How nursing practice environments limit implicit rationing of care and nurse-assessed adverse events: the role of flow at work

Background: The nursing practice environment is beneficial in curbing implicit rationing of nursing care and adverse patient events. However, the underlying mechanisms of these relationships remain unexplored. Aim: To test whether flow at work mediates the relationship between the nursing practice environment, implicit rationing of nursing care, and nurse-assessed adverse patient events. Methods: This cross-sectional study involved 231 nurses from five hospitals in Port Said, Egypt. The participants completed Arabic-translated versions of the Practice Environment Scale of the Nursing Work Index, the Work-Related Flow Inventory, the Perceived Implicit Rationing of Nursing Care instrument, and the Adverse Patient Events scale. Structural equation modeling was used to test the hypothetical model. Results: The favorable nursing practice environment positively predicted nurses’ flow at work (β = 0.64, p < 0.001), while inversely predicting implicit rationing of nursing care (β = -0.23, p = 0.014) and adverse patient events (β = -0.35, p < 0.001). Nurses’ flow at work inversely predicted implicit rationing of nursing care (β = -0.30, p = 0.002) and adverse patient events (β = -0.29, p = 0.002). Moreover, nurses’ flow at work acted as a mediator, linking the nursing practice environment to the rationing of nursing care and adverse patient events, with 500 bootstrap results for the indirect effects (β = -0.24, p = 0.001, 95% CI: -0.43 to -0.09; and β = -0.44, p = 0.003, 95% CI: -0.79 to -0.16, respectively). Conclusion: Nurses working in a favorable nursing practice environment are more likely to experience flow at work, limiting implicit rationing of nursing care and adverse patient events. Implications for nursing management: Nursing administrators should strive to create a healthy nursing practice environment to foster nurses’ flow and thereby reduce the frequency of implicit rationing of nursing care and adverse patient events.