Over the last decades it has been shown that an association exists between nursing practice environment factors and the stability of the nursing staff workforce, job satisfaction (absenteeism rates and perceived productivity), quality of care and results in patients (mortality, average length of stay, patient satisfaction).1 Kazanjian et al.2 reached the same conclusions after a systematic review which revealed that one or more unfavourable attributes in the nursing practice environment were associated with higher mortality rates. Moreover, the report of the USA Institute of Medicine, Keeping Patients Safe: Transforming the Work Environment of Nurses3 showed that 98,000 patients died each year due to errors, many of which were related to an unhealthy working environment characterized either by poor communication among health care staff, or resistance to changes and lack of leadership. On these same lines, the studies by Manojlovich et al.,4,5 also warned against the negative consequences (errors involving administering drugs) for patients of poor communication between medical and nursing professionals.

Laschinger's6 conclusions, after developing Kanter's7Theory of Empowerment, maintain that many labour attitudes and responses are more closely related to the working environment within organizations and have less to do with individual traits of the professionals who work there. In an empowered working environment, employees have access to information, resources and opportunities to improve their knowledge and skills. This translates into greater productivity for the organization, greater implication from staff8 and, with regard to results in patients, it has been demonstrated the association between empowerment and patient safety.9

From research carried out by the American Academy of Nurses on magnet hospitals, based on original studies by Kramer et al.,10 stemmed the concept “practice environment” or “working environment”, which Lake defined as the organizational features that enable or hinder professional nursing practice.11 Lake identified five key aspects relative to the nursing practice environment, that must occur in a healthy working environment as appropriate at Magnet hospitals: nurses’ participation in the organization; foundation of quality of nursing care; managers’ support to nurses; adequate workforce and resources; efficient medical/nursing staff relations. Contextual factors are also key elements to carry out an evidence based practice (EBP).12–14

Several tools have been developed to measure the nursing practice environment; among the most widely used is the Practice Environment Scale of the Nursing Work Index (PES-NWI) designed by Lake (2002).11 The PES-NWI was developed from the Nursing Work Index (NWI) drawn up by Kramer and Hafner,15 which contained 65 items and was successively revised. Noteworthy among subsequent revisions is that performed by Aiken & Patrician (2002),16 which gave rise to the NWI-Revised with 46 items. Other recent publications, however, back up the PES-NWI as an instrument of greater methodological grounding.17,18 In Spain, de Pedro-Gómez et al. have carried out studies19,20 on transcultural adaptation and validation of the PES-NWI for use in Primary Health and Hospital Care with satisfactory results.

On the grounds expressed above, this study aimed to analyze the perception of Madrid Primary Health Care Nursing Professionals of their practice environment, and to characterize this perception as a function of socio-demographic, labour and professional factors.

331 subjects were studied (response rate 69.7%). The characteristics of the participants are shown in Table 1. Regarding scores for the items in the PES-NWI, the highest percentage (56.4%) under “maximum agreement” went to item 14: “Patient assignment promotes care continuity (e.g. the same nurse cares for the patient along the time)”, pertaining to the factor Foundation Care. The item with the highest percentage (29.4%) under “minimum agreement” fell to item 12: “A newcomers’ welcome briefing and sponsorship programme is in place for nurses”, pertaining to the factor Foundation Care (Table 2).

Mean values for each factor were as follows: 2.49 [95%IC: 2.42–2.56] for the factor Participation; 2.64 [95%IC: 2.58–2.7] for Foundation Care; 2.9 [95%IC: 2.8–3] for Managers Support; 2.3 [95%IC: 2.21–2.4] for Workforce Adequacy; and 2.7 [95%IC: 2.68–2.86] for Physician/Nurse Relations.

As for summary scores, women gave higher scores than men to the factor Physician/Nurse Relations (women: 8.5; men: 7.5; p=0.004). On employment status, nurses on definite duration contracts gave higher scores than those on indefinite duration contracts to the factor Participation (definite contracts: 23.3; indefinite contracts: 21.9; p=0.049); to the factor Managers Support (definite contracts: 15.6; indefinite contracts: 14.2; p=0.015); and to the factor Physician/Nurse Relations (definite contracts: 8.7; indefinite contracts: 8.2; p=0.054). Depending on their professional category, nurses in posts of responsibility gave higher scores than clinical nursing staff to the factor Participation (nurse manager: 24.6; clinical nurse: 22; p=0.004); to factor Foundation Care (nurse manager: 28.4; clinical nurse: 26.1; p=0.016); and to the factor Managers Support (nurse manager: 16.2; clinical nurse: 14.5; p=0.057).

Regarding the academic level, nurses possessing advanced studies in nursing scored higher in the factor Participation than nurses with other qualifications (BSc/MSc in Nursing: 23.9; University Graduate degree in Nursing: 22.5; other qualifications: 20.1; p=0.017); in the factor Managers Support (BSc/MSc in Nursing: 15.7; University Graduate degree in Nursing: 14.7; other qualifications: 12.9; p=0.054).

Regarding the number of years dedicated to professional activity, professionals with 3–10 years’ experience scored higher than other groups in the factor Management Support (experience of 3–10 years: 15.7; 11–20 years: 15.3; more than 20 years: 14.1; p=0.039). Taking into account time employed at current workplace, professionals with 3–10 years’ experience scored higher than other groups in factors Foundation Care (experience of 3–10 years: 27.2; 0–2 years: 25.7; 11–20 years: 24.6; more than 20 years: 27; p=0.02); Managers Support (experience of 3–10 years: 15.2; 0–2 years: 14.2; 11–20 years: 13.3; more than 20 years: 14; p=0.021); and Physician/Nurse Relations (experience of 3–10 years: 8.6; 0–2 years: 8.4; 11–20 years: 7.7; more than 20 years: 8.2; p=0.024). However, for the factor Participation professionals with more than 20 years scored the highest: (professionals with more than 20 years: 23.4; 0–2 years: 21; 3–10 years: 22.9; 11–20 years: 20.9; p=0.013). With regard to the Health Care Area, nurses in Area number 6 scored higher than those in Area number 9 for factor Workforce Adequacy (Area 6: 10.1; Area 9: 8.6; p=0.000) (Table 3).

Nursing staff age was found to correlate negatively with the factor Participation (r=−0.117; p=0.045), Managers Support (r=−0.161; p=0.06) and PES-NWI (r=0.132; p=0.038).

The categories that remained in the multiple linear regression model (dependent variable: crude score in PES-NWI), adjusted by age, gender and employment status, with p≤0.05, were professional category (coefficient B=6.586, for “nurse manager; category of reference: clinical nurse), the number of years worked at the centre (coefficient B=2.139, for time ranging from 0 to 2 years; coefficient B=7.482, for time ranging from 3 to 10 years; coefficient B=7.867, for more than 20 years; category of reference: 11–20 years); educational level obtained a p value of 0.079 (coefficient B=5.869, for Bachelor's degree and coefficient B=7.761, for Master's degree; category of reference: other university studies) (Table 4).

This study allows knowing how the nursing professionals of Spanish Primary Health Care perceive their practice environment, as well as the factors that contribute to a more positive perception.

Practice environment perception was better in nurse managers, nurses under definite duration contracts, nurses with professional experience at the centre of 3–10 years, and staff with advanced studies in nursing. Global score in the PES-NWI was 81.04, only slightly higher than the score registered for nursing professionals in Primary Health Care in the Balearics (80.4).14

The environmental factor valued most highly was Managers Support while the lowest valuation was for Workforce Adequacy. The poor perception is easily explained by the fact that the ratio of nurses in General Care per 1000 inhabitants in Spain is considerably lower than the average in OECD countries (in 2009, the most recent data available, 4.9 in Spain against 8.4 throughout the OECD22); to which we must add the high rate of ageing in our society,23 which leads not only to an increasing nursing demand but to a greater complexity in the provision of care. It must also be stressed that Madrid is one of the three Spanish autonomous communities with the lowest ratio of general care nurses in Primary Health Care (63.8 per 100,000 inhabitants) in Spain (83.9 per 100,000 inhabitants).24

Nurse managers expressed a positive perception for the factors Participation, Foundation Care and Managers Support, coinciding with the findings of the study conducted by de Pedro-Gómez.14 It seems likely that holding a post that requires leadership encourages deeper institutional commitment, which in turn helps generate a better working environment. Both Manojlovich25 and Verhaeghe26 have shown that managers play a vital role in creating favourable working environments, by strengthening the doctor/nurse relationship and reducing stress and other threatening influences.

Professional nursing staff with seniority at the centre of less than 10 years showed a more positive perception of all factors except Participation, and a more positive overall perception of the practice environment. In the work by de Pedro-Gómez et al.,14 on the contrary, nursing staff with between 2 and 10 years’ experience expressed the poorest perception. We must point out here that although in this study experience was captured differentiating between professional life and the current centre of employment, having found a link between the latter and perception of the practice environment, in de Pedro-Gómez's study this differentiation was not drawn, which may explain the disparity. In any case, this is matter for further research, as the controversy can be seen clearly on reviewing the literature. Wieck et al.27 in their study of the generational differences regarding stress in the working environment, the intent to leave the profession and job satisfaction, reached the conclusion that it is the younger nurses (born after the 80s) who suffer greater levels of stress (a circumstance directly related to job satisfaction), and likewise surpass their older colleagues in the intention to abandon the profession (it must be remembered that a nurse's age does not necessarily correspond to his or her experience). Schmalenberg and Kramer28 found no significant differences with regard to the number of years of experience of nurses at Magnet hospitals (better environment) and other hospitals without the recognition. Sexton et al.29 made an interesting analysis combining experience and academic level, reaching the conclusion that the higher the academic qualifications, the higher the perception of the practice environment, and further, that this difference increased with experience.

The findings of Sexton et al.29 are in line with the results of this study which, despite its limitations from the point of view of statistical significance (reduced number of subjects in the category Advanced Studies in Nursing), suggest that nurses with Master's or Bachelor's studies in Nursing have a better perception of the factors Participation and Managers Support, as well as a better overall perception of the working environment. Likewise, Schmalenberg and Kramer28 have shown that Magnet hospitals have a significantly higher percentage of nurses with Master's or Doctor's degrees.

This study provides knowledge about nursing practice environments in Primary Health Care, that is fundamental in encouraging a positive working climate defined as that which encourages continuity,26 promotes low stress levels27 and good physician/nurse relations,30 greater autonomy in nurses’ jobs30 and higher quality care.31

The fact that the highest scoring factor was Managers Support should serve to reinforce the impact of nurses’ leadership on results in patients. The role of nurse manager is key to establishing standards in the provision of care, through their comprehensive knowledge of the care requirements, through their experience in applying evidence in practice,32 through their implication with the institution, and through their integrating and motivating role towards the other nurses in the team.

In these economically difficult times that require severe cuts, health institutions, in order to obtain better health results and increase the efficiency of the health system, should invest in developing leadership styles that enable human resources optimization while guaranteeing an adequate workforce, both from a quantitative and a qualitative point of view.

The results presented here form part of a study that has been funded partially with the First Prize for National Research in Nursing (12th edition) from Hospital Universitario Marqués de Valdecilla (Santander) in 2010.

The authors have no conflict of interest to declare.