This study provides evidence from the healthcare system in Malaysia, specifically from the private sector, which had complained about a high number of adverse events. The study results were supported and contributed to the Donabedian theory and SEIPS model, . Hence, the study model provided insights into providing quality and safe patient care and its associations with the structural and process indicators. The results revealed several factors were associated with enhancing quality or mitigating patient harm. Furthermore, the results provided an insight into the role of a healthy work environment in supporting person-centeredness for improving quality and safety in the private hospitals in Malaysia. This expands the SEIPS model by focusing on the patient journey in a work system  and shifting to the human-centered system, considering the needs of patients and providers simultaneously. Therefore, focusing on the patient and providers' journey in a work system.
The results presented the associations of nurses’ demographics and practice characteristics in relation to the nurse work environment, person-centeredness, quality, and patient safety. Senior nurses, in terms of age and years of experience, perceived high quality of care. The fact that they have high patient responsibilities and more substantial experience could explain that they have greater work expectations and perceived higher quality of care . Furthermore, ethnic Malay nurses perceived a more favorable work environment and rated quality and patient safety higher than Chinese nurses. However, decreasing disparities between ethnic groups is challenging . These results provide dual considerations to be addressed in future research. First is an in-depth understanding of these associations to decrease disparities between ethnic groups. Second, patient-nurse relationships and treatment of minorities are critical, and future research should address them.
In support of previous studies, the practice characteristics of this study indicated that nurses with a high workload in terms of duty length and patient ratio perceived a less preferable practice environment and were less likely to integrate patient preferences and more likely to come across adverse events in their respective units. Previous studies have indicated that a larger number of patients per nurse and working longer shifts were negatively associated with practice outcomes, , .
The Hayes Macro regression models provide meaningful results that can afford insights into the importance of the nurse work environment in enhancing person-centered care and consequently improving quality and patient safety. The first result indicated that nurse participation in hospital affairs indirectly affects the quality and patient safety through person-centeredness. This means that nurses with greater participation in hospital affairs have a higher degree of person-centeredness, which, in turn, improves both quality and patient safety.
Previous studies support these findings. Per the American Association of Critical-Care Nurses (AACN) report (2005), ensuring effective staff participation and patient and family education is required to improve quality and patient safety. Nurses with high participation and involvement have high practice and clinical outcomes, . Similarly, in the Malaysian healthcare sector, employee involvement and participation are important factors to optimize care outcomes . Furthermore, increasing nurses’ participation and enhancing their job engagement would reduce their physical and emotional exhaustion . Therefore, they will be more likely to integrate patient preferences in their workplace. Hence, if nurses address the needs and interests of patients, this focus helps prevent patient harm and improve the quality of care .
The second result indicated that person-centeredness significantly mediates the effect of nurse foundation for the quality of care on both the quality and patient safety. Simultaneously, the c′ path of the effect of a nurse’s foundation for the quality of care indicates a significant and positive effect on the quality of care and an insignificant effect on patient safety. This explains the inconsistency in previous studies. The nurse work environment dimensions were inconsistently related to care outcomes , , and a mediator variable is required to interpret these associations.
According to the AHRQ, nurse managers should engage more nurses in quality improvement programs and continuous education and training for improving quality and patient safety . For instance, nurses involved in reducing medication error programs were spending a longer time for medication preparation and patients’ orientation , which helped improve care outcomes. Similarly, an interventional study in 15 wards in Malaysian hospitals found that nursing education and training were effective tools in improving the safety climate . These findings support our assumption that a nurse foundation for quality of care as a structural factor affects care outcomes through nurse perceived person-centeredness as a process factor. Therefore, implementing a quality improvement program, upgrading equipment and extensive training can improve the structure, process, and outcome quality. Hence, a nurse foundation for quality of care reduces nurse burnout and emotional distress . Thus, nurses are more likely to integrate patient preferences, which in turn help in providing quality and safe patient care.
The third result indicated that person-centeredness mediates the effect of a nurse manager’s ability, leadership, and support on both quality and patient safety. Nurses with a skilled and supportive leader have a higher degree of person-centeredness to integrate patient preferences, which, in turn, improves both quality and patient safety. Previous literature has reported that trained and skilled leaders are required to improve the quality and patient safety ; and enhance teamwork and person-centeredness . According to the AHRQ, skilled leaders, effective decision-making, and collaboration are all required to sustain a healthy work environment. Furthermore, a comparative correlational survey in England and Malaysia found that Malaysian nurses were more obliged to their managers . Therefore, in addition to having obligated nurses to their managers, safety organizational culture requires evidence-based leaders having the ability to develop teamwork and involving nurses to be more person-centered to improve quality and prevent patient harm . Thus, this shows the importance of the nurse manager’s ability, leadership, and support in enhancing person-centered care, which, in turn, improves the outcomes of care.
The fourth result indicated that the nurse-physician relationship indirectly affects quality and patient safety through person-centeredness. Nurses with a strong relationship with collegial physicians have a higher degree of person-centeredness, which, in turn, improves both quality and patient safety. Previous studies support these findings. Hence, high nurse-physician collaboration reduces adverse events and promotes safety , . An interdisciplinary team with an excellent nurse-physician relationship helps sustain care outcomes . The fact that nurses and physicians substitute for each other and complement each other’s roles, leading to decreased workloads, helps explain this , thus, nurses on good terms with the physicians spend more time with patients and provide more person-centered care, improving both the quality and patient safety. So, effective communication among the multidisciplinary teams and periodical meetings of professionals is recommended for the outcome optimization.
4.1. Limitations and future directions
The study was completed in 2015; the data reported herein were dated. This was a result of co-authors passing away since the manuscript was completed. The surviving authors updated the references and the theories supporting the study model. Because the study variables are interpersonal interactions in a work system, they are less likely to be affected by time. Furthermore, this study was a cross-sectional survey in Malaysian private hospitals at one point in time. Therefore, it is difficult to establish the causality between the study variables and generalize the study results. The study design limited the ability to assert a causal relationship between the nurse work environment, perceived person-centeredness, and nurse reported quality and patient safety. In addition, the study sample limited the ability to generalize the results as it is conducted in private hospitals and represents 5.7% of the Malaysian private hospitals and 3.0% of total nurses in the private hospitals in Malaysia.
Furthermore, important potential variables such as nurse burnout, stress, fatigue, and nurse reported intention to leave were not explored and should be included in future work to understand the mediation role of person-centered care better. Additionally, the direct effect c′ paths of nurse reported quality and safety were significant, indicating that other mediators could be used for future research . The study mediator had a positive impact on nurse reported quality and safety. Therefore, future research must include mediators such as nursing burnout, workaround, and staffing inadequacy with negative signs to understand the study model better. Finally, lacking data of the actual outcome quality, such as reported events, mortality rates, the data relied on nurse reported quality and patient safety. However, these measures were used widely and validated internationally , , .