Nursing Work Life Research

Cypriot and Greek nurses’ perceptions of the professional practice environment E. Papastavrou1 PhD, G. Efstathiou2 RN, PhD, C. Lemonidou3 PhD, M. Kalafati4 RN, MSc, PhD, J. Katajisto5 MSocSci & R. Suhonen6 PhD 1 Assistant Professor, Department of Nursing, School of Health Studies, Cyprus University of Technology, Limassol, 2 Nursing Officer, Nursing Services, Ministry of Health, Nicosia, Cyprus, 3 Professor, 4 Researcher, Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece, 5 Senior Lecturer, Department of Mathematics and Statistics, 6 Professor and Principal Investigator, Department of Nursing Science, University of Turku, Turku, Finland

PAPASTAVROU E., EFSTATHIOU G., LEMONIDOU C., KALAFATI M., KATAJISTO J. & SUHONEN R. (2014) Cypriot and Greek nurses’ perceptions of the professional practice environment. International Nursing Review 61, 171–178 Background: Research evidence supports that the role of the professional practice environment is crucial for the delivery of quality care as it is significantly correlated with patient and nurse outcomes. However, in countries sharing similar cultural and ethnic backgrounds, like Cyprus and Greece, as well as the increased mobility of patients and healthcare workers, there is a lack of information regarding this issue. The aim of this study is to explore and compare Cypriot and Greek nurses’ perceptions of their professional practice environment. Methods: A descriptive comparative survey was employed using a sample of nurses in Cyprus (N = 150) and Greece (N = 147). Information was collected with the Revised Professional Practice Environment Scale (RPPE). Results: The results revealed significant differences between the two countries in three out of eight factors of the RPPE, with Greece’s mean value being higher than Cyprus’s: Handling Disagreements and Conflicts, Leadership and Autonomy in Clinical Practice, and Teamwork. Conclusions: The findings generate additional knowledge about the organizational context of care delivery that might help nursing leaders to understand how nurses perceive their work environment and how this influences their work, and consequently the care provided. The results can be utilized by nurse ward managers to improve the quality of nursing care provided. Further research is needed using different approaches to explore nurses’ experience in more depth. Implications for nursing or health policy: Measuring nurses’ perceptions of their professional practice environment may assist managers and policymakers in introducing interventions that contribute to a better practice environment and consequently to improved nursing, as well as patient, outcomes. Keywords: Care, Cyprus, Greece, Nurse, Professional Practice Environment

Background It is widely recognized that the nursing work environment is crucial for patient safety and quality of care. Ample evidence Correspondence address: Dr Evridiki Papastavrou, Department of Nursing, Cyprus University of Technology, 30 Archbishop Kyprianou str., Limassol 3036, Cyprus; Tel: +35722001605; Fax: +35725002750; E-mail: [email protected].

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suggests that environmental factors have a considerable impact on outcomes for patients as well as nurses (Aiken 2005; Kirwan et al. 2013). The International Council of Nurses also supports that healthcare systems are ‘immersed in a global nursing workforce crisis that is marked by a critical shortage of nurses,’ and the key reasons for this situation are ‘unhealthy work environments that weaken performance or alienate nurses and drive



Nursing Work Life Research

them away from specific work settings or from the nursing profession itself ’ (ICN 2007, p. 5). A simple definition of the professional environment would include those organizational characteristics of work settings that facilitate or constrain professional nursing practice (Lake 2002). Following this definition, many authors have described several components of the organizational context, including professional autonomy, leadership, organizational commitment (Wallin et al. 2006), control over practice and collaboration with physicians (Aiken & Patrician 2000), or a workplace characterized by clarity of mission and organizational responsiveness, creating the links for the implementation of an evidence-based practice (Estabrooks et al. 2002). Much of this work focused on identifying organizational features based on the magnet hospital movement originated in the USA (McClure et al. 1983). Drawing from the concept and the forces of magnetism, Erickson and Ditomassi (2011) developed and revised the professional practice model that resulted in the construction of the Professional Practice Environment Scale (Ives Erickson et al. 2009). The model is built around patient centeredness and embraces the six pillars of quality and safety described by the Institute of Medicine (IOM 2001): safety, effectiveness, timeliness, efficiency, patient centeredness and equity. It consists of eight elements surrounding patient centeredness: vision and values, standards of practice, narrative culture, professional development, clinical recognition and advancement, collaborative decision making, research, innovation and teamwork. These elements are similar to the hallmarks of the professional practice environment published by the American Association of Critical-Care Nurses (AACN 2002), which support professional nursing practice and allow nurses to practice to their full potential. These ideas have been expanded and studied from a European perspective, mainly in counties of western and central Europe (Aiken et al. 2009). Research evidence from these studies suggests that patient care is associated with significant improvements in nursing work environments. However, there is a lack of knowledge regarding the situation in the countries of Southern Europe. This may not allow health policymakers and nurse managers to take appropriate measures to address issues such as the negative impact of the professional environment on nurses’ morale, a willingness to stay in the profession and job satisfaction. Another reason justifying the comparison between the two countries is the increasing mobility of healthcare professionals and patients between Cyprus and Greece, mainly because of sharing similar historical and cultural heritages as well as the same language. Within the European Union (EU), free movement principles for health services is the target of a concerted European strategy to facilitate the movement of patients and

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professionals, simplify procedures, and increase the quality of and access to cross-border care (DIR 2005\36\EU, on mutual recognition of professional qualifications and DIR 2011\24 on the application of patient rights in cross-border health care). The DIR 2011\24 especially aims to facilitate patient mobility and access to safe and high-quality cross-border health care in the EU and to promote cooperation on health care between the member states.

Literature review Studies that aimed at the description of the professional environment report moderately positive perceptions of the work environment (A. Farmakas, unpublished data). When comparisons were made with magnet hospitals, lower scores on all dimensions of the professional practice environment were observed (Flynn & McCarthy 2008), whereas the better work environments in these hospitals were found to be associated with lower levels of job dissatisfaction and burnout among nurses (Kelly et al. 2012). In the Aiken et al. (2013) international study, it was found that in all countries, the quality of the hospital work environment (managerial support for nursing care, good doctor–nurse relations, nurse participation in decision making and organizational priorities on care quality) were significantly associated with patient satisfaction, quality and safety of care, and nurse workforce outcomes. Hospitals with good work environments and nurse staffing had improved outcomes for patients and nurses alike. It is also interesting that in a seven-country comparison, although the different backgrounds were taken into account, nurses from the USA and the Nordic European countries tended to rate the professional practice environment subscales higher compared with nurses from the more southern parts of Europe (Papastavrou et al. 2011). A considerable amount of research has attempted to make links between professional environment and patient outcomes, like falls and medication errors (Sochalski 2004), healthcareassociated infections (WHO 2010), mortality rates and cost control (Aiken 2005; Aiken et al. 2002; 2003). It was also found that positive practice environment enhances patient safety outcomes and quality of care (Coetzee et al. 2013). Specifically, at ward level, factors such as the pleasant practice environment or the high proportion of nurses with academic degrees were found to significantly impact safety outcomes (Kirwan et al. 2013). Attributes of the nursing work environment were also found to have a significant bearing on nurses’ job satisfaction, intention to leave, job retention, professional burnout, job-related stress and anxiety (Coetzee et al. 2013). Improvements in nurse work environments over time were found to be associated with

Nursing Work Life Research

lower rates of nurse burnout, intention to leave a current position and job dissatisfaction (Kutney-Lee et al. 2013). Other researchers found that the most highly valued factor of the practice environment was the support provided by the manager, described as the key element for hospital organizations to improve healthcare results (Moreno et al. 2013). The RN4CAST study, the largest nursing multi-country research project ever conducted in Europe, came up with interesting results with regard to nurse and patient outcomes of nurses’ perceptions of their professional practice environment. Regarding their intention to leave their jobs in hospitals, Greek nurses scored the higher rates. Nurses’ ratings of quality and job satisfaction were also worse in Greece, whose health system has had severe economic difficulties and where there have been widespread protests about the government’s austerity measures (Aiken et al. 2012). Other national studies in Greece investigated specific elements of the professional environment and found that nurses reported moderate nursing autonomy in intensive care units. This is explained in the context of a medical dominance which devalues their contribution to decision making (Iliopoulou & While 2010). The authors also support that nurses strive to enhance their authority by pursuing new and specialized knowledge. Research in Cyprus concerning the professional environment is scarce, but nurses do rate the hospital environment negatively, especially with regard to leadership and autonomy (A. Farmakas, unpublished data). Other studies in Cyprus report poor organization, communication gaps and conflicts (Pavlakis et al. 2011). In a similar study, it was reported that the clinical settings appeared as a stress-generating environment for nurses, whereas nurses working both in the private and public sector were found to experience low to severe burnout (Raftopoulos et al. 2012). Cyprus is the closest country to Greece in terms of religion, language, cultural heritage and historical roots (Cyprus Popular Bank Cultural Centre 2006). These relations, as well as the increased mobility of lay people, students and professionals within the two countries, may well justify the investigation of differences and similarities between the two countries and the nurses’ perceptions of the environment in which they are expected to practice nursing and deliver sufficient and quality care.

Aim The aim of the study was to gain insights into similarities and differences in nurses’ perceptions of their professional practice environment in orthopaedic and general surgical in-patient wards in Cyprus and Greece, two countries which are culturally and linguistically analogous. Furthermore, it aimed to provide

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evidence as to what extent the professional practice environment influences practices in each country.

Method A descriptive comparative survey design was used to explore nurses’ perceptions of their professional practice environment in acute orthopaedic and surgical in-patient wards in Cyprus and Greece. Sample

The target population of the study was registered nurses (RNs) working in hospital orthopaedic and surgical in-patient wards. Cluster sampling by hospitals and total sampling of nurses, based on the departments of the selected hospitals, was followed. Power analysis estimation required a minimum number of 133 completed questionnaires from each country in order to achieve sufficient power (power 90%, α = 0.01) and safe comparisons. Nurses were invited to participate in the study if they were involved in direct patient nursing care. In the case of Greece, which is a country with a low percentage of RNs per population, nursing assistants (with 2-year vocational nursing education) were also included, given that they were involved in most of the direct patient care in the orthopaedic and surgical wards. Data were collected between March and November 2009 from 16 orthopaedic and surgical in-patient wards in seven acute hospitals in Cyprus. Because of the limited number of nurses working in orthopaedic and surgical in-patient wards in Cyprus, all nurses in Cyprus working in these departments were invited to participate; 150 of them agreed to participate (response rate 87.7%). In the case of Greece, all nurses working in the selected departments (N = 180) were invited to participate; 147 of them accepted (response rate 81.6%). After discarding incomplete questionnaires, a number of 294 from both countries were included in the data analysis. The data collection instrument

The data were collected using the Revised Professional Practice Environment Scale (RPPE) (Ives Erickson et al. 2009). Demographic information such as age, gender, highest education level, work role, the length of working experience and employment type was also gathered. The RPPE scale was designed in 1998 (Ives Erickson et al. 2004). It consists of 39 items and measures eight professional practice environment characteristics: Leadership and Autonomy in Clinical Practice (five items), Control over Practice (five items), Communication about Patients (three items), Teamwork (four items), Handling Disagreements (nine items), Staff relationships with physicians (two items), Internal Work Motivation (eight items) and Cultural Sensitivity (three items). It is a 4-point Likert-type scale, which moves


Nursing Work Life Research

from strongly disagree (option 1) to strongly agree (option 4). Three sub-scales have negative items. The psychometric properties of the RPPE were tested in a study using a sample of 849 professionals (Ives Erickson et al. 2004). In that study, the eight components of the scale accounted for 61% of explained variance scale confirming the original structure. Cronbach’s alpha coefficients for the eight RPPE sub-scales ranged from 0.78 to 0.88, supporting a good level reliability for the instrument. Additionally, a psychometric evaluation of the RPPE scale, employing a sample of 775 nurses, reported good reliability based on a Cronbach’s alpha coefficient of 0.93. Principal components analyses with varimax rotation and Kaiser normalization showed very little difference in the variances of the eight components [eight components, 59.2% variance (CS), 59.7% (VS)] (Ives Erickson et al. 2009). In the present study, the original American version of the questionnaire was translated into the Greek language as both Greeks and Cypriots speak the same language. The forward and back translation was followed by discussions and agreement on the content, concept criteria and semantic equivalence of the terms used (MAPI Research Institute 2009). Pilot studies (n = 30 nurses in each country) were then conducted to test the data collection protocol and items and to ensure the instructions were clear. No changes were required after the pilot study analyses.

analyses. Descriptive statistics, such as frequencies, means, standard deviations and 95% confidence intervals were used to describe the sample and data. Inferential statistics (Pearson’s chi-square and independent sample t-test) were used to find differences in the demographic characteristics between national samples. Background variables that were statistically significantly different between countries were used to control a between-country comparison of the sum variables (general linear model). Adjusted means and standard errors of countries were reported. In all statistical tests, P < 0.05 were considered statistically significant. Validity and reliability of the study

To enhance the validity of the study, the appropriate statistical tests were implemented to increase the precision of comparisons between the countries. Careful forward–back translation procedures and group discussions were followed, and all the data were obtained from professional nurses working in similar and typical in-patient wards of acute hospitals. Finally, the same protocol was used for data collection and analysis. In addition, the alpha coefficients for the RPPE were high. The instrument’s reliability was measured using the Cronbach’s alpha coefficient. Both Greek and Cypriot data showed sufficient internal homogeneity of the scales (Cronbach’s alpha Cyprus = 0.90; Cronbach’s alpha Greece = 0.84).

Data collection and ethical considerations

Researchers from both countries obtained ethical approval and permission to collect the data from their national boards. The study was conducted following the generally accepted ethical standards by Beauchamp and Childress (2009). Those who agreed to participate received a questionnaire accompanied by written information about ethical issues, including confidentiality, anonymity and the right to withdraw from the study without any consequences. Questionnaires were distributed by a member of the research team and returned, sealed in an envelope, in a designed locked box located in the ward nursing manager’s office. Reminders for returning the questionnaires were offered at 1 and 2 weeks after their distribution. The data were kept safely, with restricted access only to the members of the research team. Return of a questionnaire was considered as informed consent for participation in the study. Permission to use the RPPE scale was obtained from its authors (D. Jones, pers. comm., 2008). Data analysis

The data were analysed using spss 18.0 (SPSS Inc., Chicago, IL, USA). The internal consistency reliability of the scale was examined using Cronbach’s alpha coefficient values and item

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Findings The nurses’ characteristics are described in Table 1. The sample represents a typical nurses’ sample consisting mainly of women. The older and more experienced nurses – in terms of years in practicing nursing – were in Greece. Statistically significant differences between the two countries were found with regard to their education and type of work: Most of the Cypriot nurses were holding a diploma (92%), whereas less than half of the Greek nurses were holding a diploma (43%). Finally, more than half (54%) of the Greek nurses were assistant nurses. It should be emphasized, however, that this group in Greece works as RNs because of a great shortage of nurses, offering first-line nursing care. The results regarding the differences in the nurses’ perceptions regarding their professional practice environment are presented in Table 2. Greek and Cypriot nurses have significantly different opinions in three out of the eight categories characterizing the professional practice environment. The mean scores of RPPE scales for Cypriot nurses were significantly lower than those of Greek nurses, namely, the Handling Disagreements and Conflicts (MCyprus = 2.57, MGreece = 2.85, P < 0.001), Leadership and Autonomy in Clinical Practice

Nursing Work Life Research


Table 1 Demographic data Cyprus n Gender* Male, n (%) Female, n (%) Highest education* Vocational nursing education Diploma in nursing Bachelor’s degree Masters degree or higher Work as* Registered assistant Registered nurse Specialized nurse Type of work* Full time Part time Per/diem Age, mean (SD)† Experience of nursing, total†

Greece %






27 73 145

18 82

Cypriot and Greek nurses' perceptions of the professional practice environment.

Research evidence supports that the role of the professional practice environment is crucial for the delivery of quality care as it is significantly c...
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