Nurses’ assessments of the work environment, organisational culture and work arrangements: A cross-sectional study of Estonian hospitals in 1999, 2009 and 2021

doi:10.21203/rs.3.rs-4840924/v1

Download PDF

Research Article

Nurses’ assessments of the work environment, organisational culture and work arrangements: A cross-sectional study of Estonian hospitals in 1999, 2009 and 2021

https://doi.org/10.21203/rs.3.rs-4840924/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

Nurses play a vital role in patient care, and their perceptions of their work environment are crucial for healthcare quality. A supportive and well-resourced work environment enhances the quality of care and increases employee commitment. The physical environment directly influences nurses' well-being and efficiency, while a culture that fosters collaboration and communication is essential for improving patient outcomes and ensuring high-quality care. This study aimed to analyse nurses’ assessments of the work environment, organisational culture and work organisation over three decades (1999, 2009 and 2021) to understand their connection to changes in nursing activities over time.

Methods

A cross-sectional survey methodology was adopted. Descriptive statistical analysis, correlation analysis and logistic regression analysis were conducted via IBM SPSS. These analyses sought to track temporal changes, explore relationships between workforce resources and nursing activities, and investigate the determinants of the perceived nurse-to-patient ratio.

Results

In the work environment domain, the perceived quality of the physical work environment remained stable, although the nurse-to-patient ratio increased insufficiently. Changes in organisational culture yielded improvements in communication and the mental work environment but reductions in the quality of collaboration. With respect to work organisation, a greater standardisation of nursing work emerged over time. The logistic regression analysis indicated that nurses working in regional hospitals and departments with more beds more frequently considered the nurse-to-patient ratio to be insufficient.

Conclusions

The nurses’ views showed that despite the increased health care workforce, the nurse-to-patient ratio was often seen as insufficient. Although the quality of the physical environment either remained stable or improved, organisational culture shifts indicated less group work and greater multiprofessional cooperation. This study underscores the necessity of a comprehensive approach for evaluating the nurse-to-patient ratio, integrating both quantitative and qualitative measures to effectively gauge and improve the nursing work environment.

Work environment

organisational culture

work organisation

nursing practice

nurse-to-patient ratio

Nurses’ extensive skills and higher education, along with an adequate nurse-to-patient ratio, help enhance care quality, increase workforce well-being, reduce health care expenditures and maintain workforce stability [1, 2]. The work environment and culture strongly affect nurse satisfaction and effectiveness. A supportive culture is key for quality health care and patient safety [3, 4].

The physical environment of hospitals is crucial to patient well-being and comfort, promoting a sense of belonging and a calming atmosphere, which are conducive to recovery [5]. Likewise, nurses’ well-being and work efficiency are largely contingent on the physical environment. The environment can either facilitate or hinder improvements in care quality on the basis of workflow and support well-being [6]. The nursing work environment is critical for achieving good patient health outcomes and fostering nurses’ allegiance to their institutions. An environment that is supportive and adequately resourced aids in improving care quality and heightening staff commitment [7–11].

Missed care, which can result in compromised care quality and patient dissatisfaction, is influenced by numerous factors, including the work environment and nurse-to-patient ratio [12]. Addressing these factors can significantly reduce missed care [13]. The issue is complex because care quality is affected by systemic challenges, including efficiency drives and the predominant biomedical model. A persistent nursing shortage contributes to care deficits, adversely impacting patient outcomes [14, 15]. Adequate nurse staffing is critical to enhancing care quality and nursing practice efficacy [16].

The adequacy of the nurse-to-patient ratio is a complex issue. A survey conducted in various European countries found the average number of patients per nurse was 8.4 (range: 5.2–12.7), but this ratio varies depending on the context and requires careful evaluation [17]. Although the number of nurses affects the occurrence of missed care, it is not the only factor to consider when assessing the adequacy of the nurse-to-patient ratio [12]. Various elements must be assessed, including patient care needs and nurse skills, to establish an appropriate ratio [18–21]. Limited staffing might cause nurses to focus on direct care, risking neglect of other duties or indirect care and consequently leading to incomplete or missed care [17].

Organisational culture is a complex system composed of shared values, beliefs, norms and practices that shape job allocation in departments, leadership styles, modes of communication, the psychosocial work environment and collaboration within organisations. In health care, organisational culture impacts nurses’ job satisfaction and is associated with nursing workforce mobility. Consequently, this affects organisational efficiency and care quality [22]. The success of health care institutions largely depends on an organisational culture that fosters communication and teamwork, assisting staff in managing job demands and increasing their motivation [23, 24]. To support nurses’ professional success, nursing leaders can create an inclusive work environment and ensure that necessary resources are available [25]. An effective management and leadership style can significantly improve the work environment by providing organisational support, making nurses feel valued within their team and helping to improve their work quality [26]. Various models of nursing practice exist, such as functional nursing, team or multiprofessional team nursing and primary nursing [27].

Nurses’ work organisation is significantly connected to physical, mental and emotional factors. Understanding and improving these factors are essential for enhancing nurses’ well-being, job satisfaction and patient care [28]. The nursing workload includes direct and indirect nursing activities and tasks not related to patient care, such as student supervision [29, 30]. Direct nursing activities involve interacting with patients and their families, assessing needs, assisting in daily activities and administering medication [30–33]. Indirect nursing activities do not provide direct assistance to patients and include preparing for direct nursing activities, coordinating nursing care, documenting, performing administrative duties and communicating with other health care workers [34, 35]. Nurses’ time allocation for various activities fluctuates on the basis of department characteristics, patient needs and other variables.

The fundamentals of care (FOC) framework offers an integrated approach focusing on nurse–patient relationships to address patients’ multifaceted care needs. The physical dimension encompasses basic patient needs such as hygiene, nutrition and mobility [36–39]. In the mental dimension, the emphasis is on communicating, managing mood fluctuations and monitoring patients’ psyche, creating a calming environment that supports daily routines and is centred around patients [39, 40]. The social dimension concentrates on recognising and responding to patients’ social needs, highlighting nurses’ vital role in meeting their relational needs [41]. Recognising religiosity in relation to patient well-being is also crucial. This entails understanding patients’ faith, engaging in discussions about their life’s meaning and acknowledging their values, thus enabling nurses to offer holistic care, independent of their own religious views [42–44]. The advantage of this approach lies in its clarity and structure, which help prevent care from becoming task- oriented and ensure better consideration of patients’ psychosocial and communication needs, fostering collegial collaboration [45]. Thus, the FOC framework is not only foundational to care but also a tool that enables nurses to sense and respond to all patient needs.

This study aimed to analyse nurses’ assessments of the work environment, organisational culture and work organisation over three decades (1999, 2009 and 2021) to understand their connection to changes in nursing activities over time.

RQ1: How do changes in the physical work environment, nurse-to-patient ratios, shift compositions and particularities, and numbers of beds, doctors and care workers compare across 1999, 2009 and 2021?

RQ2: How do nurses’ assessments reflect the development of organisational culture concerning departmental work distribution, leadership style, communication methods, the mental work environment and collaboration in 1999, 2009 and 2021?

RQ3: What changes have occurred in work organisation, and what is the correlation between workforce resources and time spent on physical, mental, social and religious nursing in 1999, 2009 and 2021?

RQ4: What influences nurses’ perceptions of the adequacy of the nurse-to-patient ratio (insufficient or sufficient)?

A cross-sectional survey was conducted over three years: 1999, 2009 and 2021. The methodology and materials were documented following the Strengthening the Reporting of Observational Studies in Epidemiology guidelines [46].

The study used repeated cross-sectional data, employing a quantitative approach with three surveys conducted in 1999, 2009 and 2021. Data were collected from a consistent demographic, Estonian hospital nurses, although not from the same individuals [47]. This approach enabled the examination of the views of various generations of nurses on organisational culture, the work environment and work organisation, comparing them over time (Table 1). The study involved Estonian hospitals across three phases, starting with 14 hospitals with internal medicine and surgery departments, followed by six hospitals in the second phase and 14 ‘hospital network development plan’ hospitals in the final phase. Methodological consistency was preserved across the three phases by initially using paper questionnaires and later transitioning to electronic versions. Anonymisation assured privacy, and informed consent was obtained via questionnaire completion. The surveys used a consistent tool from the Baltic–Finland NuRsE project, aligned with the Donabedian model, integrating theories relevant to nursing in the Baltic region. The study methodology has been detailed in previous articles [44, 48, 49].

Table 1

Overview of the concepts, variables and corresponding survey questions used in the study
	Type of variables	Variables	Subcategory/indicator		Survey question	Description
Descriptive statistics	Independent	Year	1999, 2009 and, 2021			The years used in the study determine the temporal frame and context for the data.
	Dependent	Work environment	Opinion on the nurse-to-patient ratio		Q19	These indicators reflect the nurses’ assessments of various aspects of nursing practice and their evolution over time, highlighting changes and developments.
			Physical environment of the department		Q31
			Departmental bed count and numbers of nurses, doctors and care workers		Q13–18
			Shift length (hour)		Q22
		Organisational culture	Work distribution in the department		Q29	The elements of organisational culture encompass the nurses’ perspectives on factors that influence their behaviour and the overall effectiveness of the health care institution.
			Main leadership style in department		Q30
			Communication style of department staff		Q32
			Psychosocial work environment of the department		Q33
			Interprofessional collaboration within the department		Q34
		Work organisation	Balance of direct and indirect nursing activities during the day		Q36	Through these indicators, the nurses’ perceptions of work environment quality and teamwork efficacy are evaluated, both of which are crucial for ensuring patient care quality and health care service delivery.
			Primary work drivers in the department		Q35
Pearson correlation			Total shift length	Physical nursing care	Q24
				Mental nursing care	Q25
				Social nursing care	Q26
				Religious nursing care	Q27
	Independent		Departmental bed count and numbers of nurses, doctors and care workers
Logistic regression	Dependent	Nurse-to-patient ratio			Q19	The regression analysis assesses the determinants that shape the nurses’ perceptions of the nurse-to-patient ratio, a crucial aspect for ensuring quality patient care and health care service efficacy.
	Independent		Year
			Work experience, (year)		Q4
			Nursing speciality (no/yes)		Q7
			Workplace		Q10
			Number of beds and nurses		Q13 and 14
			Main leadership style in the department		Q30

The data collection instrument contained 42 questions, focusing on demographic and work-related variables, such as age, experience, workplace and ward. Questions 13–20, 22 and 31 explored nurses’ views of the work environment, departmental setup, bed space numbers, physical conditions, nurse-to-patient ratios and staffing levels. Questions 29, 30 and 32–36 examined opinions on organisational culture, leadership, communication, the psychosocial environment and collaboration. Questions 24–27, 35 and 36 targeted assessments of work conditions and care dynamics. The participants assessed direct and indirect care and the dynamics of departmental work, including the time allocated to physical, mental, social and religious nursing, in relation to workforce resources (Table 1).

The study population consisted of nurses who had at least 1 year of professional experience in the field. The study focused on nurses working in the inpatient departments of general and development plan hospitals across Estonia. A total of 832 nurses participated in three consecutive surveys: Survey I (1999), n = 463; Survey II (2009), n = 198; and Survey III (2021), n = 171.

The data were analysed via IBM SPSS version 22.0 (IBM Corp., Armonk, NY, USA). The analytical methods included descriptive statistics for data summarisation, cross-tabulations for exploring relationships between categorical variables and Pearson’s correlation analyses to assess the strength and direction of associations between numerical variables. Analysis of variance (ANOVA) and the chi-square test were used to identify disparities across the survey years and among the sociodemographic factors and test the statistical significance of these differences. Additionally, regression analysis was conducted to assess the dependency relationships between variables and predict outcomes. Logistic regression analysis was performed to investigate nurses’ perceptions of the adequacy of the nurse-to-patient ratio. The independent variables were binary and encoded as 0 (insufficient) or 1 (sufficient). Correlations between independent variables were analysed to check for multicollinearity. A significant correlation was found between the numbers of doctors and care workers and between the numbers of care workers and nurses. Consequently, the number of nurses and their work experience were excluded from the analysis. The relationships between the numerical variables and logarithm of the odds were examined via the Box–Tidwell method to ensure linearity. All transformations were statistically nonsignificant and thus included in the analysis. Outliers, such as exceedingly large numbers of beds or nurses, were removed from the analysis. Owing to missing values, 18.8% of the sample was excluded from the regression model. Model fit was assessed via the Cox and Snell R square and Nagelkerke R square tests, with values expected to exceed 0.05. The significance level was set at α = 0.05, with a p value below this threshold deemed statistically significant.

The findings indicated shifts over time in the sample demographic and employment characteristics (Table 2). The nurses demonstrated an increase in age and work experience over time years. By 2021, the proportion of older nurses notably increased, with the average age increasing from 36.3 to 43.2 years, and the number of nurses with more than 20 years of experience also increased. In contrast, the number of younger nurses significantly decreased. The average work experience increased by nearly 3 years, with the maximum number of years of experience rising from 47 to 55 in 2009, after which it declined to 52 years by 2021.

Table 2

Demographic and work-related variables of nurses in 1999, 2009, and 2021
	1999			2009			2021
	n	%	Mean/max/SD	n	%	Mean/max/SD	n	%	Mean/max/SD
Age			36.3/66.0/11.2			40.9/73.0/11.2			43.2/72.0/12.1
21–30	210	41.6		44	21.3		44	20.8
31–40	134	26.5		69	33.3		44	20.8
41–50	91	18		55	26.6		68	32.1
≥ 51	70	13.9		39	18.8		56	26.4
Work experience, (year)			15.5/47.0/11.1			19.0/55.0/12.3			18.4/52.0/13.4
1–5	114	22.4		34	16.7		52	24.5
6–10	140	27.6		61	29.9		36	17.0
11–20	104	20.5		30	14.7		32	15.1
≥ 21	105	29.5		79	38.7		92	43.4
Workplace
Regional hospital	104	21.1		52	24.8		112	52.8
Central hospital	92	18.7		64	30.5		64	30.2
Other	296	60.2		94	44.8		36	17.0
SD, standard deviation

Temporal changes were noted within the departments’ work environments (Table 3). ANOVA revealed significant differences (p < 0.001) across all variables cross the years. The average number of beds decreased from 35.0 in 1999 to 25.3 in 2021. The number of nursing positions increased from 12.6 in 1999 to 16.9 in 2021. The number of doctor positions steadily increased from 5.1 in 1999 to 7.3 in 2021. The number of care worker positions rose from 9.4 in 1999 to 13.6 in 2021. The length of work shifts has generally remained stable, fluctuating from 13.0 hours in 1999 to 13.3 hours in 2021.

Table 3 shows that the nurses’ opinions on the adequacy of the nurse-to-patient ratio significantly changed (p < 0.001). The proportion of nurses considering the ratio to be sufficient decreased from 30.4–25.0%, whereas that of nurses deeming it insufficient increased from 36.7–43.9%. The nurses’ assessments of the physical work environment within their departments remained relatively stable (p < 0.637), with most nurses rating it as either good or satisfactory.

Table 3

Nurses’ assessments of health care facility resources, workforce dynamics and the organisational work environment in 1999, 2009 and 2021
	Year						p value*
	1999		2009		2021
	n	%	n	%	n	%
Adequacy of the nurse-to-patient ratio
Enough	153	30.4	61	29.8	53	25.0	0.000
Fairly enough	166	32.9	80	39.0	66	31.1
Not enough	185	36.7	64	31.2	93	43.9
Physical environment of the department				0.0		0.0
Good	211	41.5	85	40.9	90	42.5	0.637
Poor	20	3.9	5	2.4	11	5.2
Satisfactory	277	54.5	118	56.7	111	52.4
Work distribution in the department
According to the group work model	215	43.1	120	59.1	83	39.2	0.000
According to the primary nursing model	60	12.0	13	6.4	17	8.0
According to tasks	151	30.3	41	20.2	67	31.6
According to the multiprofessional teamwork model	22	4.4	18	8.9	35	16.5
Any combination	51	10.2	11	5.4	10	4.7
Main leadership style in the department
The leadership style is based on patients’ needs	135	27.7	66	33.2	57	26.9	0.057
Nurses’ opinions are taken into consideration	216	44.4	92	46.2	112	52.8
Orders come only from superiors	136	27.9	41	20.6	43	20.3
Communication style of department staff
Good	82	16.2	42	20.3	93	43.9	0.000
Poor	51	10.1	9	4.3	25	11.8
Satisfactory	373	73.7	156	75.4	94	44.3
Psychosocial work environment of the department
Good	186	36.5	77	36.5	95	44.8	0.034
Poor	30	5.9	12	5.7	20	9.4
Satisfactory	294	57.6	122	57.8	97	45.8
Interprofessional collaboration within the department
Good	203	40.0	98	46.7	54	25.5	0.000
Poor	24	4.7	3	1.4	12	5.7
Satisfactory	281	55.3	109	51.9	146	68.9
Primary work drivers in the department
A daily and weekly routine programme	98	19.6	38	18.4	68	32.1	0.002
Individual needs of patients assessed by nurses	323	64.5	139	67.5	111	52.4
Negotiation with patients based on their needs	80	16.0	29	14.1	33	15.6
Balance of direct and indirect nursing activities during the day
Equal time used for indirect and direct nursing	313	62.4	138	67.6	125	59.0	0.000
More time used for direct nursing	113	22.5	27	13.2	30	14.2
More time used for indirect nursing	76	15.1	39	19.1	57	26.9
Departmental bed count	35.0		27.2		25.3		0.000
Shift length (hour)	13.0		11.2		13.3		0.000
Department staffing
Number of nurses	12.6		12.9		16.9		0.000
Number of doctors	5.1		5.5		7.3		0.000
Number of care workers	9.4		10.4		13.6		0.000
* The mean difference is significant at the 0.05 level.

The study revealed changes in nurses’ perceptions of their departments’ organisational culture. The work distribution shifted notably, with group work model use declining from 59.9–39.2%. The communication quality improved, with the percentage of ‘good’ ratings rising from 16.2–43.9%. The psychosocial environment also led to an increase in ‘good’ ratings, from 36.5–44.8%. However, the rate of ‘good’ cooperation decreased to 25%, whereas that of ‘satisfactory’ cooperation rose to 68.9% (Table 4). Over time, the nurses shifted towards routine-based work, from 19.6–32.1%, reducing the focus on individual patient needs. The perceived time for indirect care rose from 15.1–26.9%, indicating an increase in administrative duties over direct patient care (Table 4).

Table 4

Correlation matrix of nurses’ assessments of hospital workforce resources and proportions of time spent on physical, mental, social and religious nursing in 1999, 2009 and 2021
				Number of			Proportion of total shift length spent on
				nurses	doctors	care workers	physical	mental	social	religious
				in the department			nursing care
1999	Number of	beds	in the department	0.258^a	0.262^a	0.348^a	−0.071	0.199^a	−0.117	−0.024
		nurses			0.474^a	0.660^a	−0.032	0.087	−0.057	0.013
		doctors				0.317^a	0.025	0.068	−0.087	−0.094
		care workers					0.006	0.054	−0.061	−0.037
2009		beds		0.160^b	-0.044	0.512^a	−0.084	−0.063	0.204^a	0.027
		nurses			0.393a	0.479^a	0.021	-0.178^b	0.096	0.213^a
		doctors				−0.186^b	−0.186^b	0.0493	0.168^b	0.210^a
		care workers					0.091	−0.199^b	0.095	−0.030
2021		beds		0.087	0.011	0.422^a	−0.047	−0.032	0.095	0.129
		nurses			0.487^a	0.450^a	0.018	0.084	−0.135	−0.062
		doctors				0.426^a	0.023	0.068	−0.132	−0.028
		care workers					−0.138	0.146	0.085	−0.032
^a The correlation is significant at the 0.01 level (two-tailed).
^b The correlation is significant at the 0.05 level (two-tailed).

Throughout the study, moderate positive correlations were found between the numbers of beds and care workers, which fluctuated each year. Variations appeared in the correlation between the numbers of beds and doctors, which were moderate in 1999 and absent by 2021. The number of nurses positively correlated with the numbers of both doctors and care workers over the years, although the strength of these correlations varied. The study revealed weak correlations between hospital resources, such as the number of beds and staffing, and the extent of nursing activities. The highest positive correlation coefficient was 0.204, whereas the most significant negative correlation coefficient was − 0.138. The correlations did not exceed the weak threshold of 0.3, suggesting that there was no pronounced relationship across all years.

Table 5

Determinants of nurses’ assessments of the nurse-to-patient ratio: logistic regression analysis
Variable in the equation
		Sig.	Exp(B)
Year	2021	0.085
	1999	0.027	1.665
	2009	0.145	1.432
Work experience (year)		0.355	1.006
Nursing specialty (no/yes)		0.481	0.891
Workplace	Other	0.088
	Regional hospital	0.030	0.646
	Central hospital	0.199	0.768
Department (medical/surgical)		0.279	0.838
Number of nurses in the department		0.995	1.000
Number of beds in the department		0.000	0.963
Main leadership style in the department	Orders come only from superiors	0.017
	The leadership style is based on patients’ needs	0.285	0.798
	Nurses’ opinions are taken into consideration	0.099	1.366
The Cox and Snell R square is 0.081, and the Nagelkerke R square is 0.110.

The factors influencing nurses’ perceptions of the adequacy of the nurse-to-patient ratio were also evaluated. Various organisational and temporal factors correlated with these perceptions (Table 5). A significant determinant of the nurses’ assessments was the year. The likelihood of nurses deem the nurse-to-patient ratio sufficient was significantly greater in 1999 than in 2021 (Exp(B) = 1.665). The type of hospital was also a significant factor in nurses’ judgments, with those in regional hospitals being more likely to consider the nurse-to-patient ratio insufficient (Exp(B) = 0.646). The size and structure of the department also had an impact. More beds in a department increased the likelihood of the nurse-to-patient ratio being deemed insufficient (Exp(B) = 0.963). Other characteristics included in the logistic regression model did not emerge as statistically significant influences.

This study focused on analysing and understanding changes in the work environment, organisational culture and work organisation from nurses’ perspectives over three decades. Improving in the work environment and optimising staff ratios are crucial steps to reduce missed care and support positive health outcomes [13]. A better work environment can lessen mental and physical fatigue among staff, consequently enhancing the quality of patient care [9–11]. The physical environment in nursing impacts practice, communication, teamwork and patient well-being [5]. Within the scope of this research, no significant changes were observed in the nurses’ assessments of the physical work environment, suggesting that although the workload and number of staff changed over time, the quality of the work environment was either maintained or even improved. This finding aligns with the FOC framework, which underscores the importance of an appropriate work environment to support nurses in their practice and meet the diverse needs of patients [36–38].

The present study revealed that departmental structure and workforce composition evolved during the study period on the basis of nurses’ perceptions. A decrease in the number of beds and an increase in the number of doctors reflect technological advancements, health care service organisation and policy adaptation. The increase in the number of staff, including care workers, underscores the growing importance of supportive care. The analysis did not reveal strong correlations between the numbers of beds and care workers in any given year. The number of nurses and doctors has increased, particularly in regional hospitals, which may reflect a heightened need for qualified health care professionals. The correlation between the numbers of nurses and doctors was also strong in 2009, weakening by 2021 yet remaining positive. This finding indicated that although the numbers of nurses and doctors increased, they did so proportionally, suggesting coordinated workforce growth. The increase in the number of care workers points to an increase in workload or service expansion. Concerningly, the perceived adequacy of the nurse-to-patient ratio declined, and the rating of ‘insufficient’ ratios increased. Adequate nursing staff is essential for ensuring quality care and improving health outcomes [16]. The study highlights a gap between nurses’ perceptions and quantitative changes in health care staffing: Despite increased numbers, a gap in meeting patient care demands remains. This discrepancy may affect patient safety and care quality, underscoring the crucial impact of the nurse-to-patient ratio on health care outcomes and the satisfaction of patients and nurses alike. These findings suggest the need to reevaluate staff allocation to ensure effective patient care [14, 15, 50–53].

Throughout the study years, changes in the physical work environment, nurse-to-patient ratios and numbers of beds, doctors and care workers occurred. All of these factors impact the work environment as perceived by nurses. The perceived adequacy of the nurse-to-patient ratio decreased despite an increase in the number of staff, indicating a need for continuous efforts to optimise the work environment and staff ratio to ensure the quality of care and well-being of staff.

The evolution of organisational culture, as experienced by nurses, provides valuable insights into the changing landscape of health care. Our study revealed significant shifts in nurses’ assessments of work distribution, communication, the psychosocial work environment and collaboration within departments. Understanding organisational culture and addressing its associated challenges are essential for improving productivity and care quality in health care organisations [22].

A notable finding is the decreased use of the group work model and the increased adoption of the multiprofessional teamwork model. The shift away from group-centric task distribution may indicate a trend towards personalised nursing practice involving various health care specialists, aligning with modern health care models that favour comprehensive care delivery. According to the third dimension of the FOC framework, a diverse set of political and systemic factors shape a care environment focused on relationship-building and coordinated care [36, 54]. Unlike previous isolated approaches, the focus is now on the multifaceted aspects of patient care. The significant improvement in the ratings for communication style is encouraging because effective communication is crucial for the safety of patients and the efficient functioning of health care teams. This may reflect targeted interventions to improve communication skills and interdepartmental information exchange, suggesting a supportive organisational culture that fosters open dialogue and information sharing. The success of health care institutions often hinges on an organisational culture that supports communication, teamwork and social support, aiding staff in managing job demands and increasing their motivation [23, 24].

The improvements in the ratings for the psychosocial work environment are also significant. Efforts to enhance the mental and emotional aspects of the work environment were acknowledged by the nurses. A psychosocially supportive work environment is necessary for nurses’ well-being and can affect job satisfaction, staff retention and patient care quality [3, 4], thus reducing missed care [13]. Conversely, good ratings for collaboration within departments significantly decreased, whereas the satisfactory ratings increased. This finding could indicate a recalibration of collaboration expectations or a broader acceptance of mediocrity. Understanding the reasons behind the decline in collaboration ratings is essential for ensuring effective health care services. Herein, the nurses’ perspectives on leadership style within their departments indicated a gradual shift towards more open and participatory management styles. Although the changes were not statistically significant, the nurses perceived notable progress. This outcome may suggest a gradual movement towards more democratic and participatory management methods in health care institutions, potentially enhancing nurses’ job satisfaction and involvement.

Our study underlines the need for balanced autonomy and teamwork in organisational culture, robust communication and a nurturing psychosocial work environment for quality health care. Effective teamwork is key to navigating health care complexities and delivering superior care. The FOC framework promotes holistic care, integrating physical, psychological, social and spiritual elements and aligning care with patients’ fundamental needs for overall well-being [36, 44]. The approach is validated by studies by Halvorsen et al. [37], Kitson [36] and Kitson et al. [38], who reported that care quality improves when it is aligned with patients’ basic needs and overall well-being.

The study indicated a pivot to routine-focused work organisation by 2021, despite a commitment to patient-centred decisions. Over time, the balance shifted from equal time for direct and indirect care to more administrative tasks by 2021. This finding reflects the evolving role of nursing and shifts in the health care sector, underscoring the critical nature of effective resource and time management for quality patient care.

Although the correlations were generally weak, the data from 1999 revealed a noticeable correlation between more beds and more time spent on mental nursing. This relationship suggests that resource expansion may have supported a more thorough approach to patients’ mental health needs, in line with the FOC framework [36–38]. However, the observed decrease in the time spent on physical and social nursing may indicate changes in work organisation or a shift in the focus of patient care due to various factors, including changes in staff and patient ratios. Within the context of the FOC framework [36–38], nurses’ work organisation, encompassing both direct and indirect care tasks [29–35, 55], is vital for patients’ physical, mental and social well-being. Assessing how nursing staff can most effectively use their time to cover all patient needs, following the FOC framework, is necessary. The growing importance of religious nursing, which has remained a critical component of practice [43, 44], suggests that nurses must find ways to integrate patients’ religious needs as part of their comprehensive care. This reflects broader societal expectations that demand that the health care system promote not only physical health but also mental health and well-being. Nursing work organisation must be flexible and adapt to both resource and health policy changes to ensure comprehensive and patient-centred care [28, 29, 34, 35]. The changes in work organisation highlighted in this study are consistent with the FOC framework, emphasising the importance of nurse–patient relationships.

The present findings provide insights into nurses’ assessments of the optimal nurse-to-patient ratio (sufficient vs insufficient), highlighting several factors that influence this judgment. Notably, time had a significant impact: the nurses in 1999 were more likely to consider the nurse-to-patient ratio sufficient than those in 2021were. This result may indicate a negative shift in nursing conditions and the availability of resources over the study period.

The study underscores the significant impact of the type of hospital, with nurses working in regional hospitals more frequently perceiving the nurse-to-patient ratio as insufficient. This is confirmed by the influence of department size and structure: the nurses in larger departments felt a greater shortage of staff. Therefore, departmental resources and management styles affect nurses’ perceptions of their work environment, influencing their job satisfaction and care quality. The complexity of work organisation, involving both direct and indirect nursing, is critical [28–35, 55]. These findings support the view that optimising the staff-to-patient ratio is crucial for minimising missed care and ensuring quality care [12, 17]. The nurse-to-patient ratio differs across Europe, making regular evaluation and improvement essential, considering regional specifics and demands. Finding the ideal ratio requires considering factors such as staff availability and patient needs [17–21]. Evaluating the nurse-to-patient ratio demands a nuanced, context-sensitive method, that incorporates qualitative aspects of the work environment and organisational culture alongside quantitative measures to enhance care quality and nursing practice.

The study’s robustness stems from its repeated cross-sectional methodology, which offers an in-depth observation of nursing practices and the work environment across different times. It surveyed nurses’ experiences and insights, capturing health care’s changing landscape in 1999, 2009 and 2021. However, the main constraint is the low response rate, possibly affecting the broad applicability of the findings. Variations in health care during these times might have also altered the participant pool. The investigation pursued an all-encompassing review of nursing activities, yet some elements might remain unexplored due to the nature of surveys. Furthermore, the data relied heavily on nurses’ subjective judgments. Future studies should explore more nuanced ways to document and interpret nurses’ experiences. In the final phase, the COVID-19 pandemic might have influenced the response rates and shifted the focus from certain patient needs due to the exceptional situation. Despite these factors, the insights obtained from the findings are significant.

Despite the evolution of work dynamics and resource availability, the nurses consistently rated their physical work settings positively. However, increasing concerns exist regarding the adequacy of the nurse-to-patient ratio, despite a general increase in health care staffing. Shifts towards more integrated teamwork and away from traditional group work models were noted, emphasising the importance of balancing independence with teamwork, fostering communication and nurturing a supportive psychosocial work environment. Ultimately, the study validates the complexity of assessing the nurse-to-patient ratio, which must consider quantitative data as well as qualitative aspects of work conditions, resources and organisational culture.

Acknowledgements

We would like to express our gratitude to all the participants in this study and to Birgit Aasmäe for her statistical support and advice. This article was supported in part by language translation and phrasing assistance provided by OpenAI’s language model, ChatGPT-4. The manuscript was professionally reviewed and edited by two editors from Cambridge Proofreading to ensure the accuracy and clarity of the presented content.

Author contributions

All authors made a significant contribution to the work reported UK: conceptualisation, methodology, formal analysis, investigation, data curation, writing – original draft, writing – review and editing, and visualisation. MS: conceptualisation, resources, writing – review and editing, and supervision. ÜE: conceptualisation, methodology, data curation, resources and writing – review and editing.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

The full anonymity of the participants was guaranteed. The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study was reviewed and approved by the Research Ethics Committee of the University of Tartu, with approval numbers 332/T-21 21.12.2020 and 345/M-7 14.06.2021. In according with the Estonian legal system, Surveys I and II required written or verbal permission from the institutions involved in the study. All participants provided informed consent to participate in the study. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no conflicts of interest.

Leary A, Tomai B, Swift A, Woodward A, Hurst K. Nurse staffing levels and outcomes – mining the UK national data sets for insight. Int J Health Care Qual Assur. 2017;30(3):235–47.
McHugh M, Aiken D, Windsor LH, Douglas C, Yates C. P: Case for hospital nurse-to-patient ratio legislation in Queensland, Australia, hospitals: an observational study. BMJ Open 2020, 10(9).
Firmanda GI, Ahsan A, Lestari R. Impact of organizational culture and job satisfaction on nurse performance in general hospital: a path analysis. Jurnal Aisyah: Jurnal Ilmu Kesehatan. 2023;8(1):6.
Potrebny T, Igland J, Espehaug B, Ciliska D, Graverholt B. Individual and organizational features of a favorable work environment in nursing homes: a cross-sectional study. BMC Health Serv Res. 2022;22(1):1244.
Hjorhöy LG, Thomsen TG, Beck M. Physical environment as a tool in caring for the hospitalized patient: a qualitative study of nurses’ experiences in hospitals. HERD – Health Env Res. 2022;15(3):143–53.
De Brehmer LCdF AP, Ramos FRS, Canever BP, Manfrini GC, Bozzetti GP. Healthy work environments in the perception of nursing professors and students. J Nurs Educ Pract 2023, 13(7).
Aiken LH, Sloane DM, Barnes H, Cimiotti JP, Jarrín OF, McHugh MD. Nurses’ and patients’ appraisals show patient safety in hospitals remains a concern. Health Aff. 2018;37(11):1744–51.
Lake ET, Sanders J, Duan R, Riman KA, Schoenauer KM, Chen Y. A meta-analysis of the associations between the nurse work environment in hospitals and 4 sets of outcomes. Med Care. 2019;57(5):353–61.
Lasater KB, Aiken LH, Sloane DM, French R, Martin B, Reneau K, Alexander M, McHugh MD. Chronic hospital nurse understaffing meets COVID-19: an observational study. BMJ Qual Saf. 2021;30(8):639–47.
Sloane DM, Smith HL, McHugh MD, Aiken LH. Effect of changes in hospital nursing resources on improvements in patient safety and quality of care. Med Care. 2018;56(12):1001–8.
Wynendaele H, Willems R, Trybou J. Systematic review: association between the patient–nurse ratio and nurse outcomes in acute care hospitals. J Nurs Manag. 2019;27(5):896–917.
Griffiths P, Recio-Saucedo A, Dall'Ora C, Briggs J, Maruotti A, Meredith P, Smith GB, Ball J. The association between nurse staffing and omissions in nursing care: a systematic review. J Adv Nurs. 2018;74(7):1474–87.
Lake ET, Riman KA, Sloane DM. Improved work environments and staffing lead to less missed nursing care: a panel study. J Nurs Manag. 2020;28(8):2157–65.
Martsolf GR, Gibson TB, Benevent R, Jiang HJ, Stocks C, Ehrlich ED, Kandrack R, Auerbach DI. An Examination of Hospital Nurse Staffing and Patient Experience with Care: Differences between Cross-Sectional and Longitudinal Estimates. Health Serv Res. 2016;51(6):2221–41.
Kalisch BJ, Tschannen D, Lee KH. Do staffing levels predict missed nursing care? Int J Qual Health C. 2011;23(3):302–8.
Cho SH, Lee JY, You SJ, Song KJ, Hong KJ. Nurse staffing, nurses prioritization, missed care, quality of nursing care, and nurse outcomes. Int J Nurs Pract 2020, 26(1).
Ausserhofer D, Zander B, Busse R, Schubert M, De Geest S, Rafferty AM, Ball J, Scott A, Kinnunen J, Heinen M, et al. Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ Qual Saf. 2014;23(2):126–35.
Lake ET, Riman KA, Lee CS. The association between hospital nursing resource profiles and nurse and patient outcomes. J Nurs Manage. 2022;30(3):836–45.
Junttila JK, Haatainen K, Koivu A, Nykänen P. How the reliability and validity of the patient classification system can be ensured in daily nursing work? A follow-up study. J Clin Nurs. 2023;32(13–4):3720–9.
Lee SH, Lee H, Yu S. Factors associated with nursing needs and nursing hours in acute care hospital settings: a cross-sectional study. J Nurs Manag. 2022;30(6):2005–14.
Ko Y, Park B. Calculating the optimal number of nurses based on nursing intensity by patient classification groups in general units in South Korea: a cross-sectional study. Nurs Open. 2023;10(6):3982–91.
Pedrosa J, Sousa L, Valentim O, Antunes V. Organizational culture and nurse’s turnover: a systematic literature review. Int J Healthc Manag. 2021;14(4):1542–50.
Tawfik DS, Profit J, Webber S, Shanafelt TD. Organizational factors affecting physician well-being. Curr Treat Options Pediatr. 2019;5(1):11–25.
Zhu X, Kunaviktikul W, Sirakamon S, Abhicharttibutra K, Turale S. A causal model of thriving at work in Chinese nurses. Int Nurs Rev. 2021;68(4):444–52.
Zhai Y, Cai S, Chen X, Zhao W, Yu J, Zhang Y. The relationships between organizational culture and thriving at work among nurses: the mediating role of affective commitment and work engagement. J Adv Nurs. 2023;79(1):194–204.
Al-Hamdan Z, Manojlovich M, Tanima B. Jordanian nursing work environments, intent to stay, and job satisfaction. J Nurs Scholarsh. 2017;49(1):103–10.
Fawcett J. Thoughts about models of nursing practice delivery. Nurs Sci Quart. 2021;34(3):328–30.
Ferramosca FMP, De Maria M, Ivziku D, Raffaele B, Lommi M, Tolentino Diaz MY, Montini G, Porcelli B, De Benedictis A, Tartaglini D, Gualandi R. Nurses´ organization of work and its relation to workload in medical surgical units: a cross-sectional observational multi-center study. Healthcare. 2023;11(2):156.
Alghamdi MG. Nursing workload: a concept analysis. J Nurs Manag. 2016;24(4):449–57.
Fagerström L, Vainikainen P. Nurses’ experiences of nonpatient factors that affect nursing workload: a study of the PAONCIL instrument's nonpatient factors. Nurs Res Pract. 2014;2014:167674.
Fitch MI, Fliedner MC, O'Connor M. Nursing perspectives on palliative care 2015. Ann Palliat Med. 2015;4(3):150–5.
Yu P, Song L, Qian S, Yao X, Huang J, Min L, Lu X, Duan H, Deng N. Work pattern of neurology nurses in a Chinese hospital: a time and motion study. J Nurs Manag. 2019;27(2):320–9.
Hale A, Barton B, Serino-Cipoletta J, Sheldon Y, Vessey JA. Direct care nurses’ perceptions of their roles in clinical research: an integrated review of the literature. J Nurs Scholarsh. 2022;54(1):104–16.
Brady AM, Byrne G, Horan P, Griffiths C, MacGregor C, Begley C. Measuring the workload of community nurses in Ireland: a review of workload measurement systems. J Nurs Manag. 2007;15(5):481–9.
Asvad F, Adel Mehraban M, Rasouli M. Indirect patient care by nurses in the intensive care unit of a hospital in Iran during the COVID-19 pandemic. Iran J Nurs. 2022;35(139):478–89.
Kitson AL. The fundamentals of care framework as a point-of-care nursing theory. Nurs Res. 2018;67(2):99–107.
Halvorsen K, Jensen JF, Collet MO, Olausson S, Lindahl B, Sætre Hansen B, Lind R, Eriksson T. Patients’ experiences of well-being when being cared for in the intensive care unit—an integrative review. J Clin Nurs. 2022;31(1–2):3–19.
Kitson A, Conroy T, Kuluski K, Locock L, Lyons R. Reclaiming and redefining the fundamentals of care: nursing’s response to meeting patients’ basic human needs: School of Nursing, Faculty of Health Sciences. South Australia: The University of Adelaide; 2013.
Rautava-Nurmi H, Westergård A, Henttonen T. Hoitotyön taidot ja toiminnot. Sanoma Pro OY; 2016.
Meriläinen M. Tehohoitopotilaan hoitoympäristö: psyykkinen elämänlaatu ja toipuminen. Oulu: Oulun yliopisto; 2012.
Hull D. Clinical trial: physical, psychological and social needs of patients. Br J Nurs. 2013;22(2):76–80.
Flinck A. Hengellisyys hoitotyössä–palvelemista potilaan ehdoilla. Viesti 2012:4–6.
Karaman E, Erkin Ö, Göl İ. The relationship between spiritual care levels of turkish nurses with the spiritual well-being of their patients: an exploratory study. J Relig Health. 2022;61(3):1882–93.
Korgemaa U, Sisask M, Ernits U. Daily nursing activities in relation to patient well-being: a serial cross-sectional study. P Est Acad Sci. 2023;72(3):277–89.
van Belle E, Giesen J, Conroy T, van Mierlo M, Vermeulen H, Huisman-de Waal G, Heinen M. Exploring person-centred fundamental nursing care in hospital wards: a multi-site ethnography. J Clin Nurs. 2020;29(11–2):1933–44.
Vandenbroucke JP, von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, Poole C, Schlesselman JJ, Egger M. Initiative ftS: Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Epidemiol. 2007;18(6):805–35.
Wang X, Cheng Z. Cross-Sectional Studies: Strengths, Weaknesses, and Recommendations. Chest. 2020;158(1):S65–71.
Kõrgemaa U, Sisask M, Ernits Ü. Nurses retrospective view on nursing education: a repeated cross-sectional study over three decades. Heliyon 2024, 10(4).
Ernits Ü. Viron hoitotyön kehittyminen ja muotoutuminen yhteiskunnallisessa muutoksessa: seurantatutkimus. Tampere: Tampere University; 2018.
Jones TL, Hamilton P, Murry N. Unfinished nursing care, missed care, and implicitly rationed care: state of the science review. Int J Nurs Stud. 2015;52(6):1121–37.
Aiken LH, Cimiotti JP, Sloane DM, Smith HL, Flynn L, Neff DF. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care. 2011;49(12):1047–53.
Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. New Engl J Med. 2011;364(11):1037–45.
Griffiths P, Ball J, Drennan J, Dall'Ora C, Jones J, Maruotti A, Pope C, Recio Saucedo A, Simon M. Nurse staffing and patient outcomes: strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development. Int J Nurs Stud 2016, 63:213–225.
Feo R, Kumaran S, Conroy T, Heuzenroeder L, Kitson A. An evaluation of instruments measuring behavioural aspects of the nurse–patient relationship. Nurs Inq. 2022;29(2):e12425.
McCloskey JC, Bulechek GM. In: Nursing interventions classification (NIC). edn.; 2000: 911.

No competing interests reported.

Download PDF

Reviewers invited by journal
08 Aug, 2024
Editor invited by journal
06 Aug, 2024
Editor assigned by journal
06 Aug, 2024
Submission checks completed at journal
06 Aug, 2024
First submitted to journal
01 Aug, 2024

You are reading this latest preprint version

Nurses’ assessments of the work environment, organisational culture and work arrangements: A cross-sectional study of Estonian hospitals in 1999, 2009 and 2021

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Background

Methods

Results

Discussion

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1