Relationship between nurses’ perception of professional shared governance and their career motivation: A cross-sectional study

Amal Dia Ghanem Atalla ,Loujain Sau Sharif ,Nouran Essam Katooa ,Faten Shawky Kanil ,Alaa Mahsoon ,Naglaa Aelaziz Mahmou Elseesy

a Department of Nursing Administration, Faculty of Nursing, Alexandria University, Alexandria, Egypt

b Department of Psychiatric and Mental Health Nursing, Faculty of Nursing, King Abdulaziz University, Jeddah, Saudi Arabia

c Department of Maternity and Child Health, Faculty of Nursing, King Abdulaziz University, Jeddah, Saudi Arabia

d Department of Medical Surgical Nursing, Faculty of Nursing, King Abdulaziz University, Jeddah, Saudi Arabia

e Department of Public Health Nursing, Faculty of Nursing, King Abdulaziz University, Jeddah, Saudi Arabia

Keywords:Career motivation Nurses Nursing administration research Shared governance

ABSTRACT Objective: This study aimed to investigate the level of professional shared governance and career motivation and their relationship among nurses in Egypt.Methods: A cross-sectional survey was conducted.A total of 724 nurses working in inpatient medical,surgical,and critical care units in Alexandria Main University Hospital were recruited from May to August 2022.The Index of Professional Nursing Governance (IPNG) version 3.0 and the Career Motivation Scale were used for evaluation.Results: The IPNG version 3.0 total score was 109.18 ± 22.76,that nurses perceived had a low level of professional shared governance;the access to information dimension achieved the highest average mean score(2.81±0.76),followed by the ability to set goals and conflict resolution dimension(2.75±0.53).On the other hand,the dimension of participation in the committee structure achieved the lowest average mean score (1.65 ± 0.37).The total score of career motivation was 69.82 ± 9.70 this reflects that nurses perceived a moderate level of career motivation.The career insight dimension achieved the highest average mean score (3.56 ± 0.34),while the career resilience dimension achieved the lowest average mean score(3.07±0.49).Male nurses,less than 30 years old,had a bachelor’s degree in nursing sciences,and worked in the ICU had higher total scores of the IPNG and career motivation(P ＜0.001).There was a positive correlation between the IPNG version 3.0 score and the Career Motivation Scale score(r=0.239,P=0.003).Conclusions: The study’s findings can serve as a theoretical foundation for nursing managers to re-plan the management model and develop appropriate methods to give better career planning for nurses.

What is known?

· The prominence of professional shared governance and career motivation is accentuated in health systems.

· Career motivation may still be taken the wrong way.

What is new?

· This study investigated the relationship between nurses’perception of professional shared governance and their career motivation.There was a statistical correlation between both of those variables.

· Based on the study findings,we highlight the importance of nurses’ participation in nursing governance committees’ structures and clinical decision-making and developing professional shared governance awareness programs in healthcare systems.

1.Introduction

Shared governance has become more predominant,particularly in healthcare settings aiming to maintain excellent patient care service areas and interested in fulfilling Magnet requirements or starting the pathway to excellence [1].Healthcare organizations work to create the conditions for excellent professional practice in the rapidly evolving healthcare system.Improving clinical nurse work conditions presents a significant challenge for nurse executives and administrators.They must cultivate nursing governance prototypes and leadership approaches that empower nurses to participate in work interactions and connections demonstrably related to patient consequences and care quality [2].

Shared governance is defined as a specialized practice model that supports nursing empowerment and mutual decision-making by making nurses accountable for decisions that influence policies and care delivery processes[3].The shared governance structure is a distinguishing feature of incorporating the front-line workforce in guiding excellence,a nursing practice model.Ownership,responsibility,empowerment,teamwork,leadership,creativity,independence,and equity are the main tenets of shared governance.When combined with formal models,these fundamental ideas of shared governance can inspire long-term action planning for development [4].

Successful shared governance mechanisms help healthcare organizations in internal succession planning.Bedside nurses can see their leadership abilities by actively participating in decisionmaking,rules,and procedures.Nurses now lead these councils from becoming council members to serving as chair.As a result of this participatory process,active learning happens.The development of nursing leaders internally enables healthcare businesses to invest in the organization’s future and supports career ladder plans[5].A promising technique to enhance the well-being of new nurses and their retention in the profession is organizational initiatives to boost autonomous over controlled career motivation [6].

Regarding nurses’ career motivation,autonomy and control were emphasized as essential needs.It involves having authority over one’s work life and being able to behave in a way compatible with their values [7].The wellness,organizational performance,satisfaction,retention,engagement,and commitment of nurses are all impacted by their level of job motivation [8].The feeling of happiness is seen as a highly developed psychological experience of individuals in relation to wellness [9].Intrinsically driven people discovered that their jobs are interesting,stimulating,and enjoyable [10].

Career motivation is well-defined as the aspiration to augment career goals.It is a multidimensional construct that syndicates the basics of requirements,securities,and personality characteristics that return the incentive,track,and perseverance of career-related behaviors[11].It boosts nurses to participate in career planning and decision-making by allowing them to do so.Also,it increases their ability to become accustomed to varying conditions,allowing them to achieve organizational and personal goals [12].

The significance of the present study stems from the importance of the variables addressed in the research process and the value of the study population,which is the nurses’staff in general.Nursing is a challenging profession that requires extraordinary focus and competency to deliver the highest quality care and seeks to achieve different goals simultaneously.Nurses are considered the prevalent professional cluster in healthcare organizations and significantly influence safe,high-quality patient care [13].Alternatively,the employment of shared governance in the healthcare industry is crucial for achieving quality and excellence in patient care.It also helps to improve the working conditions for nurses and helps healthcare organizations provide the best care possible,which benefits nurses,financiers,and patients in addition to the healthcare organizations themselves [14].

Therefore,improving nurses’ shared governance is necessary.Particularly,the selected study hospital has the utmost sum of healthcare suppliers.It has diverse categories and educational qualifications for nurses.It accepts patients from all governorates in Egypt.It delivers wide-ranging healthcare services.Also,it is recognized by applying the four focal principles of nursing governance that are well-thought-out as the crucial components and cornerstone of governance.These principles are partnership,accountability,equity,and ownership.When these principles are unified within the hospital environment,professional work empowerment is heightened,and nurses’ career motivation is reinforced.Thus,further exploration and measurement of professional nursing governance is recommended in wider,diverse healthcare contexts.

The career motivation system was discovered to be the most important factor in an employee’s success or failure at work,and if it is disregarded,initiative resources may be wasted.Therefore,any enterprise must support employee career motivation to increase job success and reduce resource wastage.Career motivation is a key result of shared governance;head nurses become managers of their care through shared governance.This grants them more autonomy in practice,increases their sense of worth,and encourages them to pursue professional and personal career advancement,enabling them to improve the working environment for themselves and their patients [15].Conversely,a research gap was recognized in inspecting the relationship between professional shared governance and nurses’ career motivation.Conducting regular pulse checks to evaluate the existing state of shared governance and career motivation among nurses is crucial for ongoing progress and development in the Alexandria governorate.These assessments,along with others,will enable a thorough understanding of the achievements of the shared governance framework and provide necessary data to facilitate ongoing evaluation and planning for performance improvement.The current study explores the correlation between nurses’ views on professional shared governance and their drive for career advancement.So,there is a significant need to address and examine the relationship between both to provide strong research-based evidence supporting the available literature.

2.Methods

2.1.Study setting and participants

A cross-sectional design was conducted.The present study was executed in all inpatient surgical,medical,and critical care units at Alexandria Main University Hospital.The hospital is furnished with 6,658 beds and is considered the utmost sum of healthcare suppliers with diverse categories and qualifications of nurses,for instance,professional,technical,and diploma nurses.Also,this hospital delivers wide-ranging healthcare services as inpatient,outpatient,critical,intensive,and emergency care,radiological,laboratory,and physical therapy service areas for patients from all governorates in Egypt.The size of surgical care units and their specialties is 775 beds,medical care units include 953 beds,and critical care units have 101 beds.Surgical care units and their specialties include 17 units,while medical care units their specialties include 25 units,and critical care units comprise 13 units.

The study participants included all target populations of nurses:that is a type of purposive sampling technique where we choose to examine the entire population(i.e.,the total population)that has a particular set of characteristics (inclusion criteria) [16].The participants included nurses who were working in the previously mentioned units with an experience of a minimum of one year to be more familiar with the hospital system,administrative rules,policies,and regulations and who were present throughout data collection and willing to take part in this study(n=724).They were classified as follows: nurses who were working in surgical care units (n=260),in medical care units (n=236),and critical care units (n=228).Participants in the study were the nurses selected based on the following criteria: 1) working in previously selected settings;2) having experienced a minimum of one year in the working unit;and 3) delivering direct patient care.

2.2.Instrument

2.2.1.Sociodemographic information questionnaire

This questionnaire gathered information on demographic characteristics,including sex,age,department,educational qualifications,years of experience in nursing,years of experience in working units,and weekly working hours.

2.2.2.Index of Professional Nursing Governance(IPNG)version 3.0

The shorter IPNG version 3.0,which was developed by Dr.Robert Hess in June 2017 [17],was used to evaluate professional nursing governance level on a scale ranging from traditional to shared governance to self-governance,comprised of 50 items distributed into six dimensions,namely;control over professional practice (8 items),influence over resources (8 items),official authority (authority granted and recognized by the organization) or control over personnel (12 items),participation in committee structure (8 items),access to information (9 items),and ability to set goals and conflict resolution(5 items).The responses were rated on a five-point Likert scale ranging from 1 to 5 in this manner:1=nursing administration only,2=primarily nursing administration with some nurses input,3=equally shared by nurses and nursing administration,4=primarily nurses with some nursing administration,and 5=nurses only.Scoring for the total scale ranged from 50 to 250,reflecting the nursing governance environment.The total score of IPNG ranges from 50 to 250 distributed on the following levels:1) score ranges from 50 to 149 replicating traditional management decision-making;2)score ranges from 150 to 199 replicating professional nursing shared governance decision-making between nurses and management;3)score ranges from 200 to 250 replicating self-governance by nurses [18].The IPNG survey was reliable,with Cronbach’s α coefficient of 0.914[18].

2.2.3.Career Motivation Scale

London developed this scale in 1993 [19] and NOE et al.,1990[20]and adapted by Day&Allen 2004[21]and this adapted version was used by the researchers.This scale consists of four main domains and 21 sub-items classified as follows[17]:career insight(7 items),career resilience(7 items),and career identity(7 items).The responses were graded on a five-point Likert scale ranging from 1(a very slight extent)to 5(a very large extent).The whole score ranges from 35 to 105.The total score ranging from 35 to 58 reflects that nurses perceived a low level of career motivation,59-81 reflects the moderate level of career motivation,and 82-105 reflects a high level of career motivation as perceived by nurses.This scale was reliable,with Cronbach’s α coefficient of 0.989 [14].

2.2.4.Data quality control technique

The study tools were reformed,translated,and back-translated into Arabic and tested for face validity by a panel of five experts in the field of the study.They were as follows:two professors from the Faculty of Nursing,Alexandria University,and three professors from the Faculty of Nursing,Damanhur University,to evaluate face and content validity and provide feedback concerning the relevance,the accuracy of translated questions,and the simplicity of items.Their commentaries were considered to guarantee accuracy.The pilot study was carried out on 10% of nurses (n=73) to safeguard the simplicity and practicability of items and identify barriers and issues that may arise during data collection.There was no need for modification.The study sample did not include those who participated in the pilot study.The completed questionnaires were analyzed for inclusiveness and correctness by the researchers.

2.3.Data collection

The study questionnaires were circulated individually to nurses.Because of the nurses’ regular attendance at the hospital,the researchers distributed hand-delivered questionnaires individually to each nurse and collected the completed forms.The study tools were hand-delivered and distributed to the study participants;after explaining the purpose of the study,they were asked to return it to the researcher.These scales were completed in the presence of the researcher to ensure the objectivity of the respondents’ responses,non-contamination of their opinions,and that all items were answered.As they linked to specific working units,it was easy to follow up on the distribution and collection to ensure the maximum response rate.Participants received small treats for their participation.Data collection took three months,from May to August 2022.Researchers provide nurses with slight threats of their involvement,thus ensuring the maximum response rate (100%)(n=724).Clarifications were given,and all nurses’questions were answered.

2.4.Ethical considerations

The Research Ethics Committee of the Faculty of Nursing,Alexandria University,approved the study protocol(IRB00013620).Informed consent was obtained from nurses after clarifying the study’s aim.Confidentiality and anonymity were guaranteed by allocating a code number for a questionnaire.Nurses were guaranteed that data was used only for research purposes.The right to withdraw from the study has been confirmed.

2.5.Data analysis

SPSS version 23.0 was used to analyze the data.Continuous variables were described by mean,standard deviation,and categorical variables by frequency and percentage.The data that did not follow a normal distribution were investigated after normal transformation.Comparison among groups was conducted by“post hoc”command.The Spearman’s correlation coefficient was used to explore the relationship between the study variables.The Kruskal-WallisHtest(sometimes called the“one-way ANOVA on ranks”)is a rank-based nonparametric test used to decide if there are statistically significant differences between two groups or more groups of an independent variable on a continuous or ordinal dependent variable.Mann-Whitney test is a non-parametric test used to compare two means derived from similar populations.P＜0.05 was considered statistically significant.

3.Results

3.1.Participants characteristics

Among the 724 nurse participants,the majority were female(86.0%),and 14.0%were male.Slightly less than one-half were aged 30-40 (46.8%),while 9.3% were aged 41-50.It was observed that 42.5% of nurses were working in surgical care units.Concerning nurses’educational qualifications,31.1%held a bachelor’s degree in nursing sciences.Also,31.8% of nurses had more than 20 years of experience in their working units.The majority of the nurses(92.7%) worked from 36 to 40 h/per week.

3.2.Overall status of IPNG and career motivation among nurses

As evident in Table 1,the IPNG total score was 109.18 ± 22.76,replicating that the nurses perceived traditional management decision-making.The access to information dimension achieved the highest average mean score (2.81 ± 0.76),followed by the ability to set goals and conflict resolution dimension(2.75±0.53).On the other hand,the dimension of participation in the committee structure achieved the lowest average mean score(1.65±0.37).In Table 1,the total score of career motivation was 69.82 ± 9.70 this reflects that nurses perceived a moderate level of career motivation.The career insight dimension achieved the highest average mean score (3.56 ± 0.34),while the career resilience dimension achieved the lowest average mean score (3.07 ± 0.49).

Table 1 The scores of the IPNG and Career Motivation Scale among nurses (n=724).

3.3.The influence of socio-demographic variables on the IPNG and career motivation

There were statistically significant differences in the total score of the IPNG and career motivation based on all sociodemographic characteristics (P＜0.001) except career motivation with weekly working hours,as there were no statistically significant differences(P=0.684).The total score of the IPNG and career motivation were higher among the following characteristics:male nurses,less than 30 years old,had a bachelor’s degree in nursing sciences,and worked in ICU (P＜0.001).The total score of IPNG was higher among nurses who experienced from 5 to 10 years in nursing and their working units and those who worked from 37 to 40 weekly working hours(P＜0.001),while the score of career motivation was higher among nurses who experienced less than 5 years of experience in nursing and their working units,those who worked less than 36 weekly working hours (Table 2).

Table 2 The score of the IPNG and Career Motivation Scale among nurses with different characteristics(n=724).

3.4.The correlation between IPNG and career motivation

Table 3 exhibits a statistically positive correlation between the score of the IPNG and the Career Motivation Scale (r=0.239,P=0.003).There was a positive correlation between control over professional practice and the three dimensions of career motivation: career resilience (r=0.834),career identity (r=0.715),and career insight(r=0.464)(P＜0.001).Also,there was a statistically positive correlation between participation in committee structurewith career resilience(r=0.247) and career insight (r=0.479)(P＜0.001).

Table 3 The relationship between the scores of the IPNG and Career Motivation Scale among nurse (r).

4.Discussion

Healthcare organizations are required to share nurses in decisions as an inspiring variable for motivating them.A beneficial work environment influences nurses’ satisfaction and enhances career motivation [22].The present study’s findings indicated that the studied nurses perceived a low level of shared governance and showed a traditional management level,in which top-level managers control all domains of shared governance.This may be because it is assumed that nurses won’t have the opportunity to participate in future decisions involving shared governance areas,including participation in committee structures,access to information,setting goals,and dispute resolution.During the data collection,nurses reported that managers and leaders made most nursing-related decisions without or with little input from nurses.Numerous stakeholders may identify this as a lack of nurse autonomy and accountability in clinical practice.Given that most were diploma nurses,their lack of experience in the current work units,lack of preparedness for shared governance,and rise in nurses’ workload without compensation may have contributed to their poor educational credentials.Moreover,the duty schedule and nursing shortage may also impact nurses’ decision-making.Additionally,it can be because of the study hospital’s organizational hierarchy and topdown command of modifications,as well as a misuse of the process for discussing opinions when making decisions.

In agreement with the present study,not mature enough nurses’perceptions toward shared governance to apply shared governance models,and mentioned that designing,implementing,and evaluating a shared governance program is a difficult task and found different barriers to shared governance implementation [23].This finding aligns with Wilson’s (2013) finding that nurses are still unprepared and need preparation before implementing shared governance [24].

Moreover,the present study showed that access to the information dimension achieved the highest mean score.This result could be due to the supposition that the hospital permits the free flow of healthcare information and emphasizes promoting and protecting human rights and preventing legal liabilities.Information access is related to the hospital’s mission,vision,goals and objectives,and patient and employees’ rights and responsibilities.This result is inconsistent with Mahmoud (2016),who stated that the ability to set goals was the highest mean percentage score of nursing governance,followed by conflict resolution [22].Furthermore,in contrast with the current study results,Abou Hashish &Fargally (2018) and Al-Faouri et al.(2014) reported that nurses graded the highest measurement of professional nursing governance components was said to have dominion over their professional practice [2,12].

The present study’s finding pointed out that participation in committee structure achieved the lowest mean score.This may be attributed to the fact that the studied nurses,during the data collection,stated that they were less involved in the committees’structure for clinical practice.Committees are held only for managerial matters,such as employment,scheduling,and accounting.The hospital administration committee was responsible for staff benefits,strategic planning,and no established nursing departmental committees.This was consistent with Mahmoud(2016),who stated that nurses had restricted capability to contribute to committees connected to strategic planning,multidisciplinary competence,and organizational budget[22].Along the same line,Kieft et al.(2014)stated that nurses are not in charge and have no voice in nursing focuses related to committees such asstaffing,scheduling,and clinical nursing services [25].

The study results align with Seada and Etway(2012),who noted that nurses perceived high traditional governance levels and low shared and self-governance levels [26].Additionally,Kamel and Mohammed (2015) found that traditional governance was indicated by the nursing governance’s overall mean score [27].On the other hand,about 50% of nurses believed that their hospital practiced traditional nursing governance.According to the results of the current study,the least amount of them believed that their hospital practiced self-governance,and slightly less than half believed that nursing governance levels were shared [18].The results also contradict what Afeef et al.(2010)stated on how nurses viewed the shared governance structure [28].Al-Faouri et al.(2014) also discovered that nurses had high levels of shared governance [12].

It can be observed that the studied nurses had a low level of career motivation.This may be because nurses do not have clear,realistic career goals,are unfamiliar with their strengths and weaknesses,lack awareness related to their jobs,and ignore how to become up-to-date on developments in their line of work.Nurses detailed that their supervisor was unhelpful,did not motivate subordinates to establish career goals,and did not start conversations on improvement and career-connected matters.This was in the same line with Alniacik et al.(2012),who reported that nurses have a moderate level of career motivation [29].

The current study showed that career insight reached the highest mean of career motivation domains.This may be because those nurses have clear,realistic career goals and know their strengths and weaknesses.This was supported by Day and Allen(2004),who mentioned that career insight had the highest percent of the high level of career motivation domains,confirming that managers set career goals and have a specific plan for accomplishing these career goals [21].Additionally,McLaughlin et al.(2010) concluded that nurses with more advanced career insight are more successful in cross-cultural assignments because they have a clearer understanding of their professional objectives,strengths and weaknesses,and plans.The present study showed that career resilience attained the lowest mean of career motivation domains [30].This was inconsistent with Reyes and Conde (2017),who reported that career identity was the highest percent of moderate level of career motivation domains [11].

Nurses’ overall shared governance and career motivation differ significantly regarding nurses’ sociodemographic data.In contrast,Alniacik et al.(2012) revealed that characteristics that influence career motivation are reinforced only for the position.Other individual characteristics,for instance,age,income,and years of experience,did not exert any important relations with career motivation [30].

Participants who aged less than 30 years had surpassing scores in the overall shared governance and career motivation.Nurses experienced in the nursing field and working units from five to less than ten years had higher scores.This was a very surprising result as the researchers anticipated that increased age and years of experience allow nurses to participate and give their opinions in most decisions related to control above their professional practice,personnel,and resources,allowing them to reach information and setting career goals and conflict resolution.In disagreement with the present study,Wilson(2013)supported the same results as he stated in his research,that nurses in the age group (41-50 years)and (21-26 years) reported low perception levels of shared governance [24].

The present study displayed that nurses working in ICUs had greater overall shared governance and career motivation scores.This could be due to the collaborative work environment of these units,the flexibility of nursing management,and more delegation of some roles to nurses working in these units.Also,nurses can set clear career goals and plans and sufficiently handle work problems in a supportive ICU culture with trust,respect,good communication skills,and relationships between nurses and managers.

The present study showed a positive correlation between shared governance and career motivation.This could be attributed to the assumption that managers who share decisions with their subordinates,allowing them to control their practices,helping them to establish clear,realistic career goals,have a specific plan for achieving these goals,and recognize one’s strengths and weaknesses.This finding is supported by Gyorffy et al.(2016),who found that hospitals that deliver nurses with the highest chances to be involved in shared governance,helping them to fine-tune to fluctuating conditions,be ready to take hazards,can sufficiently handle work-related problems and planned better methods of performing their work.In addition,they are more likely to offer the greatest patient experiences and better quality of care [31].Accordingly,Meyers and Costanzo (2015) stated that implementing shared governance enhanced the adoption of new practices that improve nursing outcomes [32].In the same way,Line,Reyes,and Conde(2017)found that career motivation was more closely related to the contribution of employees in decisions that correlated to their clinical actions and practice,confirming that to enhance employees'career motivation,managers should provide them with positive reinforcement,allowing them to participate in decisions and access to necessary information [11].

In contrast,Lamoureux et al.(2014) stated that nurses under traditional management (nurses not sharing in decision-making)don’t necessarily from being involved in their jobs since it is often possible for them to adapt to traditional management and becoming involved in their careers,taken courses toward a jobrelated degree and request promotions [33].

Some limitations have existed in this study.Primary generalization cannot be done as the study was done in one hub.Another,the present study assessed only the relationship between nurses’perceptions of career motivation and their perception of shared governance.Other variables that can affect career motivation can be measured in future research.Also,the paper-based questionnaire required a massive data entry and cleaning effort.As a final point,the study did not entail causality between factors.It is aimed to discover the relationship between variables.

5.Conclusion

According to the current study,nurses had a low perception of professional shared governance and career motivation at Alexandria Main University Hospital.Also,a positive correlation was found between shared governance and career motivation.Based on the present study’s findings,hospital administrators should allow nurse managers and nurses to join instructive and training programs,symposiums,workshops,and meetings on nursing governance practices and career motivation.Also,enhancing nurse managers’ and nurses’ open communication channels,supporting nurses’participation in nursing governance committees’structures and clinical decision-making,and assuring equal resource allocation and opportunities for career motivation.Finally,review the organizational policies periodically and support the organizational policies that enhance shared governance and nurses’ career motivation.

Moreover,first-line nurse managers should adopt strategies that provide nurses equal chances for training on nursing governance practices and career motivation-adjusting calendars for attending nurses’ meetings and listening to their opinions,ideas,views,and concerns.In addition,inspiring nurses’ initiative ideas concerning what is possible and how to fulfill them and enhance their positive expectations is essential-discussing how nurses can make a consensus to choose the best decisions and plan for career progress they will have to make.This can be done by considering team attitudes,priorities,and different approaches.

Funding

Nothing to declare.

Data availability statement

The datasets generated during and analyzed during the current study are available from the corresponding author upon reasonable request.

CRediT authorship contribution statement

Amal Diab Ghanem Atalla:Conceptualization,Methodology,Writing -review &editing,Software,Validation.Loujain Saud Sharif:Software,Writing -review &editing.Nouran Essam Katooa:Data curation,Writing -original draft.Faten Shawky Kandil:Visualization,Investigation,Writing -review &editing.Alaa Mahsoon:Supervision,Writing -review &editing.Naglaa Abdelaziz Mahmoud Elseesy:Software,Validation,Writing -review&editing.

Declaration of competing interest

The authors have declared no conflict of interest.

Acknowledgements

Our deepest thanks to the hospital director and first level nurse managers of clinical units at Alexandria Main University Hospital for their assistance and encouragement.We are also,extremely grateful to nurses who participate in this study,for without them,this research would never have been completed.

Appendix A.Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2023.09.016.