A tale of two systems—Nurses practice environment, well being, perceived quality of care and patient safety in private and public hospitals in South Africa: A questionnaire survey

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Abstract

Objective

To examine the practice environment, nurse reported quality of care and patient safety, and nurse workforce outcomes in medical and surgical units in private and public hospitals in South Africa (SA), and determine the association of modifiable features of the hospital such as the practice environment and patient to nurse workloads on these outcomes.

Design

Cross-sectional survey of nurses.

Setting and participants

Nurses were surveyed in medical and surgical units of 55 private hospitals and 7 public national referral hospitals in SA. A total of 1187 nurses completed the survey.

Measurements

Practice environment, patient to nurse workloads, nurse reported quality of care and patient safety, and nurse workforce outcomes including burnout, job satisfaction and intention to leave.

Results

On a national level, more than half, 54.4% (634/1166) of nurses intend to leave their hospital within the next year due to job dissatisfaction and 52.3% (600/1148) rate their practice environment as poor or fair, while almost half, 45.8% (538/1174) report high levels of burnout and 44.9% (517/1152) are not confident that management will resolve patient problems. Public hospital nurses report more negative outcomes than private hospital nurses. Some 71% (320/451) of public hospital nurses rate their practice environment as poor/fair, 62.9% (281/447) are not confident management will resolve patient problems, and 59% (272/461) intend to leave their hospital within the next year due to job dissatisfaction. On a national level, more favourable practice environments are significantly associated with more positive nurse reported quality of care, and nurse workforce outcomes. This is true for private and public hospitals. Patient to nurse workloads are also significantly associated with more positive nurse reported quality of care and patient safety, and nurse workforce outcomes, but primarily in public hospitals.

Conclusions

Improving the practice environment, including patient to nurse ratios holds promise for retaining a qualified and committed nurse workforce and may benefit patients in terms of better quality care.

Introduction

As a young democracy, South Africa (SA) faces the challenge of finding a balance between developed and lesser developed health systems to provide quality health care for all citizens. Private hospitals in SA are part of international hospital systems, attesting to their success at achieving international standards of quality in health care. Nursing education in SA is of a high standard, and SA nurses have been heavily recruited internationally, while nurses from other countries in Africa migrate to SA looking for improved working conditions and better opportunities to practice their profession (OECD, 2004). Thus SA offers a rich opportunity to understand what has worked to achieve success in health care, where gaps still exist in quality of health care and nurse retention, and how to parlay success in some settings to improvement in others in SA and beyond. The study reported here provides the first large-scale study of nurse reported quality of care and patient safety, and nurse workforce outcomes and the association of these outcomes with the practice environment and patient to nurse workloads in SA, and discusses implications for extending the successes in high performing hospitals more broadly to improve health outcomes nationally.

A growing body of literature has established associations between the practice environment, including patient to nurse workloads, on nurse reported quality of care, patient safety and outcomes, and nurse workforce outcomes. There is compelling evidence that the practice environment and adequate patient to nurse workloads is integral to better nurse reported quality of care (Aiken et al., 2002a, Aiken et al., 2002b, Aiken et al., 2012, Bogaert et al., 2009, Laschinger et al., 2001, Nantsupawat et al., 2011, Patrician et al., 2010, Sochalski, 2004) and nurse reported patient safety (Aiken et al., 2012). Additionally, favourable practice environments and adequate patient to nurse workloads have been linked to lower rates of adverse patient outcomes (Aiken et al., 2008a, Aiken et al., 2008b, Friese et al., 2008, Kane et al., 2007, Laschinger and Leiter, 2006, Kazanjian et al., 2005, Clarke and Aiken, 2003), and higher patient satisfaction (Aiken et al., 2012). In terms of nurse workforce outcomes, more favourable practice environments and lower patient to nurse workloads have been shown to be related to greater nurse workforce outcomes, predominantly job satisfaction (Aiken et al., 2002a, Aiken et al., 2002b, Aiken et al., 2008a, Aiken et al., 2008b, Aiken et al., 2012, Lake, 2007, Laschinger et al., 2003), decreased burnout (Aiken et al., 2002a, Aiken et al., 2002b, Aiken et al., 2008a, Aiken et al., 2008b, Aiken et al., 2012, Nantsupawat et al., 2011, Vahey et al., 2004) and decreased intent to leave (Aiken et al., 2012). Poor nurse workforce outcomes such as job dissatisfaction and burnout, are frequently cited as the primary contributory factors of nurses’ intentions to leave, absenteeism and turnover (Hayes et al., 2006, Larabee et al., 2003, Stone et al., 2007, Tourangeau and Cranley, 2006), as well as adverse patient outcomes (Aiken et al., 2002a, Aiken et al., 2002b, Estabrooks et al., 2005, Needleman et al., 2002).

Most of this research has been undertaken in North America and recently in Europe, although studies such as these have newly been conducted in countries with transitional economies such as Thailand (Nantsupawat et al., 2011) and China (You et al., 2012). However, this is the first study in SA to examine the practice environment, nurse reported quality of care and patient safety, and nurse workforce outcomes, including burnout, job satisfaction and intention to leave in private and public hospitals in SA, and the association of modifiable features of the hospital such as the practice environment and patient to nurse workloads on these outcomes.

Section snippets

Background

The practice environment is defined as “the organizational characteristics of a work setting that facilitate or constrain professional nursing practice” (Lake, 2002, p. 178). A favourable practice environment facilitates professional nursing practice and has structured policies, procedures and systems in place where nurses play a participatory role and are valued for their contributions; nursing foundations for quality care are emphasized; the nurse manager is viewed as a critical role, and

Objective

The objective of this study is to determine differences in nurse reported quality of care and patient safety, and nurse workforce outcomes between private and public hospitals in SA, and to determine the link between practice environments and patient to nurse workloads on nurse reported quality of care and patient safety, and nurse workforce outcomes, including burnout, job satisfaction and intention to leave in medical and surgical units in private and public hospitals in SA.

Setting and sample

This study forms part of an international collaborative research programme, Nurse Forecasting in Europe (RN4CAST), which aims to develop human resource forecast models in nursing (Sermeus et al., 2011). This cross-sectional study is of 62 hospitals in six of the nine provinces of SA: namely Gauteng, North West, Free State, Eastern Cape, Western Cape and Kwa-Zulu Natal. These provinces were selected for the study as most hospitals in the private sector and most national referral hospitals in the

Results

Table 2 provides a summary of nurses’ characteristics overall and for private and public hospitals. Public hospitals were more likely to have male nurses and nurses with baccalaureate degrees. A reason that nurses were more likely to have a baccalaureate degree in public than in private hospitals; may be due to the fact that all nurses are required to work a community service year in a public health care facility in SA upon completion of their studies. On average, nurses in private hospitals

Discussion

Our findings document serious cause for concern in both private and public hospitals in SA with regard to quality of care and patient safety, and potential challenges for retaining nurses. Overall in this large study of nurses in SA hospitals, more than one in five nurses reported quality of care as poor or fair, one third of nurses are not confident that patients can care for themselves after discharge, half of nurses are not confident that management will resolve patient problems, 6% of

Limitations

Limitations of this study include its reliance on cross-sectional data, which limits the ability to assert a causal link between more favourable practice environments and nurse to patient workloads on nurse reported quality of care and patient safety, and nurse workforce outcomes. Additionally, the patient to nurse workloads ratio is an average measure of patient to nurse workloads across different shifts and types of units and thus should not be interpreted as actual nurse to patient ratios at

Conclusions and policy implications

Both the private and public healthcare sectors should pay heed to quality and safety deficits in hospital care suggested by the findings of this study, as well as the high levels of nurse job dissatisfaction, burnout and intent to leave which may signal a worsening nurse shortage and low staff morale in the future. Our findings suggest that improving practice environments and nurse staffing in hospitals could hold significant promise for reducing quality and safety problems and improving

Authors’ contributions

All authors contributed to study design and implementation, data collection, and interpretation of findings for this manuscript. Ellis, Coetzee and Aiken were responsible for the data analysis of this manuscript. Coetzee was responsible for the finalization of this manuscript. All authors have approved this manuscript.

Acknowledgements

The authors acknowledge the overall design of the study and survey instruments were derived from the RN4CAST project. This research received funding from the Atlantic Philanthropies and the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement no 223468. Funding sponsors had no role in study design, implementation, manuscript development, or decision to publish. For more information on the RN4CAST project, please visit www.rn4cast.eu. Drs, Ronel Pretorius and Petra

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