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ORIGINAL ARTICLE
The N2N instrument to evaluate healthy work environments:an Italian validation
Alvisa Palese • Angelo Dante • Laura Tonzar •
Bernardo Balboni
Received: 2 May 2012 / Accepted: 5 February 2013
� Springer-Verlag Berlin Heidelberg 2013
Abstract
Objectives The aims of the study were to (a) validate
N2N Healthy Work Environment tool, (b) assess the
healthiness of work environments as perceived by nurses
themselves and (c) identify the factors associated with
Italian nurses’ perception of work environment healthiness.
Methods The linguistic and cultural adaptation of USA-
N2N Healthy Work Environments was achieved through a
process of forward/backward translation. Content validity
was assessed by three expert nurses. The stability of the
instrument was checked with a test/retest evaluation. The
instrument psychometric properties, the confirmatory fac-
tor analysis as well the healthiness of the work environ-
ment and its determinant factors were evaluated with a
sample of 294 nurses.
Results The content and face validity of the N2N Healthy
Work Environment instrument was confirmed. The instru-
ment demonstrated good internal consistency (a of 0.82),
excellent stability values (q[ 0.70) and high levels of
acceptability (response rate: 96.4 %). The confirmatory
factor analysis has corroborated the existence of two fac-
tors as documented in the original instrument (Mays et al.
in J Nurs Manag 19:18–26, 2011). Eighty-seven (29.6 %)
nurses perceived the work environment where they work as
‘‘healthy’’. Working under a functional model of care
delivery (v2 24.856, p 0.000) and being responsible for one
project or more (v2 5.256, p 0.021) were associated with
healthy environments.
Conclusions The instrument—valid and reliable, short in
the number of items, easy to understand and based on
international standards—allows a systematic assessment of
the healthiness of the environment and might provide not
only the opportunity to evaluate the effects of new orga-
nizational models and interventions, but also the possibility
to activate a process of self-analysis and a process of
ongoing review. The instrument can be used to systemat-
ically check the healthiness of Italian working environ-
ments, allowing for organizational diagnosis, targeted
interventions and international comparisons.
Keywords Healthy � Unhealthy � Work environment �Perceptions � Nurses � Nursing � Validation study �Confirmatory factor analysis � N2N Healthy Work
Environment � Italy
Introduction
Within the nursing work environment, ‘‘healthy’’ means an
environment in which there are carefully designed policies,
procedures and systems to allow nurses to meet organiza-
tional goals and achieve personal satisfaction (Disch 2002).
A healthy environment is characterized by the simulta-
neous presence of clear strategies aiming to enhance the
contribution of each nurse, a strong sense of trust between
managers and employees, an organizational culture that
supports communication and collaboration and an
A. Palese (&)
School of Nursing, University of Udine, Viale Ungheria,
20, 33100 Udine, Italy
e-mail: [email protected]
A. Dante
School of Nursing, University of Trieste, Trieste, Italy
L. Tonzar
Cardiological Unit, Teaching Hospital, Udine, Italy
B. Balboni
Department of Economics ‘Marco Biagi’, University of Modena
and Reggio Emilia, Modena, Italy
123
Int Arch Occup Environ Health
DOI 10.1007/s00420-013-0851-3
emotional dimension that enables individuals to feel
physically and emotionally secure (Healh et al. 2004).
Nurses who perceive their work environment as healthy are
more likely to pursue the goals of the hospital and the
objectives assigned and have a higher job satisfaction
(Laschinger et al. 2001, 2004; Ulrich et al. 2007; Lasch-
inger 2008; Aiken et al. 2009). Perceiving higher job sat-
isfaction reduces absenteeism (IOM 2004), increases
retention (Aiken et al. 2002; Hasselhorn et al. 2005;
Khowaja et al. 2005; Li et al. 2010) and improves patient
clinical outcomes and satisfaction (Laschinger and Finegan
2005; Laschinger and Leiter 2006; McGillis Hall and
Doran 2007; Donahue et al. 2008; Purdy et al. 2010).
Unhealthy work environments, by contrast, are charac-
terized by poor leadership, poor communication, a lack of
shared objectives (Bortoluzzi et al. 2012), unethical
behaviour, lack of respect and trust, resistance to change
and conflicting values (Healh et al. 2004). According to
some authors (Zohar et al. 2007; Warshawsky and Havens
2011), in these unhealthy environments, uncivil behaviour
by peers is often reported, resulting in psychological dis-
tress, increased psychosomatic symptoms, burnout and the
intention to leave the nursing profession (Rosenstein 2002;
McKenna et al. 2003; Rosenstein and O’Daniel 2005;
Yildirim and Yildirim 2007). Unhealthy environments are
more expensive, due to the high personnel absenteeism and
the loss of productivity (Addley et al. 2001; Clegg 2001;
Rodham and Bell 2002; Vessey et al. 2009).
Recently, the Nurse-to-Nurse Healthy Work Environ-
ment instrument called ‘‘N2N HWE’’ was validated in the
United States by Mays et al. (2011). The theoretical fun-
damentals of the scale were the standards considered by the
American Association of Critical-Care Nurses (AACN
2005) as a required standard for establishing and sustaining
healthy work environments. The N2N HWE instrument
consists of two sub-scales including six items each: the first
sub-scale, named ‘‘Self’’, measures the individual contri-
bution to the healthy work environment, while the second
sub-scale, named ‘‘Co-workers’’, assesses the contribution
of the nursing team towards the healthy work environment.
The N2N HWE instruments ask nurses to grade themselves
on how well they incorporate into the practice each of six
standards and how well their co-workers incorporate them.
In its preliminary US validation, the instrument was con-
sidered easy to understand. It was also considered to be
valuable for a rapid assessment of nurses’ working condi-
tions, a key measurement in monitoring healthy work
environment trends and evaluating the impact of the
interventions designed to improve them (Mays et al. 2011).
The Italian nursing context is characterized by some
peculiarities: at the time of the study, the National Health
Service was confronting a huge economic crisis which is
still a concern in the European zone (Bortoluzzi and Palese
2010); the nursing shortage is still present (Valenti et al.
2007; Lautizi et al. 2009; Stringhetta et al. 2012) even if
the amount of nurses available per 1,000 inhabitant ratio
(n = 6.3) is quite in line with the OECD average (n = 6.4)
(OECD 2010). Public health and welfare services tend to
diminish during economic recession because investments
are mainly allocated to other priorities (Scherer and Dev-
aux 2010). These cuts may lead to an increased unem-
ployment ratio among recent graduate nurses, a redesign of
healthcare roles, introducing less-educated roles in place of
previous ones (e.g. auxiliary nurses in place of registered
nurses) and reducing the amount of resources dedicated at
the bedside (Palese et al. 2006; 2012a, b). This might result
in increased tensions within the workforce (Bortoluzzi
et al. 2012; Palese et al. 2012a).
Given this scenario, only recently, following the
implementation of a new national law (Legislative Decree
81/2008), nursing has become a focus of interest along with
the context in which nurses work (e.g. the amount of
stress), aiming to prevent the intentions to leave, to reduce
turnover rates, to monitor and to improve the well-being of
the workforce.
Moreover, specific instruments aimed at assessing the
healthiness of work environments are not available in the
Italian context. Projects activated by hospitals to improve
the healthiness of the work environment do not undergo a
preliminary assessment and cannot be evaluated in their
impact. Not secondarily, the several changes introduced in
hospitals derive mainly as a consequence of cost-contain-
ment measures and cannot be evaluated for their impact on
the healthiness of work environments as perceived by
nurses. Not lastly, given that more studies are needed at the
national and international level aiming to measure the
impact of nursing care delivered daily on patient outcomes
determined by several components as well as by the nurses’
working conditions (Pisanti et al. 2011), there is a need to
develop common instruments. Therefore, the aim of the
present study was to introduce the N2N HWE instrument in
the Italian context and to summarize the results of reli-
ability and validity testing with direct-care nurses
employed in hospital settings. Creating the opportunity to
evaluate the healthiness of work environments as perceived
by nurses and to compare these perceptions both at the
national and at the international level was the general intent
of the study.
Methods
Aims and study design
The principal aim of the study was to validate the N2N
HWE in the Italian context. The secondary aim of the study
Int Arch Occup Environ Health
123
was to assess the healthiness of the work environment as
perceived by nurses at hospital level and to identify the
factors determining the nurses’ perception of healthiness
and to compare. A linguistic/cultural validation followed
by a descriptive study design was therefore adopted. The
study process was developed in three phases:
1. First Phase: Establishing the cultural relevance and
instrument appropriateness (Im et al. 2004). Given its
cross-cultural nature involving incommensurable phe-
nomena, based on socio-political and historical issues,
the standard codes embedded in the N2N HWE
instrument (AACN 2005) were preliminary discussed
and analysed by three researchers (LT, AD, AP). Their
relevance, appropriateness and applicability to the
Italian context were agreed upon.
2. Second Phase: Instrument cross-cultural, language and
psychometric validation. After having obtained the
authorization of Mary Z. Mays (11 October 2011), the
linguistic adaptation of the instrument was achieved
through a forward–backward translation process
(White and Elander 1992; De Vellis 2003). The
English version was translated into Italian indepen-
dently by two nurse specialists in administration and
then evaluated by three nurses with administrative
experience, who discussed and agreed upon the final
version of the instrument. A bilingual translator not
involved before and also experienced in nursing
administration translated the Italian version into
English, and this was then presented to the authors
of the original version to confirm the content validity.
The content validity was assured by the original
authors and then by a group of three experienced
nurses in administration research not previously
involved. To verify the stability over time, a pilot test
involving 30 nurses working at hospital level was
performed. After obtaining their informed consent and
received a questionnaire, the nurses used a code to
mark the test that allowed comparison with the
subsequent retest carried out 1 week later. Nurses
were also requested to communicate any comments
about the clarity of the tool items and to provide
suggestions and recommendations for improving its
formulation. No comments or suggestions emerged,
and the instrument was considered comprehensible to
the nurses involved. At the end of this pilot phase, the
instrument, comprising 12 items in its final form, was
tested for its psychometric properties, evaluation
reliability and validity. After having assured that no
items of the tool were missed by participants, a
confirmatory factor analysis was also performed.
3. Third Phase: Descriptive study. After having assured
instrument reliability and validity, work environment
healthiness as perceived by nurses and some individ-
ual- and organizational-associated factors were
evaluated.
Participants
Twenty-two approachable units located in a large teaching
hospital ([900 beds) situated in the north-east of Italy were
involved. Nurses working in these wards for at least for
6 months, in a permanent or temporary position, who were
involved in direct patient care and were not previously
included in the pilot phase, were eligible. Those working
less than 6 months and not available at the moment of the
survey (for personal reasons, e.g. pregnancy) were exclu-
ded. A total of 305 nurses were eligible and, therefore,
approached.
Data collection procedures
The questionnaire, which included questions on
(a) demographic data (e.g. age, gender, nationality),
(b) professional data [nursing experience (years), educa-
tional background, working position (temporary or
permanent), working unit (e.g. medical, surgical),
professional project held in the last year],
(c) organizational data (nursing care delivery models
adopted in the unit e.g. functional nursing or team
nursing) and
(d) the N2N HWEIta instrument,
was administered from November to December 2011.
Distribution of the questionnaire was preceded by a
meeting with the chief nurse of each ward involved in the
study in order to illustrate the research aims and provide
initial information to nurses aiming to engage and motivate
them to participate in the survey.
Given the level of sensitivity of the topic in question, a
scheduled meeting with each eligible nurse was pro-
grammed according to the chief nurse and the availability
of a room was requested. During each meeting, the
researcher presented the aim of the survey and then left
each nurse who had given his/her consent alone. A calm
setting, uncontaminated by external disturbances, was
considered essential in order to ensure the privacy neces-
sary to allow reflection on the healthiness of the
environment.
Nurses were asked to indicate, for each item of the
instrument, their level of agreement with reference to their
actual work experience, given that their exposure to the
workplace had to be recent to be evaluated and, if possible,
not distorted by recall bias. For each item indicating a
standard in accordance with the original tool (e.g. ‘‘Nurses
Int Arch Occup Environ Health
123
are relentless in pursuing and fostering true collabora-
tion’’), a Likert scale was reported from 4 ‘‘Well above
average’’, to 3 ‘‘Above average’’, 2 ‘‘Average’’, 1 ‘‘Below
average’’ and 0 ‘‘Failing’’ (Mays et al. 2011).
After having completed the questionnaire, nurses were
asked to place each questionnaire in a sealed urn to ensure
anonymity.
Analytic strategy
According to the aims of the study, the following data
analyses were carried out:
(a) Instrument reliability: internal consistency (a Cron-
bach) was calculated. The reliability assessment of
each item was then calculated, removing one item at a
time (Ferketich 1991). The significance of the items
was set at values of item–total correlation greater than
0.30 (Nunnally and Bernstein 1994). The stability of
the instrument was evaluated by test–retest, adopting
Spearman’s rho test (r2) according to the nature of the
variables under study. To verify that the items were
constructed in such a way as to generate responses
located at the extremes of the Likert scale, kurtosis
and skewness were calculated. The statistical signif-
icance, when appropriate, was fixed at p \ 0.05. The
SPSS statistical package for Windows, version 19.00,
was adopted for these purposes.
(b) Instrument validity: a confirmatory factor analysis
(CFA) was performed (Bagozzi and Foxall 1996),
applying a structural equation model (Bollen 1989).
The asymptotic covariance matrix as input and the
maximum likelihood fitting function as the estimation
procedure were considered. Discriminant validity was
established using the v2 difference test (Anderson and
Gerbing 1988). The LISREL 8.8 statistical package
was adopted for this purpose.
(c) Healthiness of the environment as perceived by nurses
involved: descriptive statistics [frequencies, propor-
tions, percentages (%), means, standard deviations
(SD) and ranges] were calculated aiming to summa-
rize the demographic and professional characteristics
of the participants and the characteristics of the unit
where they worked. Each item of the instrument and
each sub-scale were therefore analysed using descrip-
tive statistics (mean, SD, median, range).
According to Mays et al. (2011), nurses were divided
into two groups: (a) a group showing a response mean C3
(healthy environment) and (b) a group showing a response
mean \3 (unhealthy environment). Demographic and
professional variables of the participants and organiza-
tional variables (as nursing care delivery models adopted)
were measured in their association with healthiness/
unhealthiest work environment. The statistical inferential
analysis, by t test or Mann–Whitney U test for non-normal
distributed variables, and by chi-square test (v2), was
performed. The statistical significance was fixed at
p \ 0.05. The SPSS statistical package for Windows,
version 18.00, was adopted for these purposes.
Results
Participants
A total of 305 questionnaires were administered; 11
(3.6 %) were eliminated because they were not complete.
Therefore, 294 nurses participated (response rate: 96.4 %).
Forty-three (14.6 %) were males and 251 (85.4 %) females
(male to female ratio = 1:5). The average age was 39.5
(median 40, min 22, max 58). Participants reported having
an average of around 16 years of experience as a nurse.
Slightly more than half of the participants documented a
non-university educational background (52 %). At the time
of the survey, participants were working mainly as full-
time nurses (76.9 %) in a permanent position (96.3 %).
Few nurses were in charge of specific professional projects
(3.4 %) and the majority reported to work in team nursing
or as a primary nurse (62.6 %). Demographic, professional
and organizational data are summarized in Table 1.
N2N HWEIta: Italian version reliability and validity
The content validity was confirmed by expert nurses
involved in nursing administration and by the author (Mary
Z. Mays, October 2011). The overall internal consistency
of the instrument was a 0.82. Removing one item from the
tool at a time, the overall reliability of the instrument
remained substantially stable: only two items when
removed have increased the internal consistency of the tool
(item n 4 and n 10) as reported in Table 2. The scale
showed excellent test–retest stability (r2 [ 0.85) for all
items.
The N2N HWEIta demonstrated high levels of accept-
ability among nurses: the response rate was, in fact,
96.4 %, and the instrument was proved to be not subject to
social desirability as no item exceeded the threshold of
60 % of respondents, ‘‘average’’ (2), as suggested by the
authors (Mays et al. 2011). The response variability was
also assured: analysing the skewness and kurtosis, only in
the second item, ‘‘I am relentless in pursuing and fostering
true collaboration’’, did responses focus on ‘‘Average’’ (2)
and ‘‘Below average’’ (1).
The CFA confirmed the existence of two factors. The
overall appropriateness of the model for a combination of
indices was evaluated (v2 189.57; df = 53; NFI 0.90;
Int Arch Occup Environ Health
123
NNFI 0.93; CFI 0.93; IFI 0.93; SRMR 0.071). An exami-
nation of the squared multiple correlations confirmed that
the items were appropriate measures for the latent vari-
ables. Furthermore, all of the items demonstrated suitable
t values as indicated in Fig. 1. A measurement model was
constructed fixing the correlation between the constructs at
1.0. The v2 difference test between the ‘‘free’’ model and
the ‘‘constrained’’ model was significant (p \ 0.05), indi-
cating that discriminant validity was achieved. With regard
to the reliability analysis, both factors achieved satisfactory
levels of composite reliability ([0.70).
Differences between healthy and unhealthy
environments
Eighty-seven (29.6 %) nurses expressed an overall mean
score C3, proving that they perceived the work environ-
ment as ‘‘healthy’’. The item that received the highest score
(mean 3.18, ±0.75) was ‘‘I am relentless in pursuing and
fostering true collaboration’’, while the one that scored
lowest (mean 2.13, ±0.99) was ‘‘Nurses are recognized and
recognize others for the value each brings to the work of
the organization’’ (Table 3).
Demographic and professional variables (age, gender,
educational background, unit and work position) and the
organizational factors (e.g. models of care delivery) were
identified: for each of these factors, associations with the
perception of a healthy nursing work environment or not
were explored with a bivariate analysis (Table 4). Working
under a functional model of care delivery (v2 24.856,
p 0.000) and being responsible for one project or more (v2
5.256, p 0.021) were associated with healthy environments.
Other factors were not associated with the perception of a
healthy or unhealthy nursing work environment.
Discussion
Study limitations
In nursing administration research as well as in health
service research, two perspectives might be assumed, the
diachronic and the synchronic (Kimberly 1976). The first
includes in the process of data collection and analysis also
the history of the organization which changes over time;
the second perspective measures the organization in a
precise moment without taking into consideration its past.
Having adopted the synchronic perspective, the results
emerged reflected a precise moment for the nurses
involved; therefore, comparisons must be made with
caution.
The participants were mainly Italian and with a per-
manent job: in recent years, the Italian nursing population,
due to actions taken to cope with the shortage, has been
characterized by a large number of foreigners, temporary
workers and outsourced nurses (Valenti et al. 2007). In the
inclusion criteria, at least 6 months of work in the same
unit was requested considering the minimal experience to
develop a perception regarding environment healthiness.
Therefore, further research should validate the instrument
also among recent nursing graduates and in those working
as agency float nurses who stay for short time (sometimes
Table 1 Participants’ characteristics
Variables Total
n = 294 (%; ±)
Gender
Male 43 (14.6)
Female 251 (85.4)
Age
Years 39.5 ± 8.45
Education
School of Nursing 153 (52.0)
Bachelor of Nursing Science 111 (37.8)
Advanced Nursing Education 30 (10.2)
Nationality
Italian 284 (96.6)
Foreign 10 (3.4)
Unit
Medical 66 (22.4)
Surgical 85 (28.9)
Critical care 60 (20.4)
Ambulatory 66 (22.4)
Operating room 7 (2.4)
Other 10 (3.4)
Work position
Temporary worker 11 (3.7)a
Permanent worker 283 (96.3)
Full time 226 (76.9)
Part time 68 (23.1)
Experience as a nurse
Overall (years) 16.1 ± 9.2
In the actual unit (years) 8.2 ± 6.2
Nursing care delivery models adopted
Functional 98 (33.3)
Team nursing/primary nursing 184 (62.6)
Other (e.g. mixed model) 12 (4.1)
Projects held by a nurseb
None 126 (42.8)
C1 10 (3.4)
Missed 158 (53.8)
a 10 out of 11 of those working in a temporary position were foreign
nursesb e.g. pressure sores surveys, prevention of patients falls
Int Arch Occup Environ Health
123
less than 1 week) in the same ward. Not lastly, with the
progressive diversification of the nursing workforce in
Italy, related to the complex phenomena of the increased
number of foreign residents which is estimated in Italy at
around 4.2 million (7 % of the total population [Iavicoli
et al. 2011]), there is a need to validate the instrument also
in a more multicultural nursing environment: in fact, the
amount of foreign nurses working in the 22 units included
was limited (3.4 %) less than reported at the national level
(Iavicoli et al. 2011). The issue of healthiness as perceived
by migrant workers needs to be considered taking into
account also linguistic, social and cultural issues of dif-
ferent ethnic groups.
The instrument was validated among nurses working at
the hospital level. Given that community nurses have less
opportunity to work in a group with colleagues, there is a
need to reflect on how to measure healthiness in this
setting as well as in the districts and in the home care
contexts.
Not lastly, according to the main intent of the study and
to the analytic strategy adopted, no comparison of the
ratings of self to co-workers by j Cohen was performed.
Table 2 N2N HWEIta version: measures of reliability and validity
Item Factors
(Mays
et al. 2011)
Standard Cronbach
a if the
item is
removed
Cronbach
aCorrected
item–total
correlation
(if item is
removed)
Item–total
correlation
Test–
retest
(r2)
Kurtosis Skewness
1 Factor 1 =
Self
I am as proficient in communication
as I am in clinical skills
0.732 0.76 0.514 0.53* 0.96** 0.34 -0.38
2 I am relentless in pursuing and
fostering true collaboration
0.717 0.567 0.63* 0.95** 2.27 -1.06
3 I am a valued and committed partner
in making policy, directing and
evaluating clinical care and
leading organizational operations
0.741 0.468 0.48* 0.86** -0.12 -0.16
4 I am assigned to the types of work or
patients for which I am prepared
0.755 0.425 0.43* 0.94** 0.54 -0.78
5 I am recognized and recognize
others for the value each brings to
the work of the organization
0.715 0.564 0.60* 0.91** 0.61 -0.77
6 I fully embrace the imperative of a
healthy work environment,
authentically live it and engage
others in its achievement
0.724 0.534 0.64* 0.95** 0.24 -0.54
7 Factor 2 =
Co-workers
Nurses are as proficient in
communication skills as they are in
clinical skills
0.756 0.77 0.520 0.59* 0.83** -0.05 -0.47
8 Nurses are relentless in pursuing and
fostering true collaboration
0.734 0.617 0.64* 0.88** 0.12 -0.52
9 Nurses are a valued and committed
partner in making policy directing
and evaluating clinical care and
leading organizational operations
0.753 0.528 0.66* 0.98** 0.26 -0.62
10 Staffing ensures the effective match
between patient needs and nurse
competencies
0.795 0.395 0.47* 0.97** -0.9 -0.17
11 Nurses are recognized for the value
each brings to the work of the
organization
0.733 0.605 0.65* 0.95** -0.42 -0.28
12 Nurse leaders fully embrace the
imperative of a healthy work
environment, authentically live it
and engage others in its
achievement
0.735 0.593 0.69* 1.0** -0.13 -0.61
* p = 0.01; ** p \ 0.01
Int Arch Occup Environ Health
123
Participants
The gender distribution of the participants, although in line
with data for the north-east of Italy where the study took
place (males 15.5 %, females 84.5 %), showed a higher
percentage of females (D ? 7.8 %) compared to the
national distribution (77.6 %) (Federazione Nazionale
Collegi IPASVI 2010). The average age of the participants
was lower (D - 2.7 years) compared to the national data
(42.2 years). The longer work experience of the participants
(mean 16.1 years) explains the limited amount of nurses
with a university degree (established in 1999). The amount
of full-time nurses (76.9 %) was lower (D - 12.1) than that
reported at the NHS level (Minister of Health 2012) but was
compatible with the specific geographical area where the
study was performed in which there is a limited support for
women who have children to look after. For this reason, the
occurrence of the part-time option was higher. A limited
proportion of foreign nurses (Fortunato 2012) emerged: this
may be due to the inclusion criteria considered as reported
within the study limitations. Therefore, within some limi-
tations, the demographic and professional characteristics of
the participants involved were generally in line with the
nursing profession in the north-east of Italy.
Fig. 1 Confirmative factor
analysis. v2 = 189.57;
df = 53; p = 0.0000;
SRMR = 0.071
Int Arch Occup Environ Health
123
The majority of the nurses reported to work in a team or
as a primary nurse: this reflects the great advancement
achieved by nurses in Italy, where the functional model
based on the division of tasks, without taking into con-
sideration the needs of the patients, was the basis for
nursing care for many years (Palese et al. 2012a). On the
contrary, the number of the nurses who reported managing
a project was limited, due to the recent introduction of
these forms of nurse involvement by hospitals.
N2N HWEIta version reliability and validity
With the growing attention being paid to the places of care
where nurses work and their healthiness, in the Italian
context, it is important to identify an instrument to measure
the quality of well-being perceived by nurses, in order to
establish whether it meets the standard or is higher or
lower.
From the psychometric perspective, evaluations con-
firmed the instrument validity and reliability. In line with
the US validation study (Mays et al. 2011), where the
internal consistency reported was a 0.75 in the ‘‘Self’’ sub-
scale and a 0.83 in the ‘‘Co-workers’’ sub-scale, the overall
Cronbach’s alpha obtained in our study was a 0.82,
respectively, 0.76 and 0.77 in each sub-scale. Data
emerging from the validation process confirmed the mul-
tidimensionality of the ‘‘healthy work environment’’ con-
struct: all items showed good item-to-total and item-to-
item correlation, justifying the need to keep each of them
within the instrument. Confirmatory factor analysis also
corroborated the existence of two factors (sub-scales) as
documented for the original instrument (Mays et al. 2011).
Moreover, emerged data indicated an acceptable but not
complete fit of the tool with the theoretical model: in
accordance with the general aim of the study which was to
validate within the Italian context an instrument including
international standards as well as allowing international
comparisons, all items (especially those increasing the a of
Cronbach and those reporting less acceptable results in the
CFA performed) were maintained in the tool. In addition,
this decision was undertaken because only recently (Palese
et al. 2012a) was the possibility introduced of assigning the
patients to a specific nurse according to his/her specific
preparation (Item n 4) and to identify the staff, ensuring an
effective match between patient needs and nurse compe-
tencies (Item n 10): these models of care are just emerging
and represent a goal of Italian nursing care. With their
implementation in daily practice, there is a need to re-
evaluate the CFA of the N2N NWEIta addressing the lim-
itations emerged in our study.
The acceptability of the instrument was high: only nine
questionnaires were invalidated, and all the eligible nurses
participated. In the administration of the instrument, par-
ticular attention paid to the relationship established with
each respondent (Kramer and Schmalenberg 2008) was
important for motivating the interviewee, informing him/
her about the aim of the research and clarifying the ade-
quate method for compiling and ensuring the return of data
with a final report. However, the response rate recorded in
our sample is higher than that of other studies that have
Table 3 N2N HWEIta version: healthy work environment as perceived by nurses
Item Factor Standard Mean ± Median Range C3 n (%)a
1 Factor
1 = Self
I am as proficient in communication as I am in clinical skills 2.99 ± 0.67 3 1–4 237 (80.6)
2 I am relentless in pursuing and fostering true collaboration 3.10 ± 0.75 3 0–4 254 (86.4)
3 I am a valued and committed partner in making policy, directing and
evaluating clinical care and leading organizational operations
2.54 ± 0.77 3 0–4 157 (53.4)
4 I am assigned to the types of work or patients for which I am prepared 2.82 ± 0.89 3 0–4 213 (72.4)
5 I am recognized and recognize others for the value each brings to the work
of the organization
2.82 ± 0.89 3 0–4 209 (71.1)
6 I fully embrace the imperative of a healthy work environment, authentically
live it and engage others in its achievement
2.82 ± 0.88 3 0–4 197 (67.0)
7 Factor
2 = Co-
workers
Nurses are as proficient in communication skills as they are in clinical skills 2.74 ± 0.83 3 0–4 197 (67.0)
8 Nurses are relentless in pursuing and fostering true collaboration 2.77 ± 0.86 3 0–4 187 (63.6)
9 Nurses are a valued and committed partner in making policy directing and
evaluating clinical care and leading organizational operations
2.84 ± 0.88 2 0–4 207 (70.4)
10 Staffing ensures the effective match between patient needs and nurse
competencies
2.18 ± 1.18 2 0–4 130 (44.2)
11 Nurses are recognized for the value each brings to the work of the
organization
2.13 ± 0.99 3 0–4 126 (42.9)
12 Nurse leaders fully embrace the imperative of a healthy work environment,
authentically live it and engage others in its achievement
2.40 ± 1.06 3 0–4 157 (53.4)
a C3 healthy work environment (Mays et al. 2011)
Int Arch Occup Environ Health
123
used tools for assessing nursing environment practices (e.g.
Papastavrou et al. 2011: from 35 to 88 %), and this seems
to suggest that the shortness of the instrument might play a
role in assuring nurses’ compliance with the survey.
Profiles of healthy and unhealthy work environments
Overall, only 87 nurses (29.6 %) were assigned a score C3
in all the items that define the ‘‘healthy’’ environment. In
the previous US sample (Mays et al. 2011), 51/208
(24.5 %) nurses perceived a healthy environment. These
differences might be explained by the different expecta-
tions of the nurses regarding work environments also
determined, as in the case of the Italian nurses, by the
recent advancements in the organizational level of nursing
care achieved (Palese et al. 2012a, b). Although in the US
sample the ‘‘Co-worker’’ sub-scale indicated that nurses
believed nurse leaders were responsible for the creation of
a healthy work environment and that communication and
recognition were key elements in maintaining health, in the
Italian sample, the nurses appreciated their own efforts
towards creating a healthy environment: the prevalence
reached a value of C3 for all items in the ‘‘Self’’ sub-scale
(from 53.4 to 86.4 %). However, they valued less highly
the contribution of nurse leaders to ensure a healthy work
environment: in fact, the three of out of six items included
in the ‘‘Co-Workers’’ sub-scale—‘‘Staffing ensures the
effective match between patient needs and nurse compe-
tencies’’, ‘‘Nurses are recognized for the value each brings
to the work of the organization’’ and ‘‘Nurse leaders fully
Table 4 Demographic,
professional and organizational
factors of groups of direct-care
nurses who rated healthy or
unhealthy work environments
a e.g. pressure sores surveys,
prevention of patients falls� v2� Mann–Whitney U test
Variables Unhealthy work
environment \3
average
n = 207 (%; ±)
Healthy work
environment C3
average
n = 87(%; ±)
p value
(df)�p value
(df)�
Gender
Male 26 (12.6) 17 (19.5) 0.172 (1)
Female 181 (87.4) 70 (80.5)
Age
Years 38.9 (±8.4) 40.2 (±8.6) 0.425 (292)
Education
School of Nursing 109 (52.7) 44 (50.6) 0.210 (2)
Bachelor of Nursing Science 81 (39.1) 30 (34.5)
Advanced Nursing Education 17 (8.2) 13 (14.9)
Unit
Medical 46 (22.2) 20 (23.0) 0.000 (5)
Surgical 48 (23.2) 37 (42.5)
Critical care 50 (24.2) 10 (11.5)
Ambulatory 51 (24.6) 15 (17.2)
Operating room 2 (1.0) 5 (5.8)
Other 10 (4.8) 0 (–)
Work position
Temporary worker 6 (2.9) 5 (5.7) 0.401 (1)
Permanent worker 201 (97.1) 82 (94.3)
Full time 164 (79.2) 62 (71.3) 0.184 (1)
Part time 43 (20.8) 25 (28.7)
Experience as a nurse
Overall (years) 15.9 (±9.2) 16.5 (±9.3) 0.692 (287)
In the actual ward (years) 8.45 (±6.2) 8.78 (±6.1) 0.636 (292)
Nursing care delivery models adopted
Functional 58 (28.0) 40 (46.0) 0.000 (2)
Team nursing/primary nursing 146 (70.5) 38 (43.7)
Other (e.g. mixed model) 3 (1.5) 9 (10.3)
Projects held by a nursea
None 89 (96.7) 37 (84.1) 0.021 (1)
C1 3 (3.3) 7 (15.9)
Int Arch Occup Environ Health
123
embrace the imperative of a healthy work environment’’—
achieved a value of C3, respectively, in 44.2, 42.9 and
53.4 % of the items. These differences might be explained
with the recent introduction of the concept of the ‘‘healthy
environment’’ in the Italian context. In fact, only since
2008 (Legislative Decree 81/2008) has the need been
established of managing human resources by protecting
them from possible aggression (e.g. stress, bullying) and by
guaranteeing protection from exposure to injury: respon-
sibility for this is recognized as being mainly part of the
nurse manager’s role. Instead, in the US and in Canada,
studies dedicated to the health of work environments began
already in the eighties (Malfa 1987).
Moreover, the results suggest that nurses do not feel
completely valued and recognized as integral components
of the team. Therefore, it may be necessary for nurse
leaders to develop a greater sense of social utility among
nurses, giving them new responsibilities, ensuring real
professional autonomy and promoting positive interper-
sonal relationships in the team. In these contexts, nurses
might achieve greater job satisfaction (Chang et al. 2005);
on the contrary, a lack of nurse recognition and promotion
of autonomy, as well as a lack of integration in teamwork,
might contribute to dissatisfaction and an unhealthy work
environment (Gillespie et al. 2009).
Italian nurses, as in the USA (Mays et al. 2011), dem-
onstrated that they evaluate themselves more highly when
compared to their co-workers: moreover, while this was
observed within the US sample in each item, our research
findings suggest that Italian nurses hand in better item
scores for colleagues (items 9 and 8). This could mean that
the team is integrated, and therefore, every nurse recog-
nizes the efforts of his/her colleagues in creating a healthy
work environment.
Age, gender, work experience, nursing education and
work position (temporary vs. permanent) were not associ-
ated with different perceptions of the healthy work envi-
ronment by nurses. While similar results were documented
by Mays et al. (2011), differences in their US sample
emerged, indicating that Italian younger nurses were like-
lier to perceive unhealthy environments: it should be noted
that our sample was more homogeneous in terms of age
(with a SD of 8.45) as compared to the US sample
(±10.37). Moreover, further studies investigating the
relationship between gender, age and healthy/unhealthy
work environments as perceived by nurses are needed.
Also, in contrast to the literature in which the sense of
insecurity and the risk of exclusion from the group are well
documented (Chu and Hsu 2011), working as a part-time
nurse was not associated with the perception of an
unhealthy environment.
Nurses who only carry out nursing care activities
reported to perceive the work environment to be less
healthy than those in charge of one or more clinical pro-
jects. Probably, nurses who manage one or more projects in
addition to clinical activity appreciated their value, the
ability to be autonomous and to control the practice (Setti
and Argentero 2011), and this might affect their perception
of a healthy nursing work environment.
Paradoxically, however, participants who work in a
functional manner, performing tasks but not taking care of
the patients in a holistic fashion as the primary nursing and
team nursing models do, reported perceiving a healthier
work environment. It can be assumed that performing tasks
gives a sense of security, due to the repetitive and routine
operations. The predictability of the work (Kristensen
1999) and being able to perform one or more tasks lead to a
sense of peace, crowned by the knowledge that at the end
of the shift, all necessary actions have been undertaken
(Clarke 2004).
The more healthy work environments have proven to be
those of surgical departments probably because in these
units, autonomy, empowerment and decision-making
opportunities and a shared organizational culture (Eren-
stein and McCaffrey 2007), recognized as antecedents of
healthy/unhealthy environments, were well developed.
Conclusions and implications for practice and research
The N2N HWEIta instrument, valid and reliable, and based
on international standards, allows a systematic assessment
of the healthiness of nursing work environments in hospi-
tals. The instrument may offer the opportunity to review
systematically the degree of healthiness of the nursing
work environment and assess the effects of the introduction
of new organizational models and of continuing educa-
tional strategies, allowing a timely organizational diagnosis
and helping in individuating targeted interventions. Nurses
involved in our study were making great efforts to create a
healthy nursing work environment. They recognized that
strong efforts are also made by fellow nurses. With regard
to nursing leaders, the need for further efforts emerged:
unfortunately, many organizations are not investing
resources in the development of both current and future
nurse leaders, helping them to build the skills needed to
promote healthy work environments in times of crisis.
In addition, there is a need to develop strategies for the
development and support of nurse leaders in their ability to
promote healthy environments: periodic coaching and
mentoring activities aimed at developing and maintaining a
participative leadership style need to be offered (Bator and
Yoder 2012). Particular attention should be given to units
(e.g. medicine, operating theatres), where the perception of
unhealthy environments was more reported by nurses. Due to
the growing tendency to introduce innovative nursing care
Int Arch Occup Environ Health
123
models, clinical nurses need to be supported in their sense of
insecurity in the transition from the functional model focused
on tasks to a patient-focused care model. Future research
should focus on minorities and nurses who work part time for
whom the literature has reported risks of increased occur-
rence of unhealthy environments. Future studies should also
test the validity and reliability of the N2N Healthy Work
Environment Italian instrument in settings other than hos-
pitals, such as community or residential care centres, and
enable international comparative studies to assess the per-
ception of environmental health nursing work in different
contexts and different cultural environments.
Acknowledgments The original project was supported in part by
funds from the Division of Nursing, Bureau of Health Professions,
Health Resources and Services Administration (HRSA), Department
of Health and Human Services under HRSA grant # 1 D11HP07364-
01-00, Nurse-to-Nurse: Improving RN Retention & Patient Care.
Authors thank Mary Z. Mays, David P. Hrabe, Carol J. Stevens
(USA), for their authorization and supervision. Authors also thank
Laura Pilotto and Ilario Guardini (Italy) for their valuable contribu-
tion to the backward and forward translation.
Conflict of interest The authors declare that they have no conflict
of interest.
References
Addley K, McQuillan P, Ruddle M (2001) Creating healthy
workplaces in Northern Ireland: evaluation of a lifestyle and
physical activity assessment programme. Occup Med (Lond)
51:439–449
Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH (2002)
Hospital nurse staffing and patient mortality, nurse burnout, and
job dissatisfaction. JAMA 288:1987–1993
Aiken LH, Havens DS, Sloane DM (2009) The magnet nursing
services recognition program: a comparison of two groups of
magnet hospitals. J Nurs Adm 39:5–14
American Association of Critical-Care Nurses (AACCN) (2005)
AACN standards for establishing and sustaining healthy work
environments: a journey to excellence. Am J Crit Care 14:187–197
Anderson JC, Gerbing DW (1988) Structural equation modelling in
practice: a review and recommended two-step approach. Psychol
Bull 103:411–423
Bagozzi RP, Foxall GR (1996) Construct validation of a measure of
adaptive-innovative cognitive styles in consumption. Int J Res
Mark 13:201–213
Bator VD, Yoder LH (2012) Managerial coaching: a concept analysis.
J Adv Nurs 18(7):1658–1669
Bollen KA (1989). Structural equations with latent variables. Wiley
Series in Probability and Mathematical Statistics, Wiley, New
York, USA
Bortoluzzi G, Palese A (2010) The Italian economic crisis and its
impact on nursing services and education: hard and challenging
times. J Nurs Manag 18:515–519
Bortoluzzi G, Caporale L, Palese A (2012) Does participative
leadership reduce the onset of mobbing risk among nurse
working teams? J Nurs Manag (in press)
Chang EM, Hancock KM, Johnson S, Daily J, Jackson D (2005) Role
stress in nurses: review of related factors and strategies for
moving forward. Nurs Health Sci 7:57–65
Chu CI, Hsu YF (2011) Hospital nurse job attitudes and performance:
the impact of employment status. J Nurs Res 19:53–60
Clarke SP (2004) Failure to rescue: lessons from missed opportunities
in care. Nurs Inq 11:67–71
Clegg A (2001) Occupational stress in nursing: a review of the
literature. Occup Med (Lond) 9:101–106
De Vellis RF (2003) Scale development theory and applications. Sage
Publications, Thousand Oaks
Disch J (2002) Creating healthy work environments. Creat Nurs 8:3–4
Donahue MO, Piazza IM, Griffin MQ, Dykes PC, Fitzpatrick JJ
(2008) The relationship between nurses’ perceptions of empow-
erment and patient satisfaction. Appl Nurs Res 21:2–7
Erenstein CF, McCaffrey R (2007) How healthcare work environ-
ments influence nurse retention. Holist Nurs Pract 21:303–307
Federazione Nazionale Collegi IPASVI (2010) Albo IP: analisi dei
flussi. IPASVI Publishing http://www.ipasvi.it/archivio_news/
pagine/96/Albo%20IP%20analisi%20dei%20flussi%20-%20
Rapporto%202009.pdf
Ferketich S (1991) Focus on psychometrics: aspects of item analysis.
Res Nurs Health 14:165–168
Fortunato E (2012) Gli infermieri stranieri in Italia: quanti sono, da
dove vengono e come sono distribuiti. L’infermiere 1:9–14
Gillespie BM, Chaboyer W, Wallis M, Chang HY, Werder H (2009)
Operating theatre nurses’ perceptions of competence: a focus
group study. J Adv Nurs 65:1019–1028
Hasselhorn HM, Muller BH, Tackenberg P (2005) NEXT scientific
report. University of Wuppertal, Germany
Healh J, Johanson W, Blake N (2004) Healthy work environments: a
validation of the literature. J Nurs Adm 34:524–530
Iavicoli S, Valenti A, Persechino B (2011) The management of
foreign workers in Italy. G Ital Med Lav Ergon 33(3):355–362
Im EO, Page R, Lin LC, Tsai HM, Cheng CY (2004) Rigor in cross-
cultural nursing research. Int J Nurs Stud 41(8):891–899
Institute of Medicine (IOM) (2004) Keeping patients safe: transform-
ing the work environment of nurses. The National Academic
Press, Washington
Khowaja K, Merchand RJ, Hirani D (2005) Registered nurses
perception of work satisfaction at a Tertiary Care University
Hospital. J Nurs Manag 13:32–39
Kimberly JR (1976) Issues in the design of longitudinal organiza-
tional research. Soc Meth Res 4:321–348
Kramer M, Schmalenberg C (2008) Healthy work environments. Crit
Care Nurse 28:56–63
Kristensen T (1999) Challenges for research and prevention in
relation to work and cardiovascular diseases. Scand J Work
Environ Health 25:550–557
Laschinger HKS (2008) Effect of empowerment on professional
practice environments, work satisfaction, and patient care
quality: further testing of the Nursing Worklife Model. J Nurs
Care Qual 23:322–330
Laschinger HKS, Finegan J (2005) Using empowerment to build trust
and respect in the workplace: a strategy for addressing the
nursing shortage. Nurs Econ 23:6–13
Laschinger HKS, Leiter MP (2006) The impact of nursing work
environments on patient safety outcomes: the mediating role of
burnout/engagement. J Nurs Adm 36:259–267
Laschinger HKS, Shamian J, Thomson D (2001) Impact of magnet
hospital characteristics on nurses’ perceptions of trust, burn-
out, quality of care and work satisfaction. Nurs Econ 19:
201–219
Laschinger HKS, Finegan J, Shamian J, Wilk P (2004) A longitudinal
analysis of the impact of workplace empowerment on work
satisfaction. J Organ Behav 25:527–545
Lautizi M, Laschinger HK, Ravazzolo S (2009) Workplace empow-
erment, job satisfaction and job stress among Italian mental
health nurses: an exploratory study. J Nurs Manag 17:446–452
Int Arch Occup Environ Health
123
Legislative Decree 81/2008 (2008) Management of a prevention of
risk in the work environment, Rome, Italy
Li J, Fu H, Hu Y, Shang L, Wu Y, Kristensen TS, Mueller BH,
Hasselhorn HM (2010) Psychosocial work environment and
intention to leave the nursing profession: results from the
longitudinal Chinese NEXT study. Scand J Public Health
38:69–80
Malfa R (1987) In: AIDP (Associazione Italiana per la Direzione del
Personale), Atti del Seminario ‘‘Qualita dell’aria negli uffici: la
sindrome dei palazzi malati’’, AIDP, Milan, Italy
Mays MZ, Hrabe DP, Stevens CJ (2011) Reliability and validity of an
instrument assessing nurses’ attitudes about healthy work
environments in hospitals. J Nurs Manag 19:18–26
McGillis Hall D, Doran D (2007) Nurses’ perceptions of hospital
work environments. J Nurs Manag 15:264–273
McKenna BG, Poole SJ, Smith NA, Coverdale JH, Gale CK (2003) A
survey of threats and violent behaviour by patients against
registered nurses in their first year of practice. Int J Ment Health
Nurs 12:56–63
Minister of Health (2012) Il Personale del Sistema Sanitario. Direzione
Generale del Sistema informativo e statistico sanitario Direzione
Generale delle Professioni sanitarie e delle Risorse Umane del SSN.
Publishing http://www.salute.gov.it/imgs/C_17_pubblicazioni_
1816_allegato.pdf
Nunnally J, Bernstein I (1994) Psychometric theory. McGraw-Hill,
New York
OECD (2010) Employment and the crisis on employment and
unemployment in the OECD countries. OECD Publishing, Paris,
p 2010
Palese A, Regattin L, Bertolano T, Brusaferro S (2006) La dotazione
di personale infermieristico nei reparti di chirurgia e ortopedia
italiani: risultati preliminari di uno studio pilota. Assist Inferm
Ric 25:206–213
Palese A, Mesaglio M, De Lucia P, Guardini I, Dal Forno M, Vesca
R, Boschetti B, Noacco M, Salmaso D (2012a) Nursing
effectiveness in Italy: findings from a grounded theory study.
J Nurs Manag. doi:10.1111/j.1365-2834.2012.01392.x
Palese A, Vianelli C, De Maino R, Bortoluzzi G (2012b) Measures of
cost containment, impact of the economical crisis, and the effects
perceived in nursing daily practice: an Italian crossover study.
Nurs Econ 30(2):86–93 119
Papastavrou E, Efstathiou G, Acaroglu R, Antunes Da Luz MD, Berg
A, Idvall E, Kalafati M, Kanan N, Katajisto J, Leino-Kilpi H,
Lemonidou C, Sendir M, Sousa VD, Suhonen R (2011) A seven
country comparison of nurses’ perceptions of their professional
practice environment. J Nurs Managi. doi:10.1111/j.1365-
2834.2011.01289.x
Pisanti R, Van der Doef M, Maes S, Lazzari D, Bertini M (2011) Job
characteristics, organisational conditions, and distress/well-being
among Italian and Dutch nurses: a cross-national comparison. Int
J Nurs Stud 48:829–837
Purdy N, Spence Laschinger HK, Finegan J, Kerr M, Olivera F (2010)
Effects of work environments on nurse and patient outcomes.
J Nurs Manag 18:901–913
Rodham K, Bell J (2002) Work stress: an exploratory study of the
practices and perceptions of female junior healthcare managers.
J Nurs Manag 10:5–11
Rosenstein AH (2002) Original research: nurse-physician relation-
ships: impact on nurse satisfaction and retention. Am J Nurs
102:26–34
Rosenstein AH, O’Daniel M (2005) Disruptive behavior and clinical
outcomes: perceptions of nurses and physicians. Am J Nurs
105:54–64
Scherer P, Devaux M (2010) The challenge of financing health care in
the current crisis: an analysis based on the OECD data. OECD
Health Working Papers, No. 49, OECD Publishing. http://dx.
doi.org/10.1787/5kmfkgr0nb20-en
Setti I, Argentero P (2011) Organizational features of workplace and
job engagement among Swiss healthcare workers. Nurs Health
Sci 13:425–432
Stringhetta F, Dal Ponte A, Palese A (2012) Evoluzione della carenza
infermieristica e strategie adottate per affrontarla: studio longi-
tudinale in undici aziende sanitarie. Assist Inferm Ric 31:
203–210
Ulrich BT, Buerhaus PI, Donelan K, Norman L, Dittus R (2007)
Magnet status and registered nurse views of the work environ-
ment and nursing as a career. J Nurs Adm 37:212–220
Valenti A, Boccuni F, Rondinone BM, Vonesch N, Iavicoli S (2007)
Migration, work flexibility and early retirement of nurses in
Italy. G Ital Med Lav Ergon 29:706–708
Vessey JA, Deamarco RF, Gaffney DA, Budin WC (2009) Bullying
of staff registered nurses in workplace: a preliminary study for
developing personal and organizational strategies for the trans-
formation of hostile to healthy workplace environments. J Prof
Nurs 25:299–306
Warshawsky NE, Havens DS (2011) Global use of the practice
environment scale of nursing index. Nurs Res 60:17–31
White M, Elander G (1992) Translation of an instrument. The US-
Nordic family dynamics nursing research project. Scand J Caring
Sci 6:161–164
Yildirim A, Yildirim D (2007) Mobbing in the workplace by peers
and managers: mobbing experienced by nurses working in
healthcare facilities in Turkey and its effect on nurses. J Clin
Nurs 16:444–453
Zohar D, Livne Y, Tenne-Gazit O, Admi H, Donchin Y (2007)
Healthcare climate: a framework for measuring and improving
patient safety. Crit Care Med 35:1312–1317
Int Arch Occup Environ Health
123
