key: cord-0859023-ttft2q4l authors: Pimenta Lopes Ribeiro, Olga Maria; de Lima Trindade, Letícia; Silva Fassarella, Cintia; de Abreu Pereira, Soraia Cristina; Figueiredo Cabral Teles, Paulo João; Gomes da Rocha, Carla; da Silva Leite, Paula Cristina; Almeida Ventura‐Silva, João Miguel; Neves Sousa, Clemente title: Impact of COVID‐19 on professional nursing practice environments and patient safety culture date: 2022-04-25 journal: J Nurs Manag DOI: 10.1111/jonm.13617 sha: b1a3f08ce8fc11eaffb6b8a17a2378c7c09555d7 doc_id: 859023 cord_uid: ttft2q4l AIM: To analyse the impact of COVID‐19 on professional nursing practice environments and patient safety culture. BACKGROUND: The relationship between work environments and patient safety has been internationally recognized. In 2020, the pandemic imposed enormous challenges, yet the impact on these variables remains unknown. METHOD: This is a quantitative observational study, conducted in a Portuguese hospital, with 403 registered nurses. A self‐completion questionnaire was used. RESULTS: The impact on the Structure and Outcome components of nursing professional practice environments was positive. Although the Process component remained favourable to quality of care, a negative trend was confirmed in almost all dimensions. The results regarding safety culture showed weaknesses; ‘teamwork within units’ was the only dimension that maintained a positive culture. CONCLUSION: Positive responses regarding patient safety were significantly associated with the quality of the nursing professional practice environment. The need to invest in all dimensions of safety culture emerges to promote positive professional environments. IMPLICATIONS FOR NURSING MANAGEMENT: Improving professional nursing practice environments can be achieved through managers' investment in the participation and involvement of nurses in the policies and functioning of institutions, as well as promoting an open, fair and participatory safety culture that encourages reporting events and provides adequate support for professionals. In the last two decades, due to the technical-scientific evolution, the complexity of care and the growing demands of citizens, promoting patient safety has become one of the main challenges of the different health systems (Clark & Lake, 2020; Lake et al., 2021; Mihdawi et al., 2020) . In addition, in December 2019, an outbreak of pneumonia caused by the new SARS-CoV2 emerged in the city of Wuhan, China, whose rapid worldwide spread led the World Health Organization to designate it as a pandemic, thus making the disease known as COVID-19 (Almeida, 2020) . Around the world, the daily increase in the number of hospitalizations for COVID-19, besides causing immense pressure on all health care systems, has required organisational planning in a short time to improve professional practice environments, ensuring conditions for safe and quality care (Ventura- . Although during the pandemic it gained more attention, the work environment has already been one of the main discussion topics in the last decade. Robust research conducted in a pre-pandemic context has shown that hospitals can improve outcomes in relation to clients, nurses and the institution itself by investing in work environments (Al Ma'mari et al., 2020; Faridah et al., 2021; Fassarella et al., 2018) . Research related to the Registered Nurse Forecasting Study (RN4CAST) has confirmed that the work environment explains much-or all-of the variation in patient safety culture (Clark & Lake, 2020) . A good work environment is a prerequisite for a positive safety culture and high-quality care (Al Ma'mari et al., 2020; Lake et al., 2021) . In a pandemic situation, among nurses working in hospitals, there are growing concerns about heavier workloads, increased complexity of care, time pressure and limited resources. Therefore, a negative impact of COVID-19 is predicted on some dimensions of practice environments, which is of concern from the perspective of quality of care and patient safety. The lack of studies in the country on the characteristics of nursing practice environments during the COVID-19 pandemic makes this research even more relevant, because the identified gaps will support the need for change. It is certain that a nursing practice environment with favourable characteristics will be, among other aspects, important to improve patient safety (Clark & Lake, 2020; Lake et al., 2021; Ribeiro et al., 2020) . Although previous studies have identified the weakest areas in patient safety (Fassarella et al., 2018; Mihdawi et al., 2020) , the COVID-19 pandemic has imposed unprecedented readjustments on institutions, and evidence is currently needed to support new strategies that minimize the possibility of unexpected incidents. Working under conditions with high workloads, and lack of staff and resources, can increase the frequency of adverse events that threaten patient safety (Faridah et al., 2021) . Nurses are the health care professional group that remains 24 h a day with patients (Faridah et al., 2021; Fassarella, 2021) and have been central on the front line in the pandemic (Mohammed & Lelièvre, 2022) . In this sense, assessing professional practice environments and patient safety culture from the perspective of these professionals, in addition to being a priority, can provide excellent inputs to managers, as it will allow them to identify the weakest areas and define improvement strategies (Fassarella et al., 2018 This study was conducted in one of the largest university hospitals in Portugal. Located in the North region, it is a centre of reference in the various clinical specialties, having, already before the pandemic, a quality management system that promotes effectiveness and efficiency to obtain sustained results, in permanent continuous improvement. During the pandemic period, although the guidelines issued by the Directorate General of Health and the Ministry of Health allowed for the standardization of procedures in all hospitals of the country regarding the assistance to patients with COVID-19 and patients with other pathologies (Ventura- , the readiness of the hospital institution in question has allowed for a differentiated response (Almeida, 2020) . The logistical and structural adjustments in the hospital institution were continuous, and in accordance with the pandemic evolution, seeking to meet the needs of the community and professionals. The top management bodies anticipated the need for reorganisation and established several contingency plans, with sequential definition of services to be opened in case of increasing need for hospitalization in the different care areas. Of the various implemented measures, we highlight the acquisition of clinical and non-clinical material and the early definition of independent circuits for patients with COVID-19. In addition, some services were remodelled, and professionals were hired to satisfy more adequate ratios, as well as reinforced training and constant dissemination of guidelines issued by national and international entities (Almeida, 2020; Cardoso et al., 2021; Ventura-Silva et al., 2020) . Since the beginning of the pandemic, in March 2020, the definition of areas for hospitalization of COVID patients, non-COVID patients and areas for patients awaiting the results of disease testing assisted to reduce the risk of cross infection and to ensure the assistance of those who sought the institution for other pathologies . Because the creation of specific care areas essentially occurred in the departments of medicine, surgery and intensive and emergency care, these were the settings selected for this study. Based on the total population of these departments (913 nurses), the sample size was calculated, by adopting a confidence level of 95% and a sampling error of 5%, resulting in a sample size of 385. With the use of a nonprobability convenience sampling technique, we obtained the participation of 403 nurses (higher than necessary), of whom 208 worked in areas of care for COVID-19 patients. The inclusion criteria were being a nurse or a specialist nurse; working in the adult services of the departments of medicine, surgery, intensive and emergency care; and having worked at the institution for more than 18 months (at least since the pre-pandemic period). All professionals who were absent on leave or holiday during the data collection period were excluded. Considering the variables under study, the data collection instrument Practice, the response to each item is scored on a Likert-type scale with five options, where one corresponds to 'never', two 'rarely', three 'sometimes', four 'often' and five 'always' . The HSOPSC is composed of 42 items distributed by 12 dimensions. Each item is answered on a Likert-type scale with five response options, from one "strongly disagree" or "never" to five "strongly agree" or "always" (Eiras et al., 2014) . While completing the questionnaire, which took place from 1 to 30 June 2021, the participants were asked to respond in relation to the items of the SEE-Nursing Practice and the HSOPSC (Eiras et al., 2014; Ribeiro et al., 2021) , regarding two distinct moments in time: the pre-pandemic period and the 'current' moment, which in this study corresponds to the third critical period of the COVID-19 pandemic in Portugal (considered as the one in which there was a higher number of hospitalized patients, with a subsequent decrease in the number of new cases and deaths) . The study was approved by the ethics committee of the hospital under number 104/21. Data collection was carried out by two researchers. The questionnaires were delivered in each department under study and, subsequently, collected on site. Given the movement restrictions and the nurses' heavy workload, the researchers' visits were previously scheduled with the nurse managers. All those who agreed to participate signed the informed consent form. Confidentiality was guaranteed in the use and disclosure of the obtained data. Descriptive and inferential statistics were used using the Statistical Package for the Social Sciences (SPSS) software, version 26.0. When analysing the results, the higher the score in the SEE-Nursing Practice, the more favourable the environment of professional nursing practice is to the quality of care. Regarding the subscales, the higher the score, the more the Structure, Process or Outcome are favourable to the quality of care. For the analysis of the results related to nursing professional practice environments, the following criteria were established: score < 35%-component not very favourable to care quality; between 35% and 55%-component moderately favourable to care quality; between 55% and 75%-component favourable to care quality; and finally, >75%-component very favourable to care quality . Regarding patient safety culture, the positive responses refer to the responses in which Options 4 or 5 (agree/strongly agree) were marked for the positively formulated statements or 1 or 2 (strongly disagre/disagree) for the negatively formulated statements. Negative responses refer to responses in which Options 1 or 2 (strongly disagree/disagree) were marked for the positively formulated statements or 4 or 5 (agree/strongly agree) for the negatively formulated statements (Sorra et al., 2016) . The percentage of positive responses represents a positive reaction towards patient safety culture and allows for the identification of strong and weak areas in patient safety. For interpreting the results, 'strong areas of patient safety' are those items with 75% or more positive responses ('strongly agree' or 'agree') or those items that when written negatively, scored 75% negative responses ('strongly disagree' or 'disagree'). Similarly, 'weak areas of patient safety' and those needing improvement were those whose items scored 50% or less positive responses. Positive responses between 51% and 74% refer to 'neutral or undefined areas of patient safety' (Sorra et al., 2016) . At the beginning of the statistical analysis, using the Shapiro-Wilk and Lilliefors tests, normality was rejected for all dimensions and subscales. Consequently, for the variable 'nursing professional practice environments', comparisons between the pre-pandemic moment and after the third critical period of COVID-19 were based on the Wilcoxon test (paired samples). Regarding patient safety culture, comparisons were based on the McNemar test. The significance level adopted was .05. Subsequently, to test the relationships between nursing professional practice environments and patient safety culture, the mean score of each subscale of the pro- A total of 403 nurses participated in the study, whose sociodemographic and professional characteristics are exposed in Table 1 . Regarding the environments of professional nursing practice, the results are shown in Table 2 . Regarding patient safety culture, Table 3 Regarding the relationship between professional practice environments and patient safety culture, Table 4 With regard to nursing professional practice environments, the investment made in the institution during the first two critical periods of the pandemic, such as the increased availability of material resources, the hiring of more nurses, the mobilization of nurses from services with decreased activity to those that ensured care for COVID-19 patients, the strict separation of COVID and non-COVID areas and the frequent assessment of the adopted strategies (Almeida, 2020; Cardoso et al., 2021) , had a positive impact on the Structure and Outcome components. However, the mean percentages confirm that, similarly to the pre-pandemic context, these components remained moderately favourable to the quality of care. Despite the strategies adopted by the institution, in view of the adversities and demands during several months of the pandemic, there is an urgent need to continue the investment that was initiated, especially because the physical and emotional wear and tear to which the professionals were continuously subjected increased. With greater opportunity to collaborate in defining the institution's strategies, nurse managers gained special emphasis on the organisation of services and care management (Ventura- . This justifies that in the dimensions 'people management and service leadership', 'organisation and guidance of nursing practice' and 'quality and safety of nursing care' the mean percentage was significantly higher after the third critical period of COVID-19. As observed by other authors, in a crisis scenario, the nurse manager plays a key role by providing the physical, human and material resources necessary to ensure the safety and quality of care (Santos et al., 2022) and also by supporting the care providers, not only in the scientific and instrumental domains but also emotionally. Additionally, although the Process component remains favourable to the quality of care, a negative trend was confirmed in almost all dimensions, except for 'collaboration and teamwork' and 'interdependent practices in professional practice'. The high workload and complexity of care, in addition to determining the focus on the interdependent dimension of the profession, made teamwork T A B L E 2 Mean percentages of the components/dimensions of nursing professional practice environments at the pre-pandemic moment and after the third critical period of COVID-19 essential (Santos, Balsanelli, et al., 2021) . Moreover, the difficulties inherent to the planning, assessment and continuity of care were aggravated, the dimension that in this study showed the greatest percentage decrease (70.7% before the pandemic and 62.4% after the 3rd critical period). In the dimensions 'strategies for ensuring quality in professional practice', 'autonomous practices in professional practice' and 'theoretical and legal support of professional practice', the significant decrease in the mean percentage after the third critical period of COVID-19 points to the need to invest in the weaknesses that may be compromising a congruent performance with the essence of nursing and the profession's social mandate. Out of the 14 dimensions of the SEE-Nursing Practice, the worst scored dimension refers to 'nurses' participation and involvement in the institution's policies, strategies and management', which justifies an emerging action at this level. According to some authors, the effective involvement of nursing professionals in hospital management would empower them to make decisions regarding patient safety, which, in turn, would lead to positive outcomes for the patient (Mihdawi et al., 2020) . In a study conducted in a pandemic context, the unfavourable aspects also highlighted the low participation of nurses in decision-making (Santos, Balsanelli, et al., 2021) . Regarding patient safety culture, in the pre-pandemic moment, nine dimensions were considered mostly weak and subject to improvement. After the third critical period of COVID-19, the number of predominantly weak dimensions increased to 10. The dimension that registered this negative trend was 'handoffs and transitions'. Transitions (between shifts and/or services) are known to be one of the most complex moments in care delivery and can trigger loss of information relevant to the continuity of care (Fassarella et al., 2018) . In the context of a pandemic crisis, the increase in the number of patients, the complexity of their clinical condition and the lack of time can compromise patient safety, and the adoption of strategies that facilitate the transmission of relevant information is recommended. The dimension in which the greatest decrease in the percentage of positive responses was found from the pre-pandemic to the third critical period of COVID-19 was in 'staffing', which decreased from 50.4% to 24.6%. Although the lack of nurses in adequate numbers had been confirmed previously in Portugal and abroad (Eiras et al., 2014; Fassarella, 2021; Fassarella et al., 2018) , the pandemic by COVID-19 aggravated the lack of professionals worldwide, with important repercussions on the quality and safety of the provided care (Fassarella, 2021; Santos, Balsanelli, et al., 2021) and on the demands on these professionals (Mohammed & Lelièvre, 2022) . In this study, the dimensions with the lowest percentage of positive responses were, in both moments, the 'feedback and communication about error', the 'frequency of events reported' and the 'nonpunitive response to errors'. The consistency between these results shows that, in addition to the underreporting of events, the lack of communication and feedback regarding errors may hinder the definition and implementation of strategies to avoid them, which had already been confirmed in studies conducted before the pandemic (Fassarella et al., 2018) . In addition, because of poor communication about the error, professionals are less informed about the errors that occur in the service, which, if not properly discussed, may become recurrent. Although, currently, 10 dimensions of patient safety are considered mostly weak and subject to improvement, it should be noted that comparing the results of the two moments, there was a positive trend T A B L E 3 Percentages of positive responses on patient safety culture at the pre-pandemic moment and after the third critical period of COVID-19 confirming that despite the less favourable aspects, the pandemic also imposed positive changes in patient safety (Fassarella, 2021) . In the case of 'communication openness', the percentage of positive responses increased from 31.3% to 37.4%, which is still a low value, justifying that nurse managers invest in improving the dynamics and communication among the health care team, even advocating openness in communication as fundamental to patient safety and team performance (Clark & Lake, 2020; Silla et al., 2017) . Regarding dimensions 'manager expectations and actions promoting patient safety' and 'management support for patient safety', in addition to the percentages of positive answers being lower than 50%, both in the pre-pandemic moment and after the third critical period of COVID-19, the differences are not significant. Similarly to another study conducted in Portugal (Fassarella et al., 2018) , in these dimensions, nurses perceived that managers are insufficiently concerned with patient safety issues, revealing that not even the pandemic context has changed this trend. Regarding the relationship between professional practice environments and positive responses to patient safety culture, it was found that after the third critical period of COVID-19, in the Structure and Thus, it is important that hospital administrators and nursing managers work towards building and supporting a safety culture where errors are recognized, reported and studied to prevent recurrence and implement actions that mitigate patient harm, without penalizing the nurses (Clark & Lake, 2020) , which in fact is not current practice in the country's hospitals. In this sense, the present study contributes with new findings that significantly support the development of quality of care and patient safety culture in Portuguese hospitals. T A B L E 4 Mean percentages of professional practice environments for positive patient safety culture responses Following the above, it should be noted that overall positive patient safety responses are significantly associated with the quality of the nursing professional practice environment, which is in line with what has been reported by other authors (Clark & Lake, 2020; Faridah et al., 2021; Mihdawi et al., 2020) . In addition, positive levels of 'overall perceptions of patient safety' were associated with better scores in nursing professional practice environments, which corroborates the results obtained in different public and private hospitals in Jordan (Mihdawi et al., 2020) and in specific care settings (Al Ma'mari et al., 2020; Lake et al., 2021) . When nurses perceive that their work environment is favourable to the professional practice, they are more likely to engage in their work, thus ensuring safe patient care (Faridah et al., 2021) . In the perspective of the same authors, in this context, the main role of a strong nursing leadership is to create conditions for nurses to be involved in their work environment, which will consequently promote safe and quality care. Although the overall results showed the existence of a moderately quality-promoting professional practice environment, the safety culture is fragile, lacking greater investment, both in professional practice and in training. In this sense, it is worth highlighting the importance of managers in raising nurses' awareness about patient safety, as well as in addressing the professionals' questions/complaints, by adopting strategies to solve them as quickly as possible (Santos et al., 2022) . In this sense, in addition to the relevance of maintaining a positive work environment (Al Ma'mari et al., 2020), this study highlights the need to invest in promoting a culture of safety and organisational learning, which encourages the events' reporting, ensures feedback and communication about errors and is characterized by non-punitive responses. Therefore, it is essential that the institution's managers adopt an adverse event prevention policy as a requirement for patient safety, which, instead of highlighting individual failures, focuses on a systemic perspective that encompasses organisational and technological factors, as well as human factors (Fassarella, 2021; Fassarella et al., 2018) . Despite the relevance of the findings, this study has some limitations. The results of this study can be used by the different levels of management to adopt strategies that improve professional practice environments and, consequently, patient safety. The role of managers is fundamental not only in improving the weakest dimensions of professional practice environments but also in developing a positive safety culture. In this context, the nurses' participation and involvement in the institutions' policies, the creation of institutional professional qualification programmes, the investment in ensuring adequate nurse-topatient ratios and the development of conditions that promote the autonomous practices of these professionals are aspects that may contribute to the development of practice environments. In addition, in each service, it is up to the nurse manager to invest in actions that promote a safety culture, which encourages the reporting of events, ensures open communication about errors and prevents the professional from becoming the second victim, with possible psychological and physical repercussions. The authors have no conflict of interest to declare. OR, LT and CS contributed to conception and design. OR, JVS and CS were responsible for the acquisition of data. OR, LT, CF, SP and PT analysed and interpreted the data. OR, LT, CF, SP, CR and PL have been involved in drafting the manuscript or revising it critically for important intellectual content. OR, LT, CF, SP, PT, CR, PL, JVS and CS have given final approval of the version to be published. OR agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the Ethics Commmitee of the Centro Hospitalar (No. 104-21). The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Fatigue, burnout, work environment, workload and perceived patient safety culture among critical care nurses Internal Medicine in Centro Hospitalar Universitário S. João and the COVID-19 Pandemic The COVID-19 pandemic and nurses' attitudes toward death Association of clinical nursing work environment with quality and safety in maternity care in the United States The hospital survey on patient safety culture in Portuguese hospitals: instrument validity and reliability The correlation between work environment and patient safety in a general hospital in Indonesia Organizational culture of safety during the COVID-19 pandemic Evaluation of patient safety culture: Comparative study in university hospitals The association of the nurse work environment and patient safety in pediatric acute care The influence of nursing work environment on patient safety Lived experience of medicine nurses caring for COVID-19 patients: A quality improvement perspective Instruments for assessing professional nursing practice environments: An integrative review Scale for the environment evaluation of professional nursing practice: Construct VALIDATION Monitoring of Red Lines for COVID-19 Work environment of hospital nurses during the COVID-19 pandemic in Brazil Changes implemented in the work environment of nurses in the COVID-19 pandemic Organizational culture and a safety-conscious work environment: The mediating role of employee communication satisfaction AHRQ Hospital Survey on Patient Safety Culture: User's Guide Organizational planning in pandemic context by COVID-19: implications for nursing management How to cite this article Impact of COVID-19 on professional nursing practice environments and patient safety culture We would like to sincerely thank all nurses who participated in this study. This article was supported by National Funds through the Fundação para a Ciência e Tecnologia, within Center for Health Technology and Services Research, Research and Development Unit (reference UIDB/4255/2020).