Introduction

Neonatal intensive care nursing is a demanding profession that requires both emotional and physical resilience due to its high-acuity environment and the complexity of care provided to critically ill newborns [1,2]. Nurses in Neonatal Intensive Care Units (NICUs) provide specialized care, often in high-stress environments that can impact their Professional Quality of Life (ProQoL) [3]. ProQoL consists of three key components: Compassion Satisfaction (CS), Burnout (BO), and Secondary Traumatic Stress (STS) [4]. Compassion Satisfaction refers to the fulfillment nurses experience from their work, whereas Burnout and STS arise from prolonged occupational stress and repeated exposure to patient suffering, respectively [5].

A well-structured work environment enhances job satisfaction and mitigates stress, whereas inadequate staffing, high workloads, and limited emotional support can lead to emotional exhaustion and decreased care quality. The World Health Organization (WHO) underscores that healthcare workers’ well-being is vital for maintaining high-quality patient care [6]. Research from high-income settings shows that supportive work environments contribute to higher ProQoL by reducing burnout and improving job satisfaction [7,8]. Conversely, studies in low-resource settings highlight the negative effects of staffing shortages and high workloads on nurses’ emotional well-being [3,9]. Despite extensive research on ProQoL globally, little is known about how these factors affect NICU nurses in the West Bank, where political instability and resource limitations present additional challenges.

This study examines the relationship between ProQoL and the work environment among NICU nurses in the West Bank. Using Kanter’s Theory of Structural Empowerment, which posits that access to resources, support, and professional opportunities enhances job satisfaction and reduces stress [10], this research seeks to provide evidence-based recommendations to improve the work environment and support NICU nurses’ well-being in resource-constrained settings.

Literature review

Professional Quality of Life (ProQoL) refers to the overall well-being of healthcare professionals as they navigate the rewards and challenges of their work [4]. Stamm conceptualized ProQoL as comprising three key components: Compassion Satisfaction (CS), Burnout (BO), and Secondary Traumatic Stress (STS). Compassion Satisfaction reflects the positive emotional benefits of caregiving, such as fulfillment from helping others [4]. Burnout arises from prolonged occupational stress, leading to emotional exhaustion, cynicism, and reduced professional efficacy. Secondary Traumatic Stress occurs when healthcare workers experience emotional distress from repeated exposure to patient suffering [2,5].

NICU nurses are particularly vulnerable to burnout and secondary traumatic stress due to the high-acuity nature of neonatal care, emotionally demanding family interactions, and frequent exposure to infant mortality. Studies from high-income countries have emphasized the importance of institutional support mechanisms, such as counseling services and resilience training, in reducing burnout [1,7]. In resource-limited settings, however, research highlights the detrimental effects of workforce shortages, excessive workloads, and limited access to psychological support services, which exacerbate emotional exhaustion among NICU nurses [3,9].

The work environment is a key determinant of ProQoL. According to Kanter’s Theory of Structural Empowerment (1977), access to resources, leadership support, and professional opportunities enhances job satisfaction and reduces stress. Empirical studies show that supportive work environments are associated with higher compassion satisfaction and lower burnout among nurses [7,8]. Conversely, poor staffing, inadequate resources, and lack of nurse autonomy are linked to higher levels of burnout and secondary traumatic stress [8,11].

The Practice Environment Scale of the Nursing Work Index (PES-NWI), developed by Lake (2000), is one of the most widely used tools for assessing the nursing work environment. It comprises five key subscales: Nurse Participation in Hospital Affairs, Nursing Foundations for Quality of Care, Nurse Manager Ability, Leadership, and Support, Staffing and Resource Adequacy, and Collegial Nurse-Physician Relations [12].

Research using the PES-NWI suggests that hospitals with favorable practice environments report lower burnout rates and higher job satisfaction [13]. A study by Liu et al. found that nurse-physician collaboration and adequate staffing levels were the strongest predictors of ProQoL [8]. However, in low-resource settings, staffing shortages, high patient loads, and limited leadership support negatively impact nurses’ well-being [3,9]. Recent studies in Sub-Saharan Africa (e.g., Kenya) and South Asia (e.g., India) further highlight how systemic resource constraints and sociocultural dynamics exacerbate burnout among NICU nurses [14,15].

NICU nurses working in resource-constrained regions, such as the West Bank, face unique socio-political and economic challenges. Chronic staffing shortages, limited access to medical supplies, and unstable political conditions further burden NICU nurses, exacerbating stress and burnout [6]. Similar trends have been reported in other low-resource settings, where lack of emotional support programs and high patient-to-nurse ratios contribute to severe burnout and emotional exhaustion [14].

Despite the well-documented effects of work environment on nurse well-being, research focusing on NICU nurses in the West Bank remains scarce. Findings from similar resource-limited healthcare settings suggest that targeted interventions; such as workload redistribution, peer support programs, and leadership training, can enhance ProQoL [15,16,17]. This study seeks to bridge this gap by examining the relationship between ProQoL and work environment among NICU nurses in the West Bank, offering insights into potential solutions for improving nurse well-being in under-resourced healthcare settings.

Methodology

Results

Participant characteristics

Of the 260 questionnaires distributed, 233 were returned (response rate 89.6%). The majority of respondents were aged 30 years or younger (59.7%), and their sex was female (73.8%). Over half reported having a bachelor’s degree (64.8%), while the majority had less than five years of experience (73.0%). A majority of the nurses worked rotating shifts (62.7%), and 50.6% reported sleeping eight hours per night. As seen in Table 1 (see S1 Table in S1 File for detailed demographics)

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Table 1. Demographic characteristics of participants.

https://doi.org/10.1371/journal.pone.0322023.t001

Professional quality of life

The majority of respondents reported average levels of compassion satisfaction, 94.8%; burnout, 91.0%; and secondary traumatic stress, 84.1%. Only a few had high compassion satisfactions, 5.2%, while no participant had high burnout. This suggests that the nurses do get some fulfillment from their job roles but at the same time undergo much emotional strain. As shown in Table 2 (see S2 Table in S1 File for full breakdown)

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Table 2. Professional quality of life levels.

https://doi.org/10.1371/journal.pone.0322023.t002

Practice environment

The overall practice environment was considered moderately favorable, with a mean of 2.7 (SD = 0.3). Collegial Nurse-Physician Relations had the highest ranking, with a mean score of 2.8 and an SD of 0.5, indicative of strong relationships between professionals; Staffing and Resource Adequacy ranked lowest at 2.6 (SD = 0.4), reflecting critical shortages in key resources. As shown in Table 3 (see S3 Table in S1 File for subscale scores)

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Table 3. Practice environment scores.

https://doi.org/10.1371/journal.pone.0322023.t003

Correlation analysis

Spearman’s correlation analysis showed that a favorable practice environment was significantly associated with higher compassion satisfaction (r = 0.747, p < 0.001) and negatively correlated with burnout (r = -0.604, p < 0.001) and secondary traumatic stress (r = -0.151, p = 0.021). Among the PES-NWI subscales, Collegial Nurse-Physician Relations and Nurse Participation in Hospital Affairs exhibited the strongest relationships with compassion satisfaction and burnout. A multiple linear regression analysis was conducted to explore the predictive power of work environment factors on ProQoL components. The model explained 58% of the variance in compassion satisfaction (R² = 0.58, p < 0.001), 47% in burnout (R² = 0.47, p < 0.001), and 21% in secondary traumatic stress (R² = 0.21, p = 0.019). Staffing and Resource Adequacy was the strongest predictor of burnout (β = -0.49, p < 0.001), while Collegial Nurse-Physician Relations was the most significant predictor of compassion satisfaction (β = 0.52, p < 0.001). These findings suggest that improving staffing levels and professional relationships could enhance ProQoL outcomes. As depicted in Table 4 (see S4 Table in S1 File for regression coefficients).

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Table 4. Correlations between practice environment and ProQoL.

https://doi.org/10.1371/journal.pone.0322023.t004

Discussion

This study explored the relationship between Professional Quality of Life (ProQoL) and the work environment among NICU nurses in the West Bank. The findings indicate that staffing shortages, limited resources, and nurse-physician relationships significantly impact nurses’ ProQoL, reinforcing existing research on the subject.

Most participants (94.8%) reported moderate Compassion Satisfaction, suggesting that NICU nurses derive fulfillment from their roles despite workplace challenges. However, only 5.2% reported high Compassion Satisfaction, indicating that resource limitations and excessive workloads may hinder greater job satisfaction. Similarly, while 91.0% of nurses reported average Burnout, none reported high Burnout levels, suggesting the presence of coping mechanisms. However, continued exposure to excessive workloads and emotional strain could increase burnout risk over time. Research in high-income settings suggests that workplace wellness programs and emotional resilience training reduce burnout [11,19], yet such interventions are often underdeveloped in resource-limited settings like the West Bank.

The study also found that 84.1% of nurses experienced moderate levels of Secondary Traumatic Stress (STS), with 15.0% reporting low STS. This highlights the emotional burden NICU nurses face due to frequent exposure to neonatal mortality and distressing family interactions. Similar studies have shown that NICU nurses are particularly vulnerable to STS due to the intensity of neonatal care and the emotional demands of supporting grieving families [1]. Given the political instability and healthcare constraints in the West Bank, these challenges may be even more pronounced compared to high-income settings.

The study underscores the significant influence of work environment factors on ProQoL. Collegial Nurse-Physician Relations emerged as the highest-rated factor (mean = 2.8, SD = 0.5) and was positively correlated with Compassion Satisfaction (r = 0.683, p < 0.001). This supports research demonstrating that strong interdisciplinary collaboration enhances job satisfaction and reduces burnout [7,8]. Conversely, Staffing and Resource Adequacy received the lowest rating (mean = 2.6, SD = 0.4) and was negatively correlated with Burnout (r = -0.604, p < 0.001). Previous studies have shown that staffing shortages and inadequate resources contribute to severe burnout and emotional exhaustion, particularly in low-resource settings [14].

Regression analysis revealed that Staffing and Resource Adequacy was the strongest predictor of Burnout (β = -0.49, p < 0.001), while Collegial Nurse-Physician Relations was the strongest predictor of Compassion Satisfaction (β = 0.52, p < 0.001). These findings reinforce Kanter’s Theory of Structural Empowerment, which asserts that access to resources, leadership support, and professional collaboration enhances job satisfaction and reduces stress [10].

Addressing these challenges requires targeted interventions. Improving staffing levels and ensuring adequate resources can mitigate burnout and enhance patient care quality. Strengthening nurse-physician collaboration through structured training programs and shared decision-making protocols can further improve job satisfaction. Additionally, introducing workplace wellness programs, peer support networks, and mental health resources can help nurses manage STS and burnout more effectively.

Overall, this study highlights the critical need for systemic improvements in NICU work environments to enhance ProQoL. Future research should focus on longitudinal studies to assess changes over time and qualitative investigations to explore nurses’ lived experiences in greater depth. Intervention-based research evaluating the effectiveness of workplace wellness programs and resilience training could further inform policies aimed at improving NICU nurses’ well-being in resource-limited healthcare settings.

Conclusion

This study provides critical insights into the relationship between Professional Quality of Life (ProQoL) and the work environment among Neonatal Intensive Care Unit (NICU) nurses in the West Bank. To translate findings into action, policymakers should advocate for enforceable nurse-patient ratio laws, and allocate funding for workplace wellness programs. Hospital administrators could adopt WHO’s guidelines on staffing benchmarks and integrate peer support networks to address cultural stigma around mental health.

Supporting information

Acknowledgments

The authors would like to express their thanks to the nurses who participated in the study