The changes in the nursing practice environment brought by COVID-19 and improvement recommendations from the nurses’ perspective: a cross-sectional study

The global pandemic of COVID-19 placed many challenges on nursing and a stark reminder of nurses’ vital roles in health care [1, 2]. Long-term efforts are still needed to overcome the pandemic for the foreseeable future completely. Thus, it is important to increase investment in nursing to reduce barriers to nurses’ work and promote their work enthusiasm.

As an essential factor of nurses’ work, the nursing practice environment, defined as the organizational characteristics of a work setting that enhance or constrain professional nursing practice [3], is worth attention for exploration as a result of its significant impact on patient outcomes, care quality, nurse satisfaction, nurse retention, and healthcare organizations’ financial viability by primary studies [4‐6].

During the pandemic, nurses were reported to work with poor practice conditions, including lack of personal protective equipment, high risk of infection, heavy workload, limited participation in decisions, and lack of tests to diagnose the disease among professionals and patients, as many researchers reported [7‐9].

Therefore, given the importance of a healthy work environment for patients, nurses, and organizations, researchers and professional organizations have emphasized promoting nurse work environments [7, 9‐11]. The World Health Organization (2020) called for urgent investment by improving work conditions [12]. The National Health Commission of China released a notice that required local health authorities and medical institutions to raise income and improve nurses’ practice environment [13].

The COVID-19 pandemic has lasted more than 2 years and has affected the nursing workforce, nursing education, healthcare delivery, policy and legislative issues, and social issues [14], which might also potentially affect the nursing practice environment. With the pandemic lasting and recurring in China, the pandemic prevention and control was normalized, and public hospitals are facing the dual pressure of pandemic prevention and control and resumption of business [15]. The measures of pandemic prevention and control were integrated into the healthcare workers’ daily work, including the management of entering and leaving the hospital the ward and environmental monitoring of the ward. The changes in work content increased the burden on human resources and improved the requirements for hospital service s[16]. However, the pandemic decreased the volume of business and surgery, which took challenges to hospital finance [16]. On the other hand, the pandemic situation was driving changes in the form of services. The incentive policy, practical experience, and the cultivation of people’s medical treatment habits during the pandemic brought a novel opportunity to develop internet-based health care and digital therapeutics [17]. Changes also occurred in the portrayals of healthcare workers in the media and public opinion environment. Since the pandemic, nurses were portrayed by the media as heroic, warm-hearted, and having a strong sense of professional morality [18]. Hospital service quality is given higher expectations and requirements.

The challenges and opportunities brought by COVID-19 and the changes in the overall situation might lead to some changes in the nursing practice environment, but these changes are still unknown. Studies have highlighted the necessity of continuously improving nursing practice environments [7, 19]. There has been a lack of research on what has happened to the nursing environment and how to improve it since the pandemic, especially from the nurses’ perspective. Thus, the present study aims to (1) evaluate nurses’ perceptions of the nursing practice environment since the pandemic and (2) investigate nurses’ views on the changes in the nursing practice environment brought by the COVID-19 pandemic and how to improve the nursing practice environment.

This study focused on the nursing practice environment, which is an important issue during the COVID-19 pandemic, and there has been limited research concerning this topic. The strengths of both quantitative and qualitative approaches were utilized to assess nurses’ perceptions and views. The quantitative and content analysis results were integrated to make more nuanced interpretations of the changes in the nursing practice environment since the COVID-19 pandemic.

It was revealed that nurses had positive perceptions of the nursing practice environment in this study. For further confirmation, we compared the results of the practice environment to normative data in 2010 [24] collected by using the PES-NWI in Sichuan Province before the COVID-19 pandemic, the results of which support the conclusion that the COVID-19 pandemic was associated with the improvement of the nursing practice environment. However, the results should be treated with reserve due to the differences in the characteristics of participants.

The age, working seniority, and education level of nurses in this study and the proportion of male nurses were higher than those in Liu’s study [24]. The recruitment of nursing managers in this study might partly explain the differences, including the older age and longer working seniority, which significantly impacted nurses’ perceptions of the practice environment [27]. This study aimed to explore the altitude and views of nursing managers with consideration of their important roles in the construction and improvement of the nursing practice environment. The more significant proportion of male nurses might benefit from the huge demand for male nurses and the change in traditional views. The changes in the structure of nurses’ education levels might be accounted for by the rapid development of Chinese nurse education in the past. The increased proportion of male nurses and highly educated nurses is beneficial for improvements in the structure of nursing talent but is related to a lower evaluation of the nursing practice environment [28, 29].

In addition to Liu’s study [24], the PES has been broadly adopted in other studies in varied participants and regions in China [30‐34], which resulted in different scores but still lower scores than our findings. Meanwhile, many of these studies illustrated that the dimensions of staffing and resource adequacy and nurse participation in hospital affairs received the poorest score [30‐34], which was also confirmed in our study. The score of nurse participation in hospital affairs in Liu’s study was relatively high, which might be the reason why the result of the comparison was not significant, although the qualitative data showed a positive response. The staffing dilemmas in nursing, an existing worldwide health problem, have intensified since the onset of COVID-19 [35] and might be constant due to the normalization management of the COVID-19 pandemic for some time [36].

The most significant change in the practice environment occurs in the dimension of nursing foundations for quality of care. One possible explanation is that this dimension, regarding quality assurance programs, service requirements, and nursing concepts, is most easily controlled by organizations under the cultural background of collectivism in China. On the other hand, more stringent procedures and excellent clinical competence were urgent requirements for nurses in the pandemic situation.

Nurses’ statements about leaders’ abilities were few, while quantitative analysis showed that changes in leaders were positive. An earlier study also revealed that the COVID-19 pandemic does not weaken nurses’ and managers’ leadership, although the pandemic has impacted their work and health, including communicating and implementing policy changes, surge staffing, staff well-being, access to personal protective equipment, staff retention, furloughs, and layoffs [37]. One possible explanation they gave was clinical nurses’ and nurse leaders’ perseverance and responsiveness despite a crisis [38]. The leadership of nursing managers is essential to work environments and outcomes both during and after the pandemic, which are times of crisis and significant change [39]. Now is the time for nurse leaders and active participants with other key decision-makers to be increasingly visible and to offer our creativity [40]. Under the situation of staff shortages and heavy workloads, the human-based management concept is expected and inspirational.

The change in physician–nurse collaboration was also encouraging; although the comparison result was not significant, the positive responses from nurses confirmed it. Maintaining the relationship between nurses and doctors under the principle of equality, respect, and win-win cooperation has been a mutual recognition to give full play to the ability of nurses in the epidemic prevention and control of major infectious diseases [41]. However, this closer cooperation established in anti-pandemic work may be temporary, which is also what most participants worried about. If we want to maintain this positive change, it is essential for nurses to improve their professional competence, voice, and social status.

Although some positive changes in the nursing practice environment were found, more long-term efforts are still needed to solve obstinately and ignored problems from the perspective of nurses. The most mentioned demand was a good ward environment, including ward facilities and staff rest environments. The impact of the physical environment on human health is widely known, so a safe and comfortable environment was built to facilitate the recovery of patients. However, nurses’ demands were often ignored due to the enormous medical demands, the concentration of medical resources, and limited space in hospitals. On the other hand, the definitions and measurements of the nursing practice environment focused more on the internal social environment of the organization. Thus, while this might sound like a bit of concern, it is nevertheless a crucial problem that managers need more attention to and investment.

In addition to the nagging problem of staff shortages and low recognition/low participation mentioned earlier, another concern is the work model. Nurses in this study had a good evaluation of nursing foundations for quality of care with the quality assurance program and service requirement involved. Nevertheless, although they highlight the importance of these standardization processes, they expressed negative impacts such as increased workload and staff stress. This agrees with a study conducted in Brazil during the COVID-19 pandemic [7]. Nurses opposed tedious work sessions and paperwork and looked forward to more concise and efficient work models that allow nurses to invest more energy into professional services. As advocated by Lake [3], a professional model that emphasizes goal-centered, individual qualifications, and collegial control systems operating within the professional staff is preferable to a bureaucratic mode that emphasizes task-centered control exercised through hierarchical authority and formal rule enforcement.

This study has several limitations. First, as mentioned earlier, the results of the quantitative analysis should be taken with caution due to the differences in demographic characteristics. Second, convenient sampling might reduce the representativeness of the sample. Third, the information provided by the qualitative data collected online may be insufficient, although we thought it might reflect nurses’ core views. Despite these limitations, the findings of this study provide some enlightenment for the improvement of the nursing practice environment during the pandemic.

The COVID-19 pandemic is not just a time of crisis but an opportunity for achieving a better nursing practice environment. Some good changes in the nursing practice environment occurred, including improvement of nurse’s professionalism and skill, more attention/recognition on nursing, and closer communication and cooperation. More efforts are needed to solve the problems of staff shortages and low participation. Given the particular period found, nursing managers and hospital leaders were suggested to listen to nurses’ concerns about the practice environment and value this suitable opportunity to change and improve to achieve better health services and coping ability to deal with emergency events. Improving the ward environment and taking a professional model instead of sticking to the tedious process might be worthwhile.