The Relationship between Nurses' Work environment, Resilience, and Nurse and Patient Outcomes in Primary Healthcare Centers Serving Syrian Refugees: A Secondary Data Analysis

Abstract

The Syrian war has displaced over 13 million Syrians - 6.6 million internally, and 5.5 million into neighboring countries, namely Lebanon, Jordan, Iraq, and Turkey. By the end of 2015, the number of Syrian refugees (SR) in Lebanon had reached 1.5 million, resulting in a 30% increase in the country’s pre-crisis population, and registering the highest per capita concentration of refugees in the world since 1980. The influx of SRs increased healthcare demand. Even though the primary healthcare network has absorbed a huge number of Syrian beneficiaries, the impact of this increased demand on primary healthcare nurses – who are at the frontlines of health care delivery, has not been adequately studied. Hence, the overall aim of this thesis is to explore the perspective of registered nurses working in primary healthcare centers in Lebanon on refugees’ healthcare.

Purpose: The purpose of this study is to explore the relationship between the psychosocial work environment factors and their impact on nurses’ related outcomes (perceived physical and emotional health) and patient outcomes (perceived quality of care and implicit rationing of care), especially under the conditions of the increased healthcare demands created by the unexpected protracted Syrian refugees’ healthcare needs. Sample: In the original study, a convenience sample of 5,500 nurses who worked in acute care hospitals and primary healthcare centers was used. The inclusion criteria included registered nurses who were involved in direct patient care in hosting communities for at least one full month and worked at least 8 hours/ week on their respective unit or primary center. Exclusion criteria included registered nurses who were in academia and other industries, other professionals working in healthcare (nutritionists, physiotherapists, social workers) nursing students, nursing instructors, and volunteers and registered nurses who assumed managerial and administrative positions and were involved in indirect service. For the purpose of this study, only Lebanese nurses working in primary healthcare centers were selected. A total of 415 nurses serving in primary healthcare centers responded. Ethical Considerations: Before conducting the original study, the researchers obtained approval from the AUB Social and Behavioral Sciences Institutional Review Board (IRB). Before the questionnaires were sent to the nurses of the participating hospitals and primary healthcare centers, the approval to conduct the study was granted from ethical committees of the participating hospitals and the Primary Healthcare Department of the Lebanese Ministry of Public Health. Instruments: In addition to the nurses’ socio-demographic and work-related questions, seven other instruments were used to determine and measure the various work environment factors among nurses and its effect on the quality and rationing of care, as well as the impact of this work environment on nurses’ physical and emotional health, and to examine the association between resilience, and work environment and patient and nurse outcomes. The questionnaires used are: NASA Task Load Index (NASA-TLX) scale, Health Professions Stress Inventory (HPSI), Practice Environment Scale of the Nursing Work Index (PES-NWI) questionnaire, Safety Attitude Questionnaire (SAQ), 5-BERNCA subscales, Swiss Health Survey, Practice Environment Scale of the Nursing Work Index (PES-NWI) questionnaire, Maslach Burnout Inventory and the 14-item Resilience Scale Methods: Descriptive statistics were used to determine the characteristics of the study sample along with perceived psychosocial work environment factors (means, standard deviations, frequency, and percentage tables). Correlations and logistic regression to explore associations between each of the nurse-related outcomes (e.g. physical and emotional health) and quality of patient care indicators (e.g. implicit rationing of nursing care) with the different work environment factors were analyzed. Figure 2, represents the analysis framework for this study. All questions with Likert scale were presented as categories as well as average scores. Total scores were then calculated based on each domain. Bivariate spearman correlation was used to explore associations between quality of care with the different work environment factors such as workload, work stressors, nursing resources, leadership, teamwork and nursing resilience. Results: The results indicate that primary healthcare nurses in Lebanon experience above-average workloads and higher stress generated from workload. Generally, they considered the leadership approach exercised in their institutions to be effective, nursing resources to be adequate and the environment favorable for teamwork. The primary healthcare nurses also reported a high level of resilience, though more than half practiced rationing of care, but the majority considered that quality of care environment prevails in the institutions at which they serve. On the other hand, our results indicated that nurses’ physical health was moderately-to-strongly affected in most cases, while the majority reported having their emotional health influenced. Moreover, the quality of care foundation was found to be associated with teamwork, leadership, nursing resources and resilience, while it was negatively associated with lack of job preparation, emotional health and job conflict. As for the rationing of care, it was significantly associated with emotional health, workload stressors, job conflict, nursing resources and age. Our results also showed that the leadership and teamwork were the independent predictors for quality of care, physical health and job conflict were the significant predictors of emotional health, while emotional health was the significant predictor of physical health. Conclusion: This study was conducted in the midst of a political, social and economic upheaval. Data collection was finalized in December 2019, after which the COVID 19 pandemic and the August 4, 2020 Beirut Port explosion had their toll and added further distress on the Lebanese healthcare system. Subsequently, further exploration and support is needed to appraise and evaluate the stress generated from the overall collapse, to improve the quality of care provided in Lebanon