Nurses Perception of Practical Environment Relationship with Patient Satisfaction in Government Hospital Lahore

Introduction: The practical environment is described as the surrounding environments in which an employee works. Nurses practical environment control the delivery of nursing care. It is also important for nurses to develop a awareness about their own perception about working environment that have a positive impact on their performance and enhance the patients’ satisfaction. Objective: The objective of the study is to evaluate Nurses perception of practical environment relationship with patient satisfaction in Government Hospital Lahore. Methodology: Descriptive correlational study design used for study. Sixty nurses (n=60) and one thirty-three patients (n=133) were selected for study. The tool used for this study included a demographic data, Practice Environment Scale Nurse Work Index (PES-NWI) developed by Dr. Eileen Lake (2002), and 2 tool for patient satisfaction the Hospital Consumer Assessment of Healthcare Provides and Systems (HCAHPS) survey for patients developed by (Long, 2012) used for the study. Results: The results of the study showed the significance positive correlation between the nurse perception and patients’ satisfaction about practical environment. Conclusion: This study concludes that the nurse's perception about nurse practical environment and patient satisfaction from hospital environment show positive relationship. The perception of nurses and patients significantly correlated with practical environment. Healthy environment positive effect on patient satisfaction. Good nursing care enhance patient satisfaction by hospital environment and they will cure early.


Introduction
The environment influence on the nurses, patients, and organization outcomes where care is delivered to patient. When nurses have authority to work with responsibility, independently, and they have resources according to patient needs, then they can work more efficiently. They can maintain relationship with physician and communicate  (Swiger et al., 2017). Nurses performance in clinical environment impact on patient satisfaction. Nurse's education and work experience effect on their performance. (Siedlecki et al., 2014) . If patient is happy with the health care services which they received from their health care provider they feel satisfaction and their satisfaction will help to cure them early (Bawakid et al., 2017).
The nurses work environment is directly correlate to quality of patients' care. Care is effected when resources are not available or not working properly, inappropriate foundation of nurse for quality of care, insufficient staffing no administrative support, and poor involvement of nurses in hospital affairs. It is significant to identify the relationship among the nurse practice environment, and patient satisfaction. It is also important for modifiable aspects of the care environment, remove obstacles, and implement helpful strategies that will serve to improve patient outcomes. This is important to enhance nurse job satisfaction, teamwork, improve patient outcomes and patient satisfaction. (Bucco, 2015).
Nurses must participate in hospital activities for improvement of nurse's practices and reduce the mistakes and improve nurse's quality of care. Nurses discuss the daily problem with leader to improve clinical practices. Good nurse's practices improve the patient satisfaction. Relationship between clinical environment, nurse's perception and patient satisfaction, closely linked with the nursing quality of care in practical environment. Satisfied patients had better understanding with the treatment strategies. Patient satisfaction is an important factor for improving health and well-being of patients. (Brosey and March, 2015) .
Nurse's foundation for quality of care can improve the nurse's knowledge and skills by different educational programme. Nurses perception toward clinical environment can be improved by enhanced knowledge and skilled (Nageshwar et al., 2015). Clinical competence of graduated nurses in hospitals practical environment and other clinical areas is very important and focus of attention for professional associations, managers, government, and society. If Nurses has lack of clinical competence it may be significant cause of patient negligence. Clinical competence of nurses are important for patient satisfaction (Morgan et al., 2015).
Nurse manager improve practices in clinical environment by helping nurses to handle difficult situation in clinical environment. Nurses manager and leader help to manage conflict in wards with doctor and patient or patient relative. Nurses behavior with patient, in clinical setting communication skills, interpersonal relationship all modify by clinical manager by providing positive feedback and to provide effective clinical environment for learning during clinical practice. (Knight, 2018).
The practical setting is primarily designed to deliver patient care. The primary focus of the clinic practices to improve patient car. Nurses learn in practical setting that Patient care and safety are always the first priorities. Leadership skills and managers abilities are most important factor for appropriate performances of nurses for admitted and outdoor patient (Laschinger and Fida, 2015).
Nurses perceived that adequate staff and resources in clinical setting help to improve quality of care for the patient. Adequate staffing provides better care to patient, but inadequate staff and increase workload impact on their performance. (Brown, 2016).
Relationships among nurses and physicians are significant because both work together to improve the patient quality of care. Nurse's good relationship with physician improve patient care. In teamwork different aspect of patient care are discussed so advances strategies used to handle different situation. Better relationship in nurse and physician improve patient satisfaction and help to cure early. (Young, 2016). When nurses and physician work collaboratively the improve the patient and organization outcome. (Al-Hamdan et al., 2018).
When patient call the nurse if she listens them carefully it buildup the patient trust on health care provide. During patient stay in hospital nurses respect for patient and politeness enhance patient satisfaction which improve patient health status. (Al-Hussami et al., 2017).
Hospital environment impact on patient satisfaction. Neat clean environment helps in cure of patient, while uncleanliness cause of infection, in surgical wards patient wound become septic due unclean environment. (Ahmad et al., 2015).
In intensive care unit where patient unable to take care themselves, sick patients unable to go in washroom and nurses provide bedpan with the help of their attendant or work it build the relationship of trust between nurse and patient. Patient feel they are in safe hand and their health status improved (Ji and You, 2014).
Nurses provide information to patient on discharge regarding medication, and diet. They provide information to patient regarding wound care if patient have any surgical procedure. They guide the patient about how they can manage their health in home (Nates et al., 2016).

Objective of The Study
The objective of the study was to assess Nurses perception of practical environment relationship with patient satisfaction in Government Hospital Lahore

Problem Statement
It is observed that in many hospitals especially in Government hospitals there is no availability of proper practical environment for nurses to work appropriately and lack of proper resources to provide effective nursing care to patient during hospitalization. Due to insufficient educational programme there is lack of quality of care, so that patients are not satisfied with the nurse practical behaviors which affect health of patient. Nurses are working in different places where nursing leadership is not supportive or not available, number of patient are increasing, collegial relationships and communication are poor, and patients care not sufficient according to patient need. Views of patients are essential to improve the nurse's practices. This study goes to investigate work environment, nurses perception, and patients' satisfaction in Government Hospital, Lahore (Brown, 2016).

Significance of The Study
The significance of the study for nurse they identify the impact of practical environment. This study provides information, and enhances my knowledge about practical environment, Nurses perception, and patient satisfaction. This study inspires and improves the skills of registered nurses in clinical placement. The outcomes of study may give benefit for the registered nurses. It is also increased the personal and professional satisfaction of the nurses. Nurses will work to improve their practical environment which enhance the profession image and respect of the organization. The worth of this research is that it will help the policymakers and organization to offer the high-quality care for the patients. (Brown, 2016).

Literature Review
The current literature review supports the Kanter's Theory of organization and also support the study variables includes nurses' perception regarding practical environment and patients' satisfaction in the medical, surgical and Orthopedic out door patient. Multiple studies were conducted to assess the relationship between work environment nurses' perception and patients' satisfaction.
Bartlett Ellis (2016) conducted a study to evaluate the relationship between the nurse perception of the practice environment and satisfaction of patient. The study was conducted in Western New York four intensive care units of adult. Study findings shown that patients were more satisfied with nursing care when nurses were more satisfied with their work environment. Study finding reveal that when nurses perceived their practical environments negatively patients also less satisfied. Patient satisfaction study show that nurse kindliness and politeness had highest scores. There is significant relationship among nurse perception of the management and capability of the nurse manager and patient satisfaction. The study also reveals that insufficient staffing lack of resources impact on nurses' performance and patient quality of care A study carried out on the perception of the nurses and satisfaction of patients. Researcher used mixed method study quantitative and qualitative to assess the nurse's performance. For study purpose interviews was taken from patients in five different hospitals. Study finding reveal that only 30% patients response negatively about nurse caring performance and 70% patients were satisfied with nursing performance. Study reveal that due to lack of time, poor management improper hospital strategies, impact on proper care of nurses from the patients (Abdullah, 2017).
In Pakistan according to the Ayyub Rehan (2015), nurses' foundation for quality of care and good behaviors of nurses are essential to fulfill the need and expectation of patients' and satisfied the patient. According to study patients satisfied from nurses' quality of care was 54%, and patients who not satisfied with the nursing care were 46% (Rehan, 2015).
A study carried out to assess the relationship of nurse's managerial ability for improvement of patient care and satisfaction of patient. Study reveal that nurses' manger helps to handle the conflict and different challenges in ward and build the relationship of trust and satisfaction between nurses and patient. Leadership supports nurses in developing satisfactory practical environment by establishment of healthy relationships and effective communication between the nursing team and patients. Nurse's leadership emphasized on the development of nursing organization and the nursing team, for the improvement of professional practice and the quality of care which offer to patient, thus nurses improve the satisfaction of the patient.
A study conducted to find out the relationship between adequate staff and resources impact on patient satisfaction. The study finding reveal that increase workloads, inadequate nurse-patient ratios, long time for work and increased documentation cause stress, fatigue and disappointment in nurses and their levels of care. Adequate number of staff nurses and availability of proper resources positively effect on nurses performance and quality of patient care (Rivaz et al., 2017). Fox (2016) conducted a study on relationship between the nurses' performance impact on patient satisfaction on discharge. The findings of the study indicated that nurse participation in patient discharge planning enhance patient view regarding quality of care and minimize health hazards. A similar study carried out in Korea which compare nursing quality of performance, satisfaction of patient (Lee and Yom, 2007). For study purpose questionnaire was distributed to 282 nurses and 272 patients. Finding show that if nurses provide care to patient with respect, empathy, and responsibility it will improve patient health and minimize their stay in hospital.
A study designed to assess nurse physician relationship impact on patient health care improvement. It is reveal that nurses, physicians' good relationship during working in hospital enhance patient outcome. If their behavior is disruptive ,conflict will be occur in wards and reduce patient outcome (Clarke et al., 2018).

Setting
The research was conducted in Mayo hospitals Lahore.

Population
The registered Nurses of general surgical, medical, and orthopedic, and urology wards of Mayo hospital Lahore. And outdoor patient of these wards selected for the study.

Research Instrument
The tool used for this study included a demographic data, for the nurses perception toward practical environment the Practice Environment Scale for the Nurse Work Index (PES-NWI) developed by Dr. Eileen Lake (2002) , and 2 nd tool the Hospital Consumer Assessment of Healthcare Provides and Systems (HCAHPS) survey for patients developed by (Long, 2012) used for the study.

Data Gathering Procedure
Questionnaire were distributed between register nurses and outdoor patient of general surgical, medical, orthopedic, and urology department of Mayo Hospital Lahore. An adopted questionnaire regarding practical environment relationship with Nurses perception and patient's satisfaction level in Government Hospital, Lahore used for this study.

Data Analysis
Data was analyzed by using the Statistical Package of the social science (SPSS) 23 version, descriptive statistics such as frequencies, percentages. Pearson correlation was used to find relationship among variable.

Study Timeline
Study was conduct in Jan 2019 to May 2019.

Ethical Consideration
Permission was taken from the Principal Lahore School of Nursing, The University of Lahore. Permission will also take from chief Nursing superintendent of Mayo Hospital Lahore. Consent form also attached with questionnaire. The information of participant was kept in confidential. Participant has full permission to withdraw at any time if they want.

Results
This section presents the outcomes of the study.

Demographic Characteristic Research Question:
To evaluate the Nurses perception of practical environment relationship with patient satisfaction in Government Hospital Lahore.   A Pearson correlation perform to found the relationships in the nursing foundation for quality of care and nursing working environment. Nursing foundation for quality of care, r = (0.23), Work department r= .210 and p< 0.01). Which indicate significance relationship between nursing foundation for quality of care and nursing working environment.
A Pearson correlation carried out between the manager's abilities leadership, and support of nurse relationship with working environment. All items in this subscale show moderate to strong positive correlation with the working environment. The values of Pearson correlation of manager's abilities leadership, r =(0.038 , p< 0.01 and Work department r = 0.46 which show significance correlation. A Pearson correlation between subscale measuring the nurse perception of resource and staffing adequacy, and working environment show moderate to positive correlation. Pearson correlation values of resource and staffing adequacy r = (0.061), p >0.01) and Work department r = .062. Which show significance correlation among variable A Pearson correlation test used to identify the relationships in the subscale nurse-physician relationships with working department. Each questions of subscale show positive correlation with working environment. Nurse-physician relationships (r = (0.673), p< 0.01) and work department r = .072 which show significance correlation. Table 4 represented the patient frequency and percentage distribution according to their admission experience of hospital department. The patient who were admitted in General Surgery ward 32(24.1%), Medicine 42(31.6%)

Discussion
The focus of this research study is to identify Nurses perception of practical environment relationship with patient satisfaction in Government Hospital Lahore.
The objective of this study was to evaluate the awareness of the nurses about practical environment how work environment influence on nurse's performance which impact on patient satisfaction.
PES-NWI used for assessment of nurses' perception regarding practical environment. This instrument measured the role of the nurse manager, collegial relationships, resources, nurses' participation in hospital affairs and foundation of nurses for quality of care.
Assessment of Healthcare Provides and Systems (HCAHPS) instrument used for assessment of patient views regarding hospital environment.
A Pearson correlation analysis was performed to evaluate the relationship among variables. The nurses' and patients' perception relationship regarding practical environment correlate each other. Results revealed that nurses perception toward clinical environment r =.047 (p =.000) and work department r = .062 which show that significant positive correlation between nurses perceptions and working environment. Patient satisfaction with clinical environment also show positive correlation r =.051 (p =.000) and department experience r= .052 which indicate significance positive correlation.
Study on work environment relationship with nurses' perception and patient satisfaction show that Nurses participation in hospital affairs, educational programme for nurses, nurses manager support enhance nurses confidential level and nurses perform their activities with better way. Nurses relationship with physician and adequate availability of equipment help nurse to work efficiently and reduce their tension. When nurses work in calm environment they provide high quality of care to patient, and patient feel satisfaction of their treatment place.
A study conducted in Japanese acute-care setting study finding reveal that nursing practice environment impact on patient and organizational outcomes, the study findings emphasize for the needs of interventions for improvement of the nursing working environment, quality of care improve for patient and ward morale .The findings also help the policy makers and hospital administrators to improve number of staff nurses and working conditions in acute-care settings .The positive working environments enhance job satisfaction of nurses and lower levels of stress in critical care nurses. (Anzai et al., 2014) The environment influence on the patients, nurses, and organization outcome. Where care is delivered to patient. When nurses have adequate resources for patient care, they can establish positive relationships with physicians. They can communicate with physician about patient need and health problem. Good environment improve patient quality of care and enhance patient satisfaction (Aboshaiqah, 2015).

Limitations
The limitation of this study was a lack of time and less sample size of the patients (n= 133) and the staff nurses (n= 60) we cannot generalize this study on the whole population. study was also conducted from one hospital. The data was collected for this study from out-patients, indoor patients also included in future studies to examine the reliability of the study.

Conclusion
This study concludes nurse practical environment, nurse's perception and patient satisfaction from hospital environment show positive relationship. The perception of nurses and patients significantly correlated with practical environment.
The practical environment impact on nurses' performance. Effective practical environment help nurses in performing duties in best way, and they can fulfill patient needs and expectations. Adequate staff nurses, appropriate resources, educational programme and support from leaders, nurses' physician good relationship improve nurses' quality of care. Good nursing care enhance patient satisfaction from hospital environment and they will cure early.
Nursing) who gave permission to do this study. A deep sense of thanks to Mr. Hussain for his guidance and help during the present research work.