https://orcid.org/0000-0002-6042-0926
Figures
Abstract
Background
There is a well-established relationship between the quality of workplace interactions among nurses, physicians, their managers, and nurse colleagues, and the subsequent improvement in patient outcomes. However, despite the growing body of research on this topic in developed countries, there remains a notable paucity of literature exploring these dynamics in developing countries.
Aim
To investigate the impact of workplace relationships on nurse-reported quality of care and patient safety.
Method
A multiphase sampling method was applied. Purposive sampling was used to select the province, health sector and hospitals (n = 3). All-inclusive sampling was applied to in-patient units of the selected hospitals and nursing staff in those units (n = 236). Data was collected in April 2021, using validated instruments.
Results
Nurse manager ability, leadership, and support was not experienced as positively contributing to the practice environment and had the most impact on quality of care and patient safety. Collegial nurse-physician relationships were experienced as contributing positively to the practice environment, and had the most impact on adverse events, namely medication errors, patient falls after admission and healthcare-associated infections. Increased exposure to COVID-19 patients resulted in more positive perceptions of nurses regarding collegial nurse-physician relationships. The most common perpetrators of workplace violence were supervisors/managers, followed by nursing colleagues. On average participants experience more personal workplace violence than physical workplace violence. Personal workplace violence had more effect on quality of care, patient safety, and adverse events than physical workplace violence.
Citation: Tlhako N, Coetzee SK, Ajanaku OJ, Fourie E (2025) The impact of workplace relationships on nurse-reported quality of care and patient safety in the North West Province. PLoS One 20(5): e0323620. https://doi.org/10.1371/journal.pone.0323620
Editor: Moustaq Karim Khan Rony, Bangladesh Open University, BANGLADESH
Received: February 29, 2024; Accepted: April 11, 2025; Published: May 21, 2025
Copyright: © 2025 Tlhako et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript.
Funding: This work is based on research supported in part by the National Research Foundation of South Africa (Grant Number 123541). Opinions expressed and conclusions arrived at, are those of the author and are not necessarily to be attributed to the NRF.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Workplace relationships are distinct types of interpersonal relationships that have significant effects on both the people involved and the organizations in which they are formed [1]. Relationships in the workplace serve a variety of purposes, such as task assistance, career advancement, and emotional support [2]. This study focuses specifically on workplace relationships in terms of nurse-physician, nurse- manager and nurse-to-nurse workplace relationships and will focus on both positive workplace relationships or collegiality, as well as negative workplace relationships or workplace violence (WPV). Positive workplace relationships foster collaboration, trust, open communication, mutual support and innovation, creating a safe and enjoyable environment [3]. A negative workplace relationship involves threats, abuse or assault that jeopardize an employee’s health or wellbeing and safety, including during commuting [4]. Decades of research on nurse‐physician workplace relationships showed that the main facilitators and barriers influencing the relationships included: (1) communication and collaboration; (2) roles and responsibilities; (3) hierarchy and education; and (4) liability [5,6]. Positive relationships between nurses and physicians are associated with improved nurse-perceived patient safety and quality of care [6–8], with better communication and collaboration between the two professions resulting in improved patient and nurse outcomes, a positive practice environment, and decreased cost of healthcare [9–11].
Nurse management, leadership, and support of nurses are highly correlated with nurse outcomes, perceptions of the practice environment [12], quality of care and patient safety [13], as well as nurse and patient satisfaction [14]. The nurse managers have a direct or indirect impact on the quality of care and patient safety. A direct impact is through outcomes such as staff satisfaction with job factors, staff health and wellbeing, and processes such as staff’s relationships with work, their colleagues, and the organization [12]. An indirect association of leadership with quality of care and patient safety was found in patient mortality ([13,15], complications of immobility [16], medication errors [17], patient falls [15], pressure ulcers [18], hospital-acquired infections [15]) and length of hospital stay [17].
It is well documented that hospital environments are often plagued by vertical and horizontal workplace violence in the form of physical and psychological abuse, which disrupts collegial workplace relationships and healthcare delivery [19]. Vertical violence is a pattern of behavior that is usually directed against subordinates and is directed at someone who occupies a position at a lower or higher level of the hierarchical scale. Several studies have identified nurse managers and senior staff members [20], as well as physicians [21] as perpetrators of workplace violence. In the 2019–2020 American Nurses Association (ANA) and Healthy Nurse, Healthy Nation (HNHN) Survey, 23% of nurses reported having encountered vertical aggression or bullying from people in positions of authority [22]. A pattern of aggressive behaviors, such as bullying and intimidation, between nurses who are at the same rank level in the hierarchy is known as horizontal violence [23]. In South Korea, 82% of nurses indicated being exposed to some form of horizontal violence [24], while in Cape Town, South Africa, 44% of nurses working in public hospitals had experienced horizontal violence [25].
Workplace violence includes physical and psychological abuse. Physical workplace violence involves using force such as shoving, biting, pinching, shooting, kicking, slapping, stabbing, or sexual assault, regardless of injury [26]. Psychological abuse is defined as using offensive language or words that disrespect an individual’s dignity and worth, leading to abusive, humiliating, intimidating, and insulting behaviors [26]. Furthermore, Khoshknab et al. [27] are of the view that although physical and psychological violence is common, psychological violence occurs more frequently. According to a recent review by Mobaraki et al. [28], the most prevalent forms of workplace violence are, in order of prevalence from most to least common: verbal, physical and psychological.
A substantial amount of research has been done concerning workplace violence and its effect on the nurse, but less is known about its eroding effect on quality of care and patient safety [24]. Internationally workplace violence have been linked to compromised quality of care and patient safety [29] resulting in adverse events such as hospital acquired infections [30] patient mortality [31], medication errors [32], patient falls and pressure ulcers [33]. However, there is a dearth of such literature in developing countries.
A systematic review [34] revealed that 62.3% of nurses experienced workplace violence in Africa, with recent studies done in Botswana [35], Nigeria [36], Ethiopia [37] and Ghana [38] all indicating poor nurse-physician collaboration within developing countries leading to a breach in patient safety [38]. Although recent studies in South Africa concluded that patient and families were the main perpetrators of workplace violence in emergency units [39] and psychiatric hospitals [40] but in the private healthcare sector horizontal workplace violence was the most common [41].
Although much is published on the effect of workplace violence on the nurse, less is known about the effect on quality of care and patient safety, especially in the African context [20,42]. Therefore, this study will focus on how workplace relationships influence the quality of care and patient safety as well as the frequency of work-related, personal and physical workplace violence between nurses and physicians, their managers and nursing colleagues.
Methods
South Africa has a dual healthcare system, namely a public sector that provides care to approximately 83% of the population of the country, and a private sector that provides care to the rest of the population [43]. The study was conducted in the public healthcare sector of the North West Province (NWP) of South Africa. A cross-sectional survey design was applied in this study, using a valid and reliable self-administered, paper-based survey that measures five variables, namely the Practice Environment Scale of the Nurse Work Index (PES-NWI), Negative Acts Question Revised (NAQ-R), quality of care, patient safety, and adverse events, and selected nurse and unit demographics.
Positive workplace relationships or collegiality
The PES-NWI was used to measure positive workplace relationships or collegiality regarding the nurse-physician relationship and the nurse-manager relationship. The following two subscales were used: nurse manager ability, leadership, and support of nurses; and collegial nurse-physician relations. This scale consists of 11 questions answered on a Likert scale from 1 to 4, where 1 represents strongly disagree and 4 strongly agree; a mean score of 2.5 and more indicates a positive practice environment. Scores on the PES-NWI are valid and reliable for measuring the nursing practice environment across samples in the United States (US) and non-US countries [44–46] with the subscales having a Cronbach’s alpha of 0.88 (Nurse participation in hospital affairs); 0.84 (Nursing foundations for quality of care); 0.84 (Nurse manager ability, leadership, and support of nurses); 0.75 (Staffing and resource adequacy); and 0.89 (Collegial nurse-physician relationships) respectively.
Workplace violence
Workplace violence was calculated using the NAQ-R (Negative Acts Questionnaire–Revised). There are three subscales that make up the NAQ: work-related, personal, and physical workplace violence. In this study, only the personal and physical workplace violence subscales were included. These comprised 15 questions, with responses on a Likert scale of 1–5, with 1 being never and 5 denoting daily. Subscale items are calculated and averaged to determine subscale scores. The test exhibits strong validity and reliability [47] with Cronbach’s alpha for subscales being: Physically Intimidating bullying: α = 0.83; Person-related bullying: α = 0.96.
Quality of care
Four questions that were utilised as single items were used to assess the nurses’ perceptions of the quality of the care. These have been utilised in multi-country studies in Asia [48], Europe [49], North America [50], South Africa [51], and other regions. They were also included in multiple systematic reviews and meta-analyses [52]. Questions were answered according to a Likert scale ranging from 1 representing frequently to 4 representing never.
Patient safety
In this study, two questions measuring nurse-perceived patient safety were used. These questions have been used as single items in multi-country studies conducted in North America [50], Asia [48], South Africa [51], and Europe [49]. They have also been included in numerous systematic reviews and meta-analyses. These questions were answered according to a Likert scale of 1–5, where 1 is good and 5 is failing. The remaining 8 questions came from surveys on patient safety (SOPS) culture conducted by the Agency for Healthcare Research and Quality (AHRQ). The responses were given on a Likert scale of 1–5, with 1 denoting strong agreement and 5 denoting strong disagreement.
Adverse events
In multi-country studies conducted in Europe [49], North America [50], Asia [48], and South Africa [51], the nurse-perceived adverse events questionnaire consisted of seven questions. These questions have also been included in numerous systematic reviews and meta-analyses [52]. These questions were answered according to a Likert scale of 0–5, where 0 equals never and 5 equals frequently.
The study also included certain individual and unit variables, including age, gender, employment status, nursing category, Bachelor of Nursing degree, specialty of the current unit, nursing clinical specialty, level of clinical specialty, years worked as a nurse, and years employed in the hospital.
Population and sample
A multiphase sampling technique was used as the overall larger study applied and all-inclusive sampling of the Provinces in South Africa, but NWP was purposively chosen for this study, as was the public sector. Purposive sampling was also applied to select the hospitals in the public sector, including the regional and district hospitals (n = 3) neighboring the largest tertiary hospital in the province. There is no central hospital in the NWP. When choosing the study’s units and participants, all-inclusive sampling was used. The study covered every in-patient setting, including the emergency rooms and theatres. The participants included community service nurses, enrolled nurses, auxiliary nurses, registered nurses, and midwives. Nurses who have worked in the chosen hospital for less than three months may not be able to provide an overall assessment of factors such as the working environment, quality of care, or patient safety within their units or even hospitals since they are still new employees, this was used as an exclusion criterion. Participants were recruited through the researcher presenting the research project to eligible participants in every in-patient unit to both day and night shift, whereafter they had 24 hours to choose whether to participate or not. The distribution of 319 (N) surveys at the tertiary hospital resulted in 123 (N) returned surveys; distribution of 146 (N) surveys at the regional hospital resulted in 72 (N) returned surveys; and distribution of 76 (N) surveys at the small district hospital resulted in 41 (N) returned surveys. There was a total of n = 236 nurses in the overall sample. For the class of models like the ones used in this study [53] sample size of 200 provides sufficient statistical power to conduct the exploratory and confirmatory factor analysis and structural equation modelling. Statistical estimation involving a sample of 200 typically results in stable estimates of selected fit indices used to determine the degree of fit between the pattern of relationships in the data and those proposed in a model [54].
Data collection
Data was collected from 11–23 April 2021. After ethical approval was obtained from the North-West University Health Research Ethics Committee (NWU-HREC) and the NWP Department of Health (DoH). After receiving goodwill consent from the respective Chief Executive Officers, they served as gatekeepers and referred the researcher to the nursing service managers of the facilities, who acted as mediators for the study. The nursing service managers had to select an independent person to assist with data collection. When no independent person could be appointed, the principal investigator employed a research assistant for this purpose.
The researcher explained the project to potential participants in each of the units of the selected hospitals, in the presence of an independent person. The independent person obtained informed consent from possible participants after a minimum of 24 hours allowing the participants adequate time to make an informed decision on their willingness to participate.
Afterwards participants were provided with a survey, an NWU-branded pen, a sachet of coffee and a leaflet for entry into a lucky draw. The participant had 2 days to complete the survey, at a time and place that was convenient for them. After participants completed the survey, they sealed it in a C4 envelope provided and placed it in a box located in the mediator’s office. The researcher collected the boxes after one week.
Data analysis
Data was analysed using the computer software program SPSS version 27 [55]. Descriptive statistics were used to present the demographic data of the participants. Confirmatory factor analysis, and Cronbach’s alpha were conducted to ensure the validity and reliability of the scales. Factor scores were derived by calculating the means of the questions within each factor. The correlations between workplace relationships, quality of care, patient safety, and adverse events were conducted using Spearman’s rank-order correlations. Independent t-tests, ANOVAs, and Spearman’s rank-order correlations were conducted to determine the association between participant demographics and workplace relationships. Cohen’s d effect sizes were used to determine the importance of the differences in means, where 0.2 is considered as small, 0.5 as medium, and 0.8 as large. The magnitude of correlations is regarded as the effect size, where 0.1 is considered as small, 0.3 as medium and 0.5 as large. The effect size is independent of sample size and is a measure of practical significance.
Ethics
This study received ethical approval from the NWU-HREC (NWU-000270–21-A1), and the NWP DoH, with goodwill consent from the three participating hospitals. The ethical considerations of the study adhere to the principles of ethics as stipulated by the DoH guidelines on ethics in health research [56]. Participants were informed that participation in this study is voluntary, and they may withdraw from the study at any time. Participant confidentiality was ensured through participants completing the surveys anonymously, with no direct or indirect identifiers, e.g., date of birth or unique personal characteristics included in the survey. Unique codes, known only by the researcher were used to code surveys to enable data analysis at hospital and unit level.
Results
Demographic details of nurse participants and units
A total of 542 surveys were distributed, of which 236 were returned, with a response rate of 43.5%. The total number of participants across all sectors was 236. The majority of the participants were female (n = 193; 81.8%), in the category of registered nurses and/or midwives (n = 135; 57.2%) and working in medical wards (n = 47; 20.0%). There were 19.5% (n = 46) with a bachelor’s degree in nursing, and 21.6% (n = 51) with specialty training, mostly at the level of a postgraduate diploma/degree (n = 49; 20.7%). Most of the nurses were permanently employed (n = 202; 86%). The majority had occasional (n = 71; 30%) and routine contact with COVID-19 patients (n = 86; 36.4%). The most common perpetrators of workplace violence were supervisors/managers (n = 79; 33.4%), followed by nursing colleagues (n = 62; 26.2%). On average the nurses were 40.4 years of age (SD 10.1), had worked as a nurse in any category for an average of 12.6 years (SD 10.0), and had spent 9.5 years (SD 8.9) in the specific hospital (see Table 1).
Descriptive statistics
The descriptive statistics and the reliability of the instruments used are shown below in Table 2. The subscales of the NAQ-R and PES-NWI were considered reliable. Only selected items of the AHRQ were included, and therefore an exploratory factor analysis was conducted. The pattern matrix is divided into two subscales with regard to the selected items of the AHRQ survey: 1) communication (We discuss ways to prevent errors from happening again; Regularly review work processes to determine if changes are needed to improve patient safety; The actions of the hospital management show that patient safety is a top priority; Staff feels free to question the decisions or actions of those in authority; Staff speak up if they see something that may negatively impact patient care); and 2) staffing and response to errors (Staff feel that their mistakes are held against them; There is a lack of support for staff involved in patient safety errors; Relies too much on temporary, float or agency staff), with a Kaiser-Meyer-Olkin measure of sampling adequacy of 0.729, and 49.89% of the total variance explained. However, the staffing and response to errors were not reliable and were thus reported as single items.
On average, participants experience more personal workplace violence (M=1.61; SD 0.80) than physical workplace violence (M=1.51; SD 0.88). Regarding the PES-NWI, nurse manager ability, leadership, and support of nurses (M=2.45; SD 0.79) is below the mean of 2.5, indicating that it is not experienced as contributing towards a positive practice environment, although collegial nurse-physician relationships were experienced positively (M=2.86; SD 0.71). Regarding quality of care, nurses were only somewhat confident that patients and their caregivers could manage their care after discharge (M=2.52; SD 0.88), while other items such as quality of care delivered to patients (M=2.12; SD 0.78) and recommending your workplace to family and friends needing healthcare (M= 2.02; SD 0.96) were experienced positively. Patient safety issues included nurses being only somewhat confident that management would act to resolve problems in patient care that nurses identified (M=2.59; SD 0.99) and being neutral with regard to relying too much on temporary, float, or agency staff (M=3.28; SD 1.42), staff feeling that their mistakes are held against them (M=2.53; SD 1.27), and lack of support for staff involved in patient safety errors (M=2.71; SD 1.32). Overall grades on patient safety (M=2.23; SD 1.01) and the communication subscales (M=2.34; SD 0.85) were experienced positively. With regard to adverse events, healthcare-associated infections occurred most often (M=1.92; SD 0.96), followed by medication errors (M=1.80; SD 1.01). Patient falls after admission (M=1.45; SD 0.72) and treatment procedures resulting in unintended harm (M=1.66; SD 0.84) were less frequent.
Correlations between main study variables
In Table 3 (see below) the correlations between the main study variables are described. The PES-NWI: Nurse manager ability, leadership, and support of nurses had the most effect on quality of care and patient safety, with mostly medium to large, statistically significant negative correlations, especially the item management will act to resolve problems in patient care (r = -0.498; p = 0.000) and communication errors (r = -0.467; p = 0.000). It also had small to medium, statistically significant positive correlations with staff feeling that their mistakes are held against them (r = 0.320; p = 0.000), and relying too much on temporary, float, or agency staff (r = 0.138; p = 0.000). The PES-NWI: Collegial nurse-physician relationships had the most impact on adverse events, especially medication errors (r = -0.303; p = 0.000) and healthcare-associated infections (r = -0.299; p = 0.000), with medium, statistically significant negative correlations, and likewise with patient falls after admission (r = -0.244; p = 0.000).
In contrast, personal workplace violence had small to medium, statistically significant positive correlations with most aspects of quality of care and patient safety, especially regarding whether the nurses would recommend where they work to family and friends needing healthcare (r=0.345; p=0.000), lack of support for staff involved in patient safety errors (r=-0.342; p=0.000) and communication errors (r=0.340; p=0.000). This was also the case for adverse events, especially medication errors (r=0.305; p=0.000) and healthcare-associated infections (r=0.283; p=0.000).
Physical workplace violence had mostly small but also a few medium correlations with quality of care and patient safety, especially in terms of communication errors (r=0.268; p=0.000) and whether the nurses would recommend where they work to family and friends needing healthcare (r=0.257; p=0.000). Physical workplace violence also had mostly small with a few medium correlations with adverse events, especially healthcare-associated infections (r=0.288; p=0.000) and treatment procedures resulting in unintended harm (r=0.218; p=0.000).
Association between demographic profile and workplace relationships
There was a medium association between having specialty training and personal workplace violence (d = 0.66; p = 0.000) and a small association between physical workplace violence (d = 0.37; p = 0.020), with those with specialty training having a higher mean than those without ([Personal workplace violence] M = 2.00; M = 1.50; [Physical workplace violence] M = 1.77; M = 1.44). There was a small association with PES-NWI Leadership, management, and support of nurses (d = 0.32; p = 0.049), with those without specialty training rating that aspect of the practice environment higher (M = 2.51) than those without specialty training (M = 2.26). There was a medium association with PES-NWI: Leadership, management, and support of nurses and nurse category, with enrolled nursing auxiliaries rating that aspect of the practice environment higher than all of the other categories of nurses (d = 0.44–0.50; p = 0.031), with enrolled nursing auxiliaries experiencing this more positively than registered nurses, community service nurses and enrolled nurses and/or midwives (M = 2.72 [enrolled nursing auxiliaries]; M = 2.36 [registered nurses and/or midwives]; M = 2.36 [community service nurses] and M = 2.39 [enrolled nurses). There was a small to medium association between PES-NWI: Collegial nurse-physician relations and routinely caring for COVID-19 patients (d = 0.22–0.62; p = 0.028), in that the more that nurses worked with COVID-19 patients, the more positively they experienced collegial nurse-physician relations. There was no association with gender, having a Bachelor’s degree, hospital where employed, employment status, specialty of the unit, level of specialty training, age, years worked as a nurse or years worked in the specific hospital.
Discussion
The most common perpetrators of workplace violence were supervisors/managers, followed by nursing colleagues. On average, participants experience more personal workplace violence than physical workplace violence. A higher incidence of workplace violence was associated with specialty training. Personal workplace violence had more effect on quality of care, patient safety, and adverse events than physical workplace violence, both having the most impact on recommending their place of work to family and friends needing healthcare, communication errors, and lack of support for staff involved in patient safety errors. Overall, nurse managers’ ability, leadership, and support were not experienced as positively contributing to the practice environment and had the most effect on quality of care and patient safety, especially with regard to management resolving problems in patient care, communication errors, and recommending their place of work to family and friends needing healthcare. Collegial nurse-physician relationships were experienced as contributing positively to the practice environment, and after nurse managers’ ability, leadership, and support, these had the most effect on quality of care and patient safety, and specifically on adverse events, namely medication errors, patient falls after admission and healthcare-associated infections. The nursing category was linked to perceptions of leadership, management, and support of nurses. Finally, increased exposure to COVID-19 patients resulted in nurses having more positive perceptions of collegial nurse-physician relationships.
Leadership, management, and support of nurses were not perceived to be present in the practice environment; in addition, it was also perceived that managers/supervisors were most frequently the perpetrators of workplace violence. National [25,57]; and international [58,59] studies have similarly found that managers/supervisors are commonly the perpetrators of workplace violence. It is apparent that managers/supervisors influence nurses’ exposure to workplace violence in both direct and indirect ways. Direct factors include using workplace violence as a disciplinary measure, to sustain hierarchical work practices, top-down driven leadership, leadership voids, and lack of interpersonal skills; while indirect factors include the normalization of workplace violence, indifference to ethical issues related to bullying, and/or a lack of managerial abilities to address the phenomenon [60]. A systematic review concluded that when nurse managers practice moral leadership and attentively address nurses’ individual concerns while maintaining their privacy, they are less likely to perpetrate workplace violence and reduce its occurrence. When nurses practice authoritarian leadership the likelihood of workplace violence increases [61]. Furthermore, when levels of stress increase like they did during the pandemic, those with greater perceived power often express more aggression and those who perceive themselves as less powerful often believe that their only option is to submit and abide [22].
This is a problematic finding, as it is also leadership, management, and support of nurses that had the most impact on nurse-perceived quality of care and patient safety. It is well established from systematic reviews on nurse leadership [12,13] that leadership, management, and support of nurses have an impact on nurse, patient, and system outcomes. However, of all of the studies included in the systematic reviews, only two were from Africa [62], and these focused only on nurse outcomes. Authors agree that managers/supervisors have both a direct and indirect impact on patient outcomes: directly due to the fact that they make decisions about human resource variables (e.g., staffing and resources, overtime) that are connected to patient care outcomes [13], and indirectly through the health and wellbeing of nursing staff that impact on work performance (e.g., job satisfaction, turnover intention) [63], as well as through the quality standards of the organization (e.g., consultation and involvement of nurses in decision making, education, and training) [64].
According to the systematic review of Wong et al. [13] leadership directly impacts patient outcomes regarding five aspects: patient satisfaction; patient mortality; adverse events (behaviour problems, restraint use, complications of immobility, fractures, medication errors, patient falls, catheter use, pressure ulcers, inadequate pain management, and hospital-acquired infections); complications; and patient healthcare utilisation. These patient outcomes include patient reports, nurse-perceived assessments, and actual recorded incidents, all of which are considered reliable forms of measuring patient outcomes, especially nurse-perceived assessments [65].
A focus on leadership development, as well as the recruitment and retention of relationally orientated leaders, are therefore crucial to improving patient, nurse, and organizational outcomes. A systematic review on leadership education interventions [12] has shown that although these interventions differ widely with regard to programme content, length, and delivery, most showed significant increases in self-reported leadership and observed leadership practices. However, such interventions must be evidence-based, theoretically grounded, and incorporate cultural, social, and the institution’s contextual factors [66].
Collegial nurse-physician relationships were experienced as contributing positively to the practice environment, and after nurse managers’ ability, leadership, and support, this aspect had the most effect on nurse-perceived quality of care and patient safety, especially on the incidence of adverse events. This is in accordance with the international literature on the topic, where collegial nurse workplace relationships have positive effects on quality of care and patient safety, including patient satisfaction [67], recorded incidents of patient outcomes [10] and nurse-perceived assessments [6–8]. An interesting finding from this study is that increased exposure to COVID-19 patients resulted in nurses having improved perceptions of physician-nurse collaboration. This may point to the fact that there was better collaboration and communication between nurses and physicians when caring for COVID-19 patients, due to the sheer volume and changes in the workplace environment related to the COVID-19 pandemic. This was also confirmed by Matusov et al. [68], who reported increased team interdependence and appreciation among nurses and physicians during the COVID-19 pandemic.
Personal workplace violence was experienced more than physical workplace violence, and this finding is concurrent with those of international studies [69]. In Africa, studies have reported workplace violence rates ranging from as low as 26.7% in Ethiopia [70] to as high as 85% in South Africa [71]. In all cases, the most common type of workplace violence was found to be non-physical violence [58]. Also, personal workplace violence had a greater effect than physical workplace violence on nurse-perceived quality of care, patient safety, and adverse events. Interestingly, workplace violence had the most effect on recommending their place of work to family and friends needing healthcare, communication errors, and lack of support for staff involved in patient safety errors. In a systematic review conducted by Lanctôt and Guay [42], the outcomes of workplace violence include seven categories of consequences: physical, psychological, emotional, work functioning, relationship with patients/quality of care, social/general, and financial stress [42]. Additionally, Lanctôt and Guay [42] found that among the selected articles in their review, only ten of them addressed issues related to relationships with clients or quality of care [72], with most articles indicating a reduction in quality of care and patient safety. Again, workplace violence education interventions are linked to a decrease in workplace violence, due to the fact that identification of incidents is improved, reporting increases, and therefore situations can be addressed and dealt with; it also improves communication, clarification of roles and responsibilities between professionals, and knowledge of how to address workplace violence incidents [73].
Specialization level was linked to an increased perception of workplace violence, and this was also found by international studies [74]. Interestingly, it was not linked to specialty units, as found in other South African studies [75]. Also, perceptions of the practice environment with regard to leadership, management, and support of nurses were linked to nursing categories, with lower-ranked categories experiencing this subscale more positively than higher-ranked categories. It is generally found in regional and national literature that lower-ranked categories rate the practice environment, quality of care, and patient safety more positively than their higher-ranked counterparts [76]. The common argument for this is that education and training bring greater knowledge and awareness of the practice environment, quality of care, and patient safety.
Limitations
Nurse-nurse relationships were only measured through the presence of workplace violence, and not collegial or positive relationships; this is a limitation considering that in all instances both nurse-physician and nurse-manager collegial or positive relationships had a greater impact on quality of care, patient safety, and adverse events than workplace violence or negative relationships did. There are two main instruments used to measure collegiality: a 72-item survey titled Nurse-Nurse Collaboration Scale (NNCS), with reliability scores of 0.66–0.99 [77], and a 54-item survey titled Colleague Solidarity of Nurses Scale (CSNS), with reliability scores of 0.63–0.80 [78]. Due to the extent of the scales, it was decided not to include these surveys in the study, and the PES-NWI does not dedicate a portion to nurse-nurse collegial relationships. Further study of workplace relationships is necessary, considering their implications for nurses, patients and organisations. There is also a specific need for studies addressing the management of workplace violence episodes, especially violence perpetrated by co-workers or patients, visitors and patient family members. As well as studies that assess the efficacy of associated measures. This study has some limitations, including its reliance on cross-sectional data, which makes it difficult to draw a conclusion on the causal relationship between collegial relationships and care quality, patient safety, and adverse events. The results of this study, which only included hospitals from the NWP of South Africa, cannot be applied to other contexts. In addition, the province’s hospitals were purposefully sampled; nonetheless, despite the sampling’s vast participant pool, it was not a probability sample.
Conclusion
This study showed that collegial relationships or positive relationships had a greater impact on quality of care, patient safety and adverse events than workplace violence or negative relationships did. The most important collegial relationship was the nurse-manager relationship, as it had the most impact on quality of care and patient safety; this is problematic as quality of care and patient safety were not perceived as being present in the practice environment of the study participants, as well as the fact that nurse managers/supervisors were experienced as being the greatest perpetrators of workplace violence. Nurse-physician relationships had an impact on quality of care, patient safety, and especially adverse events, indicating that improved nurse-physician relationships improved perceptions of quality of care, patient safety, and adverse events. Also, increased care of COVID-19 patients improved nurses’ perceptions of the nurse-physician collegial relationship, indicating increased collaboration and communication between the professions. Personal workplace violence had a greater effect on quality of care, patient safety, and adverse events than physical workplace violence.
Relevance to clinical practice
It is clear from the findings that urgent attention must be directed towards leadership development, as well as to the recruitment and retention of relationally orientated leaders, as this aspect is perceived negatively in the participants’ current practice environment, even though it is most highly correlated with quality of care and patient safety. It would seem that the best method to improve leadership practice is through leadership education interventions; these should be evidence-based, theoretically grounded, and based on the local culture, social practices, and context, as these show the most improvement in leadership practices. Researchers especially recommend the combination of experiential learning, such as mentorship and coaching, and action learning [12]. Although workplace violence or negative relationships also impacted on quality of care, patient safety, and adverse events, it appeared from the findings that focusing on the development of collegial or positive relationships would have a greater impact not only on patient outcomes but also on nurse- and organisation outcomes.
‘What does this paper contribute to the wider global clinical community?’
- Positive workplace relationships or collegiality seemed to have a greater impact on nurse-perceived quality of care and patient safety than workplace violence.
- Of all relationships, nurse-manager’s/supervisors’ relationships had the greatest impact on nurse-perceived quality of care and patient safety.
- Nurses’ perceptions of the nurse-physician relationship improved as their nursing exposure to COVID-19 patients increased.
References
- 1. Sias PM. Workplace relationship quality and employee information experiences. Commun Stud. 2005;56(4):375–95.
- 2. Colbert A, Yee N, George G. The Digital Workforce and the Workplace of the Future. AMJ. 2016;59(3):731–9.
- 3.
Menard KI. Collegiality, the nursing practice environment, and missed nursing care. Doctoral dissertation, The University of Wisconsin-Milwaukee.
- 4.
World Health Organization. Framework guidelines for addressing workplace violence in the health sector. Geneva, Switzerland: International Labour Office. 2002.
- 5. McInnes S, Peters K, Bonney A, Halcomb E. An integrative review of facilitators and barriers influencing collaboration and teamwork between general practitioners and nurses working in general practice. J Adv Nurs. 2015;71(9):1973–85. pmid:25731727
- 6. Wynn BSN, Holden C. Nurse Practitioner and Physician Incivility in Healthcare. American Research Journal of Nursing, 2020; 5(1):1–2.
- 7. Laschinger HKS. Impact of workplace mistreatment on patient safety risk and nurse-assessed patient outcomes. J Nurs Adm. 2014;44(5):284–90. pmid:24759201
- 8. Norful AA, Ye S, Van der-Biezen M, Poghosyan L. Nurse Practitioner-Physician Comanagement of Patients in Primary Care. Policy Polit Nurs Pract. 2018;19(3–4):82–90. pmid:30517047
- 9. Clausen C, Lavoie-Tremblay M, Purden M, Lamothe L, Ezer H, McVey L. Intentional partnering: a grounded theory study on developing effective partnerships among nurse and physician managers as they co-lead in an evolving healthcare system. J Adv Nurs. 2017;73(9):2156–66. pmid:28251675
- 10. Goda R, Aref M, Abdel-Razek M. Perception of nurses and physicians about importance of their collaboration in the work. Minia Sci Nurs J. 2018;3(1):9–15.
- 11. Tervo-Heikkinen T, Kvist T, Partanen P, Vehviläinen-Julkunen K, Aalto P. Patient satisfaction as a positive nursing outcome. J Nurs Care Qual. 2008;23(1):58–65. pmid:18281877
- 12. Cummings GG, Tate K, Lee S, Wong CA, Paananen T, Micaroni SP, et al. Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. Int J Nurs Stud. 2018;85:19–60.
- 13. Wong CA, Cummings GG, Ducharme L. The relationship between nursing leadership and patient outcomes: a systematic review update. J Nurs Manag. 2013;21(5):709–24. pmid:23865924
- 14. McCay R, Lyles A, Larkey L. Nurse leadership style, nurse satisfaction, and patient satisfaction: a systematic review. J Nurs Care Qual. 2018;33(4):361–7.
- 15. Capuano T, Bokovoy J, Hitchings K, Houser J. Use of a validated model to evaluate the impact of the work environment on outcomes at a magnet hospital. Health Care Manage Rev. 2005;30(3):229–36. pmid:16093889
- 16. Anderson RA, Issel LM, McDaniel RR Jr. Nursing homes as complex adaptive systems: relationship between management practice and resident outcomes. Nurs Res. 2003;52(1):12–21. pmid:12552171
- 17. Paquet C, Yudin MH, Society of Obstetricians and Gynaecologists of Canada. Toxoplasmosis in pregnancy: prevention, screening, and treatment. J Obstet Gynaecol Can. 2013;35(1):78–81. pmid:23343802
- 18. Taylor JA, Dominici F, Agnew J, Gerwin D, Morlock L, Miller MR. Do nurse and patient injuries share common antecedents? An analysis of associations with safety climate and working conditions. BMJ Qual Saf. 2012;21(2):101–11. pmid:22016377
- 19. Sahay A, Hutchinson M, East L. Exploring the influence of workplace supports and relationships on safe medication practice: A pilot study of Australian graduate nurses. Nurse Educ Today. 2015;35(5):e21-6. pmid:25680830
- 20. Allen BC, Holland P, Reynolds R. The effect of bullying on burnout in nurses: the moderating role of psychological detachment. J Adv Nurs. 2015;71(2):381–90. pmid:25082131
- 21. Oludare TR, Kotronoulas G. Determinants and consequences of workplace violence against hospital-based nurses: a rapid review and synthesis of international evidence. Nurs Manag. 2023;30(2).
- 22. Grenny J, McNamara SA, Battie R. Vertical Violence & Workplace Bullying. 2020. Available from: https://ortoday.com/vertical-violence-workplace-bullying/
- 23. Hinchberger PA. Violence against female student nurses in the workplace. Nurs Forum. 2009;44(1):37–46. pmid:19187052
- 24. Park M, Cho S-H, Hong H-J. Prevalence and perpetrators of workplace violence by nursing unit and the relationship between violence and the perceived work environment. J Nurs Scholarsh. 2015;47(1):87–95. pmid:25352254
- 25.
Rust H. Horizontal violence among nurses working in intensive care environments within the private healthcare sector. Stellenbosch: Stellenbosch University.
- 26. Abbas RA, Selim SF. Workplace violence: a survey of diagnostic radiographers in Ismailia governorate hospitals, Egypt. J Am Sci. 2011;7(6):1049–58.
- 27. Fallahi Khoshknab M, Oskouie F, Najafi F, Ghazanfari N, Tamizi Z, Ahmadvand H. Psychological violence in the health care settings in iran: a cross-sectional study. Nurs Midwifery Stud. 2015;4(1):e24320. pmid:25830157
- 28. Mobaraki A, Aladah R, Alahmadi R, Almuzini T, Sharif L. Prevalence of workplace violence against nurses working in hospitals: a literature review. Am J Nurs. 2020;9(2):84–90.
- 29. Kim S, Mayer C, Jones CB. Relationships between nurses’ experiences of workplace violence, emotional exhaustion and patient safety. J Res Nurs. 2021;26(1–2):35–46. pmid:35251222
- 30. Boev C, Xia Y. Nurse-physician collaboration and hospital-acquired infections in critical care. Crit Care Nurse. 2015;35(2):66–72. pmid:25834009
- 31. Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34(8):464–71. pmid:18714748
- 32. Manojlovich M, DeCicco B. Healthy work environments, nurse-physician communication, and patients’ outcomes. Am J Crit Care. 2007;16(6):536–43.
- 33. Stalpers D, de Brouwer BJM, Kaljouw MJ, Schuurmans MJ. Associations between characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals: a systematic review of literature. Int J Nurs Stud. 2015;52(4):817–35. pmid:25655351
- 34. Ekpor E, Kobiah E, Akyirem S. Prevalence and predictors of workplace violence against nurses in Africa: A systematic review and meta-analysis. Health Sci Rep. 2024;7(4):e2068. pmid:38650728
- 35. Sabone M, Mazonde P, Cainelli F, Maitshoko M, Joseph R, Shayo J, et al. Everyday ethical challenges of nurse-physician collaboration. Nurs Ethics. 2020;27(1):206–20. pmid:31014168
- 36. Folorunso TR, Folorunso AE. Nurse-physician collaboration: a comparison of attitudes of nurses and physicians in Nigerian tertiary hospital care settings. West Afr J Med. 2020;37(7):776–82.
- 37. Jemal M, Kure MA, Gobena T, Geda B. Nurse-Physician Communication in Patient Care and Associated Factors in Public Hospitals of Harari Regional State and Dire-Dawa City Administration, Eastern Ethiopia: A Multicenter-Mixed Methods Study. J Multidiscip Healthc. 2021;14:2315–31. pmid:34475760
- 38. Mawuena EK, Mannion R, Adu-Aryee NA, Adzei FA, Amoakwa EK, Twumasi E. Professional disrespect between doctors and nurses: implications for voicing concerns about threats to patient safety. J Health Organ Manag. 2024;38(7):1009–25.
- 39. Nkadimeng M, Engelbrecht A, Rajan S. Workplace violence in three public sector emergency departments, Gauteng, South Africa: A cross-sectional survey. Afr J Emerg Med. 2024;14(4):252–7. pmid:39291136
- 40. Thandavhathu T, Maluleke M, Raliphaswa N, Rangwaneni M, Masutha T, Lavhelani N, et al. Patient aggression experienced by professional nurses in acute psychiatric ward: South Africa. Health SA Gesondheid. 2024;29:2158.
- 41. Lekalakala-Mokgele E, Goosen S. Bullying amongst nurses working for a private hospital group in eight provinces of South Africa. Gender Behav. 2022;20(3):19572–93.
- 42. Lanctôt N, Guay S. The aftermath of workplace violence among healthcare workers: A systematic literature review of the consequences. Aggression and Violent Behavior. 2014;19(5):492–501.
- 43. de Villiers K. Bridging the health inequality gap: an examination of South Africa’s social innovation in health landscape. Infect Dis Poverty. 2021;10(1):19. pmid:33648585
- 44. Zangaro GA, Jones K. Practice Environment Scale of the Nursing Work Index: A Reliability Generalization Meta-Analysis. West J Nurs Res. 2019;41(11):1658–84. pmid:30667349
- 45. Swiger PA, Patrician PA, Miltner RS, Raju D, Breckenridge-Sproat S, Loan LA. The practice environment scale of the nursing work index: An updated review and recommendations for use. Int J Nurs Stud. 2017;74:76–84.
- 46. Lake ET. Development of the practice environment scale of the Nursing Work Index. Res Nurs Health. 2002;25(3):176–88. pmid:12015780
- 47.
Einarsen S, Hoel H. The validity and development of the Revised Negative Acts Questionnaire. In European Congress of Work and Organizational Psychology, Praga 2001 May.
- 48. Liu K, You L-M, Chen S-X, Hao Y-T, Zhu X-W, Zhang L-F, et al. The relationship between hospital work environment and nurse outcomes in Guangdong, China: a nurse questionnaire survey. J Clin Nurs. 2012;21(9–10):1476–85. pmid:22380003
- 49. Sermeus W, Aiken LH, Van den Heede K, Rafferty AM, Griffiths P, Moreno-Casbas MT, et al. Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology. BMC Nurs. 2011;10:6. pmid:21501487
- 50. Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Sermeus W, RN4CAST Consortium. Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. Int J Nurs Stud. 2013;50(2):143–53. pmid:23254247
- 51. Coetzee SK, Klopper HC, Ellis SM, Aiken LH. A tale of two systems--nurses practice environment, well being, perceived quality of care and patient safety in private and public hospitals in South Africa: a questionnaire survey. Int J Nurs Stud. 2013;50(2):162–73. pmid:23218020
- 52. Lake ET, Hallowell SG, Kutney-Lee A, Hatfield LA, Del Guidice M, Boxer BA, et al. Higher Quality of Care and Patient Safety Associated With Better NICU Work Environments. J Nurs Care Qual. 2016;31(1):24–32. pmid:26262450
- 53.
Loehlin JC. Latent variable models: An introduction to factor, path, and structural equation analysis. Psychology Press. 2004.
- 54.
Ullman B. On Bayesian estimation of a binomial parameter. University of Michigan. 1969.
- 55.
SPSS Inc., IBM SPSS Statistics, 23, Release 23.0.0, Copyright© IBM Corporation and its licensors. 2021.
- 56.
Department of Health. Ethics in health research principles, processes and structures. 2nd ed. ed. Department of Health. 2015.
- 57.
Goosen S, Mokoena J, Lekalakala-Mokgele S. A model to manage workplace bullying between nurses at a private hospital group in South Africa. Sefako Makgatho Health Sciences University.
- 58. Boafo IM, Hancock P, Gringart E. Sources, incidence and effects of non-physical workplace violence against nurses in Ghana. Nurs Open. 2016;3(2):99–109. pmid:27708820
- 59. Nwaneri AC, Onoka AC, Onoka CA. Workplace bullying among nurses working in tertiary hospitals in Enugu, southeast Nigeria: Implications for health workers and job performance. JNEP. 2016;7(2).
- 60. Olender LD. Nurse manager caring and workplace bullying in nursing: The relationship between staff nurses’ perceptions of nurse manager caring behaviors and their perception of exposure to workplace bullying within multiple healthcare settings. J Nurs Manag. 2023;60(1):1–10.
- 61. Peng X, Zeng Q, Yang D, Cheng Y, Zhao S, Song J, et al. Association of nurse managers’ paternalistic leadership and nurses’ perceived workplace bullying: The mediating effect of organizational climate. J Adv Nurs. 2024;80(8):3226–35. pmid:38382898
- 62. Sojane JS, Klopper HC, Coetzee SK. Leadership, job satisfaction and intention to leave among registered nurses in the North West and Free State provinces of South Africa. Curationis. 2016;39(1):1–0.
- 63. Cullati S, Bochatay N, Maître F, Laroche T, Muller-Juge V, Blondon K, et al. When team conflicts threaten quality of care: a study of health care professionals’ experiences and perceptions. Mayo Clin Proc Innov Qual Outcomes. 2019;3(1):43–51.
- 64. Magobe N, Ally H, Mogakwe L. Recommendations to facilitate managers’ compliance with quality standards at primary health care clinics. Curationis. 2019;42(1):1–8.
- 65. Tvedt C, Sjetne I, Helgeland J, Bukholm G. A cross-sectional study to identify organisational processes associated with nurse-reported quality and patient safety. BMJ Open. 2012;2(6):e001967. Abbas R, Selim S. Workplace violence: A survey of diagnostic radiographers in Ismailia governorate hospitals, Egypt. J Am Sci. 2011;7(6):1049–58.
- 66. Galuska LA. Education as a springboard for transformational leadership development: listening to the voices of nurses. J Contin Educ Nurs. 2014;45(2):67–76. pmid:24624446
- 67. Larrabee JH, Ostrow CL, Withrow ML, Janney MA, Hobbs GR Jr, Burant C. Predictors of patient satisfaction with inpatient hospital nursing care. Res Nurs Health. 2004;27(4):254–68. pmid:15264264
- 68. Matusov Y, Matthews A, Rue M, Sheffield L, Pedraza IF. Perception of interdisciplinary collaboration between ICU nurses and resident physicians during the COVID-19 pandemic. J Interprof Educ Pract. 2022;27:100501.
- 69. Pandey M, Bhandari TR, Dangal G. Workplace Violence and its Associated Factors among Nurses. J Nepal Health Res Counc. 2018;15(3):235–41. pmid:29353895
- 70.
Oljira S. Assessment of workplace violence against nurses working in emergency department of referral public hospitals in Addis Ababa, Ethiopia. Addis Ababa University.
- 71. Madzhadzhi LP, Akinsola HA, Mabunda J, Oni HT. Workplace violence against nurses: Vhembe district hospitals, South Africa. Res Theory Nurs Pract. 2017;31(1):28–38.
- 72. Ünsal Atan S, Baysan Arabaci L, Sirin A, Isler A, Donmez S, Unsal Guler M, et al. Violence experienced by nurses at six university hospitals in Turkey. J Psychiatr Ment Health Nurs. 2013;20(10):882–9. pmid:23216948
- 73. Rutherford DE, Gillespie GL, Smith CR. Interventions against bullying of prelicensure students and nursing professionals: An integrative review. Nurs Forum. 2019;54(1):84–90. pmid:30380142
- 74. Ming J-L, Huang H-M, Hung S-P, Chang C-I, Hsu Y-S, Tzeng Y-M, et al. Using Simulation Training to Promote Nurses’ Effective Handling of Workplace Violence: A Quasi-Experimental Study. Int J Environ Res Public Health. 2019;16(19):3648. pmid:31569382
- 75. Khamisa N, Peltzer K, Ilic D, Oldenburg B. Effect of personal and work stress on burnout, job satisfaction and general health of hospital nurses in South Africa. Health SA Gesondheid. 2017;22:252–8.
- 76. Alhassan A, Fuseini A, Musah A. Knowledge of the glasgow coma scale among nurses in a tertiary hospital in ghana. Nurs Res Pract. 2019.
- 77. Dougherty MB, Larson EL. The nurse-nurse collaboration scale. J Nurs Adm. 2010;40(1):17–25. pmid:20010373
- 78. Uslusoy EC, Alpar SE. Developing scale for colleague solidarity among nurses in Turkey. Int J Nurs Pract. 2013;19(1):101–7. pmid:23432896