The nursing work environment and quality of care: Content analysis of comments made by registered nurses responding to the Essentials of Magnetism II scale

Abstract Aim To report a qualitative study of themes Registered Nurses raised spontaneously about their work environment, in a cross‐sectional survey study when responding to the Essentials of Magnetism II (EOMII) scale. Design Qualitative descriptive survey. Methods At the end of the EOMII scale, a free form text section was included asking nurses to add comments about their ward/work environment. Of the 247 nurses who completed the EOMII scale, 30% (N = 75) provided comments. Inductive content analysis was used to analyse the textual information generated. Results Three key themes emerged: “nurses need nurses to nurse”; working as a team and workplace environment. Participants described issues they were facing which comprised high turnover rates, inadequate staffing levels, increasing workload and high stress levels. Particular attention was drawn to the role of the ward manager in promoting a positive work environment, good teamwork and quality patient care.


| Aim
The purpose of this study was to identify Registered Nurses' perceptions of and the quality of care in their working environment, by analysing the qualitative free text data provided by the nurses whilst responding to the EOMII scale.

| Design
Qualitative description was the methodology of choice for this study.
The goal of qualitative descriptive studies is to present a comprehensive summary of events in the everyday terms of those events and it entails a kind of interpretation that is low-inference and does not require researchers to move as far from or into their data (Sandelowski, 2000).

| Data collection
The study was conducted in two NHS hospitals in the South East of England. The EOMII scale asks participants to respond to each of 58 items using a four-point rating scale, but limits their ability to express in detail their views regarding their work environment. To address this major weakness of survey questionnaires (Bowling, 2005), a large space was provided by the researchers at the end of the EOMII scale asking respondents to: "Finally, please add any comments you may have about your ward/work environment." This question could be described as unstructured (Bowling, 2005) because it was intended to give participants the opportunity to offer their perceptions of their work environments in their own words. O'Cathian and Thomas (2004)

| Strategy used in increasing the response rate
To increase the response rate, nurses on the wards were made aware of the study at ward meetings and an A3-sized research poster was displayed on the notice board in each ward. The aims of the study were explained in the covering letter. One of the researchers visited each ward twice a week, over the course of the study, to check for responses, answer any questions and provide extra copies of the EOMII scale to the Registered Nurses who had lost or misplaced theirs. Reminder letters were sent 6 and 14 weeks after copies of the EOMII scale were first distributed.
Seventy-five out of 247 participants (30%) who completed the EOMII scale wrote comments about their work environment. It is worth considering the potential effect of non-response bias. It was possible that nurses who made comments about their work environment were more likely to be unhappy about the condition of their work environment and those least likely to comment were happy or indifferent about their work conditions. Although the response rate was low, it was the strength of feeling expressed by a small

Impact Statement
• Findings from this study have provided better understanding of the challenges experienced by nurses in their work environment, particularly in terms of constraints on their ability to provide high quality patient care.
• This study highlights the ward manager as a key determinant in nurses' decisions to leave or to remain in the job, and makes evident the impact of the ward manager's behaviour on staff morale.
• Findings from this paper should be an impetus for nurse leaders and policy makers to involve ward nurses in decision-making and policies for practice.
F I G U R E 1 Structure-process-outcome model (adapted from Donabedian, 1980: 83)

Structure
Process Outcome number of respondents around issues in their work environment that prompted the formal analysis of these data.

| Sample
There was an even split of respondents across the two hospitals in the study; 37 from Hospital A and 38 from Hospital B. Most respondents were females (N = 70), with ages ranging from 20-≥60 years. Fifty-five were Staff Nurses, 19 were Sisters and one was a Charge Nurse. Table 1 presents the role description of participants.
Twenty-seven were educated to degree level, while the remaining had a Diploma level qualification; years of nursing experience ranged from 1 month-40 years. Analysis of data revealed that there is no difference between the nurses with more years of working experience and the nurses with less working experience in terms of viewing their working environment.

| Ethical considerations
The study received ethics approval from London-Surrey Borders NHS Research Ethics Committee, study reference number 11/ LO/1329. Participants' anonymity and confidentiality were protected (see our earlier study).

| Data analysis
It was presumed that the 75 participants who wrote comments about their work environment would have responded to the stimulus provided by the items of the eight attributes measured by the EOMII scale. Examination of the comments revealed that data were not organized in a pre-defined manner. Their comments went beyond the scope of the EOMII scale, addressing issues such as staffing numbers, increasing workload, high stress levels and work engagement.
Inductive content analysis was used to analyse the data and it is a highly flexible method, which is applicable to a wide variety of different kinds of unstructured textual information (Bryman, 2016).
The manifest content of the data, which are those elements that are physically present, countable and describe the content (Berg & Lune, 2012), was analysed. The key contents of the data were categorized, without the use of any specialist software, following the process of open coding, creating categories and abstraction, as described by Elo and Kyngas (2008). The data were actively read and initial ideas were noted and the data were actively searched for meanings and patterns and were given codes to describe all aspects of the content (Burnard, 1991(Burnard, ,1996Elo & Kyngas, 2008), some of which are shown in Table 2.
Following open coding, words and phrases were grouped together and "reduced" through a process of crossing out repetitions and similar words and phrases to produce a list of headings that accounted for all of the data in the transcript (Burnard, 1996). Some initial codes developed into the dominant themes, while others formed subthemes; for example, ward manager formed a dominant theme, with ward manager supportive and ward manager never giving positive feedback forming subthemes (see Figure 2).
During the abstraction phase, based on semantic and conceptual similarity, themes and subthemes were further condensed and given names that described their contents (Elo & Kyngas, 2008).
For example, the themes staff acknowledgement, staff attitude, excellent teamwork and ward manager ( Figure 2) were further condensed into a generic theme Working as a team ( Figure 3); with managerial support, collegial support and staff engagement forming associated subthemes. Likewise, staff shortage, increasing paperwork, increasing workload and skill mix were condensed to form the generic theme "Nurses need nurses to work", with High turnover and Quality work under pressure, as subthemes ( Figure 3). Following this final refinement, three themes and eight subthemes were identified.
The final themes were allocated different colours and marked with corresponding fluorescent marking pens. The transcripts were then marked with different colours that corresponded to the themes and subthemes to which they belonged. Various coloured sections were then cut and pasted in their categories onto pages of A4 papers, giving a complete set of pages containing all of the analysed transcript, as recommended by Burnard (1996).

| Rigour
Three authors independently went through the transcripts and identified similar themes, giving internal validity, reliability and credibility to the findings (Burnard, 1991). Content analysis is easily replicable and is often referred to as an objective method of analysis due to this transparent nature (Bryman, 2016).

| FINDING S
Three key themes and eight subthemes were identified: "nurses need nurses to nurse," working as a team and workplace environment, as illustrated in Figure 3. Codes were used after each participant's TA B L E 1 Role description of participants

Staff nurse
The basic grade of qualified nursing staff, who are involved in direct patient care.
Ward sister A female nurse who has moved on to a higher rank/ grade from a staff nurse, and has lesser responsibility to the ward manager. She has specific responsibilities for the running of the ward, in charge of nurses and involved in direct patient care.

Charge nurse
A male equivalent role of a ward sister.
Care Support Worker (CSW) Care Support Worker, also called Health Care Assistants in some hospitals in the UK, are unlicensed/unregistered health personnel who work alongside nurses, midwives, doctors, and allied health professionals in looking after the general well-being of patients.
quotes to represent information relating to their specialities, designations and years of nursing experience. Examples are presented in Table 3.

| "Nurses need nurses to nurse"
"Nurses need nurses to nurse" is a direct participant comment and captures participants' understanding that staffing issues resulted in an inability to provide high quality care to patients. A vicious cycle existed where high turnover rates of staff on their wards resulted in inadequate staffing. Shortage of staff resulted in high patient to nurse ratios which negatively affected quality of care. Participants also associated these staffing issues to increased workload. They described the negative effects that this had on their physical and psychological well-being, leading to staff having high stress levels.
Participants expressed frustration and annoyance at having to compromise quality of care because they did not have sufficient staff on the wards. These issues are elaborated under two subthemes.

| High turnover
Participants revealed their struggles in trying to improve care delivery on their wards in the face of high turnover in the hospitals: The ward team works well together, but this is not always acknowledged by senior mgt. A thank you from management can go a long way.
Good teamwork, lack of acknowledgement This ward is an elderly acute medical ward, with patients who have dementia/confused. The staffing levels could be better, as you don't feel like a nurse.
Need for better staffing levels, low staff morale P1036(GS/SN:6y) We work very hard and have to deal with a high work load and we are short staff-the work is hard and we try to help our patients to the best of our ability.
Working hard, high workload, short staffed, hard work, pressure to help patients, helping the patients. In addition to individual staffing issues highlighted above, participants also indicated that teamwork significantly influenced the quality of their work environment.

| Working as a team
Participants

| Managerial support
Many of the participants made positive comments about their ward managers. They described the supportive role of their ward managers as facilitating nursing practice. Supportive behaviours of the ward manager were identified as "understanding," "helping to improve confidence," "approachable," "accessible," "pleasant," "good"   The presence of blame culture in the hospital was revealed as a factor that could inhibit participants from putting their best performance to team efforts: "…but feel there is a culture of blame…" [P2125(GM/SN:6y)] and "A hospital with blame culture, not good…" [P2072(EM/SR:18y)]. In addition to management, the success of working as a team rests in the degree of support received from the nurses' immediate colleagues. The importance of inter-professional relationships in the provision of high quality care was also emphasized by the participants.

| Staff engagement
Participants expressed frustration over some nurses' poor motivation and lack of interest on the job. According to the participants, being absorbed in and being enthusiastic about their job would contribute to patient care, team cohesion, as well as improving their relationship with other members of staff. Some participants expressed disillusionment when they observed others displaying lack of interest in the job, often at the expense of good quality care to patients: "…Some staff are just frustrating to work with. Other staff feels/ thinks they know everything and does not want to be told what to do, but they don't do things the way it should be done. Other staff goes to work because they have to, no interest or enthusiasm…" [P2072(EM/SR:18y)].
In contrast to the above comments, many of the participants ac- Some participants also commented that even though working on their wards could sometimes be stressful, they still enjoyed coming to work due to the workplace culture: "…I enjoy coming to work sometimes it is a bit stressful but we also have our good days" [P2119(GS/SN:2y)]; and "Stressful but fun and engaging + challeng-ing…" [P1035(GS/SR:14y)]. These comments indicated that the participants were engaged with their jobs. In addition to inadequate staffing and teamwork, the workplace environment itself, in the form of pressure to create beds, health and safety issues and professional development, was identified as having impact on their work and quality of care given to patients.

| Workplace environment
Participants expressed worries over their workplace environment in terms of the physical work space and the need for further training and development. They were concerned that the absence of specific features such as adequate ventilation in their work environment could have an impact on health and safety of both the staff and the patients. They were also concerned over the priority the management placed over bed management.

| "Clients need nurses not beds…"
"Clients need nurses not beds…" is a direct participant comment and captures participants' understanding that the quality of care given by nurses is not about the physical resources. Rather, it involves how well trained or skilled the nurse is and the availability of the nurse.
Participants believed that the focus of the Trust was on bed management, not on ensuring that patients were given the best care.
According to the participants, bed managers continued to mount pressure on the nurses to create empty beds when it was inappropriate to discharge current patients, a situation the participants believed was detrimental to patient care. Nurses reported that they do not feel "listened to" by bed managers: "…feel we are not listened to by bed management who "bed" our query homes, even though they

| Health and safety issues
Participants highlighted that the physical condition and appearance of their wards could constitute health and safety issues. For instance, lack of ventilation in the ward was an issue: "Too hot

| Professional development
Participants Participants in this study provided an insight into factors which affected the quality of their work environment and how these factors influenced their ability to provide quality care.

| D ISCUSS I ON
In response to the invitation to make comments about their work experiences, many nurses offered additional insight into aspects of their work environment which gave them concerns. This paper is the first to identify that despite the staffing problems that nurses faced and the resultant high workload and stress they were experiencing, nearly all the participants who commented about their ward managers, made positive comments. In describing their ward managers, most participants used positive words such as "approachable," "accessible" and "pleasant". Staff nurses in an American study by Schmalenberg and Kramer (2009) identified similar behaviours of the nurse manager as essential for a healthy work environment.
Some behaviours of nurse managers identified as most supportive were being accessible, approachable, promoting staff cohesiveness and providing both positive and negative feedback (Schmalenberg & Kramer, 2009 Comments made by the participants may imply that no one was listening to the nurses and that they have very little executive power to influence or change situations in the hospitals. A report by the King's Fund (Ham, 2014) has described the NHS as a service characterized by emphasis on reforms, driven from the top down by politicians and regulators, as it is centrally controlled and funded through general taxation (Buchan, 1994;Klein, 2012). It has also been highlighted (Francis, 2013;The King's Fund, 2012) that NHS leaders focused more on the delivery of targets than engaging patients and staff. The NHS Improvement (2016) has developed a framework that supports a more

| Limitations
It is acknowledged that the data gathered were short comments from the participants and this method of data collection did not present the researchers any opportunity to probe the participants or to clarify information given. In addition, this study was conducted in two NHS hospitals in the South East of England; findings may not be typical of all acute trusts in England, it may therefore limit generalization of the study. and it may have been the absence of attention to structural aspects that prompted so many nurses to give their comments.

ACK N OWLED G EM ENTS
We would like to thank the directors of nursing, ward managers/sisters/charge nurses, and staff nurses of the study hospitals for their participation in our study. We are also grateful to the research and development departments of the study hospitals for their support during data collection.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the authors.

AUTH O R CO NTR I B UTI O N S
All authors have agreed on the final versions and meet at least one of the following criteria (based on those recommended by the ICMJE*): (a) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data; (b) drafting the article or revising it critically for important intellectual content. *http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html).