The impact of nurse’s sense of calling, organizational commitment, job stress, and nursing work environment on patient safety management activities in comprehensive nursing care service units during the covid-19 pandemic

In February 2021, the COVID-19 vaccine was introduced in South Korea, and vaccination was carried out starting with healthcare professionals and then vulnerable populations. Despite the increasing vaccination rates, the number of new COVID-19 cases continued to rise, with over 1,000 new cases per day since July 2021, leading the government to declare a "fourth wave" of the pandemic [1]. During the early stages of the COVID-19 outbreak, there was confusion in hospitals regarding the screening and admission process for COVID-19 patients, which led to the revision of the Infection Management Medical Law, resulting in nurses strictly adhering to respiratory infection control, standard precautions, and the use of personal protective equipment to focus on patient safety [2]. However, as the COVID-19 situation has continued long-term, studies have suggested a reevaluation of the "heroic" image of nurses under social pressure.

Comprehensive nursing care services aim to provide high-quality nursing care, with improvements in patient safety such as prevention of falls, pressure ulcers, medication administration, and infection control emphasized in medical institution evaluations. However, the expansion of comprehensive nursing care service units coincided with the COVID-19 situation, resulting in an increased workload for nurses in these wards. Therefore, due to the close relationship between the increased direct nursing activities and patient safety nursing activities in existing comprehensive nursing care service units, and the increased sense of responsibility for patient safety nursing activities due to the COVID-19 situation, it is necessary to explore methods to improve the quality of patient safety nursing activities by nurses in these wards.

Sense of calling is a mindset that goes beyond religious meaning and involves finding fulfillment in one's work and making socially significant contributions, recognizing the value of giving meaning to one's work and contributing to society [3]. Those who possess a sense of calling not only find satisfaction in their work, but also gain the strength to persevere through various obstacles [4]. Following the COVID-19 situation, the media has shown interest in nurses who care for patients with a sense of calling, but there has been a lack of diverse activities and accurate behavior descriptions of nurses [5]. However, the professional ethics of nurses who worked at COVID-19 screening clinics to prevent the spread of infectious diseases during crisis situations was a sense of calling [6], which can be seen as the driving force behind patient safety nursing activities.

Organizational commitment refers to an individual's willingness to work for and remain a member of the organization to which they belong and is an important variable that promotes efficient task performance among members, ultimately enhancing the organization's performance and quality of nursing services [7]. Particularly during outbreaks of novel infectious diseases, securing personnel and fostering close cooperation among medical personnel are essential to respond effectively [8]. Therefore, identifying factors that contribute to patient safety nursing activities, such as organizational commitment, is not only important for clinical nurses, but also necessary for the expansion and development of comprehensive nursing care services in small and medium-sized hospitals.

Implementation of comprehensive nursing care services has been reported to increase patient satisfaction and hospital reutilization rates compared to general hospital wards [9]. However, it also leads to an increase in job stress for nurses due to demands from patients who expect nursing services beyond their scope of work [10]. Additionally, it results in increased documentation for tasks like skin care, medication management, and more, adding to job stress [11] comprehensive nursing care services wards have nurses who constantly enter and leave patient rooms depending on their demands, as there is no primary caregiver staying with the patients. Given the easy transmission of COVID-19 through close contact, comprehensive nursing care service unit nurses are stressed by the risk of exposure to infection sources [12]. Therefore, nurses in comprehensive nursing care services wards are facing a double burden of existing workload and new expectations and responsibilities related to COVID-19 prevention measures.

The nursing work environment encompasses various aspects, including physical, relational, and managerial characteristics that enable nurses to provide professional care [13]. When comparing small and large hospitals operating comprehensive nursing care service units, small hospitals face difficulties in securing nursing staff due to lower salaries and poor working conditions, leading to a concentration of nursing personnel in large hospitals [14]. Thus, there is an increasing demand for safe and secure nursing services from hospital customers [15], while small hospitals' nursing staff shortages can lead to difficulties in providing quality nursing services.

Likewise, the COVID-19 pandemic broke out during the expansion of the comprehensive nursing care service project in small and medium-sized hospitals and nurses were working with sense of calling in this chaotic nursing environment. However, because there were no approved work guidelines and protocol for nurses, nursers had to bear work stress, so they left the field and threatened patient safety. Therefore, this study attempted to identify the relationships between nurses' sense of calling, organizational commitment, job stress, and nursing work environment, and the factors influencing patient safety nursing activities among nurses in small hospitals' comprehensive nursing care service units. The conceptual framework of this study was grounded in the Job Demand Resource (JD-R) Model proposed by Bakker and Demerouti [16], upon which the following research model was constructed (Fig.  1).

The purpose of this study was to identify the factors affecting patient safety nursing activities in the context of COVID-19 by investigating the relationship between the sense of calling, organizational commitment, job stress, and nursing work environment of nurses in small and medium-sized hospitals' comprehensive nursing care service units. To achieve this, the study aimed to examine the general characteristics, level of sense of calling, organizational commitment, job stress, nursing work environment, and patient safety nursing activities of nurses in comprehensive nursing care service units. Based on these findings, the study aimed to provide information on the relationship between sense of calling, organizational commitment, job stress, nursing work environment, and patient safety nursing activities, as well as the factors influencing this relationship.

The present study was a descriptive survey research designed to investigate the level of general characteristics, sense of calling, organizational commitment, job stress, and nursing work environment of nurses working in small and medium-sized hospital nursing care service units, and to identify their impact on patient safety nursing activities. Prior to the start of the study, approval was obtained from the Institutional Review Board (IRB) of K University under the reference number (KHSIRB-21-583).

The participants of this study were from seven small to medium-sized hospitals in the S and G metropolitan areas, each with a comprehensive nursing care service unit consisting of more than 100 beds and less than 300 beds. One of the hospitals was a specialized spinal joint hospital, while the other six were general hospitals. Since the COVID-19 outbreak, three hospitals have been operating COVID-19 residential treatment centers and dispatching nurses, two hospitals have been operating COVID-19 inpatient wards, and two hospitals have been monitoring COVID-19 patients who are under home quarantine. Newly employed nurses with less than one year of clinical experience were excluded as they were in a period of adjusting to the hospital organization, which could lead to decreased organizational commitment, based on previous studies [17]. The sample size of the participants was calculated using G*power 3.1, and the study targeted a total of 206 participants, considering a dropout rate, with 183 participants required for a regression analysis to explain the study's power with an effect size of 0.15, 18 independent variables, a significance level of 0.05, and a test power of 0.9. Sixteen questionnaires with unreliable responses were excluded, resulting in 190 questionnaires being used for analysis.

This study gathered data from February 24, 2022, to March 3, 2022, at seven small and medium-sized hospitals with nursing and nursing integrated service wards, each having 100 to 300beds. These hospitals have situated in S City and the Gyeongin region. The target demographic for the data collection was nurses, and an online survey was employed for this purpose. Owing to COVID-19 quarantine protocols, external visitors had not allowed at the hospitals. Therefore, the study's objectives and details were communicated to the nursing department over the phone, and explicit permission to collect data was obtained. The researcher provided the online link to the nursing department, and through the unit manager, the department distributed an online link to the structured mobile questionnaire to those who willingly agreed to participate in the study. The research subject's consent ensures that personal information was kept confidential during their participation in the research, granting them the right to refuse involvement even after the research has started. The research results were kept anonymous and will be exclusively utilized for research purposes. These findings were intended for both statistical purposes and potential publication. The process begins with a research consent form explaining that the survey can be conducted, and only those who have confirmed their consent online before the survey were directed to the survey participation. To deter fictitious participation in the web-based survey process, participants were required to respond to all items during the survey, and each question was configured to allow only one response to prevent multiple submissions. In cases where additional clarification was necessary, participants had the option to receive explanations over the phone. As compensation for the time taken due to participation in this study, a gift (online beverage voucher) was provided. Prior to delivering the gift, phone numbers collected before sending it were checked for duplicate participation, and phone numbers collected after the confirmation of sending the gift were discarded.

Nurse’s Demographic and work characteristics were obtained by survey. Demographic and work variables included in the study were participants’ age, education level, work experience, income, increased workload after COVID-19, COVID-19 patient nursing anxiety, patient safety education experience, and institutional evaluation.

Patient safety nursing activities were measured using the tool developed by Park [18]. The tool consists of 24 items categorized into six domains: patient identification (4 items), communication among healthcare providers (5 items), high-risk medication management (2 items), accurate surgery and procedure verification (3 items), infection prevention (7 items), and fall prevention (3 items). Each item was rated on a 5-point Likert scale ranging from "never" (1) to "always" (5), with higher scores indicating higher levels of patient safety management activities. The tool demonstrated good reliability with a Cronbach's α of .87.

The Multidimensional Measure of Calling (MCM) developed by Hagmaier and Abele [19] was used to measure calling, which was adapted to Korean by Ha et al.[20]. The Korean version of the tool consists of 9 items, categorized into three dimensions: job-person fit and environmental fit (3 items), meaning and value pursuit (3 items), and transcendent summons (3 items). Each item was rated on a 6-point Likert scale ranging from "not at all" (1) to "very much" (6). The tool demonstrated good reliability with a Cronbach's α of .88.

The measurement tool for organizational commitment used in this study was a three-factor organizational commitment scale that was validated for Koreans by Lee et al. [21], based on the organizational commitment tool developed by Meyer and Allen [22]. The scale consists of three sub-factors: affective, continuance, and normative commitment, and each item was measured on a 7-point Likert scale ranging from "strongly disagree" (1) to "strongly agree" (7). The reliability of the scale was confirmed with a Cronbach's α of .93.

The measurement tool for job stress used in this study was the Effort-Reward Imbalance (ERI) tool developed by Siegrist et al. [23]. The translation was confirmed by two bilingual experts who evaluated its linguistic and cultural suitability. Job stress was assessed by the validated Korean version of the original ERI questionnaire containing 23 items [23, 24]. The reported internal consistency for the Korean version was satisfactory with 0.71 for effort and 0.86 for reward [24]. The effort and reward domains each have five items measured on a 5-point Likert scale, with the minimum score for effort being 6 and the maximum score being 30, while the minimum score for reward was 11 and the maximum score was 55. To analyze job stress, the ratio of the sum of effort items to the sum of reward items was calculated. As the number of items for effort and reward domains was different (6 and 11, respectively), the total score for the reward domain was multiplied by 6/11 = 0.545 to make the maximum score 1. A ratio of 1 indicates a balance between effort and reward, while a ratio less than 1 suggests that rewards were greater than the subjective effort, indicating no job stress, and a ratio greater than 1 indicates that rewards were lower than the subjective effort, indicating job stress.

Over commitment refers to excessive dedication to excessive work demands, with higher scores indicating more commitment due to excessive control demands. The scale for over commitment was measured on a 4-point Likert scale ranging from 6 to 24, with higher scores indicating greater commitment due to excessive control demands. The reliability of the scale was Cronbach's α of .71.

The nursing work environment was measured using the Korean version of the nursing work environment scale developed by Lake[25] and validated by Cho et al.[26] This scale consists of 29 items, organized into five sub-domains: patient surveillance (4 items), interprofessional communication (5 items), high-risk medication management (2 items), accurate procedure verification (3 items), infection prevention (7 items), and fall prevention (3 items). Each item was rated on a 4-point Likert scale ranging from "strongly disagree" (1) to "strongly agree" (4), with higher scores indicating more positive perceptions of the nursing work environment by the nurses. The reliability coefficient was Cronbach's α of .93.

From February to March 2022, an online survey was conducted targeting nurses working in seven small to medium-sized hospitals in S city and the Gyeongin area that operate comprehensive nursing care service units with 100 to 300 beds. One of the seven institutions was a specialized hospital for spinal joint care, and the others were general hospitals with more than seven essential treatment departments. All medical institutions were private hospitals, and the operation of comprehensive nursing care service units began in 2017. After the COVID-19 outbreak, three of the institutions operated hospital beds for COVID-19 infected patients, and the rest were engaged in running care centers, dispatching personnel to COVID-19 dedicated hospitals, and monitoring COVID-19 high-risk individuals in self-quarantine. As per the COVID-19 prevention guidelines, external visitors were prohibited from entering the hospital, so the researchers explained the purpose and content of the study to the nursing staff over the phone and received permission for data collection. The researchers provided an online link to the nursing staff, who then provided a structured mobile survey link (Google) to the voluntary participants via the nursing staff. Participants received a compensation of a reasonable reward (online beverage voucher) for their participation in the study.

This study used SPSS Statistics 23.0 as the analytical tool for research problem and hypothesis testing. General characteristics of subjects were analyzed using descriptive statistics such as frequency, percentage, and mean. The level of significance of nursing job stress was analyzed by chi-squared test, and the means and standard deviations of sense of calling, organizational commitment, nursing job stress, nursing work environment, and patient safety nursing activities were calculated using descriptive statistics. Differences in patient safety nursing activities according to general characteristics were analyzed using t-tests and ANOVA, and post hoc tests were conducted using Scheffé test. Pearson's correlation coefficient was used to analyze the relationships between sense of calling, organizational commitment, nursing job stress, nursing work environment, and patient safety nursing activities. Finally, the hierarchical regression analysis was used to examine the effects of sense of calling, organizational commitment, nursing job stress, and nursing work environment on patient safety nursing activities.

The demographic characteristics of the participants are presented in Table 1. Regarding the differences in patient safety nursing activities according to general characteristics, significant differences were found in the comprehensive nursing care service unit work experience (F=5.426, p<.001), income (F=3.805, p=.011), anxiety related to caring COVID-19 patients (F=2.795, p=.028), and institution evaluation experience (t=2.325, p=.021). In terms of the comprehensive nursing care service unit work experience (F=5.426, p<.001), those with less than 2 years of experience had higher patient safety nursing activity scores than those with 3-4 years of experience. Regarding income (F=3.805, p=.011), those with a monthly income of 351 million won or more had a higher patient safety nursing activity score, and a post-hoc test showed a significant difference between the income groups of 250 million won, 251-300 million won, 301-350 million won, and 351 million won or more. Anxiety related to nursing COVID-19 patients (F=2.795, p=.028) showed higher scores for those who reported "yes" (110.18±9.98 points), but there was no significant difference in the post-hoc test. Institution evaluation experience (t=2.325, p=.021) was associated with higher patient safety nursing activity among those who reported having evaluation experience. Educational level, work experience, position, increased workload after COVID-19, patient safety incident experience, and patient safety education experience within the past year were not significant (Table 1).

The overall average score of the participants' sense of calling, based on the nine questions, was 4.35 ± 0.85, with the highest average score in the area of the meaning and pursuit of work at 4.53 ± 0.91. The overall average score of the participants' organizational commitment, based on 18 questions, was 3.57 ± 1.17, with the highest average score in the normative sub-factor area at 3.63 ± 1.13. The participants' job stress was measured by 17 questions, with sub-factor areas of effort (3.58 ± 0.68), reward (1.74 ± 0.31), and the ratio of effort to reward ranging from a minimum of 0.51 to a maximum of 2.67, with an overall average score of 1.17 ± 0.35, which was higher than 1. Over commitment was measured by six questions, with an average score of 2.57 ± 0.60. The average score for the nursing work environment was 2.27 ± 0.46, with the highest average score in the area of collaboration between nurses and doctors at 2.44 ± 0.63, and the lowest average score in the areas of nursing manager's ability, leadership, and support for nurses at 2.14 ± 0.62. The average score for the participants' patient safety nursing activities was 4.77 ± 0.42, with the highest score in the area of fall prevention at 4.66 ± 0.46, and the lowest score in the area of high-risk medication management at 4.01 ± 0.76 (Table 2).

In addition, a cross-analysis was conducted to identify variables associated with job stress among study participants. The analysis results showed that there was an association between age group and increased workload after the COVID-19 outbreak, with χ2 =9.089, p=.011. This suggests that there was a correlation between job stress and age group. The highest frequency of job stress was reported among individuals in their 20s, with 38.3% (49 individuals) reporting job stress. There was also an association between job stress and increased workload after the COVID-19 outbreak, with χ2 =7.523, p=.006. Job stress was reported as "yes" by 90.6% (116 individuals) of participants who experienced increased workload after the COVID-19 outbreak, which was the highest frequency reported (Table 3).

The correlation between nurses' general characteristics, sense of calling, organizational commitment, job stress, working environment, and patient safety management activities were examined. Patient safety management activities showed a static correlation with sense of calling (r=.04), organizational commitment (r=.16), and working environment (r=.20). This means that higher sense of calling, organizational commitment, and better working environment led to higher levels of patient safety management activities. There was a significant negative correlation between job stress and patient safety nursing activities (r=-.19), indicating that higher job stress leads to lower patient safety nursing activities (Table 4)

Factors affecting patient safety nursing activities of the participants were found in Table 5. To identify the factors influencing patient safety nursing activities of the study participants, with patient safety nursing activities as the dependent variable, independent variables such as comprehensive nursing care service unit experience, income, COVID-19 nursing anxiety, institutional evaluation experience, sense of calling, organizational commitment, job stress, and nursing work environment were selected from the general characteristics with significant differences in patient safety nursing activities. Before conducting the regression analysis, multicollinearity diagnosis was performed, and the VIF (Variance Inflation Factor) ranged from 1.064 to 2.579, all of which were less than 10, and the tolerance limits ranged from .39 to .94, all of which were between 0.1 and 1.0, indicating that there was no problem of multicollinearity in the data. The Durbin-Watson test result was 1.961, indicating that there was no multicollinearity and that the residual distribution satisfied the normality assumption. In the results of residual analysis, all assumptions of linearity, normality of errors, and homoscedasticity were satisfied. There were no outliers.

In Model 1, since most demographic variables among the general characteristics have a relationship with social phenomena, age and education were used as control variables to minimize bias in the regression coefficient estimates. When comprehensive nursing care service unit experience and income, which showed statistically significant differences in the difference analysis, were entered, the regression model was statistically significant (F=5.243, p<.001). In Model 2, when COVID-19 nursing anxiety and patient safety-related characteristics were additionally included, the regression model was statistically significant (F=4.874, p<.001), and comprehensive nursing care service unit experience (β=-.235, p=.002), income (β=.224, p=.003), COVID-19 nursing anxiety (β=-.182, p=.01), and institutional evaluation experience (β=.182, p=.008) were significant influencing factors, and the explanatory power of the model increased by 17.7%.

In Model 3, when sense of calling, organizational commitment, job stress, and nursing work environment were additionally included, the regression model was statistically significant (F=6.098, p<.001), and the comprehensive nursing care service unit experience (β=.209, p=.004), income (β=.241, p=.001), COVID-19 nursing anxiety (β=-.134, p=.048), sense of calling (β=.383, p<.001), and job stress (β=-.187, p=.029) were significant influencing factors, and the explanatory power was 30% (R²=.30, adjusted R²=.26, p<.001).

This study aimed to measure the sense of calling and identify factors affecting patient safety activities among comprehensive nursing care service unit nurses during the COVID-19 pandemic and contribute to developing basic data that can be used in developing safety nursing activity indicators. Additionally, as a strategy to enhance patient safety nursing activities among comprehensive nursing care service unit nurses, it is suggested that a mentoring relationship should be developed and applied to increase their sense of calling and to reduce job stress.

Moreover, an intervention study should be conducted to examine whether the imbalance between the efforts and rewards of comprehensive nursing care service unit nurses affects patient safety nursing activities. To improve patient safety nursing activities among comprehensive nursing care service unit nurses, it is recommended to establish a reward system for nurses, measure excessive effort related to intertwined nursing duties, and verify the effects of reducing job stress through medical institution support systems.

First, the study was limited in scope to nurses working in integrated nursing and care service wards in small and medium-sized hospitals in Seoul and some areas of the Gyeongin region with at least one year of clinical experience, and the survey was conducted online during a period when the number of COVID-19 confirmed cases was increasing. Therefore, caution is needed in generalizing the results even within the selected sample of nurses who responded faithfully to the online survey. Secondly, the instruments used in this study were created before the COVID-19 situation, so there may be differences in content from the sense of mission, organizational commitment, job stress, and nursing work environment of nurses in integrated nursing and care service wards during the current situation. Finally, since the infection control measures for COVID-19 vary by institution among nurses working in integrated nursing and care service, there may be differences in the COVID-19 nursing experiences of the subjects.