In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
S udy o he S eng hs and Weaknesses o Nu sing Wo k
En i onmen s in P ima y Ca e in Spain
Vicen e Gea-Caballe o 1,2 , JoséRamón Ma ínez-Rie a 3,* , Ped o Ga cía-Ma ínez 1,2,* ,
Jo ge Casaña-Mohedo 4, Isabel An ón-Solanas 5,6 , Ma ía Vi udes Ve degue -Gómez 7,
I án San olaya-A nedo 8,9 and Raúl Juá ez-Vela 8,9


Ci a ion: Gea-Caballe o, V.;
Ma ínez-Rie a, J.R.; Ga cía-Ma ínez,
P.; Casaña-Mohedo, J.; An ón-Solanas,
I.; Ve degue -Gómez, M.V.;
San olaya-A nedo, I.; Juá ez-Vela, R.
S udy o he S eng hs and
Weaknesses o Nu sing Wo k
En i onmen s in P ima y Ca e in
Spain. In . J. En i on. Res. Public
Heal h 2021,18, 434. h ps://doi.o g/
10.3390/ije ph18020434
Recei ed: 24 No embe 2020
Accep ed: 1 Janua y 2021
Published: 7 Janua y 2021
Publishe ’s No e: MDPI s ays neu-
al wi h ega d o ju isdic ional clai-
ms in published maps and ins i u io-
nal a ilia ions.
Copy igh : © 2021 by he au ho s. Li-
censee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and con-
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ibu ion (CC BY) license (h ps://
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1Nu sing School La Fe, Adsc ip Cen e o Uni e sidad de Valencia, 46026 Valencia, Spain; [email p o ec ed]
2Resea ch G oup GREIACC, Heal h Resea ch Ins i u e La Fe, A da. Fe nando Ab il Ma o ell,
106, Pabellón Docen e To e H, Hospi al La Fe, 46026 Valencia, Spain
3Depa amen o En e me ía Comuni a ia, Medicina P e en i a y Salud Pública e His o ia de la Ciencia,
Uni e sidad de Alican e, 03080 Alican e, Spain
4Heal h Depa men , Uni e sidad Ca ólica de Valencia, C/Que edo 2, 46001 Valencia, Spain;
jo ge.casana@uc .es
5Depa men o Physia y and Nu sing, Facul y o Heal h Sciences, Uni e si y o Za agoza,
C/Domingo Mi al s/n, 50009 Za agoza, Spain; ian on@uniza .es
6Resea ch G oup Nu sing Resea ch in P ima y Ca e in A agón (GENIAPA) (GIIS094),
Ins i u e o Resea ch o A agón, A enida San Juan Bosco, 13, 50009 Za agoza, Spain
7Depa amen de Salu La Ribe a, A ención P ima ia, C a. Co be a, Alzi a, 46600 Valencia, Spain;
[email p o ec ed]
8Cen o de In es igación Biomédica de la Rioja, Log ono, 26006 La Rioja, Spain;
[email p o ec ed] (I.S.-A.); [email p o ec ed] (R.J.-V.)
9Depa men o Nu sing, Uni e si y o La Rioja, Log oño, 26006 La Rioja, Spain
*Co espondence: j [email p o ec ed] (J.R.M.-R.); [email p o ec ed] (P.G.-M.)
Abs ac :
Backg ound: Nu sing wo k en i onmen s a e de ined as he cha ac e is ics o he wo kplace
ha p omo e o hinde he p o ision o p o essional ca e by nu ses. Posi i e wo k en i onmen s
lead o be e heal h ou comes. Ou s udy aims o iden i y he s eng hs and weaknesses o p ima y
heal h ca e se ings in Spain. Me hods: C oss-sec ional s udy ca ied ou om 2018 o 2019. We
used he P ac ice En i onmen Scale o he Nu sing Wo k Index and he TOP10 Ques ionnai e o
Assessmen o En i onmen s in P ima y Heal h Ca e o da a collec ion. The associa ions be ween
sociodemog aphic and p o essional a iables we e analyzed. Resul s: In o al, 702 p ima y ca e
nu ses pa icipa ed in he s udy. Responses we e ob ained om 14 ou o he 17 Spanish Au onomous
Communi ies. Nu sing ounda ion o quali y o ca e, managemen and leade ship o head nu se
and nu se–physician ela ionship we e iden i ied as s eng hs, whe eas nu se pa icipa ion in cen e
a ai s and adequa e human esou ces o ensu e quali y o ca e we e iden i ied as weaknesses o he
nu sing wo k en i onmen in p ima y heal h ca e. Olde nu ses and hose educa ed o doc o al le el
we e he mos c i ical in he nu sing wo k en i onmen s. Va iables Age, Le el o Educa ion and
Manage ial Role showed a signi ican ela ion wi h global sco e in he ques ionnai e. Conclusion:
In e en ions by nu se manage s in p ima y heal h ca e should ocus on imp o ing iden i ied
weaknesses o imp o e quali y o ca e and heal h ou comes.
Keywo ds: nu sing; p ima y ca e; wo kplace; quali y o heal h ca e; nu se’s ole
1. In oduc ion
The nu sing wo k o ce plays a c ucial ole in heal h sys ems globally. Acco ding o he
Wo ld Heal h O ganiza ion (WHO) [
1
], nu ses mus wo k o hei ull po en ial i coun ies
a e o achie e uni e sal heal h co e age o he popula ion. Nu ses a e a key elemen in
he sus ainabili y o he heal h se ice, enhancing quali y o ca e and p omo ing pa ien
sa e y, sa is ac ion and con idence [
2
,
3
]. These easons ha e jus i ied he implemen a ion
In . J. En i on. Res. Public Heal h 2021,18, 434. h ps://doi.o g/10.3390/ije ph18020434 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2021,18, 434 2 o 12
o he in e na ional campaign “Nu sing Now” and he decla a ion o he yea 2020 as he
In e na ional Yea o he Nu se.
In o de o achie e he highes possible quali y o nu sing ca e, i is essen ial o
analyze he elemen s con ibu ing o he deli e y o such ca e; he sum o hese elemen s
is he nu sing wo k en i onmen (NWE). Thus, NWE is de ined as he cha ac e is ics o
he wo kplace ha p omo e o hinde he deli e y o quali y nu sing ca e [
4
]. Posi i e
NWEs a e cha ac e ized by lowe a es o mo ali y, mo bidi y and ad e se e en s [
5
–
7
];
educed adminis a i e cos s and absen eeism [
8
]; a lowe le el o bu nou and inc eased
pa ien sa is ac ion wi h nu sing ca e and he heal h o ganiza ion [
9
]. Imp o ing heal h
ou comes, he sus ainabili y o he heal h sys em and use sa is ac ion a e common goals
o heal hca e manage s, which can be add essed om he pe spec i e o NWE wi h
posi i e condi ions o ca e. The Magne Hospi al p og am, o example, acc edi s cen e s
o excellence and quali y o ca e based on e idence-based p ac ice [
10
–
12
]. Magne cen e s
p omo e he de elopmen o a cul u e o sa e y and quali y ca e, s a ecogni ion p og ams,
in e disciplina y communica ion and ho izon al managemen ha con ibu e posi i ely o
he wo k en i onmen [13,14].
NWE s udies ha e been ex ensi e in hospi al se ings [
15
]. Howe e , he e is a lack
o e idence abou he impac o posi i e p ima y heal h ca e (PHC) NWE on pa ien
ou comes. This may be a handicap o op imizing PHC se ices, whe e he con igu a ion
o he mic oen i onmen should be conduci e o he p o ision o excellen ca e. P e ious
s udies [
4
] ha e poin ed o a possible associa ion be ween posi i e PHC NWE and pa ien
ou comes, bu he e idence is s ill sca ce.
P e ious s udies [
4
,
16
–
18
] ha e assessed he PHC NWE in Spain, concluding ha
managemen and leade ship o he head nu se, nu se–physician ela ionship and nu sing
ounda ion o quali y o ca e a e he mos highly alued aspec s by p ima y ca e nu ses,
whe eas adequa e human esou ces o ensu e quali y o ca e is equen ly among he leas
alued cha ac e is ics o he wo kplace. A ecen scoping e iew o he li e a u e sugges ed
ha he eali y o he PHC NWE is di e en om ha o he hospi al NWE. This is due
o di e ences in he decision-making and o ganiza ional p ocesses and he ela ionships
be ween eam membe s. Thus, he e idence a ailable on he hospi al NWE may no
be applicable o he eali y o he PHC NWE [
19
]. Acco ding o Lucas and Nunes [
19
],
he wo k en i onmen is he mos in luen ial ac o wi h he g ea es impac on nu sing
ou comes and on he pe cep ions o he quali y o ca e and clien sa e y. In o de o assess
and hus imp o e he quali y o he NWE, Poghosyan e al. [
20
] de eloped a global model
o op imizing he PHC NWE. In hei model, hey p opose he in eg a ion o ins i u ional
policies, o ganiza ional inno a ion and esea ch.
We a gue ha posi i e PHC NWE can inc ease he quali y o nu sing ca e and, subse-
quen ly, imp o e pa ien ou comes. Howe e , in o de o achie e his goal, i is necessa y o
analyze he s eng hs and weaknesses o he PHC NWE. The e o e, we aim o analyze he
cha ac e is ics o NWE in PHC se ings in Spain, iden i ying hese en i onmen s’ s eng hs
and weaknesses. In addi ion, we aim o analyze he associa ions be ween sociodemo-
g aphic and p o essional a iables in ou sample, as well as he nu sing p o essionals’
pe cep ion o hei NWE.
2. Ma e ials and Me hods
2.1. Design
C oss-sec ional s udy o he s eng hs and weaknesses o NWE in PHC se ings in Spain.
2.2. Pa icipan s and S udy Loca ion
We ec ui ed a non-p obabilis ic, mul i-s age sample o quali ied nu ses wo king in
PHC se ings in Spain. Due o he limi ed esou ces o da a collec ion and he geog aphical
dispe sion o PHC p o essionals, he maximum possible numbe o pa icipan s was
p oposed as a sampling a ge du ing he se da a collec ion pe iod. Inclusion c i e ia o
pa icipa ion in his s udy we e: being quali ied as a nu se, ha ing wo ked in he same
In . J. En i on. Res. Public Heal h 2021,18, 434 3 o 12
PHC se ing o a leas 3 mon hs and signing he consen o m. Da a collec ion was paused
du ing aca ion pe iods in o de o limi he possibili y o bias a ising om s a u no e .
A o al o 817 ques ionnai es we e ecei ed, o which 115 (14.7%) we e excluded. The
easons o hei exclusion we e: 7 (6.09%) nu ses who did no wo k a PHC, 27 (23.48%)
did no comple e he ques ionnai es co ec ly and 81 (70.43%) did no mee he c i e ia o
pa icipa ion in he s udy.
Fi s , he esea che s dissemina ed he s udy h ough social ne wo ks (Twi e , Face-
book) ob aining an un es ic ed sample [
21
]. Simul aneously, di ec dissemina ion among
PHC nu ses was achie ed by con ac ing key in o man s ia ins i u ional e-mail (on wo
occasions, one mon h apa ) o encou age and emind hem o pa icipa e in he s udy. This
was done be ween June 2018 and June 2019.
A da a collec ion pack con aining he consen o m, a ques ionnai e o sociodemo-
g aphic a iables de eloped ad hoc and he P ac ice En i onmen Scale o he Nu sing
Wo k Index (PES-NWI) ques ionnai e was sen ia email o he pa icipan s. We used
Google Fo ms
®
, wi h a limi ed esponse ia In e ne P o ocol (IP), o collec he da a elec-
onically. A le e o in i a ion o pa icipa e in he s udy was also a ached, as well as
a eques o con ibu e o he dissemina ion o he s udy wi h he pu pose o eaching a
g ea e numbe o PHC nu ses h ough a snowball sampling echnique.
2.3. Ins umen s o Da a Collec ion
An ad hoc ques ionnai e was designed o collec sociodemog aphic and p o essional
a iables including age, gende , le el o educa ion, p o essional specializa ion, wo k
expe ience in PHC se ings and managemen ole and esponsibili ies.
The e a e mul iple measu emen ools o he s udy o NWE [
22
]. The PES-NWI is
among he mos widely used and has high le els o consis ency and eliabili y (C onbach’s
Alpha 0.807–0.916) [
9
,
23
,
24
]. We used he Spanish e sion o he PES-NWI, which was
adap ed and alida ed o use in Spanish PHC se ings by de Ped o-Gómez e al. [
25
]
in 2012. The Spanish PES-NWI is di ided in o 5 dimensions, namely, nu se pa icipa ion
in cen e a ai s (nine i ems) (D1), nu sing ounda ion o quali y o ca e (10 i ems) (D2),
managemen and leade ship o head nu se ( i e i ems) (D3), adequa e human esou ces
o ensu e quali y o ca e ( ou i ems) (D4) and nu se–physician ela ionship ( h ee i ems)
(D5). This ool includes a o al o 31 i ems measu ed on a 4-poin Like scale, wi h
sco es anging be ween 4 o 124. A a o able en i onmen ecei es sco es o >2.6, neu al
o con o e sial en i onmen s ecei e sco es be ween 2.6 and 2.4 and an un a o able
NWE ecei es sco es o >2.4 o each dimension. To al sco es a e in e p e ed as ollows:
alues ≥80.6
a e in e p e ed as posi i e en i onmen s o nu sing wo k, alues be ween
74.5 and 80.5 a e iden i ied as con o e sial en i onmen s and alues
≤
74.4 a e classed
as nega i e en i onmen s o nu sing wo k [
26
]. Fo he p esen s udy, C onbach’s alpha
o he PES-NWI was 0.937, wi h a eliabili y ange be ween 0.836 and 0.935 o each
dimension.
Mo e ecen ly, an abb e ia ed e sion o he PES-NWI ool was de eloped by Gea-
Caballe o e al. [
26
] wi h he aim o syn he izing and p io i izing he essen ial elemen s o
imp o ing PHC se ings in he Spanish con ex . The TOP10 Ques ionnai e o Assessmen
o En i onmen s in P ima y Heal h Ca e (he eina e TOP10) is di ided in o 3 dimensions,
namely, nu se pa icipa ion in cen e a ai s (D1a), quali y o ca e (D2a) and human e-
sou ces (D3a). I comp ises 10 i ems iden i ied as he “essen ial elemen s o ca e”; i no
posi i e, hese essen ial elemen s o ca e can se iously a ec he quali y o ca e in any gi en
NWE. The o al sco e o he TOP10 ques ionnai e anges be ween 10 and 40. The highe
he sco e, he mo e a o able he NWE. C onbach’s alpha o he TOP10 ques ionnai e was
epo ed a 0.816 in a p e ious s udy [
26
]; o he p esen s udy, C onbach’s alpha was
0.805. The TOP10 ques ionnai e was comple ed by he esea che s based on he esul s
ob ained om he Spanish e sion o he PES-NWI ool.
The in o ma ion o he analysis o he TOP10 was ex ac ed om he PES-NWI
ques ionnai e, since he 10 essen ial i ems a e pa o he 31 ha make up he PES-NWI.
In . J. En i on. Res. Public Heal h 2021,18, 434 4 o 12
2.4. S a is ical Analysis
We used desc ip i e s a is ics o analyze he sociodemog aphic and p o essional
cha ac e is ics o ou sample. Mean and s anda d de ia ion o quan i a i e a iables and
equencies, and pe cen ages o quali a i e a iables, we e calcula ed.
We calcula ed he C onbach’s alpha coe icien o bo h he PES-NWI and TOP10 ques-
ionnai e o assess in e nal consis ency and eliabili y as a whole, and o each dimension
sepa a ely. Reliabili y was conside ed excellen when C onbach Alpha was g ea e han
0.90; good be ween 0.80 and 0.89; accep able be ween 0.70 and 0.79; ques ionable be ween
0.60 and 0.69; poo be ween 0.50 and 0.59 and unaccep able below 0.50 [27].
We ca ied ou a no mali y es using Shapi o–Wilk and Kolmogo o –Smi no es s
as app op ia e o he quan i a i e a iables. Fou a iables we e ound o ha e a non-
no mal dis ibu ion, namely, dimensions D1, D3, D4 and D5, and we e analyzed using
non-pa ame ic me hods. Fo he bi a ia e analyses o a iables wi h a no mal dis ibu ion
(D2 and TOP10), we used a - es o independen samples o dicho omous a iables and
ANOVA o poly omous a iables. I signi ican di e ences in he ANOVA we e ound, he
Bon e oni es was applied o de e mine which pai s o ca ego ies p esen ed signi ican
di e ences be ween hem.
The SPSS 23 s a is ical package was used o he s a is ical analysis, and a signi icance
le el o p= 0.05 was adop ed.
2.5. E hical Conside a ions
We sa egua ded ou pa icipan s’ con iden iali y and anonymi y acco ding o Span-
ish/Eu opean da a p o ec ion egula ions (O ganic Law 3/2018). The pa icipan s we e
in o med abou he me hods and aims o he s udy and ga e hei consen o ake pa in
his in es iga ion. This s udy was app o ed by he Resea ch E hics Commi ee o he Va-
lencian Communi y (Xà i a/On inyen , Valencia, Spain). The pa icipan s did no ecei e
any compensa ion o comple ing he ques ionnai es.
3. Resul s
The inal sample consis ed o 702 quali ied PHC nu ses. The pa icipan s we e mainly
women (71.9%), aged 40 yea s o olde (61.1%) and wi h mo e han 10 yea s o wo k expe-
ience (52.4%). Mos o ou pa icipan s we e educa ed o deg ee le el (64.3%), 5.4% we e
nu se specialis s and 11.8% we e nu se manage s o coo dina o s. Responses we e ob ained
om 14 ou o he 17 Spanish Au onomous Communi ies, wi h a g ea e ep esen a ion
om he Valencian Communi y and he Cana y Islands (76.3%).
The esul s o he PES-NWI a e shown in Table 1. The NWE in Spanish PHC se -
ings was posi i e wi h a o al a e age sco e o 82.4. Th ee dimensions we e iden i ied as
s eng hs, namely, nu sing ounda ion o quali y o ca e (D2), managemen and leade -
ship o head nu se (D3) and nu se–physician ela ionship (D5), and one dimension was
iden i ied as a weakness in he PHC se ings s udied: adequa e human esou ces o ensu e
quali y o ca e (D4). Nu se pa icipa ion in cen e a ai s (D1) was conside ed as neu al o
con o e sial. Speci ically, 17 i ems we e iden i ied as s eng hs, and only 9 we e classed as
weaknesses o he PHC se ings (i ems 6, 7, 9, 12, 16, 25–28). The eliabili y o he PSE-NWI
in ou sample was con i med wi h a C onbach’s alpha 0.937 and a ange be ween 0.836
and 0.935 o each o i s dimensions.
The a e age sco e om he TOP10 ques ionnai e was 29.7. Two o i s dimensions we e
iden i ied as s eng hs: pa icipa ion in cen e a ai s (D1a) and quali y o ca e (D2a), and
one was iden i ied as a weakness: human esou ces (D3a). The eliabili y o he TOP10 ool
in ou sample was con i med wi h a C onbach’s alpha 0.805.
In . J. En i on. Res. Public Heal h 2021,18, 434 5 o 12
Table 1. To al sco es by dimensions and i ems om he PES-NWI.
Sco e Mean (SD)
S eng hs Neu al Weaknesses
Dimension 1: Nu se pa icipa ion in he cen e a ai s 2.50 (0.7)
1 *: S a nu ses a e o mally in ol ed in he in e nal managemen o he cen e (boa ds, decision-making bodies) 2.47 (0.9)
2: Nu ses a he cen e ha e oppo uni ies o pa icipa e in decisions a ec ing he a ious policies de eloped by he cen e 2.47 (0.9)
3: Many oppo uni ies exis o he p o essional de elopmen o nu ses 2.41 (0.9)
4: Managemen lis ens and esponds o he conce ns o i s nu ses 2.55 (0.9)
5: The Di ec o o Nu sing is accessible and easily “ isible” 2.90 (1.0)
6: A p o essional ca ee can be de eloped o he e a e oppo uni ies o p omo ion in he clinical ca ee 2.27 (1.0)
7: Manage s consul wi h nu ses abou p oblems and ways o doing hings on a day- o-day basis 2.34 (1.0)
8: S a nu ses ha e oppo uni ies o pa icipa e in he cen e ’s commi ees, such as he commi ee on esea ch, e hics, in ec ions 2.87 (0.9)
9: Nu sing manage s a e a he same le el o powe and au ho i y as o he manage s in he cen e 2.34 (1.0)
Dimension 2: Nu sing ounda ion o quali y o ca e 2.72 (0.6)
10: Nu sing diagnos ics a e used 2.88 (1.0)
11 *: The e is an ac i e quali y assu ance and imp o emen p og amme 2.59 (0.9)
12: The e is a p og amme o welcoming and men o ing new nu ses 2.25 (1.1)
13: Nu sing ca e is based on a nu sing model a he han a biomedical model 2.68 (0.9)
14 *: Assigning pa ien s o each nu se p omo es con inui y o ca e 3.14 (0.9)
15 *: The e is a common, well-de ined nu sing philosophy ha pe mea es he en i onmen in which pa ien s a e ca ed o 2.63 (0.9)
16: The e is a w i en and upda ed plan o ca e o each pa ien 2.44 (0.9)
17: Cen e manage s a e conce ned ha nu ses p o ide high-quali y ca e 2.58 (0.9)
18 *: A p og am o con inuing educa ion is de eloped o nu ses 2.97 (0.9)
19 *: The nu ses in he cen e ha e adequa e clinical compe ence 3.03 (0.8)
Dimension 3: Managemen and leade ship o head nu se 2.93 (0.9)
20*: The coo dina o /supe iso is a good manage and leade 2.88 (1.0)
21: The supe iso /coo dina o suppo s he s a in hei decisions, e en i he con lic is wi h medical s a 2.94 (1.0)
22: The supe iso /coo dina o uses mis akes as oppo uni ies o lea ning and imp o emen , no as c i icism 2.87 (1.0)
23: The supe iso /coo dina o is sympa he ic and ad ises and suppo s he nu ses 3.07 (1.0)
24: Wo k well done is ecognised and p aised 2.90 (1.0)

In . J. En i on. Res. Public Heal h 2021,18, 434 6 o 12
Table 1. Con .
Sco e Mean (SD)
S eng hs Neu al Weaknesses
Dimension 4: Adequa e human esou ces o ensu e quali y o ca e 2.33 (0.8)
25 *: The e a e enough employees o do he job p ope ly 2.28 (1.0)
26 *: The e a e su icien numbe s o egis e ed nu ses o p o ide quali y ca e 2.35 (1.0)
27: Suppo se ices (wa dens, adminis a i e s a , e c.) a e adequa e and make i easie o spend mo e ime wi h pa ien s 2.38 (0.9)
28: The e is su icien ime and oppo uni y o discuss ca e issues wi h he o he nu ses 2.32 (0.9)
Dimension 5: Nu se–physician ela ionship 2.87 (0.7)
29: A lo o eamwo k is done be ween doc o s and nu ses 2.63 (0.9)
30: The e a e good wo king ela ionships be ween doc o s and nu ses 3.10 (0.7)
31 *: P ac ice be ween nu ses and doc o s is based on app op ia e collabo a ion 2.87 (0.8)
TOP10 ques ionnai e S eng hs Neu al Weaknesses
Dimension 1a: Pa icipa ion in cen e a ai s 2.73 (0.7)
Dimension 2a: Quali y o ca e 2.92 (0.7)
Dimension 3a: Human esou ces 2.31 (1.0)
O e all esul
PES-NWI o al 82.43 (17.4)
TOP10 o al 29.68 (6.2)
SD: s anda d de ia ion; s eng h: sco e > 2.6; neu al o con o e sial: sco e be ween 2.4–2.6; weakness: sco e < 2.4; posi i e en i onmen : PES-NWI sco e > 80.6; con o e sial en i onmen : PES-NWI sco e
74.4–80.6; nega i e en i onmen : PES-NWI sco e < 74.4; * TOP10 i ems.
In . J. En i on. Res. Public Heal h 2021,18, 434 7 o 12
The bi a ia e analysis o he esul s om PES-NWI and he sociodemog aphic and
p o essional a iables a e shown in Table 2. Age was s a is ically signi ican o he PES-
NWI and 3 ou o i s 5 dimensions (D2, D3 and D5). The pa icipan s’ le el o educa ion
was s a is ically signi ican o he o e all PES-NWI and 4 o i s dimensions (D1, D2, D3 and
D5), and managemen ole was ound o be s a is ically signi ican o he PES-NWI and 4
o i s dimensions (D1, D2, D3 and D4). We did no ind a s a is ically signi ican co ela ion
be ween PES-NWI and he es o he sociodemog aphic and p o essional a iables.
Table 2. Bi a ia e analysis o he esul s om PES-NWI and he sociodemog aphic and p o essional a iables.
Sco ing M(SD)
Global Dimensions
D1 D2 D3 D4 D5
Age (yea s) pa0.016 * 0.123 0.047 * 0.041 * 0.467 0.000 *
Less han o equal o 30 84.98 (15.9) 2.63 (0.6) 2.74 (0.6) 3.00 (0.8) 2.44 (0.7) 3.04 (0.7)
31–40 84.99 (17.7) 2.55 (0.6) 2.83 (0.7) 3.06 (0.9) 2.31 (0.8) 3.06 (0.7)
41–50 81.56 (17.3) 2.48 (0.7) 2.70 (0.6) 2.92 (0.9) 2.29 (0.8) 2.82 (0.7)
>50 80.22 (17.6) 2.46 (0.7) 2.65 (0.6) 2.82 (0.9) 2.33 (0.8) 2.71 (0.7)
Manage ial ole pb<0.000 * <0.000 * <0.000 * <0.000 * <0.000 * 0.296
Yes 94.65 (14.4) 3.01 (0.6) 3.06 (0.5) 3.52 (0.6) 2.63 (0.8) 2.96 (0.7)
No 80.55 (17.3) 2.44 (0.6) 2.67 (0.6) 283 (0.9) 2.28 (0.8) 2.86 (0.7)
Le el o educa ion pa<0.000 * 0.026 * <0.000 * 0.011 * 0.518 0.017 *
Diploma 84.73 (17.4) 2.56 (0.7) 2.82 (0.6) 3.02 (0.9) 2.36 (0.8) 2.95 (0.8)
Deg ee 81.21 (16.1) 2.52 (0.6) 2.67 (0.6) 2.89 (0.9) 2.28 (0.7) 2.76 (0.7)
Specialisa ion 80.91 (16.1) 2.53 (0.6) 2.58 (0.6) 2.93 (0.8) 2.39 (0.7) 2.73 (0.7)
Mas e 80.49 (17.7) 2.45 (0.6) 2.66 (0.6) 2.81 (0.9) 2.30 (0.8) 2.83 (0.7)
PhD 71.13 (16.5) 2.16 (0.7) 2.27 (0.6) 2.53 (0.8) 2.09 (0.7) 2.63 (0.7)
M: mean; SD: s anda d de ia ion; D1: pa icipa ion o nu sing s a ; D2: nu sing ounda ion in quali y o ca e; D3: capaci y, leade ship
and suppo o nu sing s a by manage s; D4: he size o s a and adequacy o human esou ces; D5: ela ionships be ween nu sing and
medical p o essionals; * signi ican alues p< 0.05; pa: ANOVA; pb: S uden ’s - es .
We in es iga ed gende inequali ies in ou sample (Table 3). Ou esul s show ha
mos o he nu ses we e aged
≤
50 yea s (p= 0.031). The ep esen a ion o women a highe
educa ion le els (mas e s o doc o a e) is p opo ionally lowe han ha o men (p= 0.024)
bu , pa adoxically, women achie e a highe pe cen age o specialis aining (p= 0.048).
Table 3. Dis ibu ion and compa ison o socio-demog aphic and occupa ional da a by gende .
Gende
Man (%) Woman (%)
Age (yea s) p= 0.031 *
less han o equal o 30 22.7 77.3
31–40 28.6 71.4
41–50 22.3 77.7
>50 34.0 66.0
Le el o educa ion p= 0.024 *
Diploma 29.6 70.4
Deg ee 21.8 78.2
Specialisa ion 16.5 83.5
Mas e 29.3 70.7
PhD 46.7 53.3
Specialis aining p= 0.048 *
Yes 15.8 84.2
No 20.7 79.3
Wo king expe ience (yea s) p= 0.206
<2 22.0 78.0
2–4 21.6 78.4
5–10 31.2 68.8
>10 29.3 70.7
Manage ial ole p= 0.204
Yes 21.7 28.4
No 78.3 71.6
p: chi squa e es ; * p< 0.05
In . J. En i on. Res. Public Heal h 2021,18, 434 8 o 12
4. Discussion
The main objec i e o his s udy was o iden i y s eng hs and weaknesses in he PHC
wo k en i onmen in Spain. Ou esul s sugges ha posi i e NWEs in PHC in Spain a e
cha ac e ized by nu sing ounda ions o quali y ca e (D2), managemen and leade ship
o he head nu se (D3) and he nu se–physician ela ionship (D5). This is consis en wi h
p e ious s udies in ou con ex [
16
,
17
]. Nu se pa icipa ion in cen e a ai s (D1) was
iden i ied as neu al o con o e sial in ou s udy as opposed o a p e ious s udy by Gea-
Caballe o e al. [
16
], whe e i was iden i ied as a s eng h. O e all, ou esul s di e om
hose ob ained by de Ped o-Gómez e al. [
28
], who classi ied he NWE in PHC se ings in
he Balea ic Islands as con o e sial (80.4 poin s).
This s udy i s well wi h he imp o emen model p oposed by Poghosyan e al. [
20
].
Poli ical decision-making and o ganiza ional inno a ion in PHC se ings a e key o imp o e
iden i ied weaknesses. Fu he mo e, esea ch in heal hca e se ings is essen ial o no only
inc ease knowledge o , and imp o e, bo h p ocesses and p ocedu es, bu also o c ea e an
o ganiza ional cul u e ha p omo es he in eg a ion o he bes a ailable e idence [
18
],
hus imp o ing pa ien ou comes and inc easing se ice use sa is ac ion.
Gi en he di icul y in inding o he s udies in he PHC se ing, and due o hei
concep ual p oximi y, we compa ed ou esul s wi h hose epo ed in s udies abou magne
hospi als (as desc ibed in he in oduc ion). Ou esul s show ha dimensions D2, D3 and
D5 a e associa ed wi h a posi i e NWE. This is in ag eemen wi h he esul s om p e ious
s udies ca ied ou in “non-magne hospi als”. These a e encou aging indings, bu hey
a e s ill a om hose ob ained in “magne hospi als”, whe e e e y single dimension o he
PES-NWI was iden i ied in his o ical s udies as a s eng h [
29
,
30
]. This is an encou aging
inding as i demons a es ha he ans o ma ion o weak o con o e sial dimensions
in o s eng hs is possible, as e idenced by he esul s ob ained in magne and excellen
wo k en i onmen s.
In Spanish hospi als, he same h ee dimensions, namely, D2, D3 and D5, we e shown
o be neu al o con o e sial o he NWE [
31
]. This di e si y in he esul s sugges s ha
he quali y o he NWE in he hospi al con ex depends on ex e nal as well as in e nal
cha ac e is ics o he heal hca e se ice. The e o e, in e en ions o imp o e he NWE in he
PHC con ex should be indi idualized and based on he esul s ob ained om each sepa a e
heal hca e ins i u ion (mic oen i onmen ). The same e lec ion is applicable o PHC wo k
en i onmen s. Howe e , a s udy by de Ped o e al. [
28
] iden i ied D2 and D3 only as
s eng hs in hospi als wi h 300–500 beds. Pa adoxically, in in e na ional s udies abou he
cha ac e is ics o he NWE, we ind a g ea e di e si y o scena ios; some iden i y all he
dimensions o he PES-NWI as s eng hs [
32
,
33
], o he s show managemen and leade ship
o he head nu se and nu se–physician ela ionship as s eng hs (D3 and D5) [
34
], and
some iden i y managemen and leade ship o he head nu se as he only s eng h (D3) [
35
].
In he PHC NWE in Spain, he size o he wo k o ce o human esou ces (D4) is
iden i ied as a clea weakness, coinciding wi h na ional s udies in bo h PHC [
16
,
17
,
28
]
and hospi al [
28
,
31
,
36
] wo k en i onmen s. These esul s coincide wi h hose po ayed in
in e na ional s udies abou NWE in he hospi al se ing [
34
,
35
]. The compa a i e s udies
be ween “magne and non-magne hospi als” epo ed simila esul s in his o ical s udies,
wi h human esou ces (D4) being iden i ied as a weakness in “non-magne hospi als”;
i was no iden i ied as a weakness in “magne hospi als”, bu i was he wo s alued
dimension [
29
,
30
]. This same si ua ion was also obse ed in in e na ional s udies, bo h
Eu opean [
32
] and Asian [
33
], wi h human esou ces usually being he wo s alued
dimension. The p oblem wi h human esou ces is pa icula ly se ious in Spain, whe e
he nu se–pa ien a io is 567 pe 100,000 inhabi an s, well below he Eu opean a e age
(811/100,000) and a om he mo e indus ialized coun ies, such as Finland, Denma k
o Belgium (1500/100,000) [
37
]. Despi e he e o s made in ecen yea s o inc ease he
nu sing wo k o ce, and he commi men o nu ses as heal h agen s, i is s ill a limi a ion
ha comp omises pa ien sa e y and quali y o ca e. Fu he mo e, he nu se–physician a io
in Spain is se e ely unbalanced. Acco ding o he O ganisa ion o Economic Co-ope a ion
In . J. En i on. Res. Public Heal h 2021,18, 434 9 o 12
and De elopmen (OCED) [
38
], he numbe o physicians pe inhabi an in Spain is abo e
a e age (7 h place and abo e coun ies such as I aly, Aus alia, F ance and Finland), bu
he numbe o nu ses is well below he a e age wo ldwide (23 d place ou o 26 coun ies).
Finland and Ge many iple he numbe o nu ses in Spain, and No way quad uples i . I
should no be o go en ha he e is a di ec co ela ion be ween he a io o nu ses and
pa ien mo ali y, as well as o he unwan ed e en s and heal h ou comes [5–9].
These ac s, amed in a global SARS-COV-2 pandemic, e eal and exace ba e exis ing
p oblems wi hin he heal hca e se ice. Fo example, he COVID-19 pandemic has added
undue p essu e o he heal h se ices in Spain, hus highligh ing he lack o quali ied
nu ses. As sugges ed by Seccia Rugge o [
39
], he eplenishmen o ma e ial esou ces
can be achie ed ela i ely easily, bu ein o cemen wi h quali ied nu ses is di icul o
achie e and canno be done o e a sho pe iod o ime. An adequa e nu sing p o ision
could con ibu e o imp o ed ou comes in heal h c ises, such as a he peak o he COVID
pandemic, which has led he WHO in Ap il 2020 o call o mo e in es men in nu ses [
40
].
Key s akeholde s and hose esponsible o decision making on heal hca e se ice planning
should conside he need o inc ease he Spanish nu sing wo k o ce and d aw a plan
acco dingly in he yea s o come.
The esul s om he TOP10 scale [
26
] we e ully consis en wi h he PES-NWI e-
sul s, iden i ying pa icipa ion o nu ses in he a ai s o he cen e (D1a) and he nu sing
ounda ions o quali y o ca e (D2a) as s eng hs, and human esou ces (D3a) as a weak-
ness. We a gue ha TOP10 is a simple way o iden i ying he s eng hs and weaknesses
associa ed wi h he NWE, making i easie and simple o nu se manage s o iden i y
weakness o a eas o imp o emen wi hin hei PHC wo k en i onmen s. In addi ion,
he esul s om he TOP10 scale a e alid and eliable as suppo ed by a ecen s udy by
Ma ínez-Rie a e al. [41]
, whe e a g oup o communi y ca e expe s conside ed ha 9 ou
o he 10 i ems o he TOP10 scale we e essen ial elemen s o he PHC NWE.
The compa a i e s udy o he sociodemog aphic and p o essional a iables and he
pe cep ion o he PHC NWE shows signi ican di e ences associa ed wi h age, le el
o educa ion and he le el o managemen in which he p o essionals we e in ol ed.
Olde nu ses (50+) we e he mos c i ical wi h hei wo k en i onmen s. In addi ion,
signi ican di e ences we e ound o dimensions D2, D3 and D5 sepa a ely. The age-
ela ed di e ences ound in Spanish s udies should be assessed wi h cau ion due o he
a e age age di e ence be ween nu ses employed in public and p i a e se ices, wi h
g ea e ep esen a ion in p i a ely managed cen e s o he age ange unde 40 yea s [16].
Nu ses educa ed o doc o al le el iden i ied he Spanish PHC NWE as a nega i e
en i onmen o nu sing ca e and also poin ed o he dimensions o nu sing pa icipa ion
in cen e a ai s (D1), nu sing ounda ions o quali y o ca e (D2) and human esou ces
(D4) as weaknesses. In e es ingly, he dimension nu sing ounda ions o quali y o ca e
(D2) was iden i ied as a weakness by doc o al nu ses and as a s eng h by he es o he
nu sing p o essionals. The same was obse ed in a p e ious s udy [
17
] in he Communi y
o Mad id. This may sugges a lowe le el o job sa is ac ion among he mos he nu sing
p o essionals wi h a highes le el o educa ion [
33
], o pe haps i may e lec a g ea e
capaci y o c i ical hinking. This si ua ion is pa adoxical. PHC nu ses look a e an
ageing popula ion wi h highly complex and ch onic condi ions. Thus, i would seem
easonable o in eg a e nu ses wi h high le els o aining and hose in ad anced p ac ice
oles in PHC se ings [
42
]. The In e na ional Council o Nu ses [
43
] de ines ad anced
nu se p ac i ione s as p o essionals who ha e acqui ed he heo e ical knowledge, complex
decision-making skills and clinical compe encies o ex ended p ac ice in he coun y and
con ex o which hey a e acc edi ed. Ad anced aining, such as a mas e ’s o doc o al
deg ee, is ecommended o an ad anced nu sing p ac ice quali ica ion [
44
]. Ou esul s
show ha highly quali ied nu ses (doc o al le el) alue hei wo k en i onmen he leas ,
e lec ing he ac ha he wo k en i onmen may no be adap ed o he academic le el o
hese p o essionals. We a gue ha i is necessa y o ensu e ha highly quali ied nu ses and
hose in ad anced p ac ice oles [
45
] a e able o wo k o hei ull po en ial wi hin PHC