INTRODUCTION

Hospital working environment for nurses has been a source of concern for some decades. It has been recognized that a healthy work environment is related not only with positive outcomes for patients but also with job satisfaction, resulting in nursing staff retention⁽¹⁾. A healthy work environment for nurses is the

“perceived existence of structural characteristics and organizational processes that allow them to experience personal wellbeing and satisfaction with their professional and work practice, and which enable them to provide safe and quality care to their patients, thus increasing patient satisfaction with nursing care”⁽²⁾.

Several studies have shown the effect that a healthy work environment has on the quality of care received by the patients, and on the nurses themselves ⁽³⁾. The presence of diseases in nurses ⁽⁴⁾, effects on their mental health, such as depression and anxiety ⁽⁵⁾, as well as job dissatisfaction and thoughts of abandoning the profession, have all been associated with unhealthy work environments⁽⁶⁾.

In 2016, the World Health Assembly stated that, given the shortage of human resources in health worldwide, it is necessary to work on meeting the needs of the healthcare workers ⁽⁷⁾, nurses naturally included. According to this organization, the work environment impacts the ability to retain nursing staff ⁽⁸⁾, leading to potential staff shortages, which could in turn have a negative impact on care quality and patient safety.

In the particular case of Colombia, universities and nursing associations, among others, both individually and collectively, spoke on different occasions regarding the adverse conditions in which Colombian nursing professionals practice the profession, an argument that served as basis for the adoption of the "National Nursing Human Talent Policy and the 2022-2031 Strategic Plan". Some of these conditions, typical of the work environment, were related to low wages, work overload and instability, the underutilization of professionals by assigning administrative functions that distance them from care actions, the use of rotating staff schedules , among others⁽⁹⁾ .

Bearing in mind the significance of nursing work environments, a tool was designed to measure the nursing environment in the Colombian context. This tool, called ENLASA-Enfermeria, was found to be valid and reliable. The purpose of this research was to describe the characteristics of the working environment for nurses in a Colombian university hospital and determine whether there was an association between the sociodemographic and working characteristics of the respondents and their work environment, as well as between the environment and the outcomes for nurses and patients, using the ENLASA-Enfermería tool.

METHOD

Descriptive exploratory study carried out in two sites of a Colombian hospital. The study was approved by the ethics committees of Universidad Nacional de Colombia and of the hospital. All of the nurses doing clinical work (bedside) on inpatient wards (surgery, inpatient services, intensive care units, step-down units, basic inpatient units, obstetrics units) and in all other in-hospital services in the two sites were invited to participate, totaling 139. Of which 117 participated (84%). Information meetings were held with nurses on all shifts and e-mail messages with the invitation to participate in the study were also sent. The form was sent later using the RedCap platform, with pre-scheduled reminders asking the participants to complete the form. Additionally, the researchers communicated personally with the staff on the services, encouraging them to participate. RedCap is a free platform designed by Vanderbilt University in 2004, which allows to manage databases and questionnaires, and is used by thousands of educational centers and companies around the world, given the security it offers of the online data.

Apart from the questions of the ENLASA-Enfermería tool, the questionnaire included sociodemographic and work-related questions, as well as additional items on perceptions regarding outcomes for the patient, the organization and the individual nurse. Participation was anonymous and voluntary. The ENLASA-Nursing instrument is considered valid in terms of face and content validity. In reliability, specifically in terms of internal consistency, Cronbach's Alpha was 0.930 and 0.944 for parts A and B that compose it. In addition, the internal structure made it possible to recognize through the construct validity the conceptual elements of a healthy work environment, which supports its content⁽¹⁰⁾.

The questionnaire was applied between the months of June and August 2022. Data were analyzed using the SPSS, version 27. Frequencies and percentages were derived from sociodemographic and work-related data. The ENLASA-Enfermería data were initially computed using the crude results for the total scores, domains and subdomains and then transformed to derive scores between 0-100 using linear matching. Later, two tiers were formed using the Dalenius-Hodges method to determine scores that would represent a healthy work environment (63 or more points) and those that would correspond to a non-healthy environment (less than 63 points).

Association measures based on Chi-square as contingency coefficient, Phi and Cramer’s V were used for the analysis of the association between the scores on the Enlasa-Enfermeria tool and the sociodemographic characteristics and outcomes for nurses and patients.

RESULTS

The response rate was 84% (117 respondents). Nearly 75% of them were 41 years of age or under, three-fourths were women and 2/3 had only an undergraduate degree; 41.0% had seven years or less of experience, and 69.2% had no direct work agreement with the hospital; 82.1% had worked 10 years or less at the institution; and 84.6% of the respondents worked in inpatient, emergency or intensive care services (see Table 1).

Table 1. Sociodemographic and work-related characteristics of the participants. 

Based on the scores obtained, it was found that the proportion is almost the same between those who consider the work environment healthy and those who do not, since for 49.6% of those surveyed the work environment is unhealthy, while for 50.4% are. (See Table 2).

Tabla 2: Perception of the environment according to the nurses surveyed. 

However, if the average score is considered, the work environment could be recognized as healthy, with a score of 63.13/100, which is barely higher than expected to classify the environment as healthy based on the Dalenius-Hodges method.

The score obtained in the dimension of organizational structural components allows us to affirm that this dimension is considered unhealthy, with a score of 58.3048, while the dimension of organizational processes is considered healthy, with a score of 68.1256.

In the dimension of organizational structural components, three subdimensions obtained scores that allow them to be recognized as unhealthy aspects of the environment: human resources policies (62.2960/100), nursing resource planning, with the lowest score among all the sub-dimensions (42.9487), and that related to remuneration (52.7778). (See Table 3).

In the process dimension, clinical autonomy obtained the lowest and the only score that classifies it as an unhealthy aspect of the environment. (52.6709).

Table 3. Overall, domain an subdomain scores on the ENLASA tool. 

The analysis of the association between the sociodemographic/work-related variables and the perception of the work environment only found a statistically significant (p<0,05), albeit weak (0.260-0.269) association between seniority and the nursing work environment (see Table 4).

Table 4. Association between sociodemographic and work-related variables and the working environment of the nurses. 

Statistically significant, albeit weak associations were found between the nursing work environment and perceived job satisfaction (Phi=0.288, p=0.008), the intention of quitting the job (Phi=0.270; p=0.014); and a moderate association between the environment and the perceived quality of care (Phi=0.337, p=0.001), and work motivation (Phi=0.301; p=0.005) (see Table 5).

Table 5. Associations between the results for nurses and the organization and the working environment. 

DISCUSSION

This work offers a new look into the work environment of nurses in a hospital in Bogota with the help of a measurement tool adjusted to the unique characteristics of professional practice in the colombian context.

This study had the support of a large number of nurses from the organization under study, a group made up mostly of women with only undergraduate training and with a contract through third parties, that is, not directly with the institution.

The results reveal the challenges in the study institution as relates to human resources and nursing staffing plans. The latter has been shown to be a determinant factor for the intention of dropping out from work ⁽¹¹⁾ and that has been made visible in research such as that carried out by Oshodi, which reveals how nurses admit their concern about the pressure to free beds, as if hospitals needed to have beds and not nurses available⁽¹²⁾. It is recognized that the behaviors of the organization determine the workload (and overload) of nurses with measures such as scheduling, the nurse/patient ratio, the hiring of support personnel, among others⁽¹³⁾ .

The low score associated with the compensation subdomain is a finding which deserves special attention because the evidence regarding the impact on nurses is contradictory. Although studies have shown that compensation is a decisive factor when it comes to the decision of changing jobs⁽¹⁴⁾, other evidence shows that the higher the compensation the lower the satisfaction of the nurse, because a higher compensation implies higher training, greater responsibility or expectations and a higher workload, leading to job dissatisfaction⁽¹⁵⁾.

Even so, in the particular case of Colombia, the Collegiate Nursing Organization, based on a study carried out taking salaries between 2001 and 2015, concluded that the profession is undervalued, as well as the years of work experience of these nurses, also pointing out that "the low salaries, and the little difference between the income by area of the profession, reveal a low economic and social recognition, and the subordinate position that nursing has historically occupied.". This is a situation that does not seem to improve over the years and to which little attention has been paid in the hospital setting. In 2018, the average salary of a nursing professional in Colombia was $2,638,410 (Colombian pesos), just over half that of a general practitioner^(16)).

Clinical autonomy, with a score that rates it as an unhealthy aspect of the environment and as the only subdomain rated as unhealthy under the organizational processes domain, confirms the findings of other studies regarding the low level of clinical autonomy that nurses have ⁽¹⁷⁾. The Collegiate Nursing Organization of Colombia has ruled on this issue by referring to the tradition of subordination that has historically accompanied professional practice⁽¹⁶⁾.

In this study no association was found between socio-demographic variables such as age, sex, level of education, years of experience, form of contracting or service/work unit with the perception of the work environment; however, as in other studies, an association was found between the work environment and job satisfaction^(18,19), quality of care^(12,20), intention to quit ⁽²¹⁾ and motivation ⁽²²⁾.

It is noteworthy that no association was found between the perception of the work environment with satisfaction with the profession or with the intention to leave the profession, but it was found with the motivation and intention to quit the job, which would seem to suggest that the respondents recognize that work motivation is associated with the place where one works rather than with the practice of the profession itself. It is also highlighted that there is no association between the commitment to the institution and the perception of the environment, which raises the possibility that the commitment of the professional exceeds the commitment as an employee, that is, that the so-called regulatory "commitment" occurs, in which the professional obligation is the pillar around which the practice revolves, beyond the obligations one has as an employee⁽²³⁾.

CONCLUSIONS

The results of this research are an appeal to Colombian hospitals to recognize the importance of promoting healthy work environments for nurses.

Consistent with what appears to be a worldwide phenomenon, this study confirms that human resources policies and staffing plans, specifically in nursing, continue to be an issue that needs to be addressed, even more so considering that this, like other studies, have shown the key role of the work environment as a determinant of job satisfaction, quality of care, intention to quit the job, and motivation.

Hospital organizations as well as universities training future nursing professionals need to focus on the effects that the work environment has on patients and on the nurses themselves. Participatory mechanisms should be implemented in the future in order to allow nursing leaders to work together with clinical nurses in creating strategies designed to improve the workplace and, consequently, patient outcomes, quality of care, and staff retention in healthcare organizations.

In the particular case of Colombia, the Strategic Nursing Plan 2022-2031, which was adopted by resolution 755 of 2022, proposes an interesting challenge to trade union organizations as well as to advisory bodies on human resources in health of the Ministry of Health and Protection of Colombia with regard to the planning of the nursing resource at the national, regional, local level and of the hospital organizations. It will be imperative to work on research that allows a detailed recognition of the problems and failures that exist in the planning of this resource in hospital organizations, which are not restricted to the nurse/patient ratios and that will surely be required by nursing executives in these organizations. promote the defense of the rights of its professionals.