Analysis of the work environment and intention of perioperative nurses to quit work

Objective: to investigate how the perioperative work environment affects work dissatisfaction, professional exhaustion and the perception of the quality of care about the intention of abandoning the work of perioperative nurses. 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 were factors that indicated the intention of perioperative nurses to abandon work. Conclusion: the implementation of strategies for the retention of perioperative nurses should be considered, improving the factors that indicate how the work environment, especially the allocation of personnel and resources, dissatisfaction and emotional exhaustion. Creating positive work environments based on magnetic values can be a key strategy.

(i.e., Cronbach's alpha coefficients) was 0.90 (95%CI: 0.87-0.93) (19) . Regarding the PES-NWI responses, the mean of each dimension was performed. The The exhaustion of the nurse at work was measured using the Maslach Burnout Inventory (MBI) (20) , in its version validated to the Spanish language (21) . The instruments consists of 3 dimensions: Emotional exhaustion (EE), Depersonalization (DP) and Personal Achievement (PA), including 22 items measured on a Likert scale of 1 to 6 points ('never', up to 'every day'). The EE contains 9 items; the DP, 5 items and PA, 8 items with a maximum score of 54.48 and 30, respectively. They were categorized into 3 groups each (low, medium and high), according to the values: EE: low ≤ 18, mean [19][20][21][22][23][24][25][26], high ≥ 27; DP: low ≤ 5, medium [6-9], high ≥ 10; PA: low ≥ 40, medium [39-34], high ≤ 33. For global valuation, High Burnout occurred when 2 to 3 dimensions present high levels; when 2 or more dimensions have average or well one scale valuations at each level and low, when more than two dimensions have low levels, following the criteria that are used in the RN4Cast Spain study (10) . Following the methodology used by the study of the European RN4Cast (22) , work satisfaction (WS) was evaluated using nine articles that point out the specific aspects of job satisfaction: flexible schedules, professional development, autonomy, status, salary, training, vacations, dismissals and licenses for studies. All items used a 4-point Likert scale, ranging from 1, "very dissatisfied" to 4, "very satisfied". In addition, the perception of the quality of care was established by one question: "In general, how would you describe the quality of nursing care that is delivered to patients in your unit?". They could respond to this question on a four-point response scale with 'bad', 'regular', 'good' or 'excellent'. Finally, the intention to abandon the work that was measured by a single binary response (yes/no).  (23) and the hospitals of the RN4CAST Spain (10) study, obtained from the literature review in different databases (Pubmed, CINAHL, Scopus). The mean score per item, subscale mean or dimension, global mean, and levels are reported.

Results
In total, 130 questionnaires were obtained that were completed and the overall response rate was 98%. Most were women (91.5%, n = 119) and married (75%, n = 57). The mean age was 44.5 years (SD = 11.90); mean professional experience in the institution was 20 years (SD = 12.3) and in the unit, 13.9 years (SD = 11.14).
Most professionals (73%, n = 96), worked in the operating room (83%, n = 108), had a fixed contract (58.5%, They all belong to the nurse's participation dimension in hospital affairs. The results are presented in Table 1. and "nurse-physician relationships" were higher than the levels of those studied in Spain. In general, the scores that were obtained in this study indicate that nurses have similar qualifications of the work environment as Spanish hospitals and lower than those obtained in Magnetic Hospitals. The results are shown in Table 2 Regarding burnout, perioperative nurses presented moderate levels (global burnout: mean 47%, n=36 and high level 6%, n=5. High levels of burnout were identified in 25% (n=19) of nurses had high levels of exhaustion. High levels of depersonalization were observed in 10% (n=8) of the sample, and high levels of personal achievement in 21% (n=16).
Regarding job satisfaction, in all items, the highest response percentage was not dissatisfied, always above 52% and even reaching 98%. Despite the minimum differences between one and other variables, the highest mean, which indicates the highest degree of satisfaction, was observed in the item flexible hours. On the other hand, the variables with the highest degree of dissatisfaction were salaries, the opportunity for professional development and the licenses for studies. In total, 74.3% (n=97) of the nurses were little dissatisfied with their current work in the hospital, and 20% (n=26) intended to leave their position. Regarding the quality of care in their unit, more than half of those who were interviewed reported good quality care 61% (n=79) and excellent 14% (n=11). Results are shown in Table 3.    And nurses with emotional exhaustion also had 1.11 times more risk of intent to quit work than those who did not. The most positive perceptions of staff allocation and adequate resources were associated with a lower level of intention to abandon by nurses.
Predictors that nurses intend to abandon or change work are shown in Table 5.

2014-2015
In the Spanish health system, the past economic crisis particularly affected the nursing profession by affecting the nurse/patient relationship, being a negative trend during these years and affecting the quality of care due to work overload (28) .
Other studies showed that the environments that were perceived by nurses as positive were translated into greater job satisfaction, lower levels of exhaustion and a lower intention of abandoning current employment and the profession, resulting in improved patient care (29) . In the current study, there is an association between the environment of perioperative nurse practice and the intention to abandon, especially a negative association with the size of staff and resources. According to recent studies, staff shortages result in a work overload with significant and direct effects on adverse events in patients (11,30) . And even if the dimensions of the work environment such as quality foundations and the employment relationship between nurses and physicians seem satisfactory, the central problems are in the design of work and the management of personnel that threaten quality care to the patient. It is crucial to solve these problems, which are susceptible to intervention of institutional management, to preserve the safety and quality of patient care. These results are consistent with the findings that have been described in other studies that were conducted by the European RN4CAST (10,31) .
The dimension that was best valued by perioperative nurses regards to the quality of care they provide, which was good and is comparable with other studies with better environments (32) . Perioperative nurses have a training of specialists or those graduated in perioperative carealthough there is still no specialty course on perioperative nursing -which requires specialized skills from them (33) .
The absence of a training system that is regulated for perioperative nursing staff in Spain will stand out as In this study, the environment was also characterized by good colleague relationships between nurses and physicians, although there is an important margin for improvement, similar to other similar studies (14) . In the studies of Magnetic Hospitals, the quality of collaboration between nurse and physician was an important feature of a healthy, high-performance work environment that increases the retention of nurse (15) . Furthermore, they reported few opportunities to participate in decision making in their unit. In another study, it was demonstrated that the participation of nurses in decisions improve efficiency and efficacy at the unit level (11) . Nurses' dissatisfaction was mainly related to the few opportunities for professional development and wages. The economic remuneration they perceive is not in proportion to the work they provide and educational requirements. These aspects were also negative in the studies of RN4Cast Spain (10) , so it will reflect on the priorities in our Spanish Sanitary System and not only in our organization.

Conclusion
In the perioperative care environment of this hospital, especially, the lack of personnel and resources, dissatisfaction and emotional exhaustion provoke, in perioperative nurses, the intention to abandon their work. One will consider implementing strategies for the retention of perioperative nurses, improving predicting factors such as: the work environment, especially the allocation of personnel and resources, dissatisfaction and emotional exhaustion. Creating positive work environments that are based on magnetic values can be a key strategy.