg8SJfQricKJkumboK46cUsnS6Ogvdf7vXHHYDP9zcTBHiT8fMtpseJkrPzW2MEAgBiZfVbkux1S+t5EFwf6WkX5a+ZnlDD7h4cpK4EbTGcpkaplyjvpEaVsLJzECMEIWKQGkwtIQmwAtZUDvLW9CRmu83xYyD8NEIM9MR+BVZhTzKI7Sulg8zqn48JGRuVPt8fSIRxlzxuHWS6r+V7VHxlfEOdOd3SgnPZtoWDXFUogBXD4gIBlrmdOADApZ7Y889hwey4cN32+Xy+/9k3KCNbmAkcIrMAAAAASUVORK5CYII=","orcid":"","institution":"Semyung University","correspondingAuthor":true,"prefix":"","firstName":"Yeji","middleName":"","lastName":"Seo","suffix":""}],"badges":[],"createdAt":"2025-03-18 05:54:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6249692/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6249692/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82162676,"identity":"ae16609e-170e-4728-8b59-439cd228d39a","added_by":"auto","created_at":"2025-05-07 08:47:46","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33042,"visible":true,"origin":"","legend":"\u003cp\u003eDesign of This Study\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6249692/v1/14977177c3ec2896547143b0.jpg"},{"id":82160311,"identity":"ca43f5e8-ff97-4238-abd7-7236747bdd68","added_by":"auto","created_at":"2025-05-07 08:31:46","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32484,"visible":true,"origin":"","legend":"\u003cp\u003eSubscales of PES-NWI\u003c/p\u003e\n\u003cp\u003eM, mean; SD, standard deviations; PES_P, nurse participation in hospital affairs; PES_F, nursing foundations for quality of care; PES_M, nurse manager ability, leadership, and support of nurses; PES_S, staffing and resource adequacy; PES_R, collegial nurse–physician relations; PES-NWI, Practice Environment Scale Nursing Work Index.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6249692/v1/b9f4e3494d5bbda85cfa45ca.jpg"},{"id":82163788,"identity":"ad1797ed-b935-4ca4-9726-de4904d2c63c","added_by":"auto","created_at":"2025-05-07 08:55:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1094781,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6249692/v1/50e0fbd0-465b-46bf-9923-e2ece37f8b4d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nursing Work Environment and Clinical Nurses’ Perceptions During the COVID-19 Pandemic in South Korea: A Mixed-Method Study","fulltext":[{"header":"BACKGROUDN","content":"\u003cp\u003eThe nursing work environment refers to the characteristics of a healthcare organization that support nurses in providing high-quality professional care to patients (1). It includes factors such as nurses\u0026rsquo; involvement in hospital policies, the adequacy of staffing and resources for professional nursing, the establishment of a foundation for delivering excellent care, and fostering collaborative relationships between nurses and doctors to address patients\u0026rsquo; health needs (2). Previous studies have shown that when nurses perceive their hospital\u0026rsquo;s work environment positively, patient mortality rates decrease, and nursing performance improves\u0026nbsp;(3\u0026ndash;5).\u003c/p\u003e\n\u003cp\u003eThe COVID-19 pandemic, caused by the novel coronavirus that emerged in 2019, has profoundly disrupted healthcare systems worldwide (6). In South Korea, the country demonstrated an exemplary response by implementing early detection and isolation measures through extensive testing to prevent the spread of infection (7). However, as the number of confirmed cases increased due to community transmission and the global spread of the virus, the burden on healthcare personnel, including nurses, gradually intensified. This escalating pressure has led to significant changes in the nursing work environment (8).\u003c/p\u003e\n\u003cp\u003eNurses, as frontline healthcare providers, played a crucial role in improving patient outcomes through their nursing practice\u0026nbsp;(9) However,\u0026nbsp;numerous studies have reported that nurses faced an increased risk of infection, limitations in decision-making, and had to work under challenging conditions, often going beyond their usual duties in emergency situations during the pandemic\u0026nbsp;(10,11). In addition,\u0026nbsp;nurses experienced high levels of burnout during the COVID-19 pandemic, with emotional exhaustion, depersonalization, and lack of personal accomplishment being prevalent, and identified risk factors such as younger age, low social support, increased workload, and inadequate resources\u0026nbsp;(12\u0026ndash;14).\u003c/p\u003e\n\u003cp\u003eIn South Korea, nurses were already dealing with significant challenges in their work environments, including high patient loads and limited resources compared to their counterparts in other countries. Korean nurses reported caring for an average of 12 patients per shift, which is double the number managed by nurses in the United States and some European countries (15,16). This high workload, coupled with insufficient staffing and resources, has been linked to adverse outcomes such as burnout, job dissatisfaction, and high turnover rates. (17,18).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven these pre-existing challenges, it is essential to explore how the COVID-19 pandemic further impacted the nursing work environment in South Korea. Understanding these dynamics is critical for identifying areas of improvement and developing strategies to address systemic issues. Enhancing the work environment is key to improving nurses\u0026rsquo; well-being and retention, ensuring better patient outcomes, and preparing the healthcare system for future health crises.\u003c/p\u003e\n\u003cp\u003eThis study aims to investigate the work environment of clinical nurses in South Korea during the COVID-19 pandemic. Specifically, the study seeks to:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;1.\u0026nbsp; \u0026nbsp;\u0026nbsp;Examine clinical nurses\u0026rsquo; perceptions of the impacts of the COVID-19 pandemic on their work environment.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2. \u0026nbsp; \u0026nbsp;Identify the challenges clinical nurses faced and the strategies they employed to improve the work environment during and beyond the pandemic.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eStudy design\u003c/p\u003e \u003cp\u003eThis study is designed to use a mixed-methods approach to better understand changes in the nursing work environment from the perspective of clinical nurses during the COVID-19 pandemic, as well as to gain a deeper understanding of strategies for improving the nursing work environment. The explanatory sequential design means that the purpose of the second qualitative phase is to explain the results discovered in the first quantitative phase, and sometimes to explore outliers that are not entirely consistent with the collected data. Since qualitative data analysis is used to explain the quantitative phase’s results, the term ‘explanatory’ is used (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, the primary goal was to understand the work environment of clinical nurses during the pandemic using a quantitative approach. The qualitative phase was then used to gather more detailed insights and perspectives from nurses through in-depth exploration. The explanatory sequential design is one of the six methodologies of mixed methods research (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Quantitative data collection and analysis were conducted in the first stage. In the second stage, qualitative data collection and analysis were carried out to integrate the findings from both phases.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative phase\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eParticipants and procedure\u003c/h2\u003e \u003cp\u003eThe quantitative phase of the research involved clinical Korean nurses (n = 28). Convenience sampling was used to recruit nurses using a secure electronic online survey platform for quantitative data from June 2023 to July 2023. The inclusion criteria were clinical nurses who had more than one year of clinical experience both before and after the onset of the COVID-19 pandemic and were currently employed in medical institutions at or above the hospital level at the time of their research participation, having volunteered to take part in this survey.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eThe self-administered questionnaire consisted of three parts. To assess the nursing practice environment during the COVID-19 pandemic the Korean version of the Practice Environment Scale Nursing Work Index (PES-NWI) (Cronbach’s alpha = .901) was used. The scale consisted of five dimensions and 29 items: (a) PES_P = nurse participation in hospital affairs (9 items); (b) PES_F = nursing foundations for quality of care (9 items); (c) PES_M = nurse manager ability, leadership, and support of nurses (4 items); (d) PES_S = staffing and resource adequacy (4 items); (e) PES_R = collegial nurse–physician relations (3 items). Each item is scored on a scale of 4-point Likert scale, ranging between 1 (strongly disagree) and 4 (strongly agree) with a score range from 29 to 116. A higher score indicates a better nursing work environment (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The scoring method for PES-NWI involves calculating the average value of all items, and the scores fall within a range of 1 to 4 points. Lake and Friese (2006) considered a score of 2.5 or higher as an indication that nurses agree that their work environment is good, while a score below 2.5 was judged as otherwise (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). At the end of the PES-NWI survey, three open-ended questions were included to collect more experiences and thoughts about the working environment during the COVID-19 pandemic. These questions were adapted from a previously published study (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e): (a) “In the context of the COVID-19 situation, how do you think your nursing work environment has changed?” (Q1) (b) “In the context of the COVID-19 situation, what specific positive and negative changes do you believe have occurred in your nursing work environment, including examples such as nurse-patient ratios and direct nursing activity hours?” (Q2) (c) “As a nurse in the COVID-19 situation, what do you think are the ways you can enhance your nursing work environment?” (Q3). Lastly, demographic and occupational information collected from participants.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eFrequency distributions were adopted to describe categorical variables of demographic and occupational characteristics. Means with standard deviations (SD) were used to describe continues variables and scores of PES-NWI. All statistical analyses were conducted with SPSS 28.0. For qualitative data, traditional content analysis methods were used.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative phase\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and procedure\u003c/h2\u003e \u003cp\u003eQualitative data collection was performed to explore further details about the changes in the nursing practice environment during the pandemic in Korea. Among the subjects who participated in the survey of quantitative research, those who expressed their intention to participate in qualitative research, those who understood the purpose of the research and agreed to participate in qualitative research. Qualitative data was collected by a research assistant and a professor at the School of Nursing, from 11th to August 25th August 2023. The participants in the qualitative research interview were contacted directly by the research assistant to the subjects who expressed their intention to participate in the qualitative research among the questionnaires of the research, and the interview schedule of the participants was confirmed, and 10 people were secured.\u003c/p\u003e \u003cp\u003e In consideration of the social distancing situation due to the pandemic and the work of the research participant in the COVID-19 ward, the interview was conducted through Kakao Talk open chat so that the participants could talk comfortably. Based on previous research related to the care of COVID-19 patients, the research team asked questions with a pre-composed interview questionnaire, which has been modified from a previously published study (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). A semi-structured interview was conducted by adding a variety of questions about each person's response. The main interview question is, \"How do you think your nursing environment has been affected during the COVID-19 pandemic?\", \"What specific positive and negative impacts do you think there are in your nursing environment during the COVID-19 pandemic, including the examples? (e.g., nurse-patient ratio, hours of direct nursing activities, etc.)\", \"As a nurse in the corona situation, what do you think can be done to improve your nursing work environment during the COVID-19 pandemic?\", \"In addition, do you have any final words about the nursing work environment in relation to this study?\"\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe content analysis method is a systematic and objective analysis method that analyzes explicit or potential content by classifying and evaluating the content of the material in order to determine the meaning and effect of the main symbol or theme (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Traditional content analysis is a dynamic analysis method that inductively derives results from research data (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFirst, the researcher repeatedly read the transcription and field notes to try to understand the interview as a whole. Meaningful phrases related to the nursing work environment in the context of the COVID-19 pandemic were identified and displayed, and they were named and coded to better represent the inherent meaning and context of the displayed phrases. Afterwards, the process of categorizing and comparing the extracted code according to meaning was repeated, Finally, the research question, 'How has the nursing work environment in Korea evolved during the COVID-19 pandemic, and what specific changes have occurred?' the contents of were categorized into five domains of the nursing work environment, The code and key keywords were derived. In addition, in order to reveal the importance and degree of interest perceived by the participants, the frequency and percentage of the code according to the quantitative analysis method of the content analysis method were described according to the order of the frequency and percentage of the code (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEnsuring the validity of this study\u003c/h3\u003e\n\u003cp\u003eIn order to ensure the validity of qualitative research, we tried to meet the criteria of credibility, auditability, fittingness, and conformability proposed by (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). First, in order to meet reliability, nurses who are currently directly caring for COVID-19 patients in hospitals who are willing to voluntarily participate in the study were introduced and recruited participants, by asking open-ended questions during the interview, we wanted to allow the participants to freely state their nursing experience without restriction, thus obtaining a sufficient data.\u003c/p\u003e \u003cp\u003eIn addition, two researchers gathered to discuss until they agreed and analyzed the data to improve the reliability of the interpretation. In an effort to ensure auditability, participant statements have been presented in the results of the study so that readers and subsequent researchers can track the analysis of this study, we tried to meet the suitability by collecting the general characteristics of the study participants, such as gender, educational background, clinical experience, and hospital size. Finally, in order to establish the possibility of confirmation, two of the study participants were selected to provide the contents of the interview and the results of the analysis to see if their experiences were well reflected, the results of the analysis confirmed that there was no distortion.\u003c/p\u003e \u003cp\u003eAll the authors of this study have experience in conducting and publishing qualitative research and have tried to equip them with the readiness and competence to conduct qualitative research. We attended conferences related to qualitative research and devoured books and papers related to qualitative research methodology.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003eBefore collecting the data, this study was approved by the author's university Institutional Review Board (IRB No. XXX-XXXX). During the data collection process, the subjects were explained the purpose of the study and the confidentiality and anonymity of the collected data. Informed consent to participate was obtained from all participants, and electronic and written consent forms were filled out, and certain rewards were provided. The researcher explained that the participant could withdraw from the study at any time, and that there was no disadvantage to doing so. It was explained that the statements were recorded, and the interview was conducted with consent. The recorded contents will be used for research purposes only, in accordance with the law, the research data will be kept and then discard data. When transcribing, personal information was deleted and anonymized so that the identity of the research participant was not revealed.\u003c/p\u003e \u003cp\u003eIn addition, in principle, the collected data will be stored for 3 years at the end of the study and then discarded, it was explained that if there are any inconveniences or inquiries when participating in the study, they can be contacted at any time through the contact information written in the description. The electronic consent form and questionnaire were kept by the researcher in a locked place, Computer-generated data was locked to take into account the ethical aspects of the research participants, such as restricting access to anyone other than the researcher.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003cdiv id=\"Sec14\" class=\"Section4\"\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003ch2\u003eQuantitative phase\u003c/h2\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographic and professional characteristics of the study’s 28 participants. The average age of the participants was 35.17 years (SD = 6.4), with the majority being female. Educational backgrounds varied, and participants had an average of 140.75 months (approximately 11.7 years) of clinical experience, though variability was significant. Additionally, participants were employed in different hospital settings, held various positions, and most had experience caring for COVID-19 patients.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Information of the Participants (N = 28)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, y, mean (SD)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.71 (8.30)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen, N\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation, N\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school graduation\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome college\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 years college\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster’s degree or higher\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal clinical experience (months), mean (SD)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140.75 (103.47)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize of the hospital\u003csup\u003e†\u003c/sup\u003e, N\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary general hospital\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital with over 300 beds\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital with fewer than 300 beds\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosition/Title\u003csup\u003e†\u003c/sup\u003e, N\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharge nurse\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWard manager\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonthly income (KRW), mean\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,773,214\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience in caring for COVID-19 patients, N\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003e†\u003c/sup\u003e where you are currently working\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003ch2\u003eNursing Work Environment\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e present the scores for various subscales of the Practice Environment Scale of Nursing Work Index (PES-NWI). The overall score for the nursing work environment was 2.31 (SD = 0.38), indicating that the work environment was generally perceived as unfavorable. A detailed analysis of the various subscales of the PES-NWI revealed key areas of concern and aspects of the work environment that were rated more positively. In terms of nurse participation in hospital affairs (PES_P), the average score was notably low, with the lowest-rated item being “Administration that listens and responds to employee concerns” (M = 1.75, SD = 0.65). This suggests that nurses felt their concerns were not adequately addressed by hospital administration. Other items in this subscale, such as “Staff nurses have the opportunity to serve on hospital and nursing committees” (M = 1.89, SD = 0.83) and “Nurse managers equal in power and authority to other top-level hospital executives” (M = 2.14, SD = 0.97), further highlighted a lack of involvement and empowerment in hospital governance.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePractice Environment Scale of Nursing Work Index (PES-NWI) Subscales\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubscales\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStatements\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003ePES_P\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdministration that listens and responds to employee concerns\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStaff nurses have the opportunity to serve on hospital and nursing committees.\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.89\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCareer development/clinical ladder opportunity\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.25\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStaff nurses are involved in the internal governance of the hospital (e.g., practice and policy committees)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.11\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse managers consult with staff on daily problems and procedures\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.57\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpportunity for staff nurses to participate in policy decisions\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.79\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpportunities for advancement\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.18\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse managers equal in power and authority to other top level hospital executives\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.14\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA chief nursing officer who is highly visible and accessible to staff\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.93\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003ePES_F\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAn active quality assurance program\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.32\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA clear philosophy of nursing that pervades the patient care environment\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWritten, up-to-date nursing care plans for all patients\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.54\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActive staff development or continuing education programs for nurses\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNursing care is based on a nursing, rather than a medical model\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient care assignments that foster continuity of care, i.g., the same nurse cares for the patient from one day to the next\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.61\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking with nurses who are clinically competent\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.82\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA preceptor program for newly hired RNs\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3.46\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh standards of nursing care are expected by the administration\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.11\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePES_M\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA nurse manager who is a good manager and leader\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.39\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA supervisory staff that is supportive of the nurses\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.61\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA nurse manager who backs up the nursing staff in decision making, even if the conflict is with a physician\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.36\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePraise and recognition for a job well done\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.25\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePES_S\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnough registered nurses to provide quality patient care\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.79\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnough staff to get the work done\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.89\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdequate support services allow me to spend time with my patients\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.82\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnough time and opportunity to discuss patient care problems with other nurses\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.21\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePES_R\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA lot of teamwork between nurses and physicians\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.21\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollaboration (joint practice) between nurses and physicians\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.46\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysicians and nurses have good working relationships\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.32\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePES-NWI\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.31\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eM, mean; SD, standard deviations; PES_P, nurse participation in hospital affairs; PES_F, nursing foundations for quality of care; PES_M, nurse manager ability, leadership, and support of nurses; PES_S, staffing and resource adequacy; PES_R, collegial nurse–physician relations; PES-NWI, Practice Environment Scale Nursing Work Index.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e The nursing foundations for quality of care (PES_F) subscale received the highest rating, with a mean score of 2.67 (SD = 0.44), suggesting that nurses generally perceived the foundations for providing quality care to be in place. Notably, the item “A preceptor program for newly hired RNs” scored the highest within this subscale (M = 3.46, SD = 0.79), indicating strong support for new nurses. However, the item “A clear philosophy of nursing that pervades the patient care environment” received a lower rating (M = 2.18, SD = 0.82), suggesting that the overarching nursing philosophy was not consistently present throughout the work environment. The nurse manager ability and leadership (PES_M) subscale revealed a moderate level of support, with the item “A nurse manager who is a good manager and leader” scoring 2.39 (SD = 0.83). However, other items in this subscale, such as “A nurse manager who backs up the nursing staff in decision-making, even if the conflict is with a physician” (M = 2.36, SD = 0.73) and “Praise and recognition for a job well done” (M = 2.25, SD = 0.70), indicate that while nurse managers are generally supportive, recognition and support for nurses in decision-making were areas of concern. The staffing and resource adequacy (PES_S) subscale had the lowest overall score (M = 1.93, SD = 0.40), underscoring the critical issue of inadequate staffing. The item “Enough registered nurses to provide quality patient care” received the lowest score within this subscale (M = 1.79, SD = 0.63), pointing to significant concerns over staffing levels and their impact on patient care. Lastly, the nurse-physician relationships and teamwork (PES_R) subscale indicated moderate collaboration between nurses and physicians, with items such as “Collaboration (joint practice) between nurses and physicians” (M = 2.46, SD = 0.84) and “Physicians and nurses have good working relationships” (M = 2.32, SD = 0.67), suggesting that although teamwork was generally reported, there was room for improvement in collaboration and communication between the two groups.\u003c/p\u003e\u003cp\u003eOverall, the findings highlight significant areas of dissatisfaction, particularly in staffing, nurse participation in decision-making, and administrative support. However, aspects such as the quality of care and nurse-physician relationships were perceived more positively, suggesting areas of strength in the work environment.\u003c/p\u003e\u003ch2\u003eQualitative Phase\u003c/h2\u003e\u003cp\u003eQualitative data were collected through three open-ended questions included at the end of the quantitative survey. A total of 28 nurses provided responses, and 10 participants agreed to participate in follow-up in-depth interviews. The analysis revealed key themes and subthemes, organized according to the research questions.\u003c/p\u003e\u003ch2\u003ePerceived Changes in the Nursing Work Environment During the COVID-19 Pandemic\u003c/h2\u003e\u003cp\u003eTwo major themes emerged regarding changes in the nursing work environment during the COVID-19 pandemic:\u003c/p\u003e\u003ch2\u003eIncreased Workload and Task Complexity\u003c/h2\u003e\u003cp\u003eParticipants described how additional responsibilities related to COVID-19 screening and management led to an increased workload.\u003c/p\u003e\u003cp\u003e“After COVID-19, we had to check the infection status and symptoms of patients and caregivers before admission and surgery, which increased our workload significantly.” (Participant 1)\u003c/p\u003e\u003cp\u003e“Putting on and taking off protective equipment takes a lot of time, making the nursing process more exhausting.” (Participant 10)\u003c/p\u003e\u003ch2\u003eChallenges in Infection Control\u003c/h2\u003e\u003cp\u003e Participants reported confusion and stress caused by rapidly changing infection control guidelines.\u003c/p\u003e\u003cp\u003e “In the early days of the pandemic, infection control guidelines were unclear and constantly changing.” (Participant 3)\u003c/p\u003e\u003cp\u003e“We had to monitor not only patient symptoms but also the health status of staff members, which added to our workload.” (Participant 6)\u003c/p\u003e\u003ch2\u003ePositive and Negative Changes in the Work Environment\u003c/h2\u003e\u003cp\u003eParticipants identified both positive and negative changes in the work environment during the pandemic:\u003c/p\u003e\u003ch2\u003ePositive Changes\u003c/h2\u003e\u003cp\u003eDespite the overall challenges, participants noted improvements in teamwork and infection control practices:\u003c/p\u003e\u003cp\u003e“The creation of infection control protocols helped us respond more effectively to high-risk virus outbreaks.” (Participant 3)\u003c/p\u003e\u003cp\u003e“The crisis strengthened the teamwork among nurses. We helped each other more.” (Participant 10)\u003c/p\u003e\u003ch2\u003eNegative Changes\u003c/h2\u003e\u003cp\u003eParticipants reported challenges related to staffing and resource shortages, as well as increased pressure from patients and caregivers:\u003c/p\u003e\u003cp\u003e“The nurse-to-patient ratio remained the same, but direct care time increased, leading to overtime work.” (Participant 10)\u003c/p\u003e\u003cp\u003e“Patients and caregivers expected nearly perfect care, which added pressure.” (Participant 9)\u003c/p\u003e\u003cp\u003e“Administration was not responsive to our concerns, and we were left to figure things out on our own.” (Participant 5)\u003c/p\u003e\u003ch2\u003eStrategies to Improve the Nursing Work Environment\u003c/h2\u003e\u003cp\u003eThree main strategies were proposed by participants to improve the nursing work environment:\u003c/p\u003e\u003ch2\u003eImproved Staffing and Nurse-to-Patient Ratios\u003c/h2\u003e\u003cp\u003e“We need more nursing staff to reduce the workload and increase direct care time per patient.” (Participant 10)\u003c/p\u003e\u003ch2\u003eIncreased Support from Nurse Managers and Institutions\u003c/h2\u003e\u003cp\u003e “Nurse managers should advocate for nurses’ needs and ensure that guidelines and resources are consistently provided.” (Participant 5)\u003c/p\u003e\u003ch2\u003eEnhanced Training and Infection Control Programs\u003c/h2\u003e\u003cp\u003e“We need more specialized training on infection control and emergency response.” (Participant 7)\u003c/p\u003e\u003cp\u003e“Administrative support and increased staffing would allow us to focus more on direct patient care.” (Participant 9)\u003c/p\u003e\u003ch2\u003eIntegrated Interpretation of Quantitative and Qualitative Findings\u003c/h2\u003e\u003cp\u003eThe mixed-methods analysis provided a comprehensive understanding of how nurses in South Korea perceived their work environment during the COVID-19 pandemic, revealing alignment between the quantitative and qualitative findings. By integrating both data sets, key areas of consistency and divergence were highlighted, offering deeper insights into the factors influencing the nursing work environment and potential strategies for improvement.\u003c/p\u003e\u003cp\u003eIn terms of work environment perceptions, the overall PES-NWI score of 2.31 indicated unfavorable perceptions of the work environment. This was consistent with qualitative findings, which identified increased workload due to screening, testing, and infection control measures as a central challenge. Nurses reported being overwhelmed by the added responsibilities, which further contributed to stress and burnout during the pandemic.\u003c/p\u003e\u003cp\u003eStaffing and resource allocation were major concerns, as reflected in the lowest PES-S score of 1.93. Qualitative data further emphasized the need for improved staffing levels and better administrative support. Nurses highlighted the strain caused by insufficient resources and personnel, particularly during peak periods of the pandemic, which impacted their ability to provide optimal care.\u003c/p\u003e\u003cp\u003eDespite these challenges, several positive outcomes were identified. Infection control protocols were generally viewed as beneficial, helping to maintain patient safety during the pandemic. Additionally, improved teamwork was acknowledged as a key factor that allowed nursing staff to navigate the heightened demands of the crisis more effectively. Nurses expressed appreciation for collaborative efforts within teams, which contributed to better problem-solving and mutual support.\u003c/p\u003e\u003cp\u003eTo address the identified challenges, several recommendations for improvement emerged. These included the need for increased staffing, stronger managerial support, and structured training programs to equip nurses with the necessary skills to manage future crises. Enhanced infection control measures were also highlighted as critical to improving the work environment and ensuring the safety of both nurses and patients in similar situations in the future.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe COVID-19 pandemic placed unprecedented strain on healthcare systems globally, with clinical nurses on the frontlines facing unique challenges. This study explored the nursing work environment among South Korean clinical nurses during this global health crisis using a mixed-methods approach. The findings highlight significant areas of concern related to staffing, administrative support, and workload, while also identifying strengths in infection control and teamwork.\u003c/p\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eNursing Work Environment\u003c/h2\u003e \u003cp\u003eThe overall score of the Korean version of the Practice Environment Scale-Nursing Work Index (PES-NWI) was 2.31, indicating a generally unfavorable work environment. This score is notably lower than those reported in other settings. For example, Magnet hospitals in the U.S. reported an average score of 2.95 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), and studies from China during the COVID-19 pandemic showed an average of 3.44 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Given that a score below 2.5 indicates an unfavorable work environment (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), the findings suggest that Korean clinical nurses perceived their work environment as unsatisfactory during the pandemic. This result was significantly lower than the score of nurses in general hospitals (2.2 points) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and nurses in small to medium-sized hospitals (2.01 points) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) from the pre-COVID era in Korea. This suggests that the nursing work environment in Korean hospitals worsened during the pandemic, further highlighting the strain imposed by increased workload and resource shortages.\u003c/p\u003e \u003cp\u003eFurthermore, even in the analysis of 46 studies from 28 countries measuring the nursing work environment with PES-NWI from 1999 to 2014, staffing and resource adequacy consistently remained the lowest-rated subscale (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This aligns with the findings of this study, where staffing and resource adequacy received the lowest score, emphasizing the persistent global challenge of insufficient staffing and resources in nursing work environments. Nurses reported significant challenges due to insufficient staffing and heavy workload, which were consistent with the qualitative findings. Participants described having to manage additional responsibilities such as COVID-19 screening and infection control, which further strained existing resources. Addressing staffing shortages through increased hiring and strategic workforce allocation should be a priority for improving work environments and ensuring high-quality patient care.\u003c/p\u003e \u003cp\u003e Conversely, the highest-rated subscale was nursing foundations for quality of care (PES_F). This suggests that despite the overall challenges, nurses perceived that the foundational elements for providing quality care were in place. The highest-rated item within this subscale was the presence of a preceptor program for newly hired nurses (mean\u0026thinsp;=\u0026thinsp;3.46), highlighting the importance of structured support for new staff. However, the relatively low score for \u0026ldquo;A clear philosophy of nursing that pervades the patient care environment\u0026rdquo; (mean\u0026thinsp;=\u0026thinsp;2.18) indicates that the overarching nursing philosophy was not consistently reflected in practice. Enhancing the consistency of nursing philosophy through staff training and policy reinforcement could further strengthen the quality of care.\u003c/p\u003e \u003cp\u003eNurses also highlighted the need for an infection control education program, particularly for COVID-19, aligning with previous research showing that educational needs vary based on clinical characteristics (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The increased demand for critical care nurses during the pandemic further underscores the need for targeted education and support. A previous study emphasized the importance of improving nursing students\u0026rsquo; learning flow through systematic support and strategies at the university level, which could help bridge the gap between education and clinical practice (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Strengthening preceptor programs, reinforcing nursing philosophy, and expanding systematic training from the university level could improve nursing quality and preparedness.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLeadership and Administrative Support\u003c/h3\u003e\n\u003cp\u003eThe subscale for nurse manager ability and leadership (PES_M) received a moderate score of 2.39, reflecting mixed perceptions of leadership quality. While nurses acknowledged the presence of supportive managers, they also expressed frustration over the lack of recognition and decision-making support. For instance, the item \u0026ldquo;A nurse manager who backs up the nursing staff in decision-making, even if the conflict is with a physician\u0026rdquo; scored relatively low. This finding underscores the importance of empowering nurse managers to support staff effectively during high-stress situations. Previous studies have highlighted that strong leadership and decision-making support are critical in managing healthcare crises (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Developing targeted leadership training programs focused on crisis management and staff advocacy may enhance the work environment and improve nurse retention.\u003c/p\u003e \u003cp\u003eA key concern raised by participants was the lack of responsiveness from hospital administration. The lowest-rated item within the nurse participation in hospital affairs (PES_P) subscale was \u0026ldquo;Administration that listens and responds to employee concerns\u0026rdquo;. This reflects a significant gap in communication and decision-making processes. Qualitative findings further supported this, with nurses reporting that they often had to \u0026ldquo;figure things out on their own\u0026rdquo; due to inconsistent or delayed guidance from hospital leadership. Strengthening communication channels and establishing mechanisms for nurses to provide input on hospital policies and practices could improve overall satisfaction and engagement.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eStaffing and Resource Adequacy\u003c/h2\u003e \u003cp\u003eStaffing and resource adequacy emerged as the most critical issue, consistent across both the quantitative and qualitative phases. Nurses reported that the nurse-to-patient ratio remained unchanged despite the increased workload caused by COVID-19 screening, patient monitoring, and infection control. The lowest-rated item in the staffing subscale, \u0026ldquo;Enough registered nurses to provide quality patient care\u0026rdquo;, reflects the acute staffing shortages faced by nurses during the pandemic. Qualitative data emphasized the strain caused by overwork and overtime requirements, which contributed to burnout and reduced job satisfaction. These findings align with previous studies reporting similar challenges during health crises (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Increasing staffing levels and introducing workload management strategies, such as task delegation and shift adjustments, could mitigate these challenges and improve the work environment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eTeamwork and Interprofessional Collaboration\u003c/h2\u003e \u003cp\u003eThe nurse-physician relationships and teamwork (PES_R) subscale scored moderate perceptions of collaboration. While nurses reported generally positive working relationships with physicians, there was room for improvement in joint decision-making and communication. The qualitative findings supported this, with nurses describing increased teamwork during the pandemic as a positive change. The crisis created opportunities for enhanced collaboration and problem-solving within nursing teams. Strengthening interprofessional training and establishing structured communication protocols may further enhance teamwork and improve patient care outcomes.\u003c/p\u003e \u003cp\u003eThe integrated findings from this study highlight several key recommendations to improve the nursing work environment. Increasing staffing and resource allocation through enhanced hiring and workload management is essential to reduce stress and improve care quality. Strengthening leadership and managerial support by providing targeted training for nurse managers on crisis management and staff advocacy can empower leaders to support frontline nurses more effectively. Enhancing communication and decision-making processes by establishing structured communication channels and involving nurses in hospital decision-making can improve responsiveness and staff engagement. Developing comprehensive training programs on infection control, emergency response, and crisis management will better prepare nurses for future public health emergencies. Finally, fostering a consistent nursing philosophy by strengthening the alignment between nursing practice and institutional values can create a more cohesive and supportive work environment.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWhile this study provides valuable insights into the nursing work environment during the COVID-19 pandemic, several limitations should be acknowledged. First, the sample size was relatively small (n\u0026thinsp;=\u0026thinsp;28), which may limit the generalizability of the findings. Second, the study focused on a specific geographic and healthcare context in South Korea, which may reduce the applicability of the results to other settings. Additionally, the cross-sectional design limited the ability to assess changes over time, and the absence of longitudinal data prevents understanding how work environment perceptions evolved throughout the pandemic. Future research should explore longitudinal changes in the nursing work environment and examine the long-term impact of COVID-19 on nurse job satisfaction and retention.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis study contributes valuable data on the nursing work environment in South Korea during the COVID-19 pandemic. In light of these findings, it is essential for healthcare institutions to prioritize the development of educational programs for nurses and nurse managers to improve coping skills for future pandemic scenarios. Moreover, addressing staffing shortages, enhancing administrative support, and investing in leadership development are critical strategies for improving the nursing work environment. The implications of this study highlight the importance of adapting nursing work environments to better support staff during crises, promoting their well-being and resilience. By addressing these challenges proactively, healthcare institutions can ensure that nurses are better equipped to handle future global health emergencies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eM, mean; SD, standard deviations; PES_P, nurse participation in hospital affairs; PES_F, nursing foundations for quality of care; PES_M, nurse manager ability, leadership, and support of nurses; PES_S, staffing and resource adequacy; PES_R, collegial nurse\u0026ndash;physician relations; PES-NWI, Practice Environment Scale Nursing Work Index.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Semyung University (IRB No. SMU-2022-11-002-02). Informed consent to participate was obtained from all participants.\u0026nbsp;The study adhered to the principles outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors obtained written consent for publication from all participants involved in the study.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available upon reasonable request from the corresponding author. Due to ethical considerations and participant confidentiality, the full interview transcripts cannot be publicly shared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts interest.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy design: Yeji, SuJung. Data collection: Yeji , SuJung. Data analysis: Yeji , SuJung. Study supervision: Yeji , SuJung. Manuscript writing: Yeji , SuJung. Critical revisions for important intellectual content: SuJung. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes. J Nurs Adm. 2008;38(5):223\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLake ET, Friese CR. Variations in nursing practice environments: relation to staffing and hospital characteristics. Nurs Res. 2006;55(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCopanitsanou P, Fotos N, Brokalaki H. Effects of work environment on patient and nurse outcomes. Br J Nurs Mark Allen Publ. 2017;26(3):172\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRivaz M, Tavakolinia M, Momennasab M. 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Perceptions of authentic nurse leadership and work environment and the pandemic impact for nurse leaders and clinical nurses. JONA J Nurs Adm. 2021;51(5):257\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark J, Seo M. Influencing Factors on Nursing Students\u0026rsquo; Learning Flow during the COVID-19 Pandemic: A Mixed Method Research. Asian Nurs Res. 2022;16(1):35\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\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":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"nurses, work environment, working conditions, pandemics","lastPublishedDoi":"10.21203/rs.3.rs-6249692/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6249692/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe COVID-19 pandemic significantly impacted the nursing work environment, highlighting critical gaps in staffing, managerial support, and infection control. This study aims to investigate the nursing work environment and clinical nurses\u0026rsquo; perceptions during the COVID-19 pandemic in South Korea.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods study with an explanatory sequential design was conducted. Quantitative data were collected using the Korean version of the Practice Environment Scale-Nursing Work Index (PES-NWI) and analyzed using descriptive statistics. Qualitative data were obtained through interviews and analyzed using traditional content analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe overall PES-NWI score was 2.31 (SD\u0026thinsp;=\u0026thinsp;0.38), indicating an unfavorable work environment. Nurses reported inadequate staffing, limited participation in decision-making, and inconsistent infection control practices. The lowest-rated item was \u0026ldquo;Enough registered nurses to provide quality patient care\u0026rdquo; (M\u0026thinsp;=\u0026thinsp;1.79), reflecting severe staffing shortages. Nurses emphasized the need for greater managerial support, structured communication, and targeted infection control training.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eImproving staffing levels, enhancing managerial support, and developing comprehensive infection control protocols are essential to strengthen the nursing work environment and improve nurse satisfaction and care quality during future public health emergencies.\u003c/p\u003e","manuscriptTitle":"Nursing Work Environment and Clinical Nurses’ Perceptions During the COVID-19 Pandemic in South Korea: A Mixed-Method Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 08:31:41","doi":"10.21203/rs.3.rs-6249692/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-06-16T03:57:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139704866414582404159502577351449012537","date":"2025-06-16T03:06:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-30T02:33:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-24T07:23:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-26T07:04:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-25T23:00:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-03-25T22:59:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4c3f87f3-b6b5-4b20-8746-3599c0348c1f","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-07T08:31:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 08:31:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6249692","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6249692","identity":"rs-6249692","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}