Rev. Latino-Am. Enfermagem 2020;28:e3256 DOI: 10.1590/1518-8345.3239.3256 www.eerp.usp.br/rlae Original Article Analysis of the work environment and intention of perioperative nurses to quit work* Objective: to investigate how the perioperative work Amalia Sillero-Sillero1 environment affects work dissatisfaction, professional https://orcid.org/0000-0001-6158-161X exhaustion and the perception of the quality of care about Adelaida Zabalegui2 the intention of abandoning the work of perioperative nurses. https://orcid.org/0000-0003-1205-3997 Method: cross-sectional study with 130 nurses working in the surgical area of a high-tech Spanish public university hospital. The scale of the nursing practice environment, Maslach’s exhaustion inventory, the questions about job satisfaction, the perception of the care quality and intention to abandon work to collect data were used. Descriptive, inferential and logistic regression statistics were made. Results: in general, 20% of perioperative nurses would want to quit their work. The dimension of the work environment of staff and resources, dissatisfaction and emotional exhaustion in nurses * The publication of this article in the Thematic Series were factors that indicated the intention of perioperative “Human Resources in Health and Nursing: Training and Practice in the Americas” is part of Activity 2.2 of nurses to abandon work. Conclusion: the implementation of Reference Term 2 of the PAHO/WHO Collaborating strategies for the retention of perioperative nurses should Centre for Nursing Research Development, Brazil. Paper extracted from doctoral dissertation “Aplicación de los be considered, improving the factors that indicate how the valores del magnetismo al área quirúrgica de un hospital work environment, especially the allocation of personnel and de alta tecnología”, presented to Universidad Jaume I, Departamento de Ciencias de la Enfermería, Castellon, resources, dissatisfaction and emotional exhaustion. Creating Spain. 1 Hospital de la Santa Creu i Sant Pau, Perioperative positive work environments based on magnetic values can be Nursing, Barcelona, Spain. a key strategy. 2 Hospital Clínic, Deputy of Director of Nursing Research and Education. Barcelona, Spain. Descriptors: Nurse Turnover; Health Facility Environment; Perioperative Nursing; Job Satisfaction; Burnout, Professional; Retention. How to cite this article Sillero-Sillero A, Zabalegui A. Analysis of the work environment and intention of perioperative nurses to quit work. Rev. Latino-Am. Enfermagem. 2020;28:e3256. [Access ___ __ ____]; Available in: ___________________ . DOI: http://dx.doi.org/10.1590/1518-8345.3239.3256. month day year URL 2 Rev. Latino-Am. Enfermagem 2020;28:e3256. Introduction work(11-12). The study in perioperative environments are very scarce(13), which indicates the need to investigate The lack of nursing professionals is well documented the factors related to the perioperative environment to and it is an important concern of health systems due develop optimal ways to relieve the lack and turnover to its effects on the quality of patient care, nurse of nurses. satisfaction and financial burden in health services(1-2). In One of the measures proposed in the international particular, a growing lack and turnover of perioperative literature offers an organization model with adequate nurses is expected, although it is expected that 20% of staff allocation, lower workloads and work support the people who are employed in this specialty will retire environments is related to Magnetic Recognition. For in the coming years(3). The demand for perioperative three decades, the development of Magnetic Hospitals nurses has already been increasing, growing about 1% was one of the effective strategies to solve the lack of to 2% each year, as the volume of surgeries increases nursing professionals. Since its inception in the USA in due to an aging population and to demands for greater the 1990s, it has expanded to different types of service care, as well as by more complex interventions(4). centers to different countries and changed its name by Moreover, the recruitment and retention of nurses the Magnetic Recognition Program of the American Nurse is difficult due to the conditions of the perioperative Credentialing Center (ANCC)(14). Magnetic Hospitals have environment, where nurses are required to have the specific skills to work with a multidisciplinary team, in an become a standard for the excellence of nursing care environment complex, high-tech, and with high patient and the work environment. Nurses have lower turnover, turnover ; therefore, solutions must be sought to face (5) greater job satisfaction, autonomy in the environment such staff relay, to retain nurses and to decrease the of professional practice and good interdisciplinary turnover in the perioperative environment. work relationships. Magnetic Recognition refers to Study show that the worst working environments complying with five values that bring together the 14 are related to increased burnout , lower job satisfaction (6) forces of magnetism (FOM) and form the creation of and a greater intention to quit work(7) and that better high quality nursing work environments(15), they are: 1– environments have less burnout, greater job satisfaction Implementation of a transformative leadership (2 forces: and lower intention to abandon . (8) the quality of nursing leadership and management Most studies have measured the perceptions of style; 2 – Development of an empowered structure (5 nurses working in different acute care units and that forces: organizational structure, policies and personnel there is little understanding of the factors of the work programs, the community and health organization, environment that are related to labor dissatisfaction the nursing image and professional development); 3 – and the intentions of nurses perioperative to abandon. Establishment of good practices (5 forces: professional In the United States (USA), one study examined models of care, consultation and resources, autonomy, 11 units with different work environments and the teachers and interdisciplinary relationships); 4 – Use of researchers showed that, among them, perioperative knowledge, innovation, improvement continues through environments were the least favorable(9). Therefore, research, evidence-based practice and innovation (1 the relationships between the work environment, strength: quality improvement) and 5 – Care outcomes labor dissatisfaction, professional exhaustion and and identify the factors that influence the results of the intentions of perioperative nurses to abandon patients and professionals(16). work must be investigated. In a national study that Studies on the lack of perioperative nurses and the examined the nurses’ work satisfaction, using a sample implementation of initiatives in Spain to improve it remains of 5654 in 59 hospitals in Spain, the researchers found limited(17). Therefore, taking the previous study as the that nurses’ work satisfaction varied according to the work unit and that 26% of them would want to leave reference, the research question was: how does it affect their hospital as a consequence of unfavorable work the environment of perioperative nursing practice in job environments, job dissatisfaction and high levels of satisfaction, professional exhaustion, and the intention to burnout(10). Nevertheless, this study was not conducted abandon work? From there, the aim of this study was in perioperative units and, although there are studies to investigate how the perioperative work environment in other environments on related factors such as affects work dissatisfaction, professional exhaustion and emotional exhaustion, work overload and nurses’ the perception of the quality of care about the intention of job dissatisfaction with the intentions of abandoning abandoning the work of perioperative nurses. www.eerp.usp.br/rlae Sillero-Sillero A, Zabalegui A. 3 Method consists of 3 dimensions: Emotional exhaustion (EE), Depersonalization (DP) and Personal Achievement (PA), This was cross-sectional study. Data were collected including 22 items measured on a Likert scale of 1 to in 2014-15 and no sample calculation, although all 6 points (‘never’, up to ‘every day’). The EE contains 9 nurses working in the surgical area of a high-tech public items; the DP, 5 items and PA, 8 items with a maximum university hospital in Spain were included. The inclusion score of 54.48 and 30, respectively. They were categorized criteria were work experience greater than 1 year in the into 3 groups each (low, medium and high), according place of work and being active during the data collection to the values: EE: low ≤ 18, mean [19-26], high ≥ 27; period, for N=130 nurses from the population that was DP: low ≤ 5, medium [6-9], high ≥ 10; PA: low ≥ 40, studied. medium [39-34], high ≤ 33. For global valuation, High The key variables of this study were the work Burnout occurred when 2 to 3 dimensions present high environment, burnout level, perception of the quality levels; when 2 or more dimensions have average or well of care provided, intention to abandon work and job one scale valuations at each level and low, when more satisfaction. To measure the work environment, one than two dimensions have low levels, following the criteria of the most used instruments worldwide was used to that are used in the RN4Cast Spain study(10). Following determine the quality of the practice environments, the the methodology used by the study of the European PES-NWI (Practice Environment Scale of the Nursing RN4Cast(22), work satisfaction (WS) was evaluated using Work Index)(18) and which was validated in Spanish(19). The scale consists of five dimensions with 31 items nine articles that point out the specific aspects of job that describe a set of characteristics that are present in satisfaction: flexible schedules, professional development, organizations that support the practice of professional autonomy, status, salary, training, vacations, dismissals nursing. Nurses thus indicate the degree, according to and licenses for studies. All items used a 4-point Likert what is present in each item in their work. The five subscales scale, ranging from 1, “very dissatisfied” to 4, “very or dimensions comprising PES-NWI are: 1) Allocation of satisfied”. In addition, the perception of the quality of care adequate personnel and resources; 2) Leadership skills was established by one question: “In general, how would and support from those responsible; 3) Nurse-physician you describe the quality of nursing care that is delivered to relationships; 4) Nurses’ foundations for quality and 5) patients in your unit?”. They could respond to this question Participation of nurses in hospital matters. Reliability on a four-point response scale with ‘bad’, ‘regular’, ‘good’ (i.e., Cronbach’s alpha coefficients) was 0.90 (95%CI: or ‘excellent’. Finally, the intention to abandon the work 0.87-0.93) . (19) Regarding the PES-NWI responses, that was measured by a single binary response (yes/no). the mean of each dimension was performed. The The measurement instruments that have been used are overall PES-NWI score was the average of subscale or valid and reliable in the context of study. The Research dimension scores. To describe and compare magnetic Ethics Committee of the hospital (CEIC Code: 47/2013) characteristics in the perioperative unit with the results approved this study and all participants provided their of the international research on Magnetic Hospitals, informed consent. the dimensions of the PES-NWI and the overall scores A descriptive analysis of all variables was performed at the hospital level were added. For each dimension, using mean, standard deviation and minimum and the mean scores ranged from 1 to 4, with the value of maximum values, according to the distribution of 2.5 as neutral midpoint (i.e., neither agreement nor quantitative variables, frequencies, and percentages disagreement). Values greater than 2.5 indicate that for qualitative variables. Initially, a normality test PES-NWI elements are present in the current work using the normal Q-Q graph and the Kolmogorov- environment; values below 2.5 indicate disagreement. Smirnov goodness adjustment test were performed The environment is classified as favorable, if four or five for correlations. PES-NWI variables admit the normal average scales of dimensions are greater than 2.5; as model. Nevertheless, the satisfaction variables are far mixed, if two or three dimensions had average scores from the normal model, which is why non-parametric greater than 2.5 and as unfavorable, if neither or one of the five subscales or dimensions achieved an average tests were used. Pearson and Spearman’s correlations score of 2.5. For this study, Cronbach reliability or α for were used, according to the variables, to examine the dimensions ranged from 0.86 to 0.91 and for the score strength and direction of bivariate relationships between composed of the entire Cronbach α scale 0.89. the key variables of the study. Finally, a multivariate The exhaustion of the nurse at work was measured logistic regression analysis was performed. Statistical using the Maslach Burnout Inventory (MBI) , in its version (20) significance was set at p < 0.05. The statistical software validated to the Spanish language(21). The instruments SPSS V22 was used. www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2020;28:e3256. This study also compared the PES-NWI values participate in hospital decisions (M = 1.33, SD = 0.62), of perioperative nurses with the values of Magnetic an administration that listens and responds to employee Hospitals(23) and the hospitals of the RN4CAST Spain(10) concerns (M=1.56, SD = 0.73) and opportunities to study, obtained from the literature review in different ascend within the organization (M =1.65, SD = 0.70). databases (Pubmed, CINAHL, Scopus). The mean score They all belong to the nurse’s participation dimension in per item, subscale mean or dimension, global mean, and hospital affairs. The results are presented in Table 1. levels are reported. Regarding the comparisons of PES-NWI values, it was found that the levels of the scores of the global PES- Results NWI scale of the perioperative unit was lower (range 2.20–2.40) than the score of Magnetic Hospitals (range In total, 130 questionnaires were obtained that were 2.92–3.00). The difference to the hospitals of the study completed and the overall response rate was 98%. Most of Spanish hospitals was small (range 2.27–2.42). For were women (91.5%, n = 119) and married (75%, n = the five dimensions, the levels of the perioperative unit 57). The mean age was 44.5 years (SD = 11.90); mean were lower than those of Magnetic Hospitals. However, professional experience in the institution was 20 years the levels of the PES-NWI subscales in the perioperative (SD = 12.3) and in the unit, 13.9 years (SD = 11.14). unit as “nursing fundamentals for the quality of care” Most professionals (73%, n = 96), worked in the operating and “nurse-physician relationships” were higher than the room (83%, n = 108), had a fixed contract (58.5%, levels of those studied in Spain. In general, the scores n = 76), and worked in the morning shift. Regarding the that were obtained in this study indicate that nurses academic degree, workers presented undergraduate have similar qualifications of the work environment degrees in nursing (13.8%, n = 18), master’s degree as Spanish hospitals and lower than those obtained in (31.5%, n=41), postgraduate degree in surgical nursing Magnetic Hospitals. The results are shown in Table 2 (67%, n=67) and none had a doctoral title. Regarding Regarding burnout, perioperative nurses presented continued training, 48.5%( n=63) of the nurses studied moderate levels (global burnout: mean 47%, n=36 < 50 h over the last 24 months and 17% (22) studied and high level 6%, n=5. High levels of burnout were > 300 h. The mean number of hours worked in the last identified in 25% (n=19) of nurses had high levels shift of the hospital was 8.4 h and 26.2% (n = 34) of of exhaustion. High levels of depersonalization were the nurses stated that they had worked more hours than observed in 10% (n=8) of the sample, and high levels of what is established in their contracts. personal achievement in 21% (n=16). Characteristics of the work environment: nurses Regarding job satisfaction, in all items, the highest classified the nursing fundamentals for quality (M = response percentage was not dissatisfied, always above 2.65, SD=0.52; range 2.56–2.74) as the most favorable 52% and even reaching 98%. Despite the minimum characteristic present in the work environment, followed differences between one and other variables, the by nurse-physician relationships (M = 2.47 SD = 0.68; range 2.35–2.59). The skill, leadership and support highest mean, which indicates the highest degree of of those responsible (M = 2.27, SD= 0.67; range satisfaction, was observed in the item flexible hours. On 2.15–2.39) and the suitability of personnel and the the other hand, the variables with the highest degree resources (M = 2.12, SD = 0.65; range 2.01–2.23) did not of dissatisfaction were salaries, the opportunity for receive favorable evaluations (score < 2.5) and, finally, professional development and the licenses for studies. In the participation of nurses in hospital affairs (M =1.96, total, 74.3% (n=97) of the nurses were little dissatisfied SD = 0.43; range 1.88-2.03) was qualified as the least with their current work in the hospital, and 20% (n=26) favorable characteristic of this environment. Therefore, intended to leave their position. Regarding the quality the findings showed an unfavorable perioperative work of care in their unit, more than half of those who were environment, although there was only one subscale that interviewed reported good quality care 61% (n=79) and had an average score greater than 2.5. The data that were excellent 14% (n=11). Results are shown in Table 3. obtained from PES-NWI provided information regarding In the correlations between the dimensions of magnetic characteristics. The highest points were: PES-NWI and the other independent variables, it was we work with clinically competent nurses (M = 3.51, found that most correlations do not reach statistical SD = 0.65), followed by care are based on a nursing significance (p>0.05) and have low intensity values. It model (M = 3.16, SD = 0.91) and administrators expect was only discovered that job satisfaction and allocation a high level of care (M = 2.89, SD = 1.18) belonging of resources and personnel (r=0.013), and emotional to the dimension of nurse fundamentals for quality care. exhaustion (r=-0.206), are significantly associated. While the least present elements are the opportunities to Table 4 presents the results. www.eerp.usp.br/rlae Sillero-Sillero A, Zabalegui A. 5 Table 1 – Descriptive analysis of the subscales or dimensions of PES-NWI. (n=130 perioperative nurses). Barcelona, Spain, 2014-2015 Subscales-Dimensions PES-NWI* M† DE‡ Range 1: Staff allocation and adequate resources 2.12 (0.65) 2.01 2.23 There are adequate support services 2.67 (1.02) 2.49 2.85 There is enough time and opportunities to expose care problems to other nurses 1.94 (0.84) 1.79 2.08 There are enough nurses to provide care 1.95 (0.85) 1.81 2.10 There is enough staff to do the work 1.92 (0.81) 1.78 2.06 2: Nurse-physician work relationship 2.47 (0.68) 2.35 2.59 Physicians and nurses have a good working relationship 2.75 (0.67) 2.64 2.87 There is a lot of teamwork among medical nurses 2.35 (0.83) 2.21 2.50 There is (joint) collaboration between medical nurses 2.30 (0.89) 2.15 2.45 3: Skill, leadership and support of your guardians 2.27 (0.67) 2.15 2.39 Supervisors support from physicians 2.42 (0.81) 2.28 2.56 The supervisor is a good manager and leader 2.40 (0.89) 2.24 2.56 If they make compliments-recognitions to the work well done 1.92 (0.82) 1.77 2.06 The supervisor supports the decisions of the staff 2.39 (0.87) 2.24 2.54 Supervisors use the errors to learn 2.22 (0.88) 2.07 2.38 4: Nursing fundamentals and quality care 2.65 (0.52) 2.56 2.74 There is continued training for nurses 2.57 (0.93) 2.41 2.73 Management expects high quality nursing care 2.89 (1.18) 2.69 3.10 There is clear philosophy of nursing environment for the patient 2.75 (0.89) 2.60 2.91 If you work with clinically competent nurses 3.51 (0.65) 3.39 3.62 There is an active quality assurance program 2.78 (0.94) 2.62 2.95 There is a guidance program for new nurses 1.77 (0.90) 1.61 1.93 Nurse care is based on a nurse model 3.16 (0.91) 3.00 3.32 Carry out patient care and writing plans 2.59 (1.04) 2.41 2.77 If you plan care to foster your continuity 2.25 (1.06) 2.06 2.43 Nursing diagnoses are used 2.25 (1.04) 2.07 2.43 5: Participation of nurses in hospital matters 1.96 (0.43) 1.88 2.03 There are promotion opportunities at the professional level 1.88 (0.87) 1.73 2.04 There are opportunities in decisions on hospital management 1.33 (0.62) 1.22 1.44 The /A director of nursing is very visible and accessible 1.73 (0.90) 1.57 1.89 Authority nurse direction as other directions. 2.18 (0.94) 2.01 2.34 There are opportunities to ascend 1.65 (0.70) 1.53 1.78 The direction listens and responds to concerns 1.56 (0.73) 1.44 1.69 Nurses get involved in internal management. 2.32 (0.84) 2.18 2.47 Nurses have the opportunity to form the committees 2.75 (0.86) 2.60 2.89 The supervisor consults the staff of daily problems 2.20 (0.93) 2.04 2.36 *PES-NWI = Practice Scale-Nursing Work Index; †M = Mean; ‡SD = Standard Deviation. Table 2 – Mean levels of PES-NWI: perioperative unit. Barcelona, Spain, 2014-15; Hospitals study. Spain, 2012; Magnetic hospitals, USA, 2014 Mid-level PES-NWI* Dimensions Perioperative unit RN4Cast† Hospitals Magnetic hospitals Spanish 2014-2015 Spain 2012 USA‡ 2014 1 Allocation of adequate personnel and resources 2.01 – 2.23 2.44 – 2.56 2.65 – 2.88 2 Collegiate relationships between nurse and physician 2.35 – 2,59 1.99 – 2.08 2.99 – 3.07 3 Skill, Leadership and Support of those responsible 2.15 – 2.39 2.42 – 2.61 2.72 – 3.07 4 Nurse fundamentals for the quality of care 2.56 – 2.74 2.37 – 2.45 3.09 – 3.20 5 Nurse participation in hospital affairs 1.88 – 2.03 2.14 – 2.41 2.76 – 3.01 Global 2.20 – 2.40 2.27 – 2.42 2.92 – 3.00 *PES-NWI = Practice Scale-Nursing Work Index; †RN4Cast Spain (Forecasting Register Nurse in Spain); ‡USA = United States Finally, logistic regression analysis was times more risk of intent to quit work than those performed to predict the intention of abandonment who did not. The most positive perceptions of staff in dichotomous form (yes/no). Nurses who were allocation and adequate resources were associated dissatisfied with work are 2.3 times more likely to with a lower level of intention to abandon by nurses. leave or change work than nurses who were satisfied. Predictors that nurses intend to abandon or change And nurses with emotional exhaustion also had 1.11 work are shown in Table 5. www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2020;28:e3256. Table 3 – Descriptions of burnout results, labor satisfaction, intention to abandon and perception quality of care (n=130). Barcelona, Spain, 2014-2015 Emotional exhaustion N % Low level 74 56.9 Mid-level 31 24 High level 25 19 Depersonalization Low level 102 78 Mid-level 18 14 High level 10 7.7 Personal achievement Low level 61 46 Mid-level 48 37 High level 21 16 Burnout Global Low level 77 59.2 Mid-level 47 36.2 High level 6 4.6 Satisfaction Very Dissatisfied Dissatisfied Moderately Satisfied Very Satisfied Job satisfaction 3.7 % 74.3 % 22.0 % 0.0 % Hourly flexibility 2.9 % 52.3 % 34.9 % 10.0 % Opportunity 2.8% 92.1% 5.1% 0.0 % Autonomy 5.1 % 77.4 % 9.7 % 7.8 % Wages 1.3 % 94.6 % 4.1 % 0.0 % Training 10.7 % 57.9 % 21.6 % 9.8 % Vacation 1.7 % 78.1 % 20.3 % 0.0 % Low illness 1.3 % 91.0 % 7.7 % 0.0 % License for studies 0.0 % 97.9 % 2.1 % 0.0 % Intention to abandon Yes 20% (26) No 80% (110) Bad Regular Good Excellent Quality of Care 5% (6) 24% (30) 61% (79) 14% (11) Table 4 – Correlations between PES-NWI dimensions and the satisfaction and Burnout variables (n=130). Barcelona, Spain, 2014-2015 PES-NWI* r Spearman† r Pearson‡ Satisfaction Staffing and Collegial Nurses manager Nursing Nurse participation in resources nurse-physician ability, leadership foundations for the hospital adequacy relations and support of nurse quality of care affairs Job satisfaction 0.013† 0.135† 0.058† 0.062† 0.139† Hourly flexibility -0.127† 0.128† -0.079† -0.013† -0.125† Opportunity 0.131† 0.096† 0.064† 0.034† -0.117† Autonomy 0.083 † 0.159 † 0.057 † 0.048 † 0.075† Salary -0.184† 0.041† -0.125† 0.119 † 0.049† Training 0.144 † 0.076† 0.077† 0.110† 0.095† Vacation 0.341† -0.103† 0.033† -0.072† -0.057† Low Diseases -0.069† 0.044† -0.113† 0.035† -0.133† License studies 0.209† -0.099† 0.072† -0.111† 0.052† Burnout Emotional exhaustion -0.206‡ -0.230‡ -0.337‡ -0.249‡ -0.349‡ Depersonalization -0.098‡ -0.205‡ -0.170‡ -0.202‡ -0.105‡ Personal achievement -0.237 ‡ -0.266 ‡ -0.240 ‡ -0.355 ‡ -0.263‡ *PES-NWI = Practice Scale-Nursing Work Index; r = Spearman Correlation Coefficient; r = Pearson Correlation Coefficient † ‡ Table 5 – Logistic regression: predictors of intention of perioperative nurses to abandon. n=130. Barcelona, Spain, 2014-2015 Variable Intention to abandon work β* SE† p‡ OR§ Emotional exhaustion 0.168 0.024 0.000 1.113 Dissatisfaction 0.894 0.225 0.000 2.304 Allocation of personnel and resources -0.446 0.172 0.010 0.640 Constant 0.633 0.672 0.345 - *β = Estimated Parameter; †SE = Standard Error; ‡p = Chi-square; §OR risk www.eerp.usp.br/rlae Sillero-Sillero A, Zabalegui A. 7 Discussion environment such as quality foundations and the employment relationship between nurses and physicians We sought to investigate the work environment seem satisfactory, the central problems are in the design of perioperative nurses of a high-tech public university of work and the management of personnel that threaten hospital and its association with the work satisfaction, quality care to the patient. It is crucial to solve these burnout and the perception of the quality of the care problems, which are susceptible to intervention of provided and the intention to abandon work. The PES- institutional management, to preserve the safety and NWI scores for this study were not favorable. The means quality of patient care. These results are consistent with were lower than 2.5 for four of the five subscales of the findings that have been described in other studies PES-NWI. The subscales of the dimension “Nursing that were conducted by the European RN4CAST(10,31). fundamentals and quality care” presented higher mean The dimension that was best valued by perioperative score than those of “Nurse participation in hospital nurses regards to the quality of care they provide, which affairs”, which presented the lowest scores. Although was good and is comparable with other studies with better these results point to the need for interventions to environments(32). Perioperative nurses have a training of improve the general work environment in all areas, specialists or those graduated in perioperative care – an analysis of the relation between the factors of work although there is still no specialty course on perioperative environment, satisfaction, burnout and intention to nursing – which requires specialized skills from them(33). abandon work found significant associations. Moreover, The absence of a training system that is regulated for 20% of nurses intended to quit work, having the perioperative nursing staff in Spain will stand out as work environment, work dissatisfaction and emotional a limitation to solve by our health system. Moreover, exhaustion of perioperative nurses, predictive factors of nurse swindling decreases knowledge and experience this, which is consistent with similar studies(24-25). Nurses in an organization. Therefore, if improvements directed who were dissatisfied with work are more likely to want to to continued and advanced training are made, together abandon or change work than nurses who were satisfied. with the professional development of nurses, the system And nurses with emotional exhaustion also intended to can increase the satisfaction of nurses and contribute to abandon, corroborating other studies conducted in other them staying in their jobs and retaining the professionals. European countries(26-27). In general, it was shown that, Studies in the literature often highlight the importance in this perioperative environment, more than half of of education and the development of nurses to create a the nurses were unsatisfied with their work and that, positive work environment(34-35). also, more than a third faced emotional exhaustion. In this study, the environment was also There are studies in different countries with different characterized by good colleague relationships between health care systems that report similar deficiencies in nurses and physicians, although there is an important the work environments and in the quality of care(2,25). margin for improvement, similar to other similar In the Spanish health system, the past economic crisis particularly affected the nursing profession by affecting studies(14). In the studies of Magnetic Hospitals, the the nurse/patient relationship, being a negative trend quality of collaboration between nurse and physician during these years and affecting the quality of care due was an important feature of a healthy, high-performance to work overload(28). work environment that increases the retention of Other studies showed that the environments that nurse(15). Furthermore, they reported few opportunities were perceived by nurses as positive were translated into to participate in decision making in their unit. In another greater job satisfaction, lower levels of exhaustion and a study, it was demonstrated that the participation of lower intention of abandoning current employment and nurses in decisions improve efficiency and efficacy at the the profession, resulting in improved patient care . In (29) unit level(11). Nurses’ dissatisfaction was mainly related to the current study, there is an association between the the few opportunities for professional development and environment of perioperative nurse practice and the wages. The economic remuneration they perceive is not intention to abandon, especially a negative association in proportion to the work they provide and educational with the size of staff and resources. According to recent requirements. These aspects were also negative in the studies, staff shortages result in a work overload with studies of RN4Cast Spain(10), so it will reflect on the significant and direct effects on adverse events in priorities in our Spanish Sanitary System and not only in patients(11,30). And even if the dimensions of the work our organization. www.eerp.usp.br/rlae 8 Rev. Latino-Am. Enfermagem 2020;28:e3256. According to data from the Organization for improvements to increase the retention of perioperative Economic Cooperation and Development (OECD), the nurses. Moreover, this study could be useful for other mean number of nurses in the European Union (EU) is researchers in Spain and internationally to investigate 8.8 per thousand inhabitants and in Spain of 5.5. Our perioperative environments. An important limitation of health system has almost the same number of nurses as this study – given its cross-sectional nature – is that doctors, whereas in the EU the number of nurses doubles the nurses were asked about their intentions to change that of doctors(36). The WHO advocates for the need to or abandon their work, and there was no follow-up in have more nursing professionals to meet the needs of the following year to determine whether they actually the population, although nursing care is considered abandoned their posts. Recently, a qualitative study necessary, effective and profitable. A report that was was conducted by the same authors who reported on published by the World Nurse Innovation Summit (WISH satisfaction, dissatisfaction and possible causes of work 2018), in coordination with the Nursing Now campaign abandonment(42). We recommend future studies with – which aims to empower the nurse profession – longitudinal designs or intervention drawings. recommends investment in nursing and implement legislation , training and effective jobs to achieve the Conclusion necessary improvements in health and health care. The need for a fundamental change in health policies, both In the perioperative care environment of this globally and nationally, is indicated, which recognizes hospital, especially, the lack of personnel and resources, what nurses can achieve if they are allowed (37) . With dissatisfaction and emotional exhaustion provoke, in regard to hospital management, the need for change perioperative nurses, the intention to abandon their to authentic leadership that is focused on professional work. One will consider implementing strategies for the growth and to foster a positive work environment can retention of perioperative nurses, improving predicting improve flows and workload, wages and resources for factors such as: the work environment, especially the nurses(38). Regarding comparisons of the perioperative allocation of personnel and resources, dissatisfaction environment or other environments, our study found and emotional exhaustion. Creating positive work that nurses perceive their work environment more environments that are based on magnetic values can be unfavorable than nurses working in Magnetic Hospitals, a key strategy. following the same line as the rest of the Spanish hospitals(10) and that of some European hospitals(25). Acknowledgements Different studies were conducted to evaluate the quality of work environments and compared their environments I thank all the perioperative nurses who participated with Magnetic Hospitals. Although they obtained better in this study. I would also like to thank the Nursing results, they coincide that Magnetic Hospitals achieved Directorate of the Hospital of Santa Creu i Sant Pau. And better evaluations in the five dimensions of PES- we thank Jose Manuel Garcia for the statistical advice. NWI(39-40). Some researchers, who started the research of References Magnetic Hospitals, explained that the same positive 1. De Oliveira DR, Griep RH, Portela LF, Rotenberg L. results can be achieved by introducing changes in Intention to leave profession, psychosocial environment the organization – it is not necessary to undertake and self-rated health among registered nurses from the journey to magnetic status – such as inclusion of large hospitals in Brazil: a cross-sectional study. BMC magnetic values in nursing work environments(41). 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