Nurses' Perception toward Hallmarks of the Professional Nursing Practice Environment

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1 Abstract: Nurses' Perception toward Hallmarks of the Professional Nursing Practice Environment Fatma M. Baddar, Assistant Professor, Ph.D., MS., B.Sc.N. Hanan A. Ezzat, Lecturer, Ph.D, MS., B.Sc.N. Nora A. Bassiuni, Assistant Professor, Ph.D., MS., B.Sc.N. Nursing Administration Department. Faculty of Nursing, Alexandria University, Egypt. Hallmarks are characteristics of the practice setting that best support professional nursing practice and allow baccalaureate and higher degree nurses to practice to their full potential, and assist nursing students educated at the baccalaureate level and above to make the best decision regarding where to practice following graduation. This study aimed to assess Hallmarks of the Professional Nursing Practice Environment as perceived by Bachelor Undergraduate Nursing students, Nurse Interns and nursing staff working/training at Main University hospital, Alexandria University, and conducted at Alexandria Main University hospital, on 336 nurse students, interns and staff nurses from those meeting the inclusion criteria and were available during data collection period. " Hallmarks of the professional nursing practice environment" questionnaire developed by American Association of Colleges of Nursing (AACN 2001) was used to collect data. The study main findings were that the subjects' perception for Hallmarks of the professional nursing practice environment was below the acceptable level, however, above the average. Nurse interns tended to have significantly higher perception for all hallmarks; while staff nurses as well as nurse students tended to have the lowest one. Age and years of experience of the staff nurses were found to be not affecting nurses' perception. Diploma nurses were found to perceive hallmarks more significantly as compared to bachelor nurses. Finally, the overall perception of staff nurses working in special care units was high in comparison to those working in the general wards. Introduction The current nursing workforce shortage represents one of the most serious crises that threatening the quality health care industry. In response to such crisis, health care industry had failed to maintain a work environment that is conducive to safe, quality nursing practice and, as a result, failed to retain experienced nurses within patient care settings (1). In hospitals, in order to provide quality care for hospitalized patients and their families, administrators are essentially concerned with feeding their organizations with sufficient numbers of professional nurses, who provide 95% or more of care that patients receive throughout their hospitalization (1, 2). These essential care needs will not be met unless hospitals can solve the " nursing workforce shortage problem" that is the hospitals' inability to attract and retain competent and experienced professional nurses. (1) The work environment for practicing nursing has long been cited as one of the most demanding across all types of work settings, since its essential priority is to provide, as well as maintain, safe and quality patient care. (2) 1

2 Moreover, nurses are expected to provide the vast majority of patient care in extremely safe work environment (2), although many nurses describe their current work environment as highly stressful and professionally unfulfilling (3). On the other hand, the worldwide shortage of nurses and other allied health professionals is exacerbating the challenges to the work environment for nursing practice. Concomitantly, key government agencies and professional nursing organizations have reported on issues related to the nursing workforce. Nursing shortage evidence, as one of the highly reported issues, would suggest that, if left unchecked, current shortages of nurses will escalate into a worldwide health care crisis by the year 2010 (4). On the other hand, in the era of increasing health care workforce shortage, there is an ever expanding need for high-quality professional nursing care. This conflict rose due largely to changes in the socio-demographics of the population, advancements in the information and technology utilization, as well as changes in the health care system itself (1, 3, 4). Concomitantly, there is a critical need to fully utilize knowledge and skills of professional nurses, and to ensure their retention in the profession as well as attract an increased number of individuals to join nursing (5, 6) profession. American Association of Colleges of Nursing (AACN) task force was identifying a set of dimensions describing the environmental characteristics "Hallmarks" of the practice setting that best support professional nursing practice and allow professional nurses to practice to their full potential. These dimensions, with their set of criteria, reflect the extent to which the work environment manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability; recognize contributions of nurses' knowledge and expertise to clinical care quality and patient outcomes; promote executive level nursing leadership; empower nurses' participation in clinical decision-making and organization of clinical care systems; maintain clinical advancement programs based on education, certification, and advanced preparation; demonstrate professional development support for nurses; create collaborative relationships among members of the health care provider team and utilize technological advances in clinical care and information systems (7). 2

3 These Hallmarks are expected to manifest professional health care systems, hospitals and organizations, with their practice environment. Consequently, guide practicing nurses, executives to recognize and maintain key characteristics of health care settings that promote professional nursing practice and allow them to practice to their full potential. Moreover, hall marks assist nursing students, and new graduates to make the best decision regarding their prospective work setting following graduation. (4,7) Multiple studies have shown that achieving professional practice environment has numerous benefits for health care organizations. (7) These benefits include: Enhanced recruitment and retention of highly qualified professional nurses, results in significant cost savings; Attraction of highly qualified physicians and specialists, Enriched nursing staff satisfaction and productivity, (8) enhancing positive outcomes for both patients and nurses, lower mortality rates and higher patient satisfaction, (9) as well as greater recognition within the community for nursing and the healthcare organization. Additionally, healthcare organizations that achieve professional practice environment are able to negotiate stronger payor contracts, increase market share, decrease insurance and legal fees related to medical malpractice. (10) Internationally, different studies were handled characteristics of professional practice environment, and found that organizational autonomy, control over the practice environment and nurse-physician collaboration had a strong impact on decreasing nurses' level of burnout, and moderating trust in management. (11) These results provide further support for the importance of work place structural factors related to nurses' ability to function with autonomy, making decisions about their practice, on their satisfaction and thus performance, which as a result- create a positive patient safety climate that support high quality patient care. (7,10-12) Nationally, several studies were handled different factors affecting the Quality of Patient Care, Patients Satisfaction, Nursing Staff Satisfaction and Productivity. From these studies, a research study targeted perception of Quality care among health care providers and consumers. (132) Another one investigated the effect of leadership training program for head nurses leadership style and their nurses subordinate satisfaction. (14) Moreover, Abd El-Aal, N. investigated perception of job empowerment and organizational commitment in critical care unit. (15) While Gamel R. 3

4 handled image of nursing profession among under graduated nursing students and interns (16). However, no attempt was done to assess environmental characteristics or "Hallmarks" that identified by American Association of Colleges of Nursing (AACN) task force that attracts nurses to work in a particular hospital, provides them with job satisfaction, and encourages them to give high-quality care. So the current study was conducted to assess nurses' perception for hallmarks of the Professional Nursing Practice Environment. Aim of the Study: This study aimed to assess Hallmarks of the Professional Nursing Practice Environment as perceived by Bachelor Undergraduate Nursing students, Nurse Interns and nursing staff working/training at Main University hospital, Alexandria University Methodology: Research design: A correlation descriptive research design was selected for fulfilling the aim of this study. Setting: The study was conducted in 2 medical wards, 2 surgical wards, and 2 special care units at Alexandria Main University hospital. Subjects of the study: A convenient sample of (336) Subjects from those meeting inclusion criteria, and were available in the selected settings, were invited to participate in the study. The following categories of participants were decided to represent the study sample: - Nursing undergraduate students, who were affiliated to Faculty of Nursing, Alexandria University, and joined training sessions in a nursing course in any of the selected settings for,at least, four training weeks (n=56 ). - Nurse Interns, who were conducting their internship training in any of the selected settings for not less than 3 months (n=130). - Bed side nurses, from those working in any of the selected settings for not less than a year (N=150). Tool of the study: "Hallmarks of the professional nursing practice environment" questionnaire that developed by American Association of Colleges of Nursing (AACN 2002) was 4

5 reviewed and modified by the researchers based on the current related literatures (7). The questionnaire geared toward assessing the hallmarks of the Professional Nursing Practice Environment as perceived by Bachelor Nursing students, Nurse Interns and nursing staff working at Main University hospital. It includes eight essential Hallmarks, namely: Presence of written philosophy and mission statement that reflect an emphasis on quality; Recognition of contributions of nurses knowledge and expertise to clinical; Promotion of executive level nursing leadership; Nurses empowerment and participation in clinical decision-making; Maintaining clinical advancement programs based on education, professional development and support for nurses; Collaborative relationships among members of the health care provider team and Utilize technological advances in clinical care and information systems. Each essential hallmark included a number of statements that represent the characteristics of excellence in nursing, and in the provision of high quality care. Responses were recorded and measured on a five-point Likert-Scale ranged from: 5 which represent "Strongly Agree" to 1 which represent "Strongly Disagree". Moreover, four questions were added to reflect selected demographic characteristics of the subject, namely: age, educational qualifications, work setting, and nursing years of experience. A cover letter included a statement of confidentiality as well as instructions for completing and returning sheets to researchers, was attached to the questionnaire. Method: After the official permission was obtained from the identified settings, the researchers modified the questionnaire and translated it into Arabic. Consequently, it was submitted to five experts in the field of the study to be tested for its statements' relevance, and accordingly, necessary rewording of a number of statements was done. Then, reliability for the tool was tested to measure the internal consistency of the sub-items composing each hallmark using correlation coefficient for test-retest reliability (0.87). A pilot study was carried out on 10% of the subjects to check and insure the clarity of the statements. After obtaining the consent, and assuring information confidentiality, the participants were asked to fill the questionnaire sheets while they were in their work/training settings. Filling the sheets consumed about 15 min. and data collection, review and coding completed in the period from September 2007 to February

6 Statistical Analysis: Once the questionnaires were collected, a codebook was developed to provide numerical results for analysis. Information from the tool was original data. All available data were organized into tables for analysis. A packaged computer analysis program, Statistical Package for the Social Science (SPSS 10.5) was used for statistical analysis of this data. Descriptive measures, including frequency, percentage, arithmetic mean and standard deviation, were presented. Also statistical correlational tests, including Chi square, spearman (r) and Z-test, were used for analysis of qualitative variables. Level of significance selected for this study was (P < 0.05). Results This study aimed to assess perception of nurse students, interns and staff nurses toward hallmarks of the professional nursing practice environment. It was carried out in Alexandria Main University Hospital. The study included 150 staff nurses, 130 nurse interns and 56 nurse students. Personal characteristics of the last two groups were very similar as they had no past experience at work settings and were not permanently attached to any included units. Age of the staff nurses ranged from 20 to 51 years with a mean of ( ) years. They spent on the average ( ) years at the current work setting, with a minimum of one year and a maximum of 30 years. Exactly, one half of the staff nurses held a bachelor degree in nursing while the other half held a diploma degree in nursing. The majority of them (90.7%) were assigned to the general in-patient wards while the rest (9.3%) were working in special care units. Table (1) shows participants' perception toward hallmarks of the professional nursing practice environment The overall mean percent score ranged from zero% to 84.12% with a mean of ( %). The mean percent score of four hallmarks of the professional nursing practice environment domains were higher than the average. These domains, in order, were domain 2 " Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes " ( %), domain 1 " Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional 6

7 accountability " ( %), domain 4 " Empower nurses participation in clinical decision-making and organization of clinical care systems " ( %), and domain 6 " Demonstrate professional development support for nurses " ( %). The rest of the domains had a lower mean percent score than the average; these are, in reverse order, domain 3 Promote executive level nursing leadership" (" %), domain 8 "Utilize technological advances in clinical care and information systems" ( %), domain 5 "Maintain clinical advancement programs based on education, certification, and advanced preparation" ( %) and domain 7 "Create collaborative relationships among members of the health care provider team" ( %). Table (2) reveals perception of hallmarks of the professional nursing practice environment by categories of studied nurses and students. Nurse interns tended to have significantly higher mean scores for all of the studied domains; while staff nurses tended to have the lowest mean percent scores for all domains except for domain 2 "Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes" and 6 "Demonstrate professional development support for nurses", where nurse students had the lowest mean percent scores. The overall mean percent score of nurse interns was ( %) while nurse students and staff nurses had a mean percent score of( %) and ( %) respectively, (P < 0.001). Table (3) portrays correlation between percent score of hallmarks of the professional nursing practice environment domains from one side and age, experience of staff nurses on the other side. No significant correlation could be detected between any of the domains of professional work environment hallmarks and either age or experience of staff nurses. Table (4) denotes the relation between staff nurses' perception of hallmarks of the professional nursing practice environment and their level of education. Significant differences could be detected for only domain 2 "Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes" and 4 "Empower nurses participation in clinical decision-making and organization of clinical care systems". Nurses with Diploma certificate tended to have significantly higher score than those with Bachelor certificate for both domain 2 ( % 7

8 compared with %, P = ), and 4 ( compared with %, P = ). Table (5) shows the relationship between staff nurses' perceptions of hallmarks of the professional nursing practice environment and their work setting. Although the overall score of staff nurses working in special care units was higher than that of those working in the general wards ( % compared with %) yet, this difference was not statistically significant, (P = ). Some domains (domain 1, 3 and 8) showed significant differences between the staff nurses in the two settings. Moreover, nurses engaged in special care units tended to have significantly higher score on domain 1 "Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability" ( % compared with %, P = ), domain 3 "Promote executive level nursing leadership" ( % compared with %, P = ) and domain 8 "Utilize technological advances in clinical care and information systems" ( % compared with %, P = ). Discussion Creating a professional nursing practice work environment that allow nurses to practice to their full potential, and according to their expectation as professionals, may be a fruitful strategy for nurse managers and administrators to attract and retain nurses, promote their commitment to the organization and improve their outcomes. So this study was conducted to explore perception of nurse students, nurse interns and staff nurses toward hallmarks of the professional nursing practice environment that make hospital a good place for nurses to work. In general, the findings of the present study revealed that nurses' perception for the professional nursing practice environment was below the acceptable level highlighted in relevant literature (i.e., below 75%) (17, 18). Moreover, nurses' perception toward only four hallmarks was higher than the average, however, still below the acceptable level. These hallmarks were namely: "Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes", "Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability", "Empower nurses 8

9 participation in clinical decision-making and organization of clinical care systems" and "Demonstrate professional development support for nurses". These domains were perceived by the study subjects as utmost important features of the professional nursing practice environment. This finding goes in congruence with many prior studies. For "Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes" hallmark, McClure, et al (2002) indicated that nurses are considered vital and significant contributors to the provision of quality patient care, organization must foster the recognition of nurses' contributions and gives nurses a greater opportunity to express their concerns and suggestions, allow them for independent judgment, freedom to function, to practice nursing with their knowledge and expertise with support for their work and working conditions by both hospital and nursing administration (1). Moreover, results of Aiken, & Patrician. (2000) are consistent with the current study regarding "Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability" hallmark, Since, they justified their findings that, the organization must has a philosophy and mission statement that reflects nursing practice, safety, continuity of care, and outcomes; and Nursing staff assume responsibility and accountability for their own nursing practice. (19) In a similar vein of the result, and regarding "Empower nurses participation in clinical decision-making and organization of clinical care systems" hallmark, Mc Demott (1996) viewed empowerment as a positive step towards gaining more control of professional work environment and decisions. (20), while Wise (1995) defined empowerment as the process by which organization facilitates the participation of others in decision making and taking actions within an environment where there is an equitable distribution of power. (21). Regarding professional development support for nurses, this finding also supported by Aiken, et al, (2000), who indicated that, professional development of nurses is an objective in the entire professional nursing practice work environment, educational opportunities and programs started with the orientation of new nurses, and continuing learning experiences are available as long as the nurses are employed in the hospital. (19) 9

10 On the other hand, "Promote executive level nursing leadership" As a hallmark of professional nursing practice work environment, although subjects perceived it as lower than expected, they were consistent in recognizing and commenting on strength of nursing leadership in the hospital, this is may be due to the fact that managers in nursing are viewed as pivotal to the success of the organization, as nurse executives participate in the governing body, have the authority and accountability for all nursing or patient care delivery, financial resources, and personnel, they are knowledgeable about ideas within the large nursing world and attempting to apply that knowledge on their own setting, in addition to their ability and willingness to assist nursing personnel in dealing with clinical and administrative problems which are definitely valued. This finding was supported by Adams & Bond (2000) who indicated that nurse executives viewed as absolutely critical to the development of a positive nursing situation, and they also are viewed quite positively and make an important contribution to the professional nursing work environment (22) Moreover, Clifford, (1992) stated that nurse executives help to integrate and identify nursing within the larger hospital organization, and the visibility of the nurse executive to staff nurses helps to foster the recognition of nurses' contributions and gives nurses a greater opportunity to express their concerns and suggestions. While nursing leadership at the executive level is an important feature in professional hospital environments (23). As for the hallmark of "Utilize technological advances in clinical care and information systems", which the subjects perceived it for the least, this result is consistent with Nelson (2003) who concluded that, technological advances and information systems are becoming more and more valuable in health care settings because it helps a health care organization in reducing errors, lowering coasts, fostering care, coordinating services and records, and improving quality of services (24). Furthermore, Nelson added that supplies and equipment used in nursing units should be available based on standards regarding their quality and quantity; such standards should be based on patient needs (24). In accordance with this finding, Marriner (2004) justified that Inadequate and improper supplies and equipment serve to create tension within staff members that may eventually progress to conflict, dissatisfaction, lowered productivity, absenteeism, high turnover, and intention to leave organization (25), While availability of appropriate equipment, supplies, and 11

11 technology will optimize the efficient delivery of quality nursing care; and achieve (1, 25) nurses satisfaction In relation to professional work environment hallmarks of "Maintain clinical advancement programs based on education, certification, and advanced preparation" and "Create collaborative relationships among members of the health care provider team" the current findings highlighted that these hallmarks also were minimally perceived by the subjects. This was inconsistent with Josiah Macy (2000) study, where these hallmarks perceived as highly valued characteristics of professional nursing practice work environment, and the concept of "Enhancing Inter-professional Interaction" contributes greatly to nursing workforce retention, because the nurse does not have to wait for movement to the level at which she wishes to perform and for which she feels qualified. It contributes also to having nurses functioning at peak competency at all times. (3) In the same line, Aiken & Havens (2000) indicated that these kinds of programs are very important to the nurses and play a significant role in both recruiting and retaining the qualified staff. (26) In relation to the hallmark of "Create collaborative relationships among members of the health care provider team", the perception of the current study subjects was minimal as compared to those participants in a study conducted by American Nurses Association (2000), where relationships among members of the health care provider team, especially nurse-physician relationships, was ranked at the top. In addition, collaborative practice and ability to communicate directly with each other was considered vital to good relationships. Moreover, good nursephysician relationships are recognized as very important for the professional satisfaction of both, and crucial to create a positive work environment condition. (27) Concerning the relationship between demographic characteristics of the study subjects and their perception for hallmarks of the professional nursing practice environment, the findings proved that, nurse interns tended to have significantly higher perception for all of the studied hallmarks; while staff nurses as well as nurse students tended to have the lowest perception. This finding might be related to the fact that the staff nurses had low satisfaction regarding all circumstances of their present work environment, capacity to learn and change, while nurse students still not have enough experience with work environment that affect their recognition. This finding 11

12 is supported by Zurn et al (2005) study, which showed an obvious negative relationship between job satisfaction and intention to leave the organization. This means that the lower the satisfaction, the higher the intention to leave. (28) As regards age and years of experience of staff nurses, the current findings revealed that there was no significant correlation detected between either of them and any of the hallmarks of professional work environment. This result is contradicting with McClure et al (2002), who stated that perceptions of nurses toward identifying factors that contribute to magnetism(professional nursing practice environment hall marks) were undoubtedly influenced by a variety of factors such as age, education, experience, clinical specialty, previous positions, and length of time employed at the hospital (1) Regarding the subjects' level of education, the study findings revealed significant variance, where nurses with Diploma certificate tended to have significantly higher perception for hallmarks than those with Bachelor certificate. This is apparent mainly in hallmarks of "Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes" and "Empower nurses participation in clinical decision-making and organization of clinical care systems". Generally, this result goes in line with McClure et al (2002) who elaborated that perceptions of nurses toward factors contributing to magnetism were undoubtedly influenced by their level of education. (1) Moreover, the variance between both educational backgrounds might be due to that the bachelor nurses might have higher expectations than that hospital is able to submit, and most of them have talents to travel to work in regional and/or worldwide countries, or even to transposition their work setting to private hospitals. Mathieu et al (1990) pointed out that employee with higher education show less commitment to their organization, while people with low levels of education, who have more difficulty in changing their jobs, show greater commitment to their organization. (29) On the other hand, the current findings indicated that nurses' level of education had significantly negative association with their perception to the hallmark Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes". Where, nurses hold diploma degree perceived this dimension 12

13 more significantly as compared to those hold baccalaureate degree. This finding could elaborate the phenomenon that baccalaureate degree nurses show preference and experiencing turnover more than those who held diploma degree. Such finding becomes in consistence with Wagner (2004) findings, who found that the turnover of nurses with a bachelor degree is more serious than that of nurses with a diploma as a factor contributing to magnetism (30) As for the hallmark "Empower nurses participation in clinical decision-making and organization of clinical care systems", that perceived more significant by nurses held diploma degree than those who held baccalaureate degree. Such finding could be justified by Sands & Ismeurt (1986), who found in their study that diploma nurses, who were working in the study settings, have a sense of powerless, with little authority to participate in clinical decision or influence to affect any change within the organization. (31) However, This finding supported by Cherry & Jacob (2002), who stated that problem solving and decision making are essential skills for professional nursing practice, however, not only are these skills required in clinical patient care, but also are vital components of effective leadership and management. (32) Concerning relationship between staff nurses' perception of hallmarks of the professional nursing practice environment and their work setting, the findings of the present study revealed that although the overall perception of staff nurses working in special care units was high in comparison to those working in the general wards, this difference was not significant. This variance was apparent in their perception for the hallmarks of "Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability", "Promote executive level nursing leadership" and "Utilize technological advances in clinical care and information systems" This finding could be attributed to the conclusion that staff nurses working in special care units had higher level of job satisfaction than nurses working in the general wards. This situation justifies the difference between nurses' perception toward characteristics of professional nursing practice environment and their intention to stay. In this issue, Carayon et al (2005) supported this finding, and indicated that nurses working in special care units were more satisfied with their job. ( 33) Moreover, Kramer and Schmalenberg, (2004) referred that to an extended evidence suggesting that 13

14 dissatisfaction with the work situation is an important precursor of employees' decision to leave the organization or the profession. Moreover, characteristics of the work environment, such as quality, safety, interdisciplinary collaboration, continuity of care, professional accountability, leadership, and participation in decision making were all precipitate to improve job satisfaction, enhance quality patient care outcomes, and attract and retain professional staff. (34) Regarding the hallmark of "Utilize technological advances in clinical care and information systems" specifically, the current finding can be justified as staff nurses who are working in specialty areas are highly using the available technology to meet patient's needs more than those working in the general wards. Thus, they appreciate importance of using technology and information systems in clinical care, and, accordingly, recognize them as essential hallmarks manifest the professional nursing practice environment. Such recognition and practice from the hospital workforce may support organizational efficiency and effectiveness, attract and retain professional staff, improve organizational communication and provide for greater access to information. (34) In this context, Connors et al (2002) stated that, utilizing new technology make nurses' work easier today, can help nursing staff in accept the difficult, and sometimes frustrating, process of learning how to use it. Clinical information systems can be integrated with patient care technologies to make nurses' work more accurate and efficient. (35) Conclusion and Recommendations: Hallmarks are characteristics of the practice setting that best support professional nursing practice and allow baccalaureate and higher degree nurses to practice to their full potential, and assist nursing students educated at the baccalaureate level and above to make the best decision regarding where to practice following graduation. The current study provided a preliminary description of nurses' perception for hallmarks of the Professional Nursing Practice Environment that attracts nurses to work in a particular hospital, provides them with job satisfaction, and encourages them to give high-quality care. In response to the spotted findings, the following strategies are recommended: First, the hallmarks of the practice setting that support and optimize professional nursing practice, and allow nurses to practice to their full potential, should be 14

15 recognized and worked on by all technical, managerial and organizational levels. This is required in order to establish and maintain organization wide strategies assure safe and positive work environment for all categories of workforce, in general, and for nurses, specifically. Second, it's the time for nursing leaders to have a greater understanding of such factors, which can help them to attract and retain professional nurses in all national health care systems. Third, Nursing education administrators and faculties should plan for and maintain technical and financial strategies that support the preceptorship program. Since, nursing students and graduates who are working closely with staff nurses are expected to have the opportunity for role socialization as well as increasing clinical skills, knowledge, competence, and confidence. In addition, extended preceptorship have proven to be an excellent recruitment device, often decreasing the cost of lengthy orientation programs and reducing turnover rates among newly hired nurses. Fourth, professional excellence should be supported by a clinical ladder or defined steps for advancement within the organization based on experience in nursing, additional education, and specialty certification Further studies: Since the current study was limited to assess the nurses' perception for the hallmarks the professional nursing practice environment, further studies can be conducted to investigate characteristics of the magnet hospitals that enhance recruitment and retention of the nurses and physicians. Another study can be conducted to assess the perceived and preferred characteristics of the work setting and their relation to nurses' job satisfaction and dissatisfaction. Moreover, a study can be conducted among the Bachelor nursing students to answer such a question as "What Every Nursing Graduate Should Consider When Seeking Employment?" These studies are also preliminaries for further infrastructure healthcare redesign in all health sector organizations in Egypt and other Middle East and regional countries. References 1. McClure, M. & Hinshaw, A.S. (Eds.). (2002). Magnet hospitals revisited: attraction and retention of professional nurses. Washington, DC: American Nurses Publishing. 15

16 2. American Organization of Nurse Executives (2000). Nurse recruitment and retention study. Chicago, IL: AONE Institute for Patient Care Research and Education. 3. Josiah Macy Jr. Foundation (2000). Enhancing interaction between nursing and medicine: Opportunities in health professional education. Report of the Conference on Enhancing Interprofessional Interactions, September. Washington, DC: Author. 4. American Hospital Association (2001). Workforce supply for hospitals and health systems: issues and recommendations, January 31. Washington, DC: Author. 5. Mills, M.E., Jenkins, L.S. & Waltz, C.F. (2000). Emphasis courses: Preparing baccalaureate students for transition to the workforce. Journal of Professional Nursing, 16(5), McClure, M.L., Poulin, M.A., Sovie, M.D., & Wandelt, M.A. (1983). Magnet hospitals: Attraction and retention of professional nurses. Kansas City MO: American Nurses. 7. American Association of Colleges of Nursing, Hallmarks of the Professional Nursing Practice Environment, January,(2002). Washington, DC: Author 8. Kovner, C. T., & Mezey, M. (1999). They just don t get it. American Journal of Nursing, 99(7), American Nurses Credentialing Center (2001). Magnet nursing services recognition program. [On-line]. Available: Accessed July 6, Ailken, L. H., Sloane, D. M., Lake, E. T., Solchalski, J., & Weber, A. L. (1999). Organization and outcomes of inpatient AIDS care. Medical Care, 37, American Nurses Credentialing Center. (January 31, 2005). ANCC. Magnet Program. Unpublished document for Lashinger HKS, shamian J, Thomson D. Impact of magnet hospital characteristics on nurses perceptions of trust, burn out quality of care and work satisfaction nurses E con 2001 ; 19 (5) : Farag A, perception of quality care among health care providers and consumers, unpublished Master thesis Faculty of Nursing, Alexandria university, El Bialy, G, Effect of leadership training program for head nurses leadership style and their nurses subordinate satisfaction, unpublished Master thesis Faculty of Nursing, Alexandria university, Abed El-Aal, N, perception of job empowerment and organizational commitment in critical care unit, unpublished Master thesis Faculty of Nursing, Alexandria university,

17 16. Gamel, R, Image of nursing profession among under graduated nursing students and interns, unpublished Master thesis Faculty of Nursing, Alexandria university, Modak I.; Sexton J. B.; Lux T. R., Helmreich R. L.; Thomas E.J. Measuring Safety Culture in the Ambulatory Setting: The Safety Attitudes Questionnaire Ambulatory Version. J Gen Intern Med January; 22(1): 1 5. Available at: Accessed at: September 2007). 18. Huang D. Clermont G.; Sexton, J. B.; Karlo C. A.; Miller R.G.; Weissfeld L.; Rowan.K.; Angus D. Perceptions of safety culture vary across the intensive care units of a single institution: Clinical Investigations Critical Care Medicine 2007; 35(1): Aiken, L.H., & Patrician, P. (2000). Measuring organizational traits of hospitals: The Revised Nursing Work Index. Nursing Research, 49, Mc Demott K, Laschinger H.K.S. & Shamion J. (1996) Work empowerment and organizational commitment. Ng Manag; 27: Wise P. Leading and Managing in Nursing. London: Mosby Co 1995; Adams, A. & Bond, S. (2000). Hospital nurses job satisfaction, individual and organizational characteristics. Journal of Advanced Nursing, 32(3), Clifford, J. (1992). Fostering professional nursing practice in hospitals. The experience of Boston Beth Israel Hospital. Philadelphia: J.B. Lippincott. 24. Nelson, A (2003). Using simulation to design and integrate technology for safer and more efficient practice environments. Nursing Out look, 51(3): s27- s Marriner A. Guide to Nursing Management and Leadership. 7 th ed, Mosby Aiken, L., Havens, D., & Sloane, D. (2000).The magnet nursing services recognition program: A comparison of two groups of magnet hospitals. American Journal of Nursing, 100 (3) American Nurses Association (2000). Survey on nurses working environment. Washington, DC: American Nurses Publishing. 28. Zurn P, Dolea C, Stilwell B. Nurse retention and recruitment: developing a motivated workforce available at Mathieu J.E& Zajac D.M. A review and meta-analysis of the antecedents, correlates,and consequences of organizational commitment.psychological Bullerin 1990; 108: Wagner, CM. " Is Your Nursing Staff Ready for Magnet Hospital Status?", Journal of Nursing Administration, 34(10):

18 31. Sands D & Ismeurt R. Role alienation: staff nurse and power issues. Ng Mang 1986 ; 17 ( 5) : 42 J - 42 P. 32. Cherry B, Jacob S. Contemporary Nursing. Issues, Trends & Management. Louis: Mosby, Inc 2002; Carayon P, Alvarado C, Hundt A, Springman S, Borgsdorf A, Hoonakker P. An employee questionnaire for assessing patient safety in outpatient surgery. Journal of Advances in Patient Safety 2005; 4: Kramer M, Schmalenberg C. "Development and Evaluation of Essentials of Magnetism Tool", Journal of Nursing Administration, July/August, 2004, pp Connors, H. R., Weaver, C., Warren, J., Miller, K. L. (2002) An academic- business partnership for advancing clinical informatics. Nursing Education perspectives, 32(5), Table (1): Perception of Professional work environment hallmarks of the studied participants Professional environment Hallmarks Min Max Mean SD 1. Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes Promote executive level nursing leadership Empower nurses participation in clinical decision-making and organization of clinical care systems Maintain clinical advancement programs based on education, certification, and advanced preparation Demonstrate professional development support for nurses Create collaborative relationships among members of the health care provider team, Utilize technological advances in clinical care and information systems Total

19 Table (2): Subjects' perception of Professional work environment hallmarks as distributed by their categories. Professional environment Hallmarks Nurse Interns (n= 130) Nurse Students (n= 56) Staff Nurses (n= 150) X 2 * (P) 1. Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability, Min - Max Mean + SD 38.33± ± ±11.07 (<0.001) 2. Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes Min - Max Mean + SD 40.13± ± ±15.22 (<0.001) 3. Promote executive level nursing leadership Min - Max Mean + SD 34.66± ± ±11.53 (<0.001) 4. Empower nurses participation in clinical decision-making and organization of clinical care systems Min - Max Mean + SD 39.00± ± ±13.27 (<0.001) 5. Maintain clinical advancement programs based on education, certification, and advanced preparation Min - Max Mean + SD 37.69± ± ±11.87 (<0.001) 6. Demonstrate professional development support for nurses Min - Max Mean + SD 35.84± ± ±14.22 (<0.001) 7. Create collaborative relationships among members of the health care provider team, Min Max Mean + SD 34.87± ± ±17.48 (<0.001) 8. Utilize technological advances in clinical care and information systems Min Max Mean + SD 36.47± ± ±13.73 (<0.001) Total Min Max Mean + SD 37.13± ± ±9.24 (<0.001) Kruskal Wallis Chi square (ANOVA Test) * P 0.05 Table (3): Spearman correlation between Age, experience and perception of nurses to professional work environment hallmarks. Professional environment Hallmarks 1. Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability, 2. Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes Age Spearman (r) Experience Promote executive level nursing leadership Empower nurses participation in clinical decision-making and organization of clinical care systems 5. Maintain clinical advancement programs based on education, certification, and advanced preparation Demonstrate professional development support for nurses Create collaborative relationships among members of the health care provider team, 8. Utilize technological advances in clinical care and information systems Total score

20 Table (4): Nurses' perception for professional work environment hallmarks as distributed by their level of education. Professional environment Hallmarks Diploma Nursing (n=75) Education Bachelor Nursing (n=75) 1. Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability, Mean SD (0.2824) 2. Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes Mean * SD (0.0165) 3. Promote executive level nursing leadership Mean SD (0.1152) 4. Empower nurses participation in clinical decision-making and organization of clinical care systems Mean * SD (0.0044) 5. Maintain clinical advancement programs based on education, certification, and advanced preparation Mean SD (0.4944) 6. Demonstrate professional development support for nurses Mean SD (0.2143) 7. Create collaborative relationships among members of the health care provider team, Mean SD (0.6998) 8. Utilize technological advances in clinical care and information systems Mean SD (0.5683) Total score Mean SD (0.2005) Z* (P) Mann Whitney Z * Significant, P <

21 Table (5): Nurses' perception of professional work environment hallmarks as distributed by their work settings. Professional environment Hallmarks General wards (n=136) Work Setting Special care units (n=14) 1. Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability, Mean * SD (0.0137) 2. Recognize contributions of nurses knowledge and expertise to clinical care quality and patient outcomes Mean SD (0.3667) 3. Promote executive level nursing leadership Mean * SD (0.0134) 4. Empower nurses participation in clinical decision-making and organization of clinical care systems Mean SD (0.2665) 5. Maintain clinical advancement programs based on education, certification, and advanced preparation Mean SD (0.0751) 6. Demonstrate professional development support for nurses Mean SD (0.7551) 7. Create collaborative relationships among members of the health care provider team, Mean SD (0.3903) 8. Utilize technological advances in clinical care and information systems Mean * SD (0.0005) Total score Mean SD (0.0917) Mann Whitney Z * Significant, P < Z* (P) 21