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
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
References (54)
- et al.
Nurse turnover: a literature review
International Journal of Nursing Studies
(2006) - et al.
Factor structure of the Maslach burnout inventory: an analysis of data from large scale cross-sectional surveys of nurses from eight countries
International Journal of Nursing Studies
(2009) - et al.
Hospital staffing, organization, and quality of care: cross national findings
International Journal for Quality in Health Care
(2002) - et al.
Hospital patient to nurse workloads and patient mortality, nurse burnout, and job dissatisfaction
Journal of the American Medical Association
(2002) - et al.
Effects of hospital care environment on patient mortality and nurse workforce outcomes
Journal of Nursing Administration
(2008) - et al.
Transformative impact of magnet designations: England case study
Journal of Clinical Nursing
(2008) - et al.
The effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments
Medical Care
(2011) - et al.
Patient safety, satisfaction, and quality of hospital care: cross-sectional surveys of nurses and patients in 12 countries in Europe and the United States
British Medical Journal
(2012) - Blecher, M., Kollipara, A., DeJager, P., Zulu, M., 2011. Health financing. In: HST South African Health Review 2011....
- et al.
Hospital nurse practice environment, burnout, job outcomes and quality of care: test of structural equation model
Journal of Advanced Nursing
(2009)
Failure to rescue: needless deaths are prime examples of the need for more nurses at the bedside
American Journal of Nursing
The impact of hospital nursing characteristics on 30-day mortality
Nurse Research
Hospital nurse practice environments and outcomes for surgical oncology patients
Health Service Research
South African Health Review 2011
Hospitals and hospital reform in South Africa
Effect of the hospital nursing environment on patient mortality: a systematic review
Journal of Health Services Research & Policy
Practice environment, job satisfaction and burnout of critical care nurses in South Africa
Journal of Nursing Management
Development of the hospital nurse surveillance capacity profile
Research in Nursing and Health
Development of the practice environment scale of the nursing work index
Research in Nursing & Health
The nursing practice environment: measurement and evidence
Medical Care Research and Review
Variations in nursing practice environments: relation to staffing and hospital characteristics
Nursing Research
Predicting registered nurses job satisfaction and intention to leave
Journal of Nursing Administration
Impact of magnet hospital characteristics on nurses’ perceptions of trust, burnout, quality of care and work satisfaction
Nursing Economics
Workplace empowerment and magnet hospital characteristics: making the link
Journal of Nursing Administration
Cited by (91)
Patient safety culture and associated factors among health care workers in south Wollo zone public hospitals, north east Ethiopia
2024, Perioperative Care and Operating Room ManagementExamining the reasons for missed nursing care from the viewpoints of nurses in public, private, and university hospitals in Jordan: A cross-sectional research
2023, CollegianCitation Excerpt :Convenience sampling helps gather data from individuals who are readily available to the researcher at the time of data collection (Palinkas et al., 2015). Medical and surgical wards were selected because they provide multidisciplinary care such as medical cardiology, gastroenterology, nephrology, orthopaedics, ear, nose and throat care, and urology (Coetzee, Klopper, Ellis, & Aiken, 2013). The inclusion criteria were as follows: RNs employed in the current setting for not less than a year who can read and write in English were available at the time of data collection and willing to be involved in the study.
The association of workplace violence with personal and work unit demographics, and its impact on nurse outcomes in the KwaZulu-Natal Province
2023, International Journal of Africa Nursing SciencesThe development and evaluation of a nurse anaesthesia model for practice in South Africa
2022, International Journal of Nursing SciencesEmotional support at work: A key component for nurses’ work engagement, their quality of care and their organizational citizenship behaviour
2022, International Journal of Africa Nursing SciencesCitation Excerpt :Nurses are expected to accomplish their tasks by delivering a high-quality care service. Indeed, in the context of health care, quality of care and citizenship behaviour centred on helping others are primordial aspects of nurses’ performance (Coetzee, Klopper, Ellis, & Aiken, 2013; Keyko, Cummings, Yonge, & Wong, 2016). Organizational citizenship behaviours centred on helping others (OCB-altruism) benefit co-workers and have an indirect impact on the organisation (Pohl, Vonthron, & Closon, 2019).
The association between the practice environment and selected nurse educator outcomes in public nursing education institutions: A cross-sectional study
2022, Nurse Education in PracticeCitation Excerpt :Job satisfaction is measured with a single question: “How satisfied are you with your job in this current PNEI?” This item has been used with success in many international (Sermeus et al., 2011) and national (Coetzee et al., 2013) studies. Individual factor reliability of factors such as job turnover intention, job satisfaction and career turnover intention has been found to be.90,.78,.82 respectively.