Assessment of Nursing Practice Environment in Primary Healthcare Centers in Saudi Arabia: A Cross-Sectional Study

Abstract

A work environment that boosts nurses’ leadership skills, has adequate resources and staff and collegial nurse–physician relations, and allows nurses to participate in decision-making enhances patient care quality and nurses’ job satisfaction and performance. I used a cross-sectional design and the Practice Environment Scale of the Nursing Work Index among 519 nurses to assess the nursing practice environment in primary healthcare centers (PHCs) across the Kingdom of Saudi Arabia. Respondents’ views varied, and the general mean (2.45) showed that most nurses thought their work environment has a fair number of staff and resources. The general standard deviation (0.924) indicated that a significant variation exists between the composite score values, and there were no significant differences in the other factors. It was concluded that most PHCs have poor staff and resource adequacy, which shows the significant influence of nurses’ job satisfaction and performance on the quality of their work environment.

Keywords

nurse work environment primary healthcare nursing practice

Saudi Arabia’s healthcare system is transforming owing to a rapidly growing population and the economic influence of Vision 2030 (Al Mutair, 2015). Notably, there is an acute shortage of nurses, and the healthcare system is endeavoring to address this issue while also adhering to Vision 2030. A stable nursing workforce can ensure the quality of care and improve patient satisfaction levels in Saudi Arabia’s hospitals and primary healthcare centers (PHCs). Saudi Arabia is adopting several measures to develop the nursing practice environment and ensure patient safety and staff welfare. It is focusing on achieving four key objectives concerning the nursing environment: transformational leadership, exemplary professional practice, structural empowerment, and new knowledge, innovations, and improvements (Al-Dossary, 2018). To achieve these goals in the healthcare system and those of Vision 2030, a healthy work environment that attracts nurses is required.

Currently, Saudi Arabia’s healthcare system is focusing on redesigning traditional management models to address nursing shortages stemming from a high staff turnover while also attempting to reduce costs and improve efficiency and results (Alkorashy & Al-Hothaly, 2022).

Literature Review

Studies have shown that a healthy nursing work environment is satisfying, empowering, and safe (Wei et al., 2018). Such work environments contribute to increasing job satisfaction, performance of nurses, and the quality of patient care (Moisoglou et al., 2020). Notably, the quality of care provided to patients is directly linked to the quality of the nurse’s working environment (Al-Dossary, 2022). Several studies have emphasized the need to enhance the quality of care provided by nursing professionals to improve patient safety. For example, it has been reported that improving quality of care is necessary to overcome shortcomings that lead to negative patient experiences in Saudi Arabia (Alkorashy & Al-Hothaly, 2022). This finding is also supported by other studies that have asserted that improving nurses’ working environment is an effective strategy for enhancing patient care quality. However, barriers such as burnout and unhealthy work environments can impede accomplishing this goal (L. Y. Kim et al., 2020). Studies have particularly shown that the current nursing shortage is jeopardizing patient care, safety, and the quality of patient care (Alkorashy & Al-Hothaly, 2022). They have also revealed that inadequate staffing and resources are linked to emotional exhaustion and low job satisfaction among nurses (Alharbi et al., 2020). These findings confirm that a hostile work environment leads to many nurses leaving the profession in Saudi Arabia (Alharbi et al., 2020). Therefore, Saudi Arabia’s Ministry of Health (MOH) must prioritize improving nurses’ work environment to increase patient safety and satisfaction.

Other studies have suggested that investing in nursing leadership training and material and human resources is crucial to enhancing nurses’ work environment. One study suggested promoting nursing leadership training to prevent adverse events (Alsufyani et al., 2021). Another study asserted that engaging nurses in the management of healthcare centers improves patient outcomes because nurses feel a part of the organization, which increases their job satisfaction (Cristina Gasparino et al., 2021).

This study also recommended that interventions by nurse managers in primary health care should focus on improving the identified weaknesses to improve the quality of care and health outcomes. Therefore, a shared professional practice environment that integrates governance may serve as a valuable strategy for healthcare institutions to encourage optimum outcomes for patients and nursing professionals.

Finally, some studies have revealed different institutional, organizational, individual, and patient level factors that act as facilitators for Nurses and barriers for Registered Nurses (RNs). For example, Abou Malham et al. (2020) found that these factors include facilities and staffing arrangements, which equate to the supply and availability of human resources. Other factors include politics and legislation, interprofessional fellowship, and organizational policy support (leadership and strategies to support nurses’ practice change, professional boundaries, patient perceptions, knowledge, and capabilities). Therefore, Brofidi et al. (2018) recommended that hospital administration should focus on developing a work environment that supports continuous education and nurses’ participation through continual evaluation procedures and improving human resources management. Thus, nurses’ participation in hospital affairs and nursing foundations for quality of care are critical contributors to a healthy nursing work environment.

Thus, assessing nurses’ work environments is integral to obtaining baseline data that will help the MOH formulate policies to improve nurses’ working conditions. This study examines the work environment of nurses working in Saudi Arabia’s PHCs by using the most common instrument to measure the nursing practice environment: the Practice Environment Scale of the Nursing Work Index (PES-NWI). This scale measures “factors that enhance or attenuate a nurse’s ability to practice nursing skillfully and deliver high quality care” (Lake, 2002; Swiger et al., 2017).

Methods

Study Design and Sample

A cross-sectional design was used to assess the quality of the nursing practice environment from the perspective of nurses working in PHCs across the Kingdom of Saudi Arabia using the PES-NWI (Alkorashy & Al-Hothaly, 2022). In order to collect the data used in the study, convenience sampling was employed. Nurses were selected based on their easy reachability across the country. I received 519 (83.98%) fully answered questionnaires, and they were considered fit for analysis.

Ethical approval (approval number 113) was obtained from the Institutional Review Board of the MOH, where the study was conducted. A consent form was distributed along with the electronic survey stating that filling out the survey would be considered informed consent. No identifiable data were collected. Confidentiality of data and participants’ privacy were maintained, and subjects’ right to withdraw from the study was also ensured.

Instrument

The PES-NWI comprises 31 items across five subscales: (1) staffing and resource adequacy (SRA), (2) collegial nurse–physician relations (CNPR), (3) nurse manager ability, leadership, and support of nurses (NMALS), (4) nurse participation in hospital affairs (NPHA), and (5) nursing foundations for quality of care (NFQC). A 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree) was used to identify the subscale(s) that support nurses’ abilities to deliver a high level of patient care. PES-NWI scores above the midpoint of 2.5 indicated a favorable practice environment for nurses, while scores below the midpoint indicated an unfavorable practice environment (Swiger et al., 2017). The five subscales provide insight into the key structures of the nursing practice environment (Lake, 2002; Swiger et al., 2017). The Cronbach’s alpha of the entire questionnaire (.962) indicated very good reliability. The correlation coefficients of all items were .735, and the correlation coefficients were significant at the .05 level, as shown in Table 1.

Table 1.

Cronbach’s Alpha of the Constructs.

Construct	Items	Number of items	Cronbach’s alpha
1. Staffing and resource adequacy	1, 8, 9, and 12	4	.668
2. Collegial nurse–physician relations	2, 16, and 24	3	.498
3. Nurse manager ability, leadership, and support of nurses	3, 7, 10, 13, and 20	5	.872
4. Nurse participation in primary healthcare affairs	5, 6, 11, 15, 17, 21, 23, 27, and 28	9	.922
5. Nursing foundations for quality of care	4, 14, 18, 19, 22, 25, 26, 29, 30, and 31	10	.892
Total	31	31	.962

Statistical Analysis

The data were coded and entered in the Statistical Package of Social Science (SPSS) version 23. Descriptive statistics were generated for all variables to understand the nature of the data in this study. Pearson correlations and polyserial correlations were computed to examine inter-correlations among the subscales of PES-NWI (SRA, CNPR, NMALS, NPHA, and NFQC).

For each item, respondents could rate strongly agree (4), agree (3), disagree (2), or strongly disagree (1). The scoring of the PES-NWI was done by creating categorical references for poor, mixed, and favorable practice environments, as suggested by researcher (Lake, 2002; Swiger et al., 2017). A score more than 2.5 on all or four of the five subscales indicated a favorable environment. A score more than 2.5 on two or three of the five subscales indicated a mixed environment. Finally, a score more than 2.5 on one or none of the five subscales indicated an unfavorable environment.

The significance level of each independent variable depends on its correlation with another independent variable (Field, 2005). The correlation coefficient must be a value greater than zero. Moreover, it is necessary to prove that the variable contributes in a statistically significant manner in predicting factors in a population under study (Field, 2005). Correlation matrices were plotted to display the correlation coefficient (r) of each variable in relation to another, as shown in Table 2.

Table 2.

Sample Correlation Matrix of Staffing and Resource Adequacy.

	1. Adequate support services allow me to spend time with my patients	8. Enough time and opportunity to discuss patient/client/resident care problems with other nurses	9. Enough registered nurses on staff to provide quality patient/client/resident care	12. Enough staff to get the work done
1. Adequate support services allow me to spend time with my patients	1
8. Enough time and opportunity to discuss patient/client/resident care problems with other nurses	.499	1
9. Enough registered nurses on staff to provide quality patient/client/resident care	.511	.692	1
12. Enough staff to get the work done	.548	.630	.685	1

Results and Discussion

Of the respondents, 410 (79%) were women, and 109 (21%) were men, showing that most nurses in Saudi Arabia are women. A total of 270 (52%) participants had bachelor’s degree, 190 (35.6%) had a diploma, while only 59 (11%) had a master’s degree, as shown in Table 3.

Table 3.

Distribution of Respondents Based on Demographic Variables.

Demographic variable	Frequency	%
Sex
Male	109	21
Female	410	79
Age (years)
20–25	112	21.6
26–30	122	23.5
>35	285	54.9
Years of experience (years)
0–5	173	33.3
6–10	118	22.7
>10	228	44
Marital status
Single	295	56.8
Married	224	43.2
Education level
Diploma	190	36.6
Bachelor’s	270	52
Master’s	59	11.4

Staffing and Resource Adequacy

In a nursing environment, staffing adequacy is when the nurse-to-patient ratio does not overwork any of the nurses or put patients in jeopardy (Griffiths et al., 2018). It simply means to have enough nurses. Resource adequacy is when a medical institution has everything it needs to perform daily activities, such as enough time, supplies, and patient beds (Cimiotti et al., 2014). The findings and debates on personnel and resource sufficiency show that Saudi Arabian PHCs confront significant issues. Many nurses feel they need more time for care talks, and the low mean score for RN staffing indicates a resource deficit. These results support L. Y. Kim et al. (2020), which found that staffing affects nurses’ work satisfaction. These resource shortages must be addressed to improve the work environment and patient care. The overall mean of this construct was 2.45, and the standard deviation (SD) was 0.924, as shown in Table 4.

Table 4.

Mean and Standard Deviation of the Items and the Construct of Staffing and Resource Adequacy.

Staffing and resource adequacy (SRA)	M	SD
1. Adequate support services allow me to spend time with my patients.	2.44	1.083
8. Enough time and opportunity to discuss patient/client/resident care problems with other nurses	2.46	1.124
9. Enough registered nurses on staff to provide quality patient/client/resident care	2.40	1.100
12. Enough staff to get the work done	2.51	1.121
Overall	2.45	0.924

The mean score shows that, on average, most items had a score of 2. This indicates that most nurses believed that their work environment has a fair number of staff and resources. The SD indicates that a great variation existed between the composite score values, suggesting that respondents’ views varied.

The highest mean was of the variable “Enough staff to get the work done.” This variable had a mean score of 2.51 and a mode of 3.271 (52%). Moreover, it recorded a score of 3 or 4, scores above a fair score; thus, most respondents viewed their work environment as being adequately staffed with nurses. Staffing adequacy mainly depends on the number of patients admitted, the number of unit beds, the case mix index, and patient acuity (Mark et al., 2002). Therefore, I concluded that most PHCs in Saudi Arabia employ sufficient staff in relation to the number of patients admitted and the services to be provided.

The variable “Enough time and opportunity to discuss patient, client, or resident care problems with other nurses” had a mean score of 2.46 and a mode of 2.53%. Most nurses (274) scored it as 1 or 2, indicating that most nurses do not have adequate time to discuss the provision of care with other nurses. That is, most PHCs do not provide their employees with enough time to discuss care provision.

“Adequate support services allow me to spend time with my patients” had a mean score of 2.44 and a mode of 2. Notably, 279 nurses (54%) reported that they do not get adequate support services. This is one of the main factors limiting the time nurses get to spend with their patients.

“Enough RNs on staff to provide quality patient, client, or resident care” had a mean score of 2.40 and mode of 2. Two hundred and ninety (56%) nurses scored this item 1 or 2 and it had the lowest mean score, indicating that this is the biggest issue concerning staffing and resource adequacy in PHCs. It can be inferred that most medical institutions in Saudi Arabia do not employ an adequate number of nurses, which leads to subpar quality of services.

In conclusion, most PHCs have poor staffing and resource adequacy. L. Y. Kim et al. (2020) assessed the association between job satisfaction and the components of nurses’ working environment. They found that SRA is strongly linked to nurses’ emotional exhaustion, which, in turn, affects their job satisfaction.

Collegial Nurse–Physician Relations

Schmalenberg and Kramer (2009) described collegial nurse–physician relations as nurses collaborating with physicians to ensure that they deliver good quality patient-care services. This relationship is mainly built by the communication between the two parties (Schmalenberg & Kramer, 2009). The mean of this construct was 2.48 and the SD 0.937, as shown in Table 5.

Table 5.

Mean and Standard Deviation of the Items and the Construct of Collegial Nurse–Physician Relations.

Collegial nurse–physician relations (CNPR)	M	SD
2. Physician and nurses have good working relationships.	2.50	1.077
16. A lot of teamwork between nurses and doctors	2.45	1.074
24. Collaboration between nurses and doctors	2.47	1.061
Overall	2.48	0.937467

The overall mean shows that, on average, nurses gave a score of two to the items of this construct. This implies that nurse–physician relations are not considerably collegial. The SD shows that a great variation exists between the composite score values, indicating that respondents held different views.

“Collaboration between nurses and doctors” had a mean score of 2.47 and a mode of 2. A total of 251 (46%) nurses scored it 3 or 4, and this variable received the highest percentage of good scores in the construct CNPR. Most nurses disagreed that nurses and physicians collaborated. Studies have shown that optimum patient experience is not provided in hospital where doctors do not interact well with the nurses (Friese, 2005). Based on these statistics, most patients in Saudi Arabia do not get good quality care owing to poor collegial relations between nurses and physicians.

“Physician and nurses have good working relationships” had a mean score of 2.50 and a mode of 2, indicating that most nurses did not have a good relationship with doctors. Of these nurses, 53% (278) disagreed with having a good relationship with physicians. This item is correlated with “Collaboration between nurses and doctors” (0.68), indicating that one of the main reasons behind a poor working relationship is the lack of collaboration between nurses and doctors.

“A lot of teamwork between nurses and doctors” had a mean score of 2.45 and a mode of 2. It had the lowest mean score in this construct, demonstrating that poor teamwork is the main cause of poor collegial nurse–physician relationships. More than half of the nurses (54%) reported having poor teamwork with physicians in their PHC.

Overall, collegial nurse-physician interactions in Saudi Arabian PHCs, the research finds tension. Poor cooperation, working relationships, and teamwork may impair healthcare delivery (Y.-B. Kim & Lee, 2023).

It can be inferred that all of its variables contribute to the lack of collegial nurse–doctor relationships in Saudi Arabia’s PHCs because most nurses are women and most physicians are men. This supports Schmalenberg and Kramer’s (2009) nurse-physician teamwork emphasis. To improve patient outcomes and work harmony, these ties should be prioritized

Nurse Manager Ability, Leadership, and Support of Nurses

Al-Dossary (2018) and Alsufyani et al. (2021) showed that investing in nursing leadership is crucial to improving the work environment’s safety for nurses. Another study focused on how management, supervision, and consultancy affect nurses’ working environment (Cristina Gasparino et al., 2021). The mean of this construct was 2.44 and the SD 0.898, as shown in Table 6.

Table 6.

Mean and Standard Deviation of the Items and the Construct of Nurse Manager Ability, Leadership, and Support of Nurses.

Nurse manager ability, leadership, and support of nurses (NMALS)	M	SD
3. A supervisory staff that is supportive of the nurses	2.46	1.101
7. Supervisors use mistakes as learning opportunities, not criticism	2.48	1.125
10. A nurse manager or immediate supervisor who is a good manager and leader	2.38	1.132
13. Praise and recognition for a job well done	2.45	1.145
20. A nurse manager who backs up the nursing staff in decision-making, even if the conflict is with a doctor	2.41	1.071
Overall	2.44	0.898

“Supervisors use mistakes as learning opportunities, not criticism” had a mean score of 2.48. This item had the most positive responses in this construct. However, most respondents (264 or 51%) said that their supervisors criticized them for their mistakes.

“A supervisory staff that is supportive of the nurses” had an average score of 2.46, and 251 nurses disagreed with this item. This indicates that most supervisors in PHCs do not support their nurses.

“A nurse manager who backs up the nursing staff in decision making, even if the conflict is with a doctor” had a mean score of 2.41. A little more than half of the nurses (51%) did not view their manager as someone who always supports them, especially when the conflict is with a doctor.

“A nurse manager or immediate supervisor who is a good manager and leader” had the lowest mean score (2.38), indicating that this is the main cause of poor NMALS.

“A supervisory staff that is supportive of the nurses” and “A nurse manager or immediate supervisor who is a good manager and leader” had the highest correlation with a correlation coefficient of .6647. The items in this construct had very similar scores; it shows that one aspect contributes to the poor performance of another. Overall, nurse manager skills, leadership, and support indicate a need for PHC management improvements. The low mean score for nurse managers supporting their employees in decision-making and that many nurses see their supervisors as critical rather than helpful indicate poor leadership. Al-Dossary (2018) and Alsufyani et al. (2021) stressed the importance of nursing leadership in workplace safety.

Nurse Participation in Hospital Affairs

A good nurse should be involved in the affairs of the hospital (Sellman & Snelling, 2016). However, a related study showed that this might not be a decision nurses could make since some health centers have policies that do not support nurse participation. The mean score of this construct was 2.40 and the SD 0.866. The mean score shows that, on average, the respondents gave a score of 2 to the items in this construct, as shown in Table 7.

Table 7.

Mean and Standard Deviation of the Items and the Construct of Nurse Participation in Hospital Affairs.

Nurse participation in hospital affairs (NPHA)	M	SD
5. Career development/clinical ladder opportunity	2.46	1.080
6. Opportunity for nurses to participate in policy decisions	2.39	1.195
11. A senior nursing administrator who is highly visible and accessible to staff	2.44	1.174
15. A senior nursing administration equal in power and authority to other top level hospital executives	2.37	1.097
17. Opportunities for advancement	2.44	1.071
21. An administration that listens to and responds to employee concerns	2.39	1.088
23. Nurses are involved in the internal governance of the hospital	2.27	1.063
27. Nurses have the opportunity to serve on hospital and nursing committees.	2.37	1.076
28. Nursing administrators consult with staff on daily problems and procedures	2.38	1.084
Overall	2.40	0.866

The correlation matrix of NPHA showed that all variables are positively and statistically correlated with each other.

“Nurses are involved in the internal governance of the hospital” and “Nurses have the opportunity to serve on hospital and nursing committees” had the highest correlation coefficient (r) (.7424) among the coefficient of the items in the other four constructs. This means that many PHCs in Saudi Arabia have policies that support these two aspects. The mean of these two items was 2.277 and 2.380, respectively, and they both had a mode of 2. However, stronger leadership and support systems may improve workplace morale (Sellman & Snelling, 2016). While nurse engagement in hospital affairs may be improved, many Saudi Arabian PHCs favor nurse involvement in governance and committees. However, increasing nurses’ involvement in hospital matters may enhance decision-making and patient care.

Nursing Foundations for Quality of Care

Rigolosi (2012) asserted that most PHCs lack nursing foundations and highlighted their importance in healthcare organizations. I analyzed NFQC to check whether this assertion is true. The mean of NFQC was 2.41 and the SD 0.850. The mean shows that, on average, the respondents gave a score of two to the items in this construct. The high SD shows that there was a great variation in the composite score values, as shown in Table 8.

Table 8.

Mean and Standard Deviation of the Items and the Construct of Nurse Foundations for Quality of Care.

Nurse foundations for quality of care (NFQC)	M	SD
4. Active staff development or continuing education program for nurses	2.42	1.082
14. High standards of nursing care are expected by the administration.	2.48	1.093
18. A clear philosophy of nursing that pervades the patient/client/resident care environment	2.39	1.088
19. Working with nurses who are clinically competent	2.40	1.067
22. An active quality improvement program	2.46	1.060
25. A preceptor program for newly hired RNs	2.42	1.101
26. Nursing care is based on a nursing model, rather than a medical model.	2.40	1.016
29. Written, up-to-date nursing care plans for all patients/clients/residents	2.43	1.066
30. Patient/client/resident care assignments that foster continuity of care	2.36	1.102
31. Use of nursing diagnoses	2.32	1.108
Overall	2.41	0.850

The correlation matrix of NFQC showed that all variables are positively and statistically correlated with each other. “An active quality improvement program” and “Written, up-to-date nursing care plans for all patients/clients/residents” had the highest correlation coefficient (r) (.6950). Analyzing the mean of these two items confirms that the similar scores were either high or low. The mean of these two items was 2.505 and 2.478, respectively, and they both had a mode of 2. Thus, most respondents gave a score of two, indicating that most nurses work in an environment where “physicians and nurses have good working relationships” and there is “collaboration between nurses and doctors.” To further analyze the correlation, I plotted a scatter chart and inserted a trend line (Figure 1) to see the trend in the least and most correlated variables. The more correlated values show a line of higher gradient, indicating a growth in the scores of the two factors. This means that nurses’ working environment is better when both factors are considered. Finally, the research identified a fair nursing foundation for excellent treatment in Saudi Arabian PHCs, with a mean score of 2.41. An active quality improvement program and current nurse care plans are linked. In healthcare literature, quality improvement and documentation are stressed (Rigolosi, 2012). However, this part may be improved.

Figure 1.

Scatter plot and trendline.

The composite score of the PES-NWI was less than 2.5 (mean = 2.4, SD = 0.75), as shown in Table 9. This indicates that most PHCs in Saudi Arabia have an unfavorable nursing practice environment.

Table 9.

Mean and Standard Deviation of the Subscales of the PES-NWI and the Composite Score.

Composite score of the PES-NWI	M	SD
1. Staffing and resource adequacy (SRA)	2.45	0.92
2. Collegial nurse–physician relations (CNPR)	2.48	0.93
3) Nurse manager ability, leadership, and support of nurses (NMALS)	2.44	0.89
4. Nurse participation in hospital affairs (NPHA)	2.40	0.86
5. Nursing foundations for quality of care (NFQC)	2.41	0.85
Overall	2.4	0.75

Note. PES-NWI = Practice Environment Scale of the Nursing Work Index.

This research illuminates numerous crucial elements of Saudi Arabian PHC work environments. Fair circumstances include nursing foundations for treatment quality, but staffing, resource sufficiency, nurse-physician interactions, nurse administration, and nurse engagement in hospital affairs are difficult (Y.-B. Kim & Lee, 2023). These results and previous research emphasize the need for focused interventions to improve the work environment, benefitting healthcare personnel and patients. Resolving these issues is necessary to improve Saudi Arabian PHCs' work environments.

Conclusion

Improvement in nurses’ working environment contributes to better outcomes for not only patients but also healthcare centers and nursing professionals (Alsufyani et al., 2021). Mugenda and Mugenda (2009) state that in correlation analyses, it is important to compare sample results with opposite ones to measure the magnitude of influence. So as to analyze the correlation further, a scatter chart was plotted and a trend line inserted to show the trend in the least and most correlated variables. The more correlated values show a line of higher gradient indicating growth in the scores of the two factors. This shows that when both factors are considered, the nurses’ working environment is better.

The initial analysis was on the first construct (SRA), and it acted as a benchmark for analyzing the data in the other categories. Armstrong (1995) explains that all assumptions to be used should be proved using at least one group when one is working with different groups of similar data. The other categories also showed similar results where all the variables were positively correlated. This means that increasing one variable in a construct would increase all other variables in the construct. This shows that the work environment greatly influences nurses’ work. Based on the results of this study, all factors (variables) in one aspect (construct) of nurses’ work environment have a positive influence on each other. The strength of one aspect of an organization will positively affect the other aspects and increase nursing productivity if PHCs in Saudi Arabia have adequate staff and resources to hire and retain nurses. The conclusion to be drawn from this is that the quality of a PHC’s services can be improved by addressing this issue.

The main limitation of this study is its cross-sectional design. Using this design is subject to the incidence-prevalence bias, also known as the Neyman bias, which might influence the findings. Another limitation is that it does not investigate any external factors that can impact nursing performance; all the factors of PES-NWI were internal factors. External factors not included in a certain construct may have a negative correlation with a variable, but this was not analyzed.

Relevance for Clinical Practice

This study can benefit decision-makers and nursing leaders in healthcare centers in different ways. First, it shows the reality of the nursing practice environment in Saudi Arabia’s PHCs. Second, it shows the importance of improving nurses’ performance and increasing their medical knowledge. The results of this study can benefit nursing researchers because they extend the knowledge on different areas of nurses’ performance: caregiving, administration, clinical research, teaching, and counseling/advisory services. The results may also benefit clients because they show the most important factors that affect the nursing practice environment, such as participation in decision-making, the relationship between healthcare providers and managers, and the development of professional communication.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author expresses her gratitude to Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2023R347), Princess Nourah bint Adulrahman Univerity, Riyadh, Saudi Arabia.

ORCID iD

Noura Abdulla Almadani

References

Abou Malham

Breton

Touati

Maillet

Duhoux

Gaboury

. (2020). Changing nursing practice within primary health care innovations: The case of advanced access model. BMC Nursing, 19(1), 115. https://doi.org/10.1186/s12912-020-00504-z

Al-Dossary

R. N.

(2018). The Saudi Arabian 2030 vision and the nursing profession: The way forward. International Nursing Review, 65(4), 484–490. https://doi.org/10.1111/inr.12458

Al-Dossary

R. N.

(2022). The effects of nursing work environment on patient safety in Saudi Arabian hospitals. Frontiers in Medicine, 9, 872091. https://doi.org/10.3389/fmed.2022.872091

Alharbi

A. A.

Dahinten

V. S.

MacPhee

(2020). The relationships between nurses’ work environments and emotional exhaustion, job satisfaction, and intent to leave among nurses in Saudi Arabia. Journal of Advanced Nursing, 76(11), 3026–3038. https://doi.org/10.1111/jan.14512

Alkorashy

H. A.

Al-Hothaly

W. A.

(2022). Quality of nursing care in Saudi’s healthcare transformation era: A nursing perspective. International Journal of Health Planning and Management, 37(3), 1566–1582. https://doi.org/10.1002/hpm.3425

Al Mutair

A. A

. (2015). Quality of nursing care in Saudi Arabia: Needs for improvement. Journal of Nursing and Care, 4(6), 1000309. https://doi.org/10.4172/2167-1168.1000309

Alsufyani

A. M.

Almalki

K. E.

Alsufyani

Y. M.

Aljuaid

S. M.

Almutairi

A. M.

Alsufyani

B. O.

Alshahrani

A. S.

Baker

O. G.

Aboshaiqah

(2021). Impact of work environment perceptions and communication satisfaction on the intention to quit: An empirical analysis of nurses in Saudi Arabia. PeerJ, 9(9), e10949. https://doi.org/10.7717/peerj.10949

Armstrong

(1995). A handbook of personnel management practices. Kogan Page Limited.

Brofidi

Vlasiadis

Philalithis

(2018). Assessment of the nursing practice environment in Greek Hospitals: A cross-sectional study. Journal of Research in Nursing, 23(6), 535–545. https://doi.org/10.1177/1744987118788705

10.

Cimiotti

J. P.

Barton

S. J.

Chavanu Gorman

K. E.

Sloane

D. M.

Aiken

L. H.

(2014). Nurse reports on resource adequacy in hospitals that care for acutely ill children. Journal for Healthcare Quality, 36(2), 25–32. https://doi.org/10.1111/j.1945-1474.2012.00212.x

11.

Cristina Gasparino

Daiana Mendonça Ferreira

Ceretta Oliveira

Fernanda Dos Santos Alves

Pazetto Balsanelli

. (2021). Leadership, adequate staffing and material resources, and collegial nurse–physician relationships promote better patients, professionals and institutions outcomes. Journal of Advanced Nursing, 77(6), 2739–2747. https://doi.org/10.1111/jan.14805

12.

Field

A. P.

(2005). Is the meta-analysis of correlation coefficients accurate when population correlations vary? Psychological Methods, 10(4), 444–467. https://doi.org/10.1037/1082-989X.10.4.444

13.

Friese

C. R.

(2005). Nurse practice environments and outcomes: Implications for oncology nursing. Oncology Nursing Forum, 32(4), 765–772. https://doi.org/10.1188/05.ONF.765-772

14.

Griffiths

Recio-Saucedo

Dall’Ora

Briggs

Maruotti

Meredith

Smith

G. B.

Ball

, & Missed Care Study Group. (2018). The association between nurse staffing and omissions in nursing care: A systematic review. Journal of Advanced Nursing, 74(7), 1474–1487. https://doi.org/10.1111/jan.13564

15.

Kim

L. Y.

Rose

D. E.

Ganz

D. A.

Giannitrapani

K. F.

Yano

E. M.

Rubenstein

L. V.

Stockdale

S. E.

(2020). Elements of the healthy work environment associated with lower primary care nurse burnout. Nursing Outlook, 68(1), 14–25. https://doi.org/10.1016/j.outlook.2019.06.018

16.

Kim

Y.-B.

Lee

S.-H.

(2023). The nursing work environment, supervisory support, nurse characteristics, and burnout as predictors of intent to stay among hospital nurses in the Republic of Korea: A path analysis. Healthcare, 11(11), 1653–1653. https://doi.org/10.3390/healthcare11111653

17.

Lake

E. T.

(2002). Development of the practice environment scale of the nursing work index. Research in Nursing and Health, 25(3), 176–188. https://doi.org/10.1002/nur.10032

18.

Mark

B. A.

Salyer

Harless

D. W.

(2002). What explains nurses’ perceptions of staffing adequacy? Journal of Nursing Administration, 32(5), 234–242. https://doi.org/10.1097/00005110-200205000-00003

19.

Moisoglou

Yfantis

Galanis

Pispirigou

Chatzimargaritis

Theoxari

Prezerakos

(2020). Nurses work environment and patients’ quality of care. International Journal of Caring Sciences, 13(1), 108–116.

20.

Mugenda

O. M.

Mugenda

A. G.

(2009). Research methods: Quantitative and Qualitative Approaches. ACTS.

21.

Rigolosi

E. L.

(2012). Management and leadership in nursing and health care: An experiential approach (3rd ed). Springer.

22.

Schmalenberg

Kramer

(2009). Nurse-physician relationships in hospitals: 20000 nurses tell their story. Critical Care Nurse, 29(1), 74–83. https://doi.org/10.4037/ccn2009436

23.

Sellman

Snelling

(2016). Becoming a nurse: Fundamentals of professional practice for nursing. Taylor & Francis.

24.

Swiger

P. A.

Patrician

P. A.

Miltner

R. S. S.

Raju

Breckenridge-Sproat

Loan

L. A.

(2017). The Practice Environment Scale of the Nursing Work Index: An updated review and recommendations for use. International Journal of Nursing Studies, 74, 76–84.

25.

Wei

Sewell

K. A.

Woody

Rose

M. A.

(2018). The state of the science of nurse work environments in the United States: A systematic review. International Journal of Nursing Sciences, 5(3), 287–300. https://doi.org/10.1016/j.ijnss.2018.04.010