Nurses Wellbeing and Primary Nursing: The Experience of the Emergency Surgical Ward in the General Hospital in Piacenza

Background: The growing complex of organizations and the new demand for people's health care lead to a planned and personalized care solution. Primary nursing is a new model of care focused on the people to be treated and, at the same time, restores responsibility, autonomy and role to the nursing staff. Objectives: the study was based on an analysis of the wellbeing climate following the implementation of the primary nursing in emergency surgical ward in the General Hospital in Piacenza. Methods: In the emergency surgery ward of the General Hospital Guglielmo Da Saliceto in Piacenza the results of organization remodulation and model of care are being analyzed. In this job the observations are been focussed on wellbeing of nursing staff. A qualitative analysis was conducted through a validated questionnaire to which they have been subjected. The questionnaire was submitted in the first phase to 22 nurses and in the after phase to 12 nurses belonging to the surgical area in Piacenza General Hospital. The Mc Closkey Mueller Satisfaction Scale (MMSS) is used for the study before and after the change. A further qualitative study of climate survey to which 11 nurses were subjected was conducted by The Team Climate Inventory (TCI) and carried out after the reorganization. To complete the organizational climate assessments, a focus group survey was also carried out in which 5 nurses from the emergency surgery ward participated in the satisfaction of the patient-centered care model which showed a high level of satisfaction from the nursing staff. Results: At the beginning, with the MMSS methods, the results show an impatience with some contractual and remunerative aspects, instead, after the introduction of the primary nursing, the results show a satisfaction for a teamwork, the interaction between the team personnel and with patients. Similarly, it also increases the perception of the degree of autonomy of contribution in decision making and in the authoritativeness of the role covered. The new assistance model also shows good results from TCI and Focus Group to achieve the goals of assistance and organization. Discussions: The increased satisfactions of the nursing staff show a better quality care.


Introduction
The increased complexity of healthcare organizations and of the health conditions of the people assisted in care facilities, lead the organizational systems and the nursing staff to analyze own work and to find adequate solutions to provide ing unit before and after the change of the care model was investigated through the Mc Closkey Mueller Satisfaction Scale (MMSS).
A further study was conducted after the implementation of the PN through the team climate inventory (TCI) questionnaire and finally a focus group meeting was held on the welfare modalities. Finally, a focus group meeting carried out six months after the reorganization of the care model, allowed us to investigate the perception of the nursing model through the involvement of a sample of 5 nurses. The study presented aims to verify whether the implementation of the patient-centered care model has improved the organizational climate within the ward of emergency surgery.

Methods
The evaluation of organizational well-being has been implemented through the Mc Closkey Mueller Satisfaction Scale which is a validated tool both in terms of content [11,12] and in terms of translation into Italian [13]. It was compiled anonymously and on a voluntary basis in compliance with the privacy regulations and the processing of personal data with the authorization of the Piacenza local health authority.
The MMSS, aims to investigate the satisfaction of the staff with respect to their work and the context in which it takes place. The survey consists of 31 items with the possibility of expressing one's opinion through a Likert scale from 1 to 5 points where the value 1 indicates the maximum dissatisfaction while the value 5 represents the maximum level of satisfaction. The survey was proposed to nurses of the emergency intervention unit before/after in which the first evaluation was carried out in October 2017 on the ordinary hospitalization staff composed of 22 nurses on 30 who participated anonymously and on a voluntary basis, where most of them were transferred to the new ward of emergency surgery.
The second investigation was offered to the staff composed of 12 out of 14 nurses who responded anonymously on a voluntary basis of the latter operating unit and was carried out in January 2019.
The team climate inventory questionnaire [14] in the Italian language adapted version [15] consists of 44 elements divided into three sections. In this case the survey was proposed after the organization of the care model and was compiled by 11 out of 14 nurses anonymously and on a voluntary basis of emergency surgery ward. of care and organizational models has focused on the care methods that put people and their needs at the center, re-proposing the fundamental role of care and giving nurses the responsibility of taking care of and protecting them from your clients [2][3][4][5].
On this way, the emergency surgery ward of the Local Health Unit in Piacenza, in which a structural and organizational reorganization was recently implemented, it was decided to use this opportunity to renew the care processes going towards the application of the primary nursing (PN) model, starting with the newly formed emergency surgery unit that saw the light in October 2018.
The PN bases its roots on the need to change the paradigm of the care focus: the patient is at the center of the nurse's care.
It is clear that the fundamental aspects are the construction of relationships with one's own clients [6], the role of the reference nurse recognized as the primary nurse who holds the responsibility for the cases assigned to him emerges, the assistance is focused on the problems detected on the individual patients and addressed through care planning involving all team members, such as associate nurses, support staff and all other professionals involved in the care process [7].
The above approach would allow nurses to achieve a high degree of satisfaction in what is their favorite autonomy and independence with assistance is geared towards continuity and comprehensive global customization. This model also allows to have an overall and integrated vision of the care pathway from reception to discharge and at the same time, it allows the nurse to fully act on his own competence and to be recognized and valued [8].
According to the conception of Marie Manthey, creator of the model, the PN can represent the return to the central point of nursing, to the heart of the nursing care modernly understood [9]. The main premises are the construction of relationships and the personalized planning of assistance. The realization of an effective relationship requires a continuous and positive interaction between the nurse and the patient and the energy derived from this dynamic connection brings results to the agreement.
The PN is a model to identifies the problems for the referent nurse, which he shares with the patient and/or family member, defines objectives and related result indicators, chooses the most suitable ways to implement the plan and monitors the evolution towards the expected results. It is considered a conceptualization that aims at a better quality of care, guaranteeing a higher level of patient well-being and a higher working satisfaction of nurses.
In the study conducted at the emergency surgery ward in the Guglielmo Da Saliceto Hospital in Piacenza, which was the subject of the implementation of the PN model, the organizational climate and the perception of the change towards the aforementioned model by the nursing staff. In this regard, two separate investigations were carried out. The first of cross sectional observational type in before/after mode [10] in which the climate of the operat-divide part-time and others. In this session, the satisfaction of the interviewees between the pre and post-evaluation is mostly aggravated, with the exception of the voices concerning the use of the holidays, the flexibility of the planning of the weekend and the incentive for the festive work.
In the second part of the survey, which goes from question 12 to 31, which describes in detail the contextual aspects of the organizational climate of the group to which it belongs, a clear improvement was registered in all the articles that give a good working atmosphere with the peaks satisfaction with the relationship with doctors, assistance methods, recognition by superiors and colleagues, opportunities for updating and research, and the possibility of making organizational decisions.
In the second analysis carried out by TCI the sample made up of 11 nurses of which 3 are males and 9 females with an average age of 39.9 (± 1.2) years and a seniority in the surgical area of 12.9 years. Seven of them have a nursing degree and three a specialist master's degree.
The first part of the TCI, is composed of 26 questions and is also expressed with a Likert scale in which the minimum level of agreement corresponding to the value 1 while the maximum agreement is represented by the number 5.
In the first item, the respondent staff is invited to express their thoughts on the level of communication of the team. From the analysis of the results it emerges the highest average of the scores assigned by the nurses is referred to the sharing of information with the group with a result of 4.4 points, the development of new ideas has totaled 4.1 points, the cooperation between the group for the development of new ideas to a score of 4, the same result regarding the sharing of information on work topics and the sharing of resources for the development of new ideas.
The second part of the questionnaire consists of 11 items related to the objectives of the work. The results that emerged with higher scores, concerned the utility and appropriateness of the objectives with 3.6 points, the value attributed to the objectives themselves with an average of 3.9 and how worthy of attention they are, reaching a value of 3.6. The last seven questions were focused on collaboration between colleagues and on the performance of the activities.
Three items totaled the same score or 3.2 points related to the interest in reaching high level standards, the capacity for critical discussion of the practices in use and the use of new ideas proposed by the group. The focus group meeting involved 5 nurses, 1 male and 4 females with an average age of 43.2 (± 4.3) years with seniority in the surgical area of 17.8 years.
The interview was conducted after working hours in an appropriate environment with a conductor and an observer.
The main positions were initially identified and later categorizations were carried out to provide representativeness of the opinions.
For the question: << how satisfied are you with the new The first area is represented by the aspects of communication and innovation, consisting of 26 questions relating to the internal climate understood as a human and professional relationship with work colleagues. The second part concerns the objectives and consists of 11 items that require a subjective assessment of the work organization aimed at identifying the objectives that can be achieved as individuals and/or in collaboration with the group. The last dimension focuses on the work style through 6 questions concerning the collaboration between the nursing staff. Also in this case the questionnaire was filled in anonymously and it was requested to assign to each article a value between 1 and 5, in which 1 indicates the maximum disagreement while the value 5 represents the maximum agreement.
The TCI was administered only in the post-implementation in order to assess the stabilization of the change occurred and to verify in detail the relationships between the members of the organization. To get the impressions as much as possible narrated by the professionals involved in the implementation of the PN model, in March 2019 a focus group meeting was created, which identifies a sample of 5 nurses belonging to the emergency surgery ward. The comparison took place in a reserved area, sufficiently large and bright in the presence of an conductor and an observer who used an audio recording.
The questions proposed to the participants were taken from the proceedings of the 57 th National Congress of the Italian Society of Geriatrics and Gerontology [16]. The questionnaires and the focus group meeting were compiled by the nursing staff after working hours and as regards the questionnaires, they were collected in a ballot box accessible only to researchers. The statistical analyzes were processed with the Microsoft office excel 2007 version software, considering the central trend measurements, the percentiles and the statistical significance test, the chi framework considering it significant if equal to or less than 0.05.

Results
In the analysis carried out by means of MCSS in the "before" phase, the group of respondents was composed of 12 male nurses and 8 females with an average age of 38.4 (± 10.6) years. Eight of them have a degree in nursing and 5 have a master's degree. In the respondents of the "after" group, the gender distribution was of 4 males and 8 females with an average age of 40.5 (± 0.7) years and 6 possess degree in nursing while 3 have achieved a master's degree. The seniority of service is 13.5 and 8 years in the surgical area; there are no statistically significant differences between the two groups.
Regarding the before/after survey through the MMSS, the two groups compared did not show statistically significant differences in terms of sex, age, length of service and basic training.
In the first part of the survey or between articles 1 to 11, we find questions relating to contractual institutions such as the use of holiday leave, the wage level, the opportunity to ation, the possibility of resorting to permits and facilitations, flexibility in working hours.
In view of these aspects considered unsatisfactory, in the second observation, we note a better level of interaction between team members, a greater appreciation of the new ways of well-being, a significant recognition by other team professionals, a more effective opportunity to acquire skills through training and research and the possibility of being better considered in organizational decisions.
As in the case described, also in other experiences, the implementation of the PN led to a good level of satisfaction among the assistance personnel [17,18]. This was also confirmed by the analysis of the results collected through the TCI questionnaire administered in the post-implementation, in which a high level of satisfaction was perceived, as this model leads to a greater involvement of the team, guaranteeing better collaboration and communication among staff to achieve the set targets [19].
In the focus group, among the participants it is noted that the new model of care is highly appreciated, especially if referred to the previous treatment modalities, it also shows a greater interaction with the patient and his reference persons. With the application of these new welfare modalities, the interviewed nurses feel more autonomous, more involved and considered and also a higher level of authority.

Conclusions
The organizational change implemented in the surgical area of the Piacenza, considered a re-modulation of the welfare model, moving towards the centrality of the patient and the personalization of care. In the complex spheres more than anything else they deal with providing services to people, the task and the well-being of the professionals is a central theme that must be increasingly considered. The experience described in this analysis states how the well-being and satisfaction of the staff allows us to achieve excellent and take care of our professionals so that they are effectively effective taking care of their clients.

Implications in Clinical Practice
The results of this study show that patient-centered care and the identification of a responsible and referent nurse for some patients considerably raises the motivation of the staff by improving the climate within the group. A good working climate could improve the relationship with patients and their care outcomes. For the latter, further studies are needed to correlate the work climate with care outcomes.

Conflicts of Interest
For the second question: << according to your experience, is the clinical care path shared with the patient, family and /or caregiver? >>, the responses involved a high degree of involvement through the participation of the nurse in the conversation between family members and doctors, but also on other occasions, for example during the delivery to the patient's bed and at any time in which it was necessary to interact with them.
For the third question: << do you think this model favors the continuity of care? >>, the responses showed attention to the continuum between patient, family, nurses and doctors as an appropriate way to keep the patient at the center of well-being of the clinical project.
For the fourth question: << do you have the feeling of working in a team? >>, the perception of working in a group with the sharing of organizational and clinical assistance objectives emerges, it shows that there is a general care taken in the patient and not fractional and per formative as in other work experiences carried out by the participants.
And again: << back to a traditional welfare model? >>, unanimously, none of the participants would like to return in the most absolute way to organizations oriented to carrying out tasks for activities and tours.
For the sixth question: << in a scale of values from 1 to 5 where the latter represents the maximum satisfaction, what is your level of professional well-being at the moment? >>, on this topic the majority expressed itself on values between 4.5 and 5 points with respect to the methods of well-being, returning a very high level of professional satisfaction to the sample in question.
For the last question in question: << from the moment that you apply this model do you feel more accomplished professionally? >>, the group reports to be significantly more professionally realized thanks to the acquisition of greater autonomy, consideration, involvement, support and with a greater authority of role.
Respondents say that the satisfaction achieved in the workplace also has a positive impact on the personal sphere.

Considerations
The analysis of organizational well-being in the new emergency surgery ward of the General Hospital Guglielmo Da Saliceto in Piacenza has developed in three different ways.
First of all, Mc Colskey Mueller Satisfaction Scale was administered of satisfaction of the seller, in two phases, in the period of pre-implementation of the organizational and welfare change based on the primary care model and subsequently the same investigation was proposed again after the transformation.
Between the first and the second survey some differences emerge: in the initial evaluation there is an intolerance with respect to some general areas such as remuner-