REGISTERED NURSES’ (RNs) PERCEPTION OF THE NURSING PROFESSION AND HEALTH CARE WORK ENVIRONMENT IN TERTIARY AND SECONDARY HEALTH FACILITIES IN CALABAR, NIGERIA

Background A healthy work environment has tremendous benefits on organizational performance, health service delivery, health worker performance and patient outcome. In 2009, International Council of Nurses (ICN) undertook a global survey which sought for nurses’ opinion on the nursing profession and their work environment in 11 countries, excluding Nigeria. Little is known about how Nigerian nurses, particularly nurses in Cross River state perceive their work environment. This study explores registered nurses’ perceptions and experiences with selected features of a positive practice environment, as a basis for developing an intervention strategy for improving nurses’ work environment in Calabar, Cross River state. Methods This study was a descriptive survey by design. Perceptions of features of positive practice environment were explored among Registered Nurses in full time employment at tertiary and secondary health facilities in Calabar using a modified 51-item standard structured questionnaire originally developed by Pfizer to measure Nurses expectations and needs in a 2009 ICN Quadrennial Study. The questionnaire was adapted with the permission of Pfizer. Data were computer analyzed using SPSS for Windows version 15. Interrelationships between variables were tested using ChiSquare analysis. Results The mean (SD) age of the respondents was 37.4 ± 8.3 years while respondents’ mean (SD) working experience was 15.8 ± 8.7 years. The respondents were predominantly female 149(90.3%) while 109 (66.1%) were married. The level of education indicated that most 110(66.7%) had diploma in Nursing, 43(26.1%) had first degree, and 12(7.3%) had post-graduate qualification. Most 86(52.1%) of the nurses had heard just a little some about positive practice environment (PPE), 30(18.2%) had heard nothing at all while only 49(29.7%) were quite knowledgeable. The features of PPE rated highly by the participants were clear and comprehensive description of their job responsibility 75(45.5%) and an environment of team work and collegiality 71(43.0%). Similarly, in their practice experience, the very positive feature in their work environment was an environment of open communication, teamwork and collegiality 60(36.4); clear and comprehensive description of their job responsibility 53(32.1%). Most favorable aspect of nursing identified by the nurses was helping patients/patient contact 75 (45.5%) while the most unfavourable aspect of nursing identified were risk of contracting infections 61(37.0%). Although 96(58.2%) of the participants opined that nursing is better today than 5 years ago, only 50(30.3%) were very satisfied with nursing while 103(61.8%) of the nurses expressed the desire to remain in the nursing profession in the next 5 years. Discussion The findings have established the need for making information on PPE widely available to practicing Registered Nurses in Calabar. Employers of nurses should take urgent steps to improve health and safety policies and procedures at the work place to create a more positive practice environment for nurses to perform their duties and improve patient outcome. More efforts are required by the professional association to negotiate better pay packages, benefits and incentives for nurses in order to guarantee nurses wellbeing and retention in the profession.


INTRODUCTION
Global health workforce crisis has been adduced to the challenge of shortages of critical health manpower including nurses, underemployment, and unemployment of health professionals (ICN, 2008).
Meta-analysis has suggested that a favorable practice setting can improve nurses' satisfaction and reduce turnover. Nurse supervisors, job character management style and service quality are key factors associated with a positive practice milieu (Smith, Hood, Waldman, & Smith, 2005). Many other benefits of Positive Practice Environments (PPE) supported in literature include higher employee retention rate, better team work, improvement in patient outcome (Lowe, 2002), building management and leadership capacity of organizations (WHO, 2007;ICN, 2007), professional advancement, autonomy and participation in decision making and fair compensation (Buchan & Calman, 2004),.
The International Council of Nurses (ICN) initiated and chose Positive Practice Environments: Quality Workplaces = Quality Patient Care as its theme for International Nurses Day in 2007 (ICN, 2007;Wang, 2013). The Council also made an appeal to National Nursing Associations to make improving practice environments and protection of nursing staff their focal points (Lee, Pai, & Yen, 2008).
Positive practice environments have been defined as work settings that sustain excellence and respectable work. In specific terms, such settings endeavour to guarantee health, safety and personal well-being of staff, promote quality patient care and enhance the motivation, productivity and performance of individuals and organizations (Rondeau, Francescutti, & Zanardelli, 2005). It was observed that when health professionals are satisfied with their jobs, absenteeism decrease while staff morale and productivity increase. One of the key factors responsible for low productivity in global health workforce is an unhealthy work environment (ICN, 2007;ICN, 2008).
Elements of positive practice environments also include fair and manageable workloads and job demands/stress, equal opportunity and treatment, opportunities for professional and career advancement, job security, decent pay and benefits, access to adequate equipments, supplies and support staff, support supervision and mentorship, open communication and transparency, safe staffing levels, professional identity, autonomy and control over practice, workloads that allow work-life balance, effective management and leadership practices (ICN, 2008). The International Council of Nurses (ICN) undertook and presented the findings of a global survey that sought nurses' opinion on the nursing profession and their work environment in 11 countries, excluding Nigeria during the ICN conference in 2009 (Wang, 2013). There is paucity of published data about practice environment of Nigerian nurses and particularly nurses in Cross River state. The study examines nurses' experiences with selected features of a positive practice environment in Calabar, Cross River state, as a basis for developing an intervention strategy for improving nurses' work environment. Specifically the study was designed to: i) determine Nurses' level of awareness of positive practice health care environment among Registered Nurses (RNs) in Calabar, ii) determine RNs' perceptions of features of positive practice health care environment in Calabar, iii) explore RNs' experiences with features of positive practice environment in Calabar iv). explore RNs' opinion about the most favourable and most unfavourable aspects of nursing and v).determine RNs' satisfaction with the nursing profession. The under listed hypotheses were formulated to guide the study.
1. There is no significant association between RNs' practice environment and retention in Nursing. 2. Health care work environment will have no significant relationship on RNs' perception of the nursing profession.

Research Design
A descriptive cross sectional survey design was used to examine features of positive practice environment in tertiary and secondary health facilities in Calabar.

Setting of the study
The study was carried out at University of Calabar Teaching Hospital and General Hospital Calabar, Nigeria. The University of Calabar Teaching Hospital was selected because it is the only tertiary health facility in Calabar. It was established in 1980, as a first generation Nigerian tertiary health facility and provide clinical experience for all categories of professional health workers (Ofi, Sowunmi, Edet, & Anarado, 2008). The General Hospital Calabar on the other hand was established in 1991 and is the largest secondary health facility in Cross River State rendering medical, surgical and maternal and child health services.

Study population
The study was targeted at the nurses working in all the wards and special units of the hospitals. The study population was made up of 586 nurses from the tertiary health faculty in Cross River State and 281 nurses in secondary health facilities in Calabar.

Sample size and sampling technique
A purposive sample of 165 nurses comprising 124 nurses from University of Calabar Teaching Hospital and 41 nurses drawn from General Hospital, Calabar was used for the study.

Instrument for data collection
The main instrument for data collection was a modified 51 items standardized validated structured questionnaire originally developed by Pfizer to measure Nurses expectations and needs in a 2009 ICN quadrennial study (Wang, 2012) The tool was adapted with permission of Pfizer (APCO Insight, 2009) and consisted of 5 sections which was used to elicit information on socio-demographic data, level of awareness of positive practice health care environment, perceptions and experience with features of a positive practice health care environment, favourable and unfavourable aspects of nursing and satisfaction with the nursing profession.
All the questionnaires distributed to the respondents by the researchers were retrieved on the spot giving a 100% response rate.

Data Analysis
Data were computer analyzed using Statistical Package for Social Sciences (SPSS) version 17 for Windows. Practice environment was computed using 15 items scaled 0-10. With respect to rating of PPE features and experiences, 0-2 indicated a very negative environment, 3-4 negative environment, 5-6 somewhat negative environment, 7-8 positive environment and 9-10 very positive environment. Data were analyzed using frequencies and percentages. However in instances when the 0-10 scale was converted into scores, the maximum score obtainable was 150. Score ≥ 101 was considered very positive, 51-100 somewhat positive, while 0-50 was considered a negative practice environment. Interrelationships between variables were tested using Chi-square analysis.

Ethical consideration
A written permission to carry out the study was sought and obtained from the Chief Medical Directors and Chief Nursing Officer's In-charge of the institutions. A verbal consent was also obtained from participants. Thereafter, the purpose of the study was explained to all participants, anonymity was ensured by not writing names on the copies of the questionnaire. Strict confidentiality was maintained. Participants were allowed to opt out of the study at any time they so desire without any penalty.

Results
The mean (SD) age of the respondents was 37.4±8.3 while mean (SD) years of working experience was 15.8±8.7. Gender wise the respondents consisted of 149(90.3%) female and 16(9.7%) male. Most 109 (66.1%) were married, 45(27.3%) never married, 4(2.4%) separated and 7(4.2%) widowed. The respondents were all (100.0%) adherents of the Christian faith, Level of education indicated that most 110(66.7%) had diploma in Nursing, 43(26.1%) had a first degree while only 12 (7.3%) had post graduate qualification. Most 68(41.2%) belong to the junior nursing cadre while 97 (58.8%) were senior nurses. The sample was made up of 124 (75.2%) nurses from tertiary health facility employment while 41 (24.8%) were employed in a secondary health facility (Table 1).  As illustrated on Table 3, the 5 top features of PPE rated highly (9-10) by the participants were clear and comprehensive description of job responsibility 75(45.5%), an environment of open communication, team work and collegiality 71(43.0%), relationship with your management and supervisors 65(39.4%), and ability to make independent judgements and have control over your practice area / opportunities for professional development and career advancement 64(38.8%). The least rated (0-2) features were pay and benefits equal to your education experience and professional responsibilities 21(12.7%) and respect received as a nurse from physicians and other health care professionals 20 (12.1%). Similarly, in their practice experience, very positive features in their work experience rated positive (7--10) were: a clear and comprehensive description of their job responsibility, 121 (73.3%), control over the pace and amount of work you do, 108 (65.5%) and an environment of open communication, teamwork and collegiality 106 (64.2%). The very negative features of their work experience, rated negative (0-4) were: respect received as a nurse from physicians and other health care professionals 48 (29.0%), policies and programs at work that provide a balance and family life 42 (25.5%), involvement in management decisions that affect your work experience and the quality of patient care 35 (21.2%) and policies that encourage the reporting of any professional misconduct or violation of law that may occur 34 (20.6%). When the perceived practice experiences were computed as a score and determined as a percentage, the average score among nurses was 95.9 ± 36.7. Additionally 15(9.1%) rated their experience as poor, 67(40.6%) rated it as positive while 83 (50.3%) rated their experience as very positive. Thus implying that about 90% of the participants viewed the practice environment as positive.

Objective 5: Determine nurses' satisfaction with the nursing profession and intention to remain in Nursing
Ninety nine (60.0%) opined that nursing is better today than 5 years ago, 25 (15.2%) felt its about the same while 40(24.2%) opined that it is worse. Forty six (27.9%) were extremely dissatisfied with nursing, 10 (6.1%) were dissatisfied, 27(16.4%) were somewhat satisfied, 32 (19.4%) were satisfied while 50 (30.3%) were very satisfied with nursing (Table 7A). Many 39 (23.6%) of the respondents were extremely unlikely to remain in nursing in the next five years, 5 (3.0%) were unlikely, 18(10.9%) were somewhat likely, 20 (12.1%) were likely while 83 (50.3%) were extremely likely to remain in the nursing profession in the next 5 years (Table 7B). Ho 1 : There is no significant association between nurses' practice environment and retention in Nursing  Table 8 showed no significant association between nurses' practice environment and intention to remain in Nursing. Ho 2 : Health care work environment will have no significant influence on nurses' perception of the nursing profession. As shown in Table 9, health care work environment had a statistically significant relationship with nurses' perception of the nursing profession, 50.9% of those who perceived the environment as positive also perceive the nursing profession as better.

DISCUSSION
The study was conducted to assess nurses' perception of the nursing profession and health care work environment in tertiary and secondary health facilities in Calabar, Nigeria. The participants were mostly female, which is a reflection of the nursing profession globally including Nigeria (Ofi et al., 2008;Evans & Frank, 2003;Kolade, 2000;Parahoo, 1999). Although a higher proportion of participants who had had heard nothing at all about positive practice environments emanated from secondary health care facility those who had heard a great deal about PPE were from the tertiary institution, the observed difference based on type of health facility was not significant (p>0.05). This finding indicate that nurses from the two practice settings were equally informed about PPE, which is not surprising since both are located in urban centers and have Continuing Nursing Education Center (CEC) established by their respective hospital management to keep nurses abreast of contemporary trends and issues in nursing. What is rather worrisome is that in spite of the setting of the facilities and presence of the lifelong learning centers, more than half (70%) of the nurses claimed that they have heard nothing at all or just a little bit about PPE.
On a general note, respondents rated all the features as contributing positively to the work environment. However the features of a quality work environment rated highly by the participants were clear and comprehensive description of job responsibility, an environment of open communication, team work and collegiality and relationship with your management and supervisors. Similarities were observed when compared with findings from the ICN Global survey in which the top four features with the highest ranking were ability to openly communicate with team members and peers, sufficient and adequate resources for safety, access to adequate information for the best nursing care, occupational health and safety measures and procedures, clear work responsibilities and relationship between management and counsellors and pay and benefit in line with the education, qualification and professional responsibilities (Wang, 2012). This implies that Nigerian Nurses in this study have similar expectations as the global nurses. The top expectations of Taiwan Nurses differ slightly and comprised of resource allocation, professional growth and development, work arrangement and new staff training and counselling. (Wang, 2012) A study carried out among Lagos Nurses in South West, Nigeria observed that Nurses were less satisfied with their job environment and postulated that they could be more satisfied if there is improvement in job environment with emphasis on their work roles (Osibanjo, Abiodun, & Adeniji, 2014). A Finnish hospital based study had reported that workplace bullying of staff resulted in increase in absence from work due to sickness while in another study, the same team reported that poor teamwork resulted in physician sickness absence rates (Kivimaki, Elovainio & Vahtera, 2000;Kivimaki et al., 2001). Ayamolowo (2013) had noted in her study among Primary Care workers that good interpersonal relationships is one of the factors capable of increasing workers satisfaction (Ayamolowo, Irinoye, & Oladoyin, 2013). Spector (1997) while listing three important features of job satisfaction posits that organizations should be guided by human values. Thus implying that, such workplaces will be focussed on treating workers in fairness and with some level of respect. Furthermore a study carried out on RN's perception of their work environment found a statistically significant difference between RN's opinion about supervisors support and job satisfaction. The study showed that RNs with less than 2 years experience perceived the greatest supervisor's support (Stuenkel, Nguyen, & Cohen, 2007) while a study by physiotherapy interns in Nigeria reported that most were satisfied with support with senior colleagues but dissatisfied with their salaries, equipments and the office environment (Onigbinde, 2007).
Examination of nurses' experiences with features of positive practice environment showed that most of the nurses rated their experiences with the features positive. This indicates that most of the nurses appear to be satisfied with all the features of their work environments. However the top satisfactory features observed by Nigerian nurses were an environment of open communication, team work and collegiality, clear and comprehensive description of job responsibility , policies and programs at work that provide a balance and family life, control over the pace and amount of work you do. The least rated were sufficient staff and staff with the right qualification, rank and requisite experience to ensure safety and opportunities for professional development and career advancement. This finding shows that their expectation was met regarding the first two features rated highly. The top features they were satisfied with is in contrast to the global survey most satisfactory criteria which were new staff training and counseling, work environment and professional and development, while the least satisfying was compensation and benefits (Wang, 2012). Although, compensation and benefits was rated low by Nigerian Nurses, it was not the least satisfying; the least satisfying was sufficient staff and staff with the right qualification and designation to ensure safety. Again this assertion could depend on their work sectors and the imbalances in certain sectors. The fact that some of the respondents rated the features low should not be ignored, since it is an indication that there is room for improvement. This becomes necessary as suggested by Brooks, Hess, Weinstein et al., (2010), who opined that the nursing profession should continue its struggle with how best to meet the needs of a positive practice environment.
Studies  Cheema, & Faryal, 2011);Hanglberger (as cited in Shujat, Cheema, & Faryal, 2011). It is expected that based on these experiences Nurses would be highly committed to their workplaces in both practice settings. In view of this finding, management of the hospitals should continue with the necessary steps to enhance work-life balance policies to ensure the maintenance of a high degree of commitment among the nursing staff.
According to Hartel, Fujimoto, Strybosch, & Fitzpatrick (as cited in Shujat, Cheema, & Faryal, 2011), a wide range of work-life balance initiatives which could be incorporated hy the health facilities include: flexible work hours, job sharing, workplace child care facility & telecommuting. World Confederation for Physical Therapy (2008) noted that there are critical imbalances in unhealthy work environments and poor organizational climate characterize many workplaces. Although nurses in many health facilities including the tertiary and secondary institutions in the developing nations often work under poor organizational climates, the shortages is more acute and pronounced in secondary health facilities in Nigeria (Abiodun, 2011). Under-investment in secondary health sector coupled with poor employment conditions and policies such as insufficient remuneration, unfavourable work life and unreasonable workloads might have contributed to the poor awareness and perception of their health care environment (Kano, 2009;Olatinwo, 2013).
According to World Confederation for Physical Therapy (2008), establishing and maintaining positive practice environment across health sectors worldwide is of paramount importance if patients' safety and health workers' wellbeing are to be guaranteed. Furthermore, it is often observed that nurses in the secondary health care facilities are often fewer and therefore work longer hours and with shortage of essential materials but with lower remuneration than their counterparts in the tertiary institution (WHO, 2004;Kano, 2009;Olatinwo, 2013). These are key elements in the workplace that strengthen and support the workforce and in turn have a positive impact on patients' outcomes and organizational cost-effectiveness. Since positive practice environments are settings that support excellence and decent work, all health sectors be they private or public, tertiary or secondary should have opportunity to work under a healthy work environment with good remuneration.
Furthermore, in the nurses' opinions, the most favourable aspects of nursing were helping patients and patients' contacts. This is not a surprise because caring is a fundamental nursing value, the quintessence of the nursing profession and is believed to enhance health and well -being of patients (Benner & Wrubel, 1989;Watson, 2002;Baldursdottir & Jonsdottir, 2002). Furthermore according to Watson (2002Watson ( , 2008 caring is nurse's moral ideal of preserving human dignity by assisting a person to find meaning in illness and suffering in order to restore, promote, enhance, and preserve human dignity. Other aspects rated highly was being given career advancement and training opportunities while the most unfavourable aspects of nursing were risk of contracting infectious diseases, lack of job advancement and training; and poor remuneration or incentives. These findings are in line with the submission of Hennessy and Minnaar (2010) that job satisfaction was adversely affected by poor job advancement and frustrations with management, poor pay and nursing patients with HIV/AIDS (infectious diseases). Many nurses were said to express sadness and discouragement in nursing under such conditions while only a few found their caring role fulfilled. This finding calls for provision of adequate materials including personal protective devices and isolation facilities where necessary; and adequate training of nurses on infection control to enhance care of patients with infectious diseases and ability of nurses to practice with confidence.
With respect to nurses' satisfaction with the nursing profession overall, 49.7% were satisfied with the profession which is higher compared to the 37.3% satisfaction level obtained in Taiwan (Wang, 2012). The level of dissatisfaction is unacceptably too high and requires immediate attention by the management of the two hospitals. Thirty seven point six percent (37.6%) of the respondents were unlikely to remain in nursing for the next five years which if compared with the Taiwan study finding of 23.0% is very high. Globally the 62.4% who would likely remain in Nursing is lower than that of Portugal 77%, Brazil 75%, Canada 71% and USA 68%. Although the reasons for leaving was not explored, retention of the workforce is critical to attainment of organizational goals and should equally receive the attention of management (Wang, 2012). In addition the workplace policy and working environment in the aforementioned countries could serve as a model for Nigerian hospitals. Only one fifth of the participants opined that the nursing profession was about the same, a quarter expressed the view that it was worse or extremely dissatisfactory while 58.2% opined that it is better compared with what obtained five years ago. This is consistent with the findings of the global survey which reported that 52% of the respondents believed that medical system and resources, professional training and promotional activities are better today than five years ago (Wang, 2012). Although over half of the nurses opined that nursing is better today, the negative response by about a quarter of the nurses is too important to be ignored. If the global mandate for improvement of nurses' practice environments had been achieved, nurses are more likely to feel more satisfied with nursing profession than what was obtained in this study. The findings of this study is in line with the findings of a study involving USA, Canada, England, Scotland and Germany which showed that 41.0% of hospital nurses were dissatisfied with their job and further showed a significant relationship between workplace stress and nurses morale, job satisfaction, commitment to the organization and intention to leave (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Brooks, Hess, Weinstein et al. (2010) noted that ICN had emphasized that building a positive practice environment should be a key strategy in attaining and maintaining an effective workforce. WHO (2012) had also mounted a similar campaign. This can be achieved partly by enhanced workforce training and recruitment of nurses, adequate provision of material resources, decreased workloads, suitable inter-disciplinary relationships and appropriate professional status of nurses particularly in the developing nations. Furthermore, the authors emphasized that, empowering nurses through provision of quality practice environments enhances workers' health and wellbeing, contributes to positive outcomes and organizational excellence. Quality work environment also enhances satisfaction with the nursing profession and intention to remain in the nursing profession. This argument is further strengthened by the fact that in this study, health care work environment had significant influence on nurses' perception of nursing profession. Thus although many of the nurses were not aware of PPE to a great extent, in their opinion, their practice environment and the nursing profession require a great deal of improvement to make it highly satisfying.

CONCLUSION
In conclusion, findings from this study have established the need to make information on positive practice environment widely available to practicing nurses in Calabar. The study has also shown that positive perception of the work environment is highly associated with positive perception of the nursing profession (p<0.05). The study points to the fact that the first step towards creating a positive practice environment is to enhance the overall level of satisfaction of nurses. Employers of nurses should take urgent steps to improve health and safety policies and procedures at the workplace, improve nurse workforce training, reduce workloads, provide adequate material resources and enhance professional status of registered nurses. More efforts are required by the professional association, National Association of Nigerian Nurses & Midwives to negotiate better pay packages, benefits and incentives for nurses in order to retain them in the profession. Employers should be responsive as much as possible to such negotiations in the good interest of health care consumers.