Nurses’ Perceptions of Professional Practice Environment and Its Relation to Missed Nursing Care and Nurse Satisfaction

The professional practice environment is a factor that can have a significant impact on missed nursing care. The study aimed to find a relationship between nurses’ perceptions of their professional practice environment and missed nursing care and job satisfaction. An additional aim was to find differences in nurses’ perceived rating of the professional practice environment according to hospital location and job position. A descriptive correlational study was performed. The sample included 513 general and practical nurses providing direct care in nine Czech hospitals. The Revised Professional Practice Environment scale and the Missed Nursing Care (MISSCARE) survey were used to collect data. The professional practice environment was most correlated with satisfaction with the current position (0.4879). The overall score of missed care correlated most strongly with the subscale “staff relationships” (−0.2774). Statistically significant differences in the rating of two subscales, “control over practice” and “cultural sensitivity”, were found between nurses from hospitals in district capitals and those from hospitals in smaller cities. Statistically significant differences in the rating of the “leadership and autonomy in clinical practice” and “teamwork” subscales were found between general nurses and practical nurses. The professional practice environment is related to nurse satisfaction and missed nursing care.


Introduction
The professional practice environment is a factor that can have a significant impact on missed nursing care [1]. At the same time, it is a factor of great significance in the recruitment and retention of healthcare professionals [2]. Aspects of the professional practice environment directly and indirectly influence the quality of nursing care [2].
Several studies confirmed that nurses in hospitals with a favorable professional practice environment reported less missed care [3][4][5]. Research in 1406 hospitals across nine countries revealed that hospitals with consistently better professional practice environments have lower nurse burnout and job dissatisfaction, and that nurses have a more positive perception of the quality of care on their units [6]. The associations between an unfavorable professional practice environment and nurse dissatisfaction and burnout, and between an unfavorable professional practice environment and quality care deficits were also confirmed in other studies [7,8].
The professional practice environment is defined by Lake [9] as "the organizational characteristics of a work setting that facilitate or constrain professional nursing practice". Professional practice environments support nurses to work at the highest scope of nursing practice, to work effectively in a multidisciplinary team, and to mobilize resources quickly [10]. According to

Data collection
Data were collected from January to August 2019 using a paper-and-pencil questionnaire. To measure the main variables (perception of professional practice environment, and missed nursing care), the RPPE scale [14] and the Missed Nursing Care (MISSCARE) survey [20] were used. Both questionnaires were translated into Czech using forward-backward translation. The Czech version of the MISSCARE Survey was previously used and tested in the Czech Republic [23]. In addition, unit staff characteristics (age, gender, education, job position, job satisfaction) and hospital characteristics (hospital location) were examined. Hospitals where the nurses included in the study worked were assessed according to their location-either district capitals or smaller cities. Three hospitals were located in district capitals (more than 300 beds), and six hospitals were located in smaller cities (with fewer than 300 beds, bar one exception). As another key study variable, job position of nurses was examined. Two groups-general nurses and practice nurses-were involved in the study.
Job satisfaction is defined as a positive affective orientation toward employment [24]. To measure nurse job satisfaction, three single-item scales were used. Nurses were asked to rate their satisfaction with their current position, their satisfaction with being a nurse or a nurse assistant, and their satisfaction with the level of teamwork on a five-point Likert scale from 1-very satisfied to 5very dissatisfied.
The RPPE is a 39-item scale. Nurses were asked to indicate their level of agreement on a fourpoint Likert-type scale ranging from 1-strongly disagree to 4-strongly agree. The scale consists of the following eight sub-scales: "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" (two items), "internal work motivation" (eight items), and "cultural sensitivity" (three items). Eight items required reversal. Item 22 ("staff withdraw from conflict") was not reversed as recommended. Statistical analysis showed that Czech nurses understood item 22 in a way opposed to its original sense.
The MISSCARE Survey comprises 24 items in part A (activities of nursing care) and 17 items in part B (reasons for missed care). In part A, nurses are asked to indicate the frequency with which care is missed using the scale "rarely", "occasionally", "frequently", "always", or "non-applicable". In part B, nurses are asked to rate each item using the scale "significant factor", "moderate factor", "minor factor", or "not a reason for unmet nursing care".
In the present study, Cronbach's alpha for parts A and B was 0.97 and 0.92, respectively. In this study, only total scores (the mean frequency ratings across all items) of part A were used.
The research protocol was approved by the institutional ethics committee (no. 1/2019 Ethics Committee, Faculty of Medicine, University of Ostrava, Czech Republic).

Data Analysis
After data cleaning, frequencies were calculated to explore the distribution of nurses' perceptions of the professional practice environment, nurse satisfaction, missed care, staff, and hospital characteristics. Spearman's correlation coefficient was used to test relationships between both missed care and nurse satisfaction and nurses' perceptions of the professional practice environment. The Wilcoxon-Mann-Whitney two-sample rank-sum test was used to test differences in rating the professional practice environment by job position and hospital location. Data were analyzed using the Stata software package.

Results
The mean age of nurses was 38 (SD 11.1) years. The majority were general nurses (78%), female (97%), and graduates from secondary vocational schools (67%). Slightly more than half worked in hospitals in district capitals (51%). The majority of nurses were satisfied with their current position, with being a nurse, and with the level of teamwork on their units (Table 1). The highest scores (3.0) were obtained for the subscales "control over practice", "communication about patients", and "staff relationships". These subscales were rated as favorable. "Teamwork", with the lowest mean (2.2), was the worst-rated subscale. The lowest rated item of the RPPE scale was "there are enough staff to provide quality patient care" (2.0) from the "control over practice" subscale. The highest rated item was "I feel a high degree of personal responsibility for the work I do" (3.4) from "internal work motivation" ( Table 2). There were statistically significant differences in the rating of two subscales, "control over practice" and "cultural sensitivity", between nurses from hospitals in district capitals and those in smaller cities. Nurses from hospitals in district capitals rated "control over practice" significantly more highly than did nurses from smaller city hospitals. By contrast, nurses from smaller city hospitals rated "cultural sensitivity" significantly more highly. The total RPPE scale score was slightly higher among nurses from hospitals in district capitals (Table 3). General nurses generally rated their professional practice environment (RPPE total score) slightly more highly than practical nurses. Statistically significant differences in the rating of the subscales "leadership and autonomy in clinical practice" and "teamwork" were found between general nurses and practical nurses. While "leadership and autonomy in clinical practice" was rated statistically significantly more highly by practical nurses, "teamwork" was rated statistically significantly more highly by general nurses (Table 4). The overall score of missed nursing care negatively correlated with the RPPE total score (−0.2141), i.e., a better professional practice environment reflected a lower level of missed nursing care. This correlation was weak. The overall score of missed care correlated most strongly with the subscale "Staff relationships" (−0.2774). The correlation was negative, i.e., better staff relationships reflected a lower level of missed nursing care. The professional practice environment (RPPE total score) correlated most with satisfaction with current position (0.4879). Satisfaction with the level of teamwork on this unit correlated with the RPPE total score (Table 5).

Discussion
The professional practice environment is linked to different nurse outcomes such as unmet patient care needs, job satisfaction, burnout, intention to leave, and missed nursing care [6,25,26]. The present study investigated the professional practice environment of Czech nurses and its relation to missed care and nurse satisfaction. In this respect, the study is unique, since Czech nurses were not previously the focus of such research.
In the present study, the worst-rated item of the RPPE scale was "there are enough staff to provide quality patient care". Staff shortage is a consistently reported problem in Czech samples in nursing research [23,27], as well as in other international studies [28][29][30][31]. However, despite this shortage, missed care may be reduced when a positive work environment for nurses is ensured. Several previous studies [28,32] suggested that teamwork and cooperation are associated with lower reports of missed care. In the present study, "teamwork", containing items related to teamwork and communication with other departments, was the worst-rated subscale. A study by Kalisch and Lee [21] confirmed that, when teamwork was stronger, less missed nursing care was reported. In contrast, "staff relationships" was the most highly rated subscale in the present study. Relationships within and communication between departments may be improved by appropriate interventions.
Data analysis further revealed that nurses' satisfaction with the level of teamwork on their units significantly correlated with the RPPE total score. Professional practice environment correlated most with satisfaction with current position. The association between the professional practice environment, resource adequacy, and nurse satisfaction was confirmed in a systematic review [33]. Nurses' perceptions of their professional environment influence their job satisfaction [33].
It is well documented that nurse satisfaction has a significant impact on both nurses and patients [34]. Moreover, lower nurse satisfaction with current position leads to more frequent missed care [35]. In the present study, the most highly rated item of the RPPE scale was related to internal work motivation, suggesting this as the reason for the high level of nurse satisfaction.
The additional aim of this study was to find differences in nurses' perceived rating of the professional practice environment according to hospital location and job position. Although the practice environment was rated slightly more highly by nurses from hospitals in district capitals than by those from hospitals in smaller cities, the differences were not statistically significant. Hospital location is probably a variable with only a minor impact on the professional practice environment.
General nurses rated the professional environment generally slightly more highly than practical nurses. Differences were found for two subscales, "leadership and autonomy in clinical practice" and "teamwork", with the former being rated more highly by practical nurses and the latter by general nurses.
Several studies confirmed that practice environment is statistically significantly related to missed nursing care. Better nursing practice environments are associated with less missed nursing care [4,5,36,37]. In a better practice environment, nurses miss approximately one fewer necessary care activity [37]. A recent study by Lake, Riman, and Sloane [12] indicated a reduction in missed care in hospitals with better work environments or improved nurse staffing, with the effect of changes in the work environment being greater than that of nurse staffing on missed care. The conclusion of a systematic review by Zhao et al. [1] also confirmed the negative correlation between the professional environment and missed care [1].
Kim, Yoo, and Seo [38] (p.125) stated that "missed nursing care is not an outcome associated with individual skills, but an organizational quality of nursing affected by nursing work environment factors". Improvements to the work environment may contribute to ensuring both the supply of a healthy workforce and the enhancement, effectiveness and motivation of that workforce [2].

Implication for Nursing Practice
Significant reductions in rationing nursing care may be achieved by identifying modifiable features of the nursing practice environment. The results of this study suggest the need for strategies to improve the work environment. The establishment of a positive practice environment is of importance in guaranteeing quality of care for patients.

Limitation
The selection of nurses from a single region in Czech Republic did not allow extrapolation of the results to the entire country. In addition, cross-sectional design and self-reporting data may be sources of potential biases. Despite these limitations, similar results from various previous studies tend to support the validity of our findings.

Conclusions
The professional practice environment is linked to nurse satisfaction, as well as missed nursing care. Missed nursing care in hospitals can be reduced by improvements to the professional practice environment, with an emphasis on strengthening teamwork. Better work environments will likely improve nurses' satisfaction with their current position, as well as with the level of teamwork on their units.

Conflicts of Interest:
The authors declare no conflict of interest.