The impact of the nurse practice environment, workload, and professional support on job outcomes and standards of care at primary health care clinics in South Africa: A structural equation model approach.

Background: There is substantial evidence on the associations between a positive nurse practice environment and improved nurse and patient outcomes, as well as the factors that mediate these associations, in high-income countries and in hospital settings. The knowledge gaps in African and primary health care settings motivated this empirical study. Objective: The objective of this study was to examine the impact of the dimensions of the nurse practice environment, specifically human resource management, foundations for nursing care, and participation in clinic affairs, on job outcomes and standards of care. Design: A cross-sectional study was conducted between November 2021 and June 2022. Setting: 180 primary health care clinics in two South African provinces of Gauteng and North West. Participants: 665 nurses of all categories. Methods: A causal model was developed with pathways between the nurse practice environment dimensions and the outcomes of job satisfaction, intention to leave, and standards of care. A set of standardised instruments was used to measure the study variables. Using structural equation modelling, workload and professional support were tested as potential mediators between the nurse practice environment and the outcome variables. Results: The nurses scored the domain of foundations for nursing care 71.2 out of 100 on average, indicating high agreement, while the mean scores for nurses' participation in clinic affairs and human resources management were lower at 68.0 and 61.7 respectively. Although nurses expressed moderate satisfaction with professional support (67.7), they were less satisfied with their workload (52.2). The mean score of overall job satisfaction was moderate (58.9), with 53.8 % of the nurses reporting that they intended leaving the clinic where they were working. Thirty-six percent intended leaving the nursing profession, indicating low intention to stay. The final mediation model was judged to fit the data adequately based on goodness-of-fit indices, confirming that workload and professional support had a mediating role between the nurse practice environment dimensions of interest and both nurses' job outcomes and standards of care. Conclusions: We have highlighted the value of supportive practice environments, effective workload management, and enhanced professional support in improving nurses' job outcomes and satisfaction with standards of care. Improving nurses' practice environments at primary health care level may have a wide-ranging impact on the performance of the health system. Therefore, primary health care facility managers should ensure that workload is distributed equitably, professional support for nurses is enhanced, and the overall work environment is improved.