901533
research-article2020
WHSXXX10.1177/2165079920901533WORKPLACE HEALTH & SAFETYWORKPLACE HEALTH & SAFETY
Workplace Health & Safety
ORIGINAL RESEARCH
The Influence of Nursing Work Environment on
Patient Safety
Maha Mihdawi, RN, MSN1 , Rasmieh Al-Amer, PhD1, Rima Darwish, DDS2, Sue Randall, RGN, PhD3,
and Tareq Afaneh, RN, MSN, CPHQ4
Abstract: Background: Patient safety has been a concern
over the past two decades. The value of nurses and their
work environment in relation to patient safety has been
acknowledged by studies and international organizations.
This study aimed to examine the relationship between
patient safety practices and the nursing work environment.
Methods: In total, 570 registered nurses were invited
from the inpatient units in public and private hospitals.
Perceived patient safety was evaluated using the Overall
Perceptions of Patient Safety subscale from the Hospital
Survey of Patient Safety Culture (HSPSC). The nursing
work environment was assessed using the Practice
Environment Scale of the Nursing Work Index (PES-NWI).
Findings: Of the 350 of 570 (64.6%) nurses surveyed,
35.2% (125) reported positive levels of perceived patient
safety. Staffing and resource adequacy, professional
communication style, and nurses’ participation in hospital
quality improvement activities were associated with higher
levels of perceived patient safety. Conclusion/Application
to Practice: This study provided empirical results about
perceived patient safety culture in relation to nursing
work environment. It is paramount to focus on specific
dimensions of the nursing work environment, such as
staffing and resource adequacy, nurses’ participation
and advancement, and communication style to improve
the quality of care provided to patients. Hospitals are
considered one of the most hazardous places compared
with industries. Policy makers would help reduce injuries,
save resources, and build a culture of safety when taking
into consideration the importance of the nursing work
environment in relation to patient safety.
Keywords: nursing, work/practice environment, patient
safety culture, occupational health and safety
DOI: 10.1177/2165079920901533. From 1Isra University, 2Jordan Ministry of Health, 3The University of Sydney and 4Jordanian Nursing Council. Address correspondence to: Maha Mihdawi, RN,
https://doi.org/
MSN, School of Nursing and Midwifery, Isra University, P.O. Box (3678), Amman, Amman 11953, Jordan; email: maham_1917@yahoo.com
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2020 The Author(s)
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August 2020
Background
Over the last two decades, patient safety has been the center
of attention in health care organizations globally. Patient safety
is an essential element in delivering individualized quality care.
Internationally, well-recognized reports such as from the United
States “To Err Is Human” (Institute of Medicine [IOM], 2000),
from the United Kingdom “An Organization With a Memory”
(Donaldson et al., 2000), and the Garling Report in Australia
(Garling, 2008) focused on the importance of improving patient
safety within health care settings. Because the work
environment is an important facet with respect to patient safety,
the IOM issued a report in 2004 “Keeping Patients Safe:
Transforming the Work Environment of Nurses” reporting an
inverse relationship between patient safety and a negative
nursing work environment (Page, 2004). This report identified
common shortcomings regarding patient safety in areas such as
administration practices and elements of organizational
structure. It also emphasized that the degree to which nurses
are involved with inpatient health decisions also influences
patient outcomes. When nurses are given an opportunity to
participate in managing a health setting, they are empowered to
view patient safety as a priority. In addition, it addressed the
importance of active nursing leadership, which engenders a
constructive work environment and enhances a culture of safety.
This report also ascertained that many hospitals have
insufficient number of staff which in turn would reduce quality
of health care and threaten patient safety (Page, 2004).
Inadequate nursing staff ratios have shown to result in
decreased quality of nursing care and increased patient
mortality rates (Mudallal et al., 2017). A systematic review
revealed that self-governance, positive relationships between
doctors and nurses, and nursing care and leadership focused on
professional development and growth have been associated
with better patient outcomes (Aiken et al., 2008). It is plausible
that suboptimal nursing practice environments correlate with
vol. 68  ■  no. 8
Applying Research to Practice
This research study suggests that there are significant
nurse work environment dimensions that may not be
directly observable. These dimensions include safe nursing
staffing levels and availability of resources, nurses’
participation levels in decision making at the organization,
and communication and collegial relationship.
Occupational health nurses should focus on these
dimensions, as they can be determinant factors affecting
the health of both nurses and their patients. Occupational
health nurses may use a variety of approaches to address
the impact of these dimensions on health. This includes
enhancing hospitals’ preparedness to implement safe
nursing staffing levels, ensuring availability of safe levels of
practice resources, supporting nurses’ participation in
leadership activities, and enhancing collegial relationship
and communication between health care providers. In
addition, occupational health future research can build on
the results of this study by investigating the impact of each
nurse work environment dimension separately on nurses’
safety and patient safety.
poor patient health outcomes, including hospital-associated
infections and medication errors (Olds et al., 2017). A 2015
study of Jordanian nurses assessed the perceptions of patient
safety and revealed that nurses believed certain aspects of the
nursing environment need serious improvement, especially
communication and staffing (Khater et al., 2015). To date, no
studies have evaluated a possible relationship between
perceived patient safety and the nursing practice environment
among Jordanian nurses. The purpose of this study was to
examine the relationship between perceived patient safety
culture and nursing work environments in Jordan.
Methods
This study was conducted using a cross-sectional design.
Participants were registered nurses and midwives employed in
the inpatient hospital setting. A convenience sample of 570
registered nurses were invited to participate between January
2016 and June 2016 from inpatient units of different public and
private hospitals in Jordan. To be included, the participant had
to be a registered nurse or midwife, who delivered bedside care
for a minimum of 3 months before the data collection started.
We included only registered nurses because the study addressed
a high level of nurses’ work domains in which only registered
nurses are typically engaged. Nurses with less than 3 months’
clinical experience were considered too inexperienced to
provide relevant information about the study-related variables.
Nurses who occupied administrative roles were also excluded
because it was previously reported that they spent only 25% of
their time in direct patient care (Armstrong et al., 2015).
Workplace Health & Safety
Potential participants were approached by the main
researcher or by the research facilitators in their institutions and
the purpose of the study explained. Those who met the
inclusion criteria and agreed to participate were asked to sign a
consent form. Thereafter, nurses were provided with a paper
survey. To ensure anonymity, participants were provided with a
self-sealed envelope to place the completed tool, which was
collected by the study researcher within 1 week after
distribution. Approval for this study was issued by the
Institutional Review Board (IRB) at the Applied Science Private
University, Amman, Jordan, and each of the IRBs of participating
hospitals.
Questionnaires ascertained information about (a)
worker demographics (sex, marital status, and age), (b)
Hospital Survey of Patient Safety Culture (HSPSC), and (c)
Practice Environment Scale of the Nursing Work Index
(PES-NWI).
Patient safety was measured using the HSPSC. The
instrument is composed of 12 subscales and 42 items. The
HSPSC was initially devised by the Agency for Healthcare
Research and Quality (AHRQ) in 2012 to assess organizational
perception of safety culture with the intent to identify areas of
improvement, discover progress in patient safety culture,
evaluate cultural effect on patient safety, and compare results
internally with external benchmarks (Sorra & Nieva, 2004). The
12 sections of the instrument are (a) teamwork within hospital
units, (b) supervisor/manager expectations and promotion of
safety, (c) organizational action for learning and continuous
improvement, (d) feedback and communication in relation to
error, (e) communication openness, (f) staffing, (g) nonpunitive
response toward error, (h) management support about patient
safety, (i) teamwork across units, (j) hands-off and transitions,
(k) overall perceptions of safety, and (l) frequency of reporting
events. This scale is reliable and valid with Cronbach’s alpha of
.63 to .84 (AbuAlRub & Abu Alhijaa, 2014). The subscale that
was used in this study was the Overall Perceptions of Patient
Safety, which is comprised of four items: Patient safety is never
sacrificed to get more work done, our procedures and systems
are good at preventing errors from happening, it is just by
chance that more serious mistakes do not happen around here,
and we have patient safety problems in this unit. Each item is
rated by a 5-point Likert-type scale, with scores ranging from (1
= strongly disagree to 5 = strongly agree; Sorra & Nieva, 2004).
The Likert-type scale was collapsed to form three categories: (a)
the two lowest scores (negative response), (b) the two highest
scores (positive response), and (c) responses at the midpoint of
the Likert-type scale (Famolaro et al., 2016). For this scale, we
calculated the average number of positive responses over the
total number of items as recommended by the developer
(Famolaro et al., 2016). Items that scored 50% or less are
considered as areas requiring improvement as reported by
AHRQ (Famolaro et al., 2016). The score for each dimension of
the instrument was calculated as the average number of positive
responses over the total number of items. The higher the score,
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 Workplace Health & Safety August 2020

the better is the perception on patient safety culture (AbuAlRub

& Abu Alhijaa, 2014). Table 1.  Sociodemographic Characteristic of the Nursing
We employed the PES-NWI to measure the nursing work Sample (N = 350)
environment. It is a reliable and valid Likert-type scale with
Cronbach’s alpha ranging between .88 and .98, and has been Characteristics n (%)
widely used in the literature (Lake & Friese, 2006; Warshawsky Sex
& Havens, 2011). It is composed of 31 items using the following
response format of 1 = strongly agree to 4 = strongly disagree.  Male 153 (43.7)
It measures five areas: (a) staffing and resource adequacy, (b)
 Female 197 (56.3)
nurse manager’s ability, (c) nurse participation and
advancement, (d) nursing model for professional growth and Marital status
quality assurance, and (e) collegial nurse–physician relationship
 Single 175 (50)
(Lake, 2002). In this current study, Cronbach’s alpha for this
scale was .971.  Married 162 (46.3)

Data Analysis  Divorced 8 (2.3)

The Statistical Package for the Social Sciences, Version 22  Widowed 5 (1.4)
(SPSS 22) was used to analyze data. Descriptive analysis was
utilized to describe the demographic data of the respondents. Hospital type
Composite scores of the PES-NWI and the overall perceptions  Government 165 (47.1)
of patient safety were obtained after we reverse-coded the
negatively worded items as recommended by Lake (2002). The  Nongovernment 185 (52.9)
dependent variable was perceived patient safety culture, while
Work area
the independent variables included worker demographics and
the PES-NWI. Covariate correlation was conducted to assess  Critical 163 (46.6)
the magnitude of the relationship between perceived patient
 Noncritical 187 (53.4)
safety and the dimensions of nursing work environment.
Pearson’s R was computed to determine the magnitude of the Shift type
relationship between the Nursing Work Environment and the
Overall Perceived Patient Safety subscales. Logistic regression   Fixed shift duty 104 (29.7)
was employed to examine the predictors of patient safety.   8-hour shifts 246 (70.3)
Adjusted models were calculated which controlled for
demographics and PES-NWI variables. Adjusted odds ratios Educational background
(AORs) and 95% confidence intervals (95% CIs) were   Bachelor’s degree 341 (97.4)
calculated.
 Postgraduate 9 (2.6)
Results
Characteristics M ± SD
A total of 368 nurses responded (response rate of 64.6%),
and 18 questionnaires were excluded due to missing data. This Age, years 29 ± 5.6
sample included 350 participants; 56.3% were women, 50%
were single in comparison with 46.3% married, 3.7% were either Total years of experience 6.7 ± 5.3
divorced or widowed, and 52% worked at nongovernmental
(private and nonprofit) hospitals (Table 1). The mean age of the Years of experience in current 4.8 ± 4.7
study participants was 29 (SD = ±6) years. In relation to the hospital
educational levels, 97.4% had a bachelor’s degree and 2.6% had Work hours per week 45 ± 4
a postgraduate degree. The average years of experience was 6.7
(SD = ±5.3). A vast majority (70.3%) of the participants of the
study worked 8-hour shifts compared with 29.7% who worked
12-hour shifts.
The nurses’ positive response in relation to perceived that the “procedures and systems at their units were good at
patient safety reached 35.2% for the “Overall Patient Safety” preventing the occurrence of errors.” Moreover, 36.3% believed
subscale, taking into consideration that each item that scored that “patient safety is never sacrificed to get more work done,”
50% or less is considered as area requiring improvement 27.4% perceived “no safety problems in their clinical unit,” and
(Famolaro et al., 2016). Analysis of individual item responses 24.2% believed that “chance has nothing to do with preventing
of this subscale revealed that 52.9% of the nurses perceived serious mistakes.” Figure 1 illustrates the percentages of

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vol. 68  ■  no. 8
Figure 1.  Percentage and distribution of positive
responses per item in the Overall Perceived Patient Safety
scale (N = 350).
Table 2.  The PES-NWI (N = 350)
Subscales M ± SD
Staffing and Resource Adequacy 2.40 ± 0.83
Nurse Manager Ability, Leadership, and
2.51 ± 0.85
Support for Nurses
Nurse Participation in Hospital Affairs 2.65 ± 0.72
Nursing Model for Professional Growth 2.73 ± 0.60
and Quality Assurance
Collegial Nurse–Physician Relationship
2.84 ± 0.83
Overall Nursing Work Environment 2.65 ± 0.71
Note. PES-NWI = Practice Environment Subscales of Nursing Work
Index.
positive responses per item in the overall perceived patient
safety.
Table 2 illustrates M (±SD) for all dimensions of PES-NWI.
The highest nursing work environment dimension was for
Collegial Nurse–Physician Relationship, the average score was
M = 2.84, SD = ±0.83, followed by Nursing Model for
Professional Growth and Quality Assurance, M = 2.73,
SD = ±0.60. Conversely, the lowest nursing work dimension
score was for Staffing and Resource Adequacy (M = 2.40,
SD = ±0.83). The overall Nursing Work Environment (M =
2.65, SD = ±0.71) and Nurse Participation in Hospital Affairs
(M = 2.65, SD = ±0.72) had similar weight in terms of patient
safety, respectively.
Table 3 shows that the selected subscales of nursing work
environment correlated positively with the Perceived Patient
Safety Culture scale. Nurse manager’s ability yielded the highest
correlation with perceived patient safety culture (r = .579, p <
.001), followed by staffing and resource adequacy (r = .565,
p < .001).
Workplace Health & Safety
For the multivariate analysis, Table 4 illustrates that only sex
in the sociodemographic factors was a significant predictor of
the perceived patient safety culture (AOR = 0.419, 95% CI =
[0.224, 0.783]). Marital status and age did not have a significant
relationship to perceived patient safety culture. Female nurses’
perception of patient safety culture was lower than that among
male nurses. The regression analysis indicated that three out of
five subscales of nursing work environment were significantly
associated with perceived patient safety. Those who perceived
that the staffing resources were low were more likely to report
lower perception of patient safety culture (AOR = 0.441, 95% CI
= [0.201, 0.968]), and those who recognized that nurses do not
participate actively in the hospital affairs are 4 times more likely
to report low score on perceived patient safety (AOR = 0.40,
95% CI = [0.16, 1.02]). Nurses who perceived low levels of
collegial nurse–physician relationship were approximately 3
times more likely to report negative patients’ outcomes (AOR =
0.27, 95% CI = [0.134, 0.567]).
Discussion
To our knowledge, this study is the first to evaluate a
possible relationship between perceived patient safety and the
nursing practice environment among Jordanian nurses. The
findings of this study revealed that nurses perceived there was a
significant relationship between the nursing work environment
and perceived patient safety. The nurses perceived a low level
of patient safety in our sample of hospitals in Jordan. Around
half of the participants of this study reported that the
procedures and the health system are not good at preventing
mistakes, and around two thirds of them believed that patient
safety was jeopardized to get more of the work done. Moreover,
around three quarters of the study participants provided
negative responses in relation to the occurrence of mistakes and
reported that critical mistakes were prevented by chance. These
results could be related to the shortage of nurses and the high
workload in hospitals in Jordan (Khater et al., 2015; Mrayyan,
2006). Furthermore, the health system in Jordan is lacking the
use of innovative technology such as barcode scanning and
Computer Physician Order Entry (CPOE), which would reduce
medical errors and enhance positive patients’ outcomes (Salami
et al., 2018).
The most significant predictors of perceived patient safety
were adequacy of staffing and resources. This could be
explained by the high workload that is encountered daily by
nurses. Jordanian hospitals experience high pressure due to the
fact that nurse–patient ratio on average is one nurse for nine to
14 patients, in comparison with other regions such as the
United States in which nurse–patient ratio is one nurse for five
patients (Salami et al., 2018). Such nurse–patient ratios are
highly likely to reduce the quality of care and result in poor
patients’ outcomes. These findings lend support to previous
literature, which reported that high workload would reduce the
quality of patients’ care and lead to negative patients’ outcomes
(DeCola & Riggins, 2010; Habibi et al., 2017). Moreover, the
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 Workplace Health & Safety August 2020

Table 3.  Correlation Measures of Perceived Patient Safety and Selected PES-NWI (N = 350)

Variables 1 2 3 4 5 6
1. Staffing and resources 1.000  
2. Nurse manager ability .864** 1.000  
3. Nurse participation and advancement .838** .901** 1.000  
4. N
 ursing model for professional growth and quality .775** .814** .887** 1.000  
assurance
5. Collegial nurse–physician relationship .694** .769** .769** .774** 1.000  
6. Overall perceptions of patient safety .565** .579** .552* .410** .410* 1.000

Note. PES-NWI = Practice Environment Scale of the Nursing Work Index.

*Correlation is significant at the .05 level (two-tailed). **Correlation is significant at the .01 level (two-tailed).

Table 4.  Multivariate Model of Sociodemographic and Nursing Work Environment (PES-NWI) Subscales on Patient Safety (N = 350)

Patient Safety subscale

OR 95% CI
Sociodemographic and Nursing Work Environment (PES-NWI) Subscales Lower Upper
Low staffing and resources 0.441 0.201 0.968
High staff ratio and resources
— 1 1
Low nurse manager ability 0.531 0.220 1.284
High nurse manager ability
— 1 1
Low levels of nurse participation and advancement 0.400 0.160 1.002
Active participation in the hospital affair
— 1 1
Working without reference to the nursing model 1.218 0.527 2.818
Working with reference to the nursing model
— 1 1
Low levels of positive collegial nurse–physician relationship 0.275 0.134 0.567
Positive relationship between nurses and physicians
— 1 1
Female 0.419 0.224 0.783
Male
— 1 1
Married 0.829 0.659 1.043
Single
— 1 1

Age ≤30 years 1.023 0.551 1.900

Age >30 years — 1 1

Note. PES-NWI = Practice Environment Subscales of Nursing Work Index; OR = odds ratio; CI = confidence interval.

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vol. 68  ■  no. 8
current study showed that nurses’ participation in hospital
affairs and advancement predicated higher levels of perceived
patient safety. The possible reason is that effective engagement
by nurses in hospital management would empower them to
make decisions in relation to patient safety, which in turn lead
to positive patient outcomes and vice versa. Similarly, previous
studies reported that nurses’ participation and advancement are
key issues in respect to patient safety (Habibi et al., 2017;
Mudallal et al., 2017; Sears & Stockley, 2017).
The study findings revealed collegial nurse–physician
relationships are an important aspect of perceived patient
safety. These results lend support to former research that
found a significant relationship between professional
nurse–physician interconnection and patient safety (Cho &
Han, 2018). Miscommunication between nurses and
physicians was reported to be the leading cause of
inadvertent patient harm (Sears & Stockley, 2017), and
professional communication is important for patient safety.
These findings are consistent with other literature that
reported professional communication would increase the
levels of patient safety and enhance the quality of patient
care. In addition, alarming results were reported by the Joint
Commission for Hospital Accreditation in which around 2,455
events in U.S. hospitals that jeopardized patient safety were
analyzed and found that communication failure was a main
cause for such incidents (Sears & Stockley, 2017). Effective
communication and teamwork in promoting positive patients’
outcomes is crucial (Cho & Han, 2018).
This study is similar to other cross-sectional designed studies
in which some limitations need to be considered. The nature of
the mentioned design does not allow the study to draw causal
associations. Furthermore, the study recruited a convenience
sample of nurses, and this type of sampling has its own
limitations as only motivated individuals to participate. This also
limits the generalizability of the study findings. Moreover, this
study was conducted in hospital settings; hence, the study did
not echo the voice of nurses working in primary health care
settings. Although the study has limitations, we believe that it
has yielded important empirical data that would be the baseline
data for upcoming research, not only in Jordan but also in the
Arab region where such data are scarce.
Conclusion
This study provided empirical results about perceived
patient safety culture in relation to nursing work environment
among nurses. It is paramount to focus on specific dimensions
of the nursing work environment, such as staffing and
resources adequacy, nurses’ participation and advancement,
and communication style to improve the quality of care
provided to the patients. Taking into account that nursing is a
science and art that deals with patients on a continuous basis,
the provision of care should be combined with a positive
work environment that empowers nurses to improve patients’
outcomes.
Workplace Health & Safety
Implications for Occupational Health Nursing Practice
The nurse work environment has gained great attention
because it is a detrimental factor that influences health care
practices. Working in conditions with high working load, lack
of staff and resources, unprofessional communication, and
lack of engagement in decision-making policy in hospitals
would negatively affect the nurses’ physical, psychological,
and social health, which in turn will result in negative patient
outcomes. If these conditions lasted for a long time, they
might result in an irreversible harm in terms of patients’ care
and nurses’ health, leaving minimal options for impactful
recovery. Poor work environment dimensions including the
constraints in reaching management positions (lack the access
to work of greater complexity); might result in disruption in
nursing self-worth, increasing the role ambiguity, which in turn
might lead to low-quality of life among nurses. In addition,
health difficulties would stem from physical overload that is
related to shortage of staff and work resources. Hence, the
finding from this study embodied the importance of
considering teaching occupational health to nursing students
to help nurses be more aware and well suited for supporting,
advocating, and planning initiatives that serve health care
providers as well as patients.
The data provided by our work could be used by policy
makers to coordinate and deliver service programs that
emphasize the importance of an interdisciplinary approach to
health care. In addition, the data can be used to advocate for
nurses’ rights in terms of receiving professional communication.
Supporting nurses’ rights to be at higher positions in health care
settings will encourage nurses to take responsibility for their
health. For example, nurses at administrative positions can create
exercises/fitness, nutrition activities, and stress management
programs. Also, nurses at such positions can encourage research
that study workplace health in health care settings.
Author’s Note
Rima Darwish is now affiliated with the Jordanian Medical
Services as an Endodontic Resident.
Acknowledgments:
The authors are thankful for all the nursing managers, research
facilitators, and nurses who generously shared their time for the
purpose of this study. They also acknowledge the effort of
Professor Samiha Jarrah for her support, and Dr. Ahmad Saifan,
Dr. Waddah Aldomeh, and Dr. Malakeh Malak for their
invaluable feedback.
Author Contributions
M.M. conceived the study, participated in its design, collected
the data, and drafted the manuscript. R.A.-A. and R.D. conducted
the statistical analysis, wrote the “Results” section, and provided
substantial contribution in editing drafts of the study. S.R. and
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 Workplace Health & Safety
T.A. wrote the “Discussion” section and edited the final draft. All
authors read and approved the final manuscript.
Conflict of Interest
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Maha Mihdawi https://orcid.org/0000-0002-9754-3671
Permissions
The permission to utilize the study instruments was gained from
their respective authors via email. The Hospital Survey of Patient
Safety Culture (HSPSC) was gained by contacting the Agency for
Healthcare Research and Quality (AHRQ) who devised the scale
(despite being available for use without permission). Practice
Environment Scale of the Nursing Work Index (PES-NWI)
secured by contacting the author Ms. Lake also via email.
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60(1), 17–31.
Author Biographies
Maha Mihdawi, RN, MSN, is lecturer at Isra University of Jordan
(IUJ), School of Nursing and Midwifery. She received her MSN
degree in clinical nursing from the Applied Science University in
Amman, in 2016. She worked as nursing quality improvement
coordinator; she designed and implemented many performance
improvement and patient safety projects.
Rasmieh Al-Amer, RN, BSc, MSc, PhD, is assistant professor in
mental health nursing at IUJ, School of Nursing and Midwifery.
She is an adjunct fellow with Western Sydney University at School
of Nursing and Midwifery. Her research interests include mental
health issues, patient safety, and nursing workforce mental health.
Rima Darwish, DDS, is doctor in Ministry of Health. She had her
bachelor’s degree of dentistry from Jordan University in Amman.
Sue Randall, RGN, PhD, is senior lecturer in Primary Health Care
Nursing at the University of Sydney, Susan Wakil School of
Nursing and Midwifery, Sydney, Australia. Her teaching and
research seek to address workforce issues and improve equity and
access, thus improving quality of care and outcomes for patients.
Tareq Afaneh, RN, MSN, CPHQ, is head of Planning, Studies,
and Policies Department, Jordanian Nursing Council. He is a
PhD candidate at University of Jordan, School of Nursing. He
has been directly involved in performance improvement at
organizational level of different health care organizations.