Article Review Research

American Journal of Nursing Research, 2013, Vol. 1, No. 1, 10-19

Available online at http://pubs.sciepub.com/ajnr/1/1/2

DOI:10.12691/ajnr-1-1-2

Investing in Human Relations for Healthy Nursing

Practice Environment, Nurses’ Job Satisfaction and

Quality of Nursing Care

Nazlee Siddiqui *

School of Business, North South University, Bangladesh

*Corresponding author: nazlee@northsouth.edu

Received January 01, 2013; Revised February 01, 2013; Accepted February 25, 2013

Abstract Relationship between the three domains of nursing practice environment, nurses‟ job satisfaction and quality of nursing care have been studied for a way forward to superior healthcare delivery. However, the literature

and management practices frequently viewed the relationship as one directional; which may have resulted to

restructuring in the nursing practice environment that are insensitive to nurses‟ need. This paper provides evidence

of reciprocal relationship between the three domains in the context of interactions between nurses at NSW health

organisations. Mixed methods of survey questionnaire and one-on-one semi-structured interview were used in this

research in sequential design, with 136 survey respondents and 21 interviewees. The research result identified

interactions between nurses as a vehicle through which the reciprocal relationship between the domains are kept in

motion. While healthy interactions between nurses that generate trust and gratitude were seen to positively impact

the domains, the opposite was noticed in case of unhealthy interactions. Therefore, management practices in nursing

administration should invest for healthy human relations to achieve enhancements across the three domains.

Keywords: interactions between nurses, nursing practice environment, job satisfaction, quality of nursing care

1. Introduction

Studies concerning with providing a better workplace

for nurses, have consistently looked at how nursing

practice environment affects critical nurse outcomes such

as job satisfaction and quality of care [1,2,3,4,5,6]. Some

of these studies [4,6] are based on the Structure-Process-

Outcome (SPO) paradigm [7] and provide empirical

evidence that nursing practice environment represents the

structure and process, that can lead to the outcomes of

nurses‟ job satisfaction and quality of nursing care. One of

the valuable insights from these literatures is that, changes

in the nursing practice environment could bring desirable

positive outcomes in nurses‟ job satisfaction and quality

of nursing care.

Nonetheless, the existing literature analyses the

relationship between the three domains of nursing practice

environment, nurses‟ job satisfaction and quality of

nursing care as one-directional, rather than considering the

possibility of “reciprocity” of directions that might exist.

The term “reciprocity” here is referring to the mutual

dependence of the three domains, that is, how each of

these domains are impacting each other and mutually

dependent on each other. For example, Reference [3]

reported that nurses in an unfavourable nursing practice

environment are 11 times more likely to deliver fair to

poor quality of care. However, there were no reporting of

how the delivery of fair to poor quality of care might also

impact on nurses‟ job satisfaction and work environment.

In fact, the author of this paper conducted a literature

search from 1999 until February 2010 and failed to arrive

at any paper that studied the three domains of nursing

practice environment, nurses‟ job satisfaction and quality

of nursing care in reciprocal directions. It may be

mentioned, that the search was limited to articles written

in English, published in peer reviewed journals and

analysing nursing practice environment with a validated

instrument.

Similar to the literature, management practices in

healthcare organisations also seem skewed, towards a

concept of one-directional relationship between the three

domains. It seems that changes in the nursing practice

environment are drawn, without a comprehensive view of

how each of the domains can affect each other. A

symptom in this regard is nurses are reported to believe,

changes in health care system will worsen the timeliness,

effectiveness and efficiency aspects of patient care [8].

Despite constant restructuring in the health system,

substantial portion of nurses are still facing verbal abuse

(56%), hostility at workplace (24%) and physical injuries

(38%) (8: 324). Hence, there is a need to learn how to

achieve improvements across the three domains of nursing

practice environment, nurses‟ job satisfaction and quality

of nursing care. A step towards that learning can be to

comprehend the reciprocity between the three domains,

especially for its human relations aspect.

The purpose of this paper is to draw insight for possible

reciprocal relationships between the three domains of

nursing practice environment, nurses‟ job satisfaction and

quality of nursing care. Although this insight is not an

 

 

American Journal of Nursing Research 11

innovation, given the background in the previous

paragraphs, it is believed that the insight is certainly not

well articulated and practiced in nursing management. The

research question that the paper addresses is:

“How are the domains of nursing practice environment,

nurses‟ job satisfaction and quality of nursing care

interrelated?”

The paper will approach the research question with

mixed methods, including a survey questionnaire and one-

on-one interviews. Data from the survey is expected

provide a quantitative picture of the possibility of a

reciprocal relationship between the domains. The

interviews will search for insights of human relations

aspect in answering the research question. That is, whether

the lived experiences of interaction between nurses (e.g.

nursing administrators, nurse managers, nurse clinicians,

new graduate registered nurses) in the workplace could

provide an insight behind the proposed interrelationship of

the domains. Such research can contribute to fill the

scarcity of reciprocal study between the domains in the

literature. It has the potential to generate interest for

investing behind human relations, as a gateway towards

healthy nursing practice environment, nurses‟ job

satisfaction and quality of care.

2. Conceptual Framework

The following section briefly describes the three

domains, along with the importance of studying the

interrelationship between the domains. Such information

is pivotal to the conceptual framework of this paper.

Sample scales of the three domains are provided in

Appendix 1.

2.1 Nursing Practice Environment

In this paper, the nursing practice environment is

referring to nurses‟ work context which is represented

through organisational characteristics such as staffing and

resource adequacy, nurse manager ability, nurse

participation in hospital affairs, nursing foundation for

quality of care, nurse-doctor relationship and cultural

values [9,10,11].

2.2 Nurses’ Job Satisfaction

The literature continue to find job satisfaction to be an

ambiguous and yet important domain in management

[12,13,14]. Reference [12] described that the domain can

be defined as reaction to job from different perspectives

such as emotional assessment, evaluation of attitude,

expectation gap and appraisal of belief system. In this

paper, job satisfaction is accepted as a contented

emotional state that results when one is achieving the

desired job values [15]. This study captured aspects of

nurses‟ job satisfaction by assessing job values such as

pride in the job, sense of fulfillment from committing to

patient care and satisfaction with working conditions

[16,17,18].

2.3 Quality of Nursing Care

In this study, the quality of nursing care domain is

perceived as the degree to which the nurses‟ initiatives

meet the individual need of patients [19,20]. An

examination of quality of nursing care might involve

assessment of the structures, processes and outcomes that

meets patient needs for technical care, as well as the

interpersonal relationship with nurses [20,21,22].

However, such a vast examination of nursing care is

beyond the scope of this paper. The author of this paper

attempted to capture aspects of quality of nursing care, by

assessing nurses‟ initiatives regarding technical care,

informational and emotional support to patients [22].

The importance of studying the association between the

above mentioned three domains, as shown in Figure 1,

was identified as early as in the 1980s, through „magnet

study‟. The American Academy of Nursing (AAN)

conducted this study in 1981, in response to hospitals

facing a severe crisis in sourcing nursing staff and

maintaining patient safety [2]. The AAN task force had

studied 41 reputable hospitals, that is, hospitals that

achieved low nurse turnover and high quality of nursing

care even in the crisis period in USA. The task force

revealed that reputable hospitals, which are commonly

known as „magnet hospitals‟, usually maintain certain

organisational characteristics (e.g. staff & resource

availability, nurse participation in hospital affairs) in the

work place to function at a superior level with job

satisfaction and quality care. As McClure, a member of

the 1981 task force, explained:

Simply stated, these (magnet hospitals) were good

places for all employees to work (not just nurses) and

these were good places for patients to receive care. The

goal of quality was not only stated in the mission of these

institutions but it was lived on a daily basis (23: 119).

 

Figure 1. Conceptual Framework: The Magnet Study

Currently „magnet hospitals‟ are designated by

American Nurses Credentialing Centre (ANCC), to label

hospitals with excellence in quality of care and innovative

nursing practice [24]. Research has consistently shown

that „magnet hospitals‟ score favourably against the non-

magnet ones, hospitals that do not have endorsement from

ANCC, in the domains of nursing practice environment,

nurses‟ job satisfaction and quality of nursing care

[25,26,27,28]. Whereas, the association between the three

domains are evidenced both in the magnet and non-

magnet hospitals [1,3,6,26]. Therefore study of the

relationships between three domains in Figure 1, can

inform efforts towards positive changes in the context of

both magnet and non-magnet hospitals.

3. Method

 

 

12 American Journal of Nursing Research

3.1 Design

The study employed mixed methods, including a survey

questionnaire and one-on-one interviews with a two-stage

sequential design. The survey questionnaire was

conducted first, as it could provide a snapshot of the

possibility of a reciprocal relationship between the

domains in objective term. The interviews, that happened

four months later than the survey, were necessary for

deeper insight of human relations aspect in the

interrelationship between the domains. Mixing of methods

in this study is expected to integrate quantitative and

qualitative views, resulting in a “superior explanation” (29:

115) of the relationship between the domains of nursing

practice environment, nurses‟ job satisfaction and quality

of nursing care.

The survey measured the nursing practice environment,

nurses job satisfaction and quality of nursing care

according to the adapted instruments of practice

environment scale-nursing work index [10], organisational

job satisfaction instrument [16] and nursing performance

instrument/individual patient care [22] respectively. These

instruments were adapted to the context of Australian

nursing practice environment for language, content and

structure [30,31]. The language component assessed

whether items in the instrument contained words that are

in use in the Australian context. The content component

assessed whether the themes of the instrument are relevant

to the Australian registered nurses. While the structure

assessed respondents‟ comfort with structural matters of

the instrument, such as the number of scale points in

questions, the length of the instrument. The adaptation

process covered review of existing literature, peer review,

pilot study and confirmatory factorial and reliability

analysis. The reliability analysis confirmed each of the

three domains having a Cronbach‟s standardized alpha

(CSA) value higher than the cut-off point of 0.7 (32, 33).

All the domains also had acceptable factorial stance with

factor loadings of at least 0.5 (34). Sample questions of

the survey questionnaire for each of the three domains are

provided in Appendix 1.

The on-on-one interviews began by reporting a

summary of the findings from the survey, that is, the score

on nursing practice environment, nurses‟ job satisfaction

and quality of nursing care. This introduction provided a

context for posing an overarching question about

participants‟ feelings about their current nursing practice

environment and to open up a discussion relevant to the

research question. Query regarding the research question

read as; “We have been talking about the three factors;

nursing work environment, nurses‟ job satisfaction and

quality of nursing care. Do you think these three are

related?” As prescribed in the literature [35,36], an

interview format was developed to prepare for the

interviews . The format was helpful to steer the interviews

to the extent that did not jeopardise the flow of

independent thinking process, of the interviewees.

3.2 Participants

The data for this paper came from 136 survey

respondents and 21 interviewees. In the survey sample,

more that 70% belonged to public hospitals and 95%

worked in hospital type work environment. The survey

respondents came from clinical practice areas of;

Medical/Surgical (23.6%), Critical care (18%), Midwifery

(10.6%), Mental health (8.9%), Aged care (8.1%), Peri-

operative (7.3%) and others (23.5%). Ninety two percent

of them are females, with an average age of 50. The

nursing classification composition of the survey sample is;

bedside/registered nurse (61%), nurse manager (15%),

clinical nurse specialists (13%), clinical nurse consultant

(7%), clinical nurse educators (2%) and nurse educators

(2%). Out of the 21 interviewees, the majority came from

public hospitals and belonged to variety of clinical

practice areas such as mixed medical, critical care, aged

care, midwifery and paediatrics. The nursing classification

of the interviewees are; bedside/registered nurses [7],

nurse managers [7], clinical nurse consultants [3], clinical

nurse specialists [2] and clinical educators [2]. The

interviewees‟ age ranged from 39 to 63 years.

3.3 Procedure

The Nursing & Midwifery Board (NMB), New South

Wales (NSW) had approved a request for assistance, in

recruiting participants for the survey questionnaire.

Subsequent to NMB’s approval, ethical clearance was also

received from the Human Research Ethics Committee of

the University of Western Sydney in Australia.

Participants in this study were recruited through purposive

sampling from the register of the NMB, NSW. The

respondents were required to be practicing nurses and

have a minimum of two years of experience in an inpatient

practice environment. These two desired characteristics of

the research participants were printed in the introduction

of the survey questionnaire. Such purposive recruitment

ensured a research focus on practice environment, where

nurses are likely to have high interaction with patients and

thereby possess a thorough view of the relationship

between the three domains.

The registrar at NMB had circulated survey packs in

hard copy, to 2050 nurses at their residential addresses. A

total of 157 packs were returned, achieving a response rate

of 7.6%. A return of the questionnaire was deemed to be

implied consent for voluntary participation. Sixty five

respondents agreed to an interview by returning the signed

interview consent forms, which they received during the

survey. The interviewees were recruited again with a

purposive method to arrive at nurses who belonged to a

variety of clinical practice areas (e.g. medical, critical care,

per-operative) and nursing classifications (e.g. clinical

nurse consultants, nurse managers, clinical nurse

educators, clinical nurse specialists, registered nurses).

Nurses from such a variety of backgrounds were expected

to provide pragmatic and comprehensive answers to the

research question. Both the data for survey questionnaire

and interview were collected in the year 2009.

4. Data Analysis

This section will explain how the data from the two

methods, were analysed to study how the domains of

nursing practice environment, nurses‟ job satisfaction and

quality of nursing care are affecting each other. There are

two parts in this section, the first part explains the

quantitative analysis technique of mediation by regression

and the next part is about the qualitative analysis of theme

identification.

 

 

American Journal of Nursing Research 13

4.1 Mediation by Regression with the Survey

Data

The mediator analysis technique was applied to learn

about the possibility of reciprocity between the three

domains of nursing practice environment, nurses‟ job

satisfaction and quality of nursing care. A mediator works

as the mechanism through which the independent variable

can exert full or partial influence on the dependent

variable [37]. Each domain was analysed for its role as a

mediator, between the reciprocal relationships of the other

two domains. The combined results of the mediator

analysis of each of the domains of nursing practice

environment, nurses‟ job satisfaction and quality of

nursing care, as shown in Figure 2, can reveal whether

there is reciprocity when the three domains are put in

relationships at once.

 

Figure 2. Mediators in the reciprocal relationship between nursing

practice environment (NPE), nurses‟ job satisfaction (JS) and quality of

nursing care (QNC)

Only detailed explanation of the mediating role of the

nursing practice environment is provided here, since the

steps are exactly the same for all of the three domains. In

this analysis, the task was to assess whether nursing

practice environment can influence the reciprocal

relationship between nurses‟ job satisfaction and quality

of nursing care. It should be clarified at this stage, that the

authors of this paper applied the mediation analysis not to

indicate cause and effect relationship between the domains.

Instead, the mediation analysis was as indication of a role

of nursing practice environment that influenced the

association between job satisfaction and quality of nursing

care. The following Figure 3 depicts the regression steps

for the mediator analysis on the domain of nursing

practice environment.

 

Figure 3. Mediator analysis on nursing practice environment as per

Barron & Kenny

The analysis ran three regressions as shown above [37].

The first was between nurses‟ job satisfaction and nursing

practice environment, to test the influence of nurses‟ job

satisfaction towards the possible mediator nursing practice

environment. The second had nurses‟ job satisfaction as

an independent domain impacting the domain of quality of

nursing care. Then the third and the last one had two

independent domains, nurses‟ job satisfaction and nursing

practice environment, impacting on the dependent variable

of quality of nursing care. In order to capture the

mediating role of nursing practice environment, between

nurses‟ job satisfaction and quality of nursing care from

both directions, another three regressions were run again.

This time, the first regression was between quality of

nursing care and nursing practice environment. The six

arrows, including the ones with the broken lines in Figure

3, reflect mediator analysis on nursing practice

environment from both directions.

According to reference [37], nursing practice

environment can be a mediator if four conditions are met:

first one, nurses‟ job satisfaction and quality of nursing

care are found to have a significant influence on nursing

practice environment in the first regressions; second one,

nurses‟ job satisfaction and quality of nursing practice

environment are found to be significant influencers to

each other in the second regressions; third one, the third

regressions show nursing practice environment to be a

significant influencer to quality of nursing care and

nurses‟ job satisfaction and lastly, the third regressions

show reduction in the degree to which nurses‟ job

satisfaction and quality of nursing care impact on each

other in comparison to that of the second regression.

In the above four conditions, the significance is decided

by the unstandardized coefficient (B) values at ranges of

p< 0.05 to p <0.001. Regarding condition four, if the

reduction is as such that the third regression is showing a

zero influence between nurses‟ job satisfaction and quality

of nursing care then nursing practice environment is

evidenced to be a single and dominant mediator [37].

Since this study is not expecting the mediation analysis to

represent a cause and effect relationship, the mediator role

of nursing practice environment was not statistically

validated by applying ‘sobel’ tests [37] or bootstrapping

procedures [38]. As it is, there are criticisms that

mediation results can indicate a valid causal relationship

[39]. Rather it is preferred to learn more of nursing

practice environment‟s role as a mediator, from nurses‟

real life experiences to be collected during interviews.

Literature [38] suggests that combination of quantitative

and qualitative information, can provide greater insights

into mediation relations.

4.2 Theme Identification with the Interview

Data

The data analysis started with the search of themes in

each interview. Themes refer to recurrent concepts that

describe aspects of experiences relevant to an inquiry [40].

Accordingly, themes were identified when discussions

reflected intense and recurrent feelings in an interviewee.

For example intense feeling was noticed, when an

interviewee expressed frustration in situations when nurse

administrators roll out impractical changes in the

workplace. This feeling had intensity, as it reflected the

interviewee‟s desire for greater control and respect in her

job. Moreover, the interviewee had expressed such feeling

of frustration frequently while describing interactions with

 

 

14 American Journal of Nursing Research

nursing administrators in the work environment. Thus, a

theme was coded as “interaction with nursing

administrators”. Codes such as “interaction with nursing

administrators” were considered provisional at this stage,

since it reflected experiences of individual nurses rather

than that of the collective group. The finalization of

themes involved further search of commonality, within the

group of 21 interviewees. This stage of analysis helped to

amend the themes with suitable aspects of the relevant

experience. Furthermore it could be assessed, whether the

themes were reflected by majority or minority in the group.

The amendment of the themes came to an end, when it

was felt that the themes are representing stable

experiences. A database of transcripts and memos were

maintained in the QSR NVivo™ 8, to support the analysis

process.

Three themes were finalized in relevance to the

research question in this paper. These are; one, interaction

between nurse managers and nurse clinicians, two,

interaction with new graduate registered nurses and three,

interaction with nursing administrators. Nurse managers

refer to nurses working in the role of unit manager, while

the nurse clinicians include nurses in classifications of

registered/bedside nurses, clinical nurse specialists,

clinical nurse educators and clinical nurse consultants. The

new graduate registered nurses refer to fresh graduates

from the university. Lastly, the nursing administrators

relate to nurses working at higher organizational level,

usually holding the position of Director of Nursing. It may

be noted that none of the interviewees in this study,

belonged to the roles of nursing administrators and new

graduate registered nurse.

5. Results

In this section, survey and the interview results are

presented to answer the research question: How are the

three domains of nursing practice environment , nurses‟

job satisfaction and quality of nursing care interrelated?

5.1 Understanding the Relationship between

the Domains with the Survey Data

The survey results answered the above mentioned

research question through mediation test on each of the

three domains in reciprocal directions, as shown in Figure

2. The combined picture of the three sets of mediation

analysis revealed that the nursing practice environment,

nurses‟ job satisfaction and quality of nursing care are

interrelated, with possibility of reciprocal relationship.

The analysis found each of the three domains to be

capable of partially mediating the relationship between the

other two domains. In this paper, to avoid being repetitive,

results are explained only for the analysis of mediation on

nursing practice environment. A summary of the

mediation test results on nursing practice environment are

presented in the following Table 1.

Table 1. Summary of mediator analysis on nursing practice environment (NPE) between reciprocal relationships of job satisfaction (JS) and

quality of nursing care (QNC)

Notes:

*** Unstandardised coefficient B value is significant at p <0.001 * Unstandardised coefficient B value is significant at p< 0.05

† Reduction in 3rd regression: 0.26

‡ Reduction in 3rd regression: 0.27

The mediator analysis results presented in the above

table examined the relationship in both directions, being

consistent to the intention of analysing reciprocal

relationships as depicted in Figure 3. One set of

regressions is for the direction where the relationship is

initiated at nurses‟ job satisfaction (JS). The other set of

regressions is for the other direction, where quality of

nursing care (QNC) is the starting point. The results

presented in Table 1 show that nursing practice

environment is in line with most of the Baron and

Kenny‟s [37] conditions of being a mediator in both

directions.

According to Baron and Kenny‟s first condition,

nurses‟ job satisfaction and quality of nursing care are

found to have a significant (p< 0.001 level) influence on

nursing practice environment. This is indicated by the

unstandardised coefficient value of 0.585 (p< 0.001 level,

for relationship initiating at nurses‟ job satisfaction) and

0.573 (p< 0.001 level, for relationship initiating at quality

of nursing care) in the column of 1 st step regressions in

Table 1. The unstandardised coefficient values reflect

explanatory power of nurses‟ job satisfaction or quality of

nursing care. It measures possible response effect in

nursing practice environment for a one standard deviation

change in nurses‟ job satisfaction or quality of nursing

care [34]. Readers can see Figure 3 to understand the

directions of relationships that the 1 st step regressions are

referring to.

The second condition is also met as nurses‟ job

satisfaction and quality of nursing care are found to be

Initiates at JS

1st step regression: JS to NPE

F (1, 133) = 68.9

2nd step regression: JS to QNC

F (1, 133) = 37.1

3rd step regression: JS + NPE to QNC

F (2,132) = 35.5

Unstandardized Coefficient B

Standard error

t-value Unstandardized Coefficient B

Standard error

t-value Unstandardized Coefficient B

Standard error

t-value

Constant 1.356 .391 3.464 2.664 .423 6.229 2.062 .404 5.108

JS .585*** .070 8.306 .464*** .076 6.094 .204*† .086 2.379

NPE .444*** .086 5.175

Initiates at QNC

1st step regression: QNC to NPE

F (1, 133) = 63.2

2nd step regression: QNC to JS

F(1, 133) = 37.14

3rd step regression: QNC + NPE to JS

F (2,132) = 38.5

Unstandardized

Coefficient B

Standard

error t-value

Unstandardized

Coefficient B

Standar

d error t-value

Unstandardized

Coefficient B

Standard

error t-value

Constant 1.57 .381 4.129 3.014 .409 7.365 2.275 .392 5.801

QNC .573*** .072 7.953 .471*** .077 6.094 .201*‡ .085 2.379

NPE .471*** .084 5.606

 

 

American Journal of Nursing Research 15

significant influencers to each other. The unstandardised

coefficient values of 0.464 (p<0.001 level, for relationships

initiating at nurses‟ job satisfaction) and 0.471 (p<0.001,

for the relationship initiating at quality of nursing care) in

the column of 2 nd

step regressions are supporting the claim.

The third condition of Baron and Kenny [37] has also

been matched as nursing practice environment is found to

be a significant influencer to quality of nursing care with

unstandardised coefficient value of 0.444 (p<0.001 level)

and to nurses‟ job satisfaction with unstandardised

coefficient value of 0.471 (p<0.001 level) respectively.

These data can be found in the column of 3 rd

step

regression in Table 1.

In line with the fourth condition, it is seen in Table 1,

there are reductions by unstandardised coefficient value of

0.26 (for relationship initiating at nurses‟ job satisfaction)

and 0.27 (for relationship initiating at quality of nursing

care) in the 3 rd

regressions from that of the corresponding

2 nd

regressions. However, contrary to the guidance of

Baron and Kenny [37], the 3 rd

regressions still show the

relationships between nurses‟ job satisfaction and quality

of nursing care to be significant with unstandardised

coefficient values of 0.204 (p<0.05 level ) and 0.201

(p<0.05 level).

In view of recent literature [38,41], such a situation

indicates that the proposed mediator (i.e. nursing practice

environment) is not the only domain to account for the

relationship between nurses‟ job satisfaction and quality

of nursing care. Zhao et al. (41: 14) labels such a role of

mediator as “complementary mediator” and Mackinnon et

al (38: 602) labels it as “partial mediator”. Therefore the

results presented in Table 1, indicates nursing practice

environment to be a partial mediator that partially

influences the reciprocal relationships between nurses‟ job

satisfaction and quality of nursing care. Additionally, it

implies actions taken at the point of nurses‟ job

satisfaction or quality of nursing care should influence the

situation in a nursing practice environment and that, such

influence can have a cascading impact to the third domain.

Having established the possibility of a partial

mediator‟s role for the domain of nursing practice

environment, it is time to look into analysis of mediations

on the other two domains of nurses‟ job satisfaction and

quality of nursing care. It was found that mediation results

on these two domains met the first three conditions of

Baron and Kenny (1986) completely. Regarding the fourth

condition, the domain of nurses‟ job satisfaction showed

reductions of 0.12 (for the relationship initiating at nursing

practice environment) and 0.19 (for the relationship

initiating at quality of nursing care). Similarly, on the

fourth condition, the mediation analysis on quality of

nursing care projected reductions of 0.11 (for the

relationship initiating at nursing practice environment) and

0.18 (for the relationship initiating at nurses‟ job

satisfaction. These results confirm that both the domains

of nurses‟ job satisfaction and quality of nursing care can

also be partial mediators between the reciprocal

relationships of the other two domains. Therefore the

collective view of the mediation analysis supports, that the

relationships between the three domains can be reciprocal.

With the support of the survey result, the next section (5.2)

will look into the interview findings to understand the

rationale behind the relationship.

5.2 Understanding the Relationship between

the Domains with the Interview Data

Nurses gave account of experiences from workplace as

they were asked about how the three domains of nursing

practice environment, nurses‟ job satisfaction and quality

of nursing care interrelate. Their account exhibited a

common consensus that the three domains are definitely

interrelated. A sense of reciprocity in the interrelationship

of the domains was also indicated, in some of the

responses. For instance, a nurse manager stated:

They (the domains of nursing practice environment,

nurses‟ job satisfaction and quality of nursing care) affect

each other all the time. I don‟t see that one is coming

before the others. (NM-JK).

As mentioned in the introduction, the interviews were

expected to shed light on the possible reciprocal

relationship between the domains from the human

relations perspective. Hence interaction between nurses in

different roles (i.e. nursing administrators, nurse managers,

nurse clinicians, new graduate registered nurses), in day to

day work life was taken as the context to analyse the

interviews. The interview result are segregated into three

sections to highlight, how nurses perceived each of the

domains of nursing practice environment, nurses‟ job

satisfaction and quality of care to impact the other two

domains.

5.2.1 Interaction between Nurses: Nursing

Practice Environment Impacting the other

Domains

An ample number of examples of interactions between

nurses emerged as they were describing the

interrelationship between nursing practice environment

and the other two domains. Nurse clinicians mentioned

that guidance from managers in the work environment,

has a significant influence on their work and the quality of

care. This influence came in different forms, such as the

way a manager handles clinical errors, provides guidance

for quality care, recognises clinicians for their hard work

and manages resources of staffing and/or medical

equipment in the ward.

Similarly, managers mentioned their dependence on the

skill of the clinicians to maintain the quality of care in the

workplace. While managers are not delivering direct

patient care, they expressed that they are still responsible

for the quality of care and are involved in its critical points.

They gave accounts of guiding clinicians to deliver quality

care by activities such as coordinating resources (e.g. staff,

equipment), maintaining a high profile on the floor,

ensuring staff education, endorsing standards of

Australian Council on Healthcare standards (ACHS) about

infection control, management of medication, discharge

procedures, reporting quality of care [42]. Therefore the

accounts from both nurse managers and nurse clinicians,

indicated that interactions between them were an

important element, through which nursing practice

environment impacted the quality of nursing care.

The interactions between nurses that generate quality

care, as mentioned above, were also found to be

dependent on a sense of “trust”. As a nurse manager

expressed:

 

 

16 American Journal of Nursing Research

I think you set the standard, you know the quality of

your staff and you trust the staff to give the best possible

care. (NM-BC).

Here, the manager mentions that quality of care is

developed through exchanges of managers‟ support and

the clinicians‟ effort towards care. The statement, more

importantly, indicates that trust has a role to play in these

exchanges in the nursing practice environment. From

discussions with interviewees, such a role of trust seemed

quite necessary and logical. This is so, as the managers

cannot be certain about how clinicians will actually

deliver the care when they are in face to face contact with

patients. Therefore, the managers have to provide the

guidance to clinicians and trust that the clinicians will do

their best. Likewise, the clinicians need to trust that the

managers‟ guidance will be effective in providing quality

care to patients. The clinicians can comply with managers‟

guidance with that trust in mind.

The interview data provided a similar picture in how

nursing practice environment impacted nurses‟ job

satisfaction. Nurses‟ accounts described how interactions

between nursing administrators (e.g. Director of Nursing,

General Manager) and nurses (e.g. nurse managers,

clinicians) in the work environment, sometimes, generated

emotions that negatively impacted nurses‟ sense of job

satisfaction. During the discussion, majority of nurses

explained that there is not enough visibility of the nursing

administrators in the work place. While nurses understood

that the nursing administrators have just too many things

to do, they still worried that the lack of visibility is

deterring the administrators from being (re) oriented to the

working life of nurses at bedside. This note about

disoriented nursing administrators is important; it could

explain several of the nurse managers‟ frustrations with

their job when administrators directed them to do things

that they felt, were not necessarily practical.

Few of the nurses reflected on the visibility of nursing

administrators a bit differently from the above. A nurse

clinician explained that administrator‟s visit to the

workplace generates a positive feeling for their job as it

shows that the top management is aware of the hard work

in the „coal face‟. Another nurse manager showed stronger

negative perception about nursing administrators, stating

that the administrator‟s distance from the coal face

portrays a disrespectful attitude towards nurses. She used

the following words to explain this sense of disrespect:

Our director of nursing, she has been director of nursing

for three years. In three years she has been in theatre room

once or not at all…she does not give the respect to the

staff to even come down to the theatre units… you are only

going to see the DON (Director of Nursing) if you are in

trouble. (NM-SD).

The above information provide evidences to state that

nurses’ interactions with nursing administrators in the

nursing practice environment, can significantly influence

their feelings towards job. Therefore, the research result

can propose that nursing practice environment can impact

nurses‟ sense of job satisfaction through exchanges

between nurses. In summary, the interview result

identified the interaction between nurses to be an

important platform for the interrelationship between the

domains of nursing practice environment, nurses‟ job

satisfaction and quality of care. Additionally, it is revealed

that affective aspects such as “trust” and “respect” are

crucial in maintaining a healthy interrelationship between

the domains.

5.2.2 Interactions between Nurses: Nurses’ Job Satisfaction Impacting the other Domains

During discussions with the interviewees, it was

recognised that the positive sense of job satisfaction from

successful exchanges between nurses, as explained in

section 5.2.1, can perpetuate more positive interactions in

the nursing practice environment. Nurses mentioned that

when they enjoy the job and their interactions with

colleagues, they exert a positive influence on the work

environment. A nurse manager described the interplay

between job satisfaction and the positive influences with

the following words:

I‟m very fortunate in particular…that all the Nursing

Unit Managers…get on really well and we can talk to each

other, and debrief with each other, and support each other.

So when the chips are down, one person is having a bad

day or you know having a hard time at work, we can be

around there to support that person right. So in that sense

its good job satisfaction for all. (NUM-CD).

A nurse clinician gave similar account as she mentioned

how a nurse in state of contentment, is more likely to be

supportive in the work environment. Such support is

exhibited through simple actions such as, adjusting her

roster hours to help colleagues. In return, the colleagues

usually also express gratitude or offer an obligation of

similar help in future; thereby generating force towards

future positive interactions in the nursing practice

environment. Furthermore, these perpetuating interactions

could enhance quality of nursing care as a satisfied nurse

is likely to be nurturing to patients. Support to this notion

came from another clinician as she stated:

I think if you don‟t have job satisfaction then you

become like a machine. And you can‟t give to people if

you don‟t have anything to give. Part of job satisfaction is

part of nurturing as well; nurturing patients, nurturing

other people. (NC-RM).

In the above statement, nurses‟ job satisfaction appears

as an important factor in developing a sense of nurturing

within the workplace. The clinician perceives that a nurse

cannot be expected to offer nurturing to patients and

colleagues around her, if she herself is not satisfied. The

view of the nurses as presented here, conveys that nurses‟

job satisfaction can create a wide impact in the other

domains of nursing practice environment and quality of

care. In addition to that, the findings in this section

highlight that interactions between nurses can be a vehicle

for the interrelation between nurses‟ job satisfaction and

the other two domains.

5.2.3. Interactions between Nurses: Quality of Nursing Care Impacting the other Domains

Nurses in different roles, specially the nurse managers

and nurse clinicians, were seen to feel an obligation to

promote quality of care to the best of their ability. On

occasions, nurse managers expressed dissatisfaction when

administrative work blocked them from guiding clinicians

in patient care. Their dissatisfaction is associated with the

perception that guiding clinicians in patient care is part of

their obligation to patient care.

 

 

American Journal of Nursing Research 17

It was also evident that majority of the nurses accepted

achievements with patients, as crucial motivation for their

job. This notion can be noticed in the following statements:

I would say that 90% of the reason I stay in this job is

because I enjoy what I can do for patients. (NC-HH).

We work one on one with the women particularly in

labour. We know the women in our team because we case

load them so we look after them through the pregnancy.

We come in for the birth 90% of the time and then we care

for them two weeks after their birth. We believe the

women are getting excellent care from us. We get good

job satisfaction from what we do. (NC-KD).

Another point to note from the second statement (KD),

is that the midwife has given a clear indication that quality

of nursing care is impacting on nurses‟ sense of job

satisfaction. It is seen that her sense of job satisfaction is

enhanced, as she believed to have delivered excellent care

to patients.

Once the finding in the above paragraph is placed

against that of section 5.2.1, where quality of care was

found to be developed through exchanges between nurses,

we get a context to claim a similar role of the same (i.e.

exchanges between nurses) in maintaining the

interrelationship between quality of care and nurses‟ job

satisfaction. Thereby, successful interactions between

nurses are necessary to generate quality care and to ensure

positive consequences of nurses‟ job satisfaction.

The notion in the above paragraph was further endorsed

with discussions of exchanges between experienced

registered nurses (i.e. nurse managers, nurse clinicians)

and the new graduate registered nurses. Nurses‟

discussions often centred on the issue that new graduate

registered nurses, when first emerging from university, are

not yet ready to handle basic care of patients. The

experienced nurses believed that the lack of skill of the

new graduates, is due to the inadequate hospital work

exposure in university education of nursing. A few of the

nurse managers expressed grievances that sometimes new

graduates have a certain superior attitude, being university

trained against some of the hospital trained senior nurses,

which makes it harder to work with them. It is quite easy

to perceive how such discords between experienced and

new graduate registered nurses could threaten the quality

of care and nurses‟ sense of job satisfaction.

A constructive suggestion to mitigate the discord

between the experienced and new graduate registered

nurses came from a nurse manager. She referred to a

practice where clinical nurse educators used to be

physically present as new graduates performed different

tasks in the ward. The manager believed such practice was

effective in facilitating quality of care and nurturing

nurses as;

It broke down that barrier of new graduates feeling like

they have to know, broke down that barrier of being

embarrassed to ask. It helped with that gap between senior

and junior nurses where senior nurses felt respected and

junior nurses focused on improving care and learning from

what nurses on the wards are doing. (NM-JK).

In the above statement, interactions between nurses are

found to be facilitating quality of care as new graduates

are learning and improving care under the guidance of

experienced (senior) nurses. An enhancement in nurses‟

sense of job satisfaction is also indicated here, since

experienced nurses felt respected when new graduates

learnt from them.

The information in sections 5.2.1, 5.2.2 and 5.2.3 have

told stories of interactions between nurses to exhibit how

each of the three domains of nursing practice environment,

nurses‟ job satisfaction and quality of nursing care is

impacting each other. Therefore, the interview result

answered the research question by identifying „interaction

between nurses‟ as a vehicle through which the reciprocal

relationship between the domains are kept in motion. This

result is consistent to the quantitative one, provided in

section 5.1, which indicated a reciprocal relationship

between the three domains is possible. The next section

will discuss the implication of the findings in this paper.

6. Discussions

This paper provides support for the perspective of a

reciprocal relationship between nursing practice

environment, nurses‟ job satisfaction and quality of

nursing care. Such perspective adds to previous

researchers‟ work [4,6] where, on the platform of

structure-process-outcome paradigm [7], a better

healthcare delivery is aimed through interventions in the

nursing practice environment. Whereas, the knowledge of

reciprocity between the domains communicates that

improvement in healthcare delivery should come from

interventions across the three domains. It is crucial to

avoid management initiatives that may make the nursing

practice environment efficient in the metric of resource

utilisation, at the cost of nurses‟ job satisfaction and/or

quality of nursing care. Such note of caution is necessary

as rising cost of healthcare is making it harder to deliver

quality care [43,44] . Nursing management need to be

vigilant against cost cutting initiatives that can

compromise ethical nursing practices and quality of care.

Alternatively, researchers and practitioners should

research for balanced progress in each of the domains of

nursing practice environment, nurses‟ job satisfaction and

quality of nursing care.

Another significant insight from this paper is the role of

human relations, in maintaining positive status in each of

the three domains. It was seen that healthy interactions

between nurses in different roles (i.e. nursing

administrators, nurse managers, nurse clinicians and new

graduate registered nurses) are associated with feelings

such as trust, respect and consequently provide positive

disposition to nurses regarding their nursing practice

environment, nurses‟ job satisfaction and quality of

nursing care. On the other hand, absence of or unhealthy

interactions between nurses were seen to create the

opposite consequences. A point to note here is that certain

notions of „interaction between nurses‟, such as possibility

of opposite consequences and dependence on trust, makes

the phenomenon very similar to that of “Social

Exchanges”. Blau explains social exchanges as reciprocal

actions based on trust and motivated towards “ends that

are mutually advantageous and can only be achieved

through interactions with other persons (45: 5) ”. Due to

the presence of trust, social exchanges are not negotiated

in concrete terms and follow the basic process of “to

return good for good received…to return evil for evil that

has been done” (Adam Smith, cited in 45: 19).

 

 

18 American Journal of Nursing Research

As this paper finds the „interaction between nurses‟ to

be similar to the phenomenon of „social exchanges‟, it

makes a case for nursing management to invest behind

human relations. Nursing management should invest time

and money to understand the nature of affective feelings

that are desirable for nurses in different roles. Priority

should be given to management practices that can

facilitate trust and healthy exchanges between nurses.

Practitioners should be guided with further research to

define trustworthy relationships amongst nursing staff

[46]. In light of the interviews in this research, it is felt

that some simple actions, for instance, monthly rewards to

nurses for exemplary guidance to new graduates or

occasional ward events with the director of nursing in an

informal capacity, could generate valuable benefits in this

regard.

Nursing practice environment, nurses‟ job satisfaction

and quality of nursing care are three important domains of

nursing work life. As nurses interact with each other to

deliver patient care, they also experience an

interrelationship between these three domains. The human

relations aspect in the interrelationship between the three

domains, makes it apparent that initiatives in one domain

will inherently impact the others. Therefore, management

practices in nursing administration cannot be

compartmentalised, into any one of the domains.

Investment in human relations seems to be the key to

achieve benefits across the three domains. Given the

understanding that unhealthy interaction between nurses

can create mistrust and jeopardise progress in the three

domains (i.e. nursing practice environment, nurses’ job

satisfaction and quality of nursing care), there is little

doubt to the merit of such investment.

7. Limitations

One important limitation of this paper, is that the survey

achieved only a 7.6% response rate. This could have made

the study vulnerable to non-response bias, where a

“significant number of people in the survey sample do not

respond to the questionnaire and that these people have

different characteristics from those who do respond,

moreover when those different characteristics have

importance to the study” (47: 10). An attempt taken to

minimise the possible non-response bias was to mention

the screening criteria (i.e. nurses to be currently in practice

and having minimum of two years‟ experience at inpatient

NSW health organisations) in the survey questionnaire.

However, in line with the low response rate, this paper is

not proposed to represent a generalisable picture of the

nursing practice environment in NSW health service

organisations. In any case, proposition of ‘generalisability’

is not consistent to the inherent design of this paper, as the

paper applied mixed methods, which included qualitative

analysis as well.

8. Conclusion

This paper found evidence to argue that the relationship

between the nursing practice environment, nurses‟ job

satisfaction and quality of nursing care can be reciprocal.

Whereas, the current literature mostly studied the

relationship between the three domains in one direction,

assuming improvement in nursing practice environment

will lead to similar consequences in nurses‟ job

satisfaction and quality of nursing care. Such assumption

is risky as hospital practitioners are focusing on cost

efficiency, ignoring nurses’ voices in this matter. The

paper proposes, management practices that invest for

better interactions between nurses, will benefit from

enhancements in each of the three domains of nursing

practice environment, nurses’ job satisfaction and quality

of nursing care.

Acknowledgement

The author would like to acknowledge Dr. Anneke

Fitzgerald for her guidance during the PhD study, that

helped to conceptualise the paper.

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Appendix 1. Sample Questions in the

Three Domains

 Nursing Practice Environment o Cultural values:  Concern for patients is paramount  Cultural values are transmitted to new team

members

o Nurse manager ability  Nurses are praised & recognised for a job well

done

 Nurse unit managers provide the needed resources o Nurse participation in hospital affairs  The Director of Nursing in the hospital is highly

visible and accessible to staff

 The Director of Nursing in the hospital is equal in power & authority to other top-level hospital executives

o Nursing foundations for quality of care  There is an active quality assurance program  There is a preceptor program for newly hired

registered nurses

o Staffing and resource adequacy  Adequate support services allow me to spend time

with my patients

 Generally, there are enough staff to get work done o Nurse-doctor relations  Doctors & nurses have good working relations  There is collaboration (joint practice) between

nurses & doctors

 Nurses’ job satisfaction  My job doesn‟t add up to anything significant  If I had to make the decision all over again, I

would choose the same line of work

 Quality of nursing care  Generally, nurses I work with evaluate the

effectiveness of nursing care

 Generally, nurses meet emotional needs of patients

Please note that the all the questions in the three

domains had item a scale of: 1 = Strongly disagree , 2 =

Disagree , 3 = Somewhat disagree, 4 = Neutral , 5 =

Somewhat agree , 6 = Agree and 7 = Strongly agree.