Clinical Competence on Patient Care Quality with Workplace Support as Mediator among Nurses

Clinical Competence on Patient Care Quality with Workplace Support as Mediator among Nurses

Emily C. Go, MANM, Joel B. Serad, MD, DM, MAN, Joan P. Bacarisas, DM, MAN, Geronima Emma A. Amores, DM, MAN, and Resty L. Picardo, DM, JD, MAN

College of Allied Health Sciences, University of the Visayas

DOI: https://doi.org/10.51244/IJRSI.2025.12060030

Received: 14 May 2025; Revised: 26 May 2025; Accepted: 30 May 2025; Published: 01 July 2025

ABSTRACT

Nursing competence is fundamental to ensuring the delivery of safe, effective, and high- quality care. However, possessing clinical skills does not always guarantee quality outcomes, especially when influenced by organizational and environmental factors. This study aimed to assess the level of competence of nurses, evaluate the perceived quality of nursing care, examine the extent of workplace support, and determine the relationship among these variables, including the potential mediating role of workplace support. A descriptive-correlational research design was employed, involving nurses from a tertiary hospital. Standardized tools were used to measure nurse competence across multiple domains, quality of care, and workplace support. Data were collected through stratified random sampling and analyzed using descriptive statistics, Pearson correlation, and mediation analysis. Nurses perceived themselves as very competent, especially in teaching- coaching, managing situations, and diagnostic functions. However, the quality of nursing care they provided was rated as fair. No significant relationship was found between overall competence and quality of care. Although workplace support had a significant direct effect on quality of care, it did not significantly mediate the relationship between competence and care quality. These findings suggest that high competence alone is not enough to ensure excellent care outcomes without supportive systems in place. The results align with Dee Fink’s Competence Theory, Eisenberger’s Organizational Support Theory, and Lee Schmidt’s Quality of Nursing Care Model, emphasizing the need for enabling environments that allow competence to be fully actualized in practice.

Keywords: Nursing competence, quality of care, workplace support, organizational environment, nurse performance.

INTRODUCTION

Clinical competence mediates the relationship between knowledge, experience, and effective patient care by ensuring that healthcare providers can apply their skills in real- world settings. It serves as a bridge between education and practice, allowing nurses and other healthcare professionals to translate theoretical knowledge into safe and efficient clinical interventions (Benner, 1984). Through continuous learning and hands-on experience, clinical competence enhances critical thinking, decision-making, and adaptability, leading to improved patient outcomes and reduced medical errors (Fukada, 2018). Additionally, it plays a crucial role in linking work environment factors, such as staffing and resources, to job satisfaction and performance, as competent professionals can navigate challenges more effectively (Laschinger & Fida, 2014). Furthermore, it ensures that healthcare policies and protocols are successfully implemented in practice, reinforcing adherence to safety and ethical standards (World Health Organization [WHO], 2020). Overall, clinical competence acts as a key mediator in healthcare, optimizing both patient care and professional development. In the study of Manary et al. (2013) it highlights that patient satisfaction correlates strongly with better healthcare results, emphasizing its importance as a measure of care quality. Similarly, a study by Jenkinson et al. (2002) found that hospitals with higher patient satisfaction scores exhibited better clinical outcomes, demonstrating the impact of patient perceptions on overall healthcare quality.

The level of nurses’ competence encompasses various dimensions, including clinical knowledge, technical skills, critical thinking, and communication abilities. A competent nurse demonstrates proficiency in performing clinical tasks, provides clear and compassionate communication, and ensures patient safety and well-being (Cheng et al., 2019). Studies have shown that nurses who possess higher levels of competence are more likely to engage in evidence-based practices, demonstrate effective decision-making, and foster therapeutic relationships with patients (Chang et al., 2016). As a result, patients are more likely to report higher satisfaction with their care, reflecting the positive influence of nursing.

According to Needleman et al. (2002) the lower nurse staffing and reduced nurse competence were associated with higher rates of patient complications and adverse outcomes, further demonstrating the vital role that nursing competence plays in ensuring high-quality care. Overall, nurse competence is a cornerstone of quality care, as it underpins both the safety and satisfaction of patients. The competence of nurses is critical to the provision of high-quality nursing care. However, nursing competence does not develop in isolation; it is heavily influenced by the work environment and the level of support nurses receive from their organization, supervisors, and peers (Laschinger et al., 2009). Research has shown that supportive workplace conditions, including access to resources, mentorship, constructive feedback, and opportunities for professional development, are crucial for enhancing and sustaining nurses’ competence (Cheng et al., 2019). As healthcare organizations strive to improve patient outcomes, understanding how workplace support influences nurses’ competence has become a vital area of study.

Workplace support is multi-dimensional, comprising both tangible resources, such as continuing education and adequate staffing, and intangible elements, such as psychological support, encouragement, and recognition from colleagues and supervisors (Shen et al., 2017). Studies indicate that a supportive work environment positively impacts nurses’ ability to provide high-quality care, as it fosters a sense of job satisfaction, reduces burnout, and promotes professional growth (Laschinger & Leiter, 2016). In particular, nurses who receive ongoing training and have access to supportive supervisors are better equipped to handle complex clinical situations, adapt to new technologies, and make critical patient care decisions (Kramer & Schmalenberg, 2008). This link between workplace support and competence highlights the importance of investing in supportive structures within healthcare organizations to nurture nurses’ skills and ensure high standards of patient care.

Furthermore, workplace support is associated with increased confidence and resilience among nurses, which are essential for maintaining competence in a demanding and often high-stress profession (Squires et al., 2010). Research suggests that when nurses feel supported, they are more likely to seek out additional learning opportunities, collaborate effectively with other healthcare professionals, and remain committed to delivering excellent care (Wu et al., 2016). Conversely, a lack of workplace support can lead to stress, decreased job satisfaction, and ultimately a decline in nursing competence, which may compromise patient safety and care quality (Aiken et al., 2014).

As a nurse with ten years of experience in Caraga Regional Hospital, one of the researcher have had the opportunity to observe firsthand the dynamics that influence patient satisfaction and the overall quality of care. Over the years, one of the researchers have noticed that patient satisfaction is heavily influenced by both the competence of nurses and the level of support available in the workplace. In many instances, patients who receive care from highly competent nurses tend to have more positive experiences, showing higher levels of satisfaction with their treatment. Competent nurses are not only more efficient in delivering care, but they also have better communication skills, which significantly contributes to patient comfort and trust. One of the researcher have observed that when nurses are knowledgeable, confident, and skilled, patients feel more assured about their health outcomes, leading to increased satisfaction and trust in the healthcare system.

However, one of the researcher have also seen how a lack of workplace support—such as inadequate staffing, limited access to continuous education, or insufficient mentoring—can affect nurse performance and, in turn, impact patient care. Nurses who feel unsupported or overwhelmed by their workload are more likely to experience burnout, which negatively affects their ability to deliver high-quality care. In contrast, those who work in environments where they feel supported by management and colleagues are more motivated, engaged, and confident in their abilities. This positive work environment fosters greater competence, which directly improves patient care. These observations and experiences have led me to recognize the importance of investigating the relationship between workplace support, nurse competence, and patient satisfaction. The researchers hope that this study will provide insights into how improving workplace conditions and enhancing nurse competence can lead to higher levels of patient satisfaction and better overall quality of care.

The practical value of this study lies in its potential to inform nursing management strategies and contribute to the improvement of healthcare systems. By examining the relationship between nurse competence, workplace support, and patient satisfaction, the findings can guide nursing managers in creating more supportive work environments that enhance the professional development of nurses. This, in turn, can lead to improved nursing performance, greater job satisfaction, and higher-quality patient care. The study’s insights could assist nursing managers in identifying areas where additional training, resources, and support are needed to boost nurse competence and satisfaction, ultimately fostering a more efficient and effective healthcare workforce.

Moreover, this study aligns with several key targets of the United Nations Sustainable Development Goals (SDGs), particularly SDG 3: “Good Health and Wellbeing.” By focusing on the quality of care and patient satisfaction, the research contributes to the overarching goal of ensuring healthy lives and promoting well-being for all at all ages. Additionally, the study supports SDG 8: “Decent Work and Economic Growth,” by highlighting the importance of improving workplace conditions for nurses. Empowering nurses through continuous education and creating supportive environments not only enhances their competence but also promotes their well-being and job satisfaction, which are vital for long-term workforce sustainability in healthcare. Ultimately, this study can help bridge the gap between nursing management practices and global health goals, fostering a more competent, satisfied, and effective nursing workforce that can deliver high-quality care to all patients.

Research Objectives

The main purpose of the study was to assess the relationship between competence and patient care quality. Further it assessed the influence of workplace support to the competence of the nurses for the first quarter for the year 2025.

Specifically, the study answered the following questions:

What was the level of competence as perceived by the nurses in terms of:

helping role;

teaching-coaching

diagnostic functions;

managing situations;

therapeutic interventions;

ensuring quality; and

work role?

What was the satisfaction on nursing care quality as perceived by the nurses in terms of?

task oriented activities;

staff characteristics;

pre-condition;

physical environment;

patient outcomes; and

human oriented activities?

What was the extent of workplace support as perceived by the nurses?

Was there a significant relationship between competence and nursing care quality?

Was there a significant relationship between competence and nursing care quality when mediated by workplace support?

What nursing care quality enhancement plan was proposed based on the findings of the study?

Statement of Null Hypotheses

There was no significant relationship between competence and nursing care quality.

There was no significant relationship between competence and nursing care quality when mediated by workplace support.

REVIEW OF RELATED LITERATURE AND STUDIES

Level of Competence of Nurses.

The level of competence among nurses is a crucial factor in ensuring high-quality patient care and improving healthcare outcomes. Competence encompasses a range of skills, knowledge, and attitudes necessary for effective nursing practice. Recent studies have examined various aspects of nurse competence, including educational preparation, continuing professional development, and competency assessment. Educational Preparation and Competence. Educational preparation plays a significant role in determining the competence of nurses. A study by Haddad and Toney-Butler (2020) found that nurses with higher levels of education, such as bachelor’s degrees, demonstrated greater competence in clinical practice compared to those with lower levels of education. This study underscores the importance of advanced nursing education in enhancing competence. Continuing Professional Development. Continuing professional development (CPD) is essential for maintaining and enhancing the competence of nurses. According to a study by Smith et al. (2021), participation in CPD programs significantly improved nurses’ clinical skills and confidence in their practice. The study highlighted the need for healthcare organizations to support ongoing education for nurses.

Competency Assessment.

Regular assessment of nursing competence is crucial for ensuring high standards of care. A study by Wang et al. (2019) explored the use of simulation-based assessments to evaluate nurses’ competence. The findings indicated that simulation-based assessments provided a reliable and valid method for assessing nursing competence, allowing for targeted interventions to address gaps in skills and knowledge. Impact of Experience on Competence. Experience is a significant factor influencing the competence of nurses. A longitudinal study by White and Duncan (2020) found that nurses with more years of clinical experience demonstrated higher levels of competence in critical thinking and clinical decision-making. This research emphasizes the value of clinical experience in developing nursing competence.

Cultural Competence.

Cultural competence is an important aspect of nursing competence, particularly in diverse healthcare settings. A study by Betancourt et al. (2021) examined the impact of cultural competence training on nurses’ ability to provide culturally sensitive care. The results showed that cultural competence training significantly improved nurses’ confidence and skills in working with diverse patient populations. Recent literature underscores the multifaceted nature of nursing competence, highlighting the importance of educational preparation, continuing professional development, competency assessment, clinical experience, and cultural competence. Ensuring that nurses possess and maintain high levels of competence is essential for delivering high-quality patient care and improving healthcare outcomes.

Nursing Care Quality.

The quality of nursing care is a critical aspect of healthcare delivery, influencing patient outcomes, satisfaction, and overall healthcare efficiency. Recent studies have focused on various dimensions of nursing care quality, including patient safety, nurse staffing levels, and the use of technology in nursing practice. Patient Safety and Quality of Care. Patient safety is a fundamental component of nursing care quality. Recent research highlights the importance of implementing safety protocols and continuous education for nurses to enhance patient outcomes. According to a study by Kim and Park (2020), the implementation of a comprehensive safety program significantly reduced the incidence of patient falls and medication errors in hospitals.

Nurse Staffing Levels.

Adequate nurse staffing is crucial for maintaining high quality care and ensuring patient safety. A study by Griffiths et al. (2019) found that higher nurse staffing levels were associated with lower mortality rates and better patient outcomes. This research underscores the need for hospitals to invest in sufficient staffing to improve care quality. Technology in Nursing Practice. The integration of technology in nursing practice has been shown to enhance care quality and efficiency. A study by Johnson et al. (2021) examined the impact of electronic health records (EHRs) on nursing care quality. The findings revealed that EHRs improved documentation accuracy and facilitated better communication among healthcare providers, leading to improved patient outcomes.

Patient Satisfaction.

Patient satisfaction is a key indicator of nursing care quality. A recent study by Lee et al. (2022) highlighted the relationship between nursing care and patient satisfaction, indicating that patients who perceived higher levels of empathy and communication from nurses reported greater satisfaction with their care. The recent literature emphasizes the multifaceted nature of nursing care quality, highlighting the importance of patient safety, adequate staffing, technological integration, and patient satisfaction. Ongoing research and continuous improvement in these areas are essential for enhancing the overall quality of nursing care.

Workplace Support.

Workplace support is a critical factor influencing nurses’ job satisfaction, retention, and overall well-being. It encompasses various forms of support, including organizational, managerial, and peer support. Recent studies have highlighted the impact of workplace support on nurses’ professional performance and mental health.

Organizational Support.

Organizational support plays a significant role in enhancing nurses’ job satisfaction and reducing turnover. A study by Galletta et al. (2019) found that perceived organizational support was positively associated with job satisfaction and negatively associated with turnover intentions among nurses. This study underscores the importance of creating supportive organizational environments to retain nursing staff. Managerial Support. Managerial support, including effective communication and leadership, is crucial for nurses’ professional development and well-being. According to a study by Boamah et al. (2020), transformational leadership practices by nurse managers were significantly related to higher job satisfaction and lower burnout rates among nurses. The study highlights the importance of leadership training for nurse managers to foster a supportive work environment. Peer Support. Peer support, including teamwork and collegial relationships, is essential for maintaining a positive work environment. A study by Van der Heijden et al. (2018) demonstrated that strong peer support networks were associated with lower levels of job stress and higher levels of job satisfaction among nurses. This study emphasizes the value of fostering a collaborative and supportive team culture. Mental Health Support. Workplace support also extends to mental health resources and interventions. A study by Melnyk et al. (2021) found that implementing mental health programs and providing access to counseling services significantly reduced symptoms of depression and anxiety among nurses. This research highlights the importance of mental health support in the nursing profession. The recent literature emphasizes the critical role of workplace support in promoting nurses’ job satisfaction, mental health, and retention. Organizational, managerial, peer, and mental health support are essential components of a supportive work environment, especially during crisis situations. Healthcare organizations must prioritize these forms of support to ensure the well-being and effectiveness of their nursing staff.

Level of Competence and Nursing Care Quality.

The level of competence among nurses is directly linked to the quality of nursing care provided. Competent nurses ensure better patient outcomes, safety, and satisfaction. Recent studies have explored various dimensions of this relationship, including the impact of educational preparation, continuing professional development, and competency assessment on nursing care quality. Educational Preparation and Nursing Care Quality. Educational preparation is crucial for ensuring high levels of competence among nurses, which in turn affects the quality of care. A study by Al-Dossary, Kitsantas, and Maddox (2020) found that nurses with baccalaureate degrees demonstrated higher levels of clinical competence and provided better quality care compared to those with associate degrees. This study emphasizes the importance of advanced nursing education in improving care quality. Continuing Professional Development. Continuing professional development (CPD) is vital for maintaining and enhancing nurses’ competence, thereby improving care quality. According to a study by Edwards et al. (2019), participation in CPD programs significantly enhanced nurses’ clinical skills and improved patient care outcomes. This research underscores the necessity of ongoing education and training for nurses.

Competency Assessment and Quality of Care.

Regular assessment of nursing competence is essential for ensuring high standards of care. A study by Cant et al. (2021) explored the use of simulationbased assessments to evaluate nurses’ competence and its impact on care quality. The findings indicated that simulation-based assessments were effective in identifying competency gaps and led to targeted improvements in nursing care quality. Experience and Nursing Care Quality. Clinical experience is a significant factor influencing both competence and care quality. A longitudinal study by Cheng et al. (2020) found that nurses with more years of clinical experience demonstrated higher competence levels and provided better quality care. This study highlights the importance of clinical experience in developing nursing skills and ensuring high-quality patient care.

Cultural Competence and Quality of Care. Cultural competence is increasingly recognized as a critical component of nursing competence, affecting care quality in diverse settings. A study by Sharifi, Adib-Hajbaghery, and Najafi (2019) found that culturally competent care improved patient satisfaction and outcomes. This research highlights the importance of cultural competence training for nurses to enhance care quality. Recent literature underscores the strong link between nurses’ competence levels and the quality of nursing care. Educational preparation, continuing professional development, competency assessment, clinical experience, and cultural competence are all crucial factors that contribute to high-quality patient care. Healthcare organizations must prioritize these aspects to ensure competent nursing practice and improved care outcomes.

Level of Competence and Workplace Support.

The level of competence among nurses is influenced significantly by the support they receive in the workplace. Effective workplace support, including organizational backing, managerial support, and peer collaboration, is essential for fostering competence and enhancing professional development.

Organizational Support and Nurse Competence.

Organizational support, including resources and a conducive work environment, plays a critical role in enhancing nurse competence. A study by Liu et al. (2020) found that nurses who perceived high levels of organizational support reported greater job satisfaction and higher competence levels. This study highlights the importance of organizational investments in resources and support systems to foster nurse competence. Managerial Support. Effective managerial support, including leadership and communication, is crucial for enhancing nursing competence. According to a study by Boamah and Laschinger (2021), transformational leadership practices by nurse managers were positively associated with higher levels of competence and professional development among nurses. This study emphasizes the importance of leadership training for nurse managers.

Peer Support and Competence.

 Peer support, including teamwork and collaborative relationships, significantly influences nurse competence. A study by Zhang et al. (2019) demonstrated that strong peer support networks were associated with higher competence levels and reduced job stress among nurses. This research underscores the value of fostering a supportive and collaborative team environment.

Continuing Professional Development and Workplace Support.

Workplace support for continuing professional development (CPD) is essential for maintaining and enhancing nurse competence. A study by Pool et al. (2021) found that nurses who participated in CPD programs supported by their organizations reported higher levels of competence and job satisfaction. This study highlights the importance of organizational support for ongoing education and training. Workplace Support During Crisis Situations. The COVID-19 pandemic has highlighted the importance of workplace support in maintaining nurse competence during crises. A study by Liu et al. (2021) found that adequate workplace support, including access to resources and mental health support, was crucial in helping nurses maintain competence and cope with the increased demands during the pandemic. Recent literature highlights the significant impact of workplace support on nurse competence.

Organizational support, managerial leadership, peer collaboration, and support for continuing professional development are all crucial for fostering and maintaining high levels of competence among nurses. Healthcare organizations must prioritize these aspects to ensure a competent and well-supported nursing workforce.

Workplace Support and Nursing Care Quality.

Workplace support is a critical determinant of nursing care quality. Effective support systems in the workplace can enhance nurses’ job satisfaction, reduce burnout, and improve patient outcomes. Recent studies have explored various dimensions of workplace support, including organizational, managerial, and peer support, and their impacts on the quality of nursing care.

Organizational Support and Nursing Care Quality.

Organizational support is fundamental in creating an environment that fosters high-quality nursing care. A study by Bakker and Demerouti (2019) found that organizational support, including adequate staffing and resources, significantly improved nursing care quality by reducing workload and stress. This study highlights the importance of organizational investments in support systems to enhance care quality. Managerial Support. Effective managerial support is crucial for improving nursing care quality. According to a study by Wong et al. (2020), transformational leadership by nurse managers was positively associated with better patient safety outcomes and higher nursing care quality. This research emphasizes the importance of leadership practices that support and empower nursing staff. Peer Support and Nursing Care Quality. Peer support, including teamwork and collaboration, plays a significant role in enhancing the quality of nursing care. A study by Wei et al. (2018) demonstrated that strong peer support networks were associated with higher levels of job satisfaction and improved quality of care. This study underscores the value of fostering a collaborative team environment in healthcare settings.

Mental Health Support and Nursing Care Quality.

Workplace support that includes mental health resources is vital for maintaining high-quality nursing care. A study by Melnyk et al. (2021) found that providing mental health support and resources for nurses led to reduced burnout and improved patient care outcomes. This research highlights the importance of addressing the mental health needs of nursing staff to ensure high-quality care.

Support During Crisis Situations.

The COVID-19 pandemic has emphasized the critical need for robust workplace support systems. A study by Shahrour and Dardas (2020) explored the impact of workplace support on nurses’ psychological well-being and care quality during the pandemic. The findings revealed that adequate workplace support, including access to resources and mental health services, was crucial in maintaining care quality under crisis conditions. Recent literature underscores the significant impact of workplace support on nursing care quality. Organizational, managerial, peer, and mental health support are essential components that contribute to enhancing the quality of nursing care. Healthcare organizations must prioritize these support systems to ensure the well- being and effectiveness of their nursing staff, ultimately leading to better patient outcomes.

RESEARCH METHODOLOGY

Design

This quantitative research made use of the descriptive correlation research design. In application to the study, the descriptive design was used in determining the generational age, work values, organizational communication and collaboration of nurses. The correlational design was used in assessing the relationship between level of competence and satisfaction of nursing care quality and the relationship of the level of competence mediated with workplace support and satisfaction of nursing care quality of nurses in Surigao City for the first quarter of 2025.

Environment

The study was conducted in a Government Hospital that is DOH retained and PhilHealth Accredited in Barangay Washington, Rizal Street, Surigao City.

Respondents

The respondents of the study were the 250 staff nurses employed in various wards or units within the hospital.

Sampling Design.

The sampling design for this study was a stratified random sampling method.

Inclusion and Exclusion Criteria.

The inclusion criteria consist of registered nurses employed at the hospital. Nurses with a minimum of one year of work experience are included. Additionally, only full-time nurses are included to ensure consistent exposure to the hospital environment and workplace support systems, which could influence their perceptions of clinical competence and patient care quality.

The exclusion criteria: Nurses currently on extended leave, such as maternity leave or sick leave, are also excluded since their absence from the workplace might affect their current understanding and assessment of workplace support Furthermore, nurses who primarily hold administrative roles and do not engage in regular patient care activities are excluded to maintain the focus on those directly involved in clinical practice.

Instrument

A structured questionnaire was used as the primary instrument. This questionnaire was divided into three main sections: clinical competence, patient care quality, and workplace support. Each section was sourced from validated and widely recognized scales to ensure the instrument’s reliability and validity.

The clinical competence section was based on the Nursing Competence Scale (NCS) developed by Meretoja et al. (2004). The NCS is a comprehensive tool used to measure nurses’ self-assessed competence across various domains. It utilizes a Likert scale with response categories ranging from 0 to 4, where 0 indicates “Not applicable,” and 4 indicates “Very much competence.” Scores for each item are summed to produce a total score, which can range from 0 to 212. Higher scores indicate greater perceived competence. The NCS has demonstrated high reliability, with a Cronbach’s alpha of 0.94.

The instrument used in this study is a standardized tool adopted from the work of Lin and Wang (2010) and further supported by Chen et al. (2015). It measures nurses’ perceived quality of care competence across six dimensions: task-oriented activities (14 items), staff characteristics (8 items), preconditioning (7 items), physical environment (6 items), patient outcomes (6 items), and human-oriented activities (7 items), totaling 48 items. Each item is rated on a 4-point scale: 0 (not applicable), 1 (used very seldom), 2 (used occasionally), and 3 (used very often). Higher scores indicate greater competence in delivering quality nursing care. The instrument has demonstrated strong psychometric properties, with a Cronbach’s alpha of 0.94 for the overall scale and subscale alphas ranging from 0.85 to 0.91, indicating excellent internal consistency. Content validity was also high, with a Content Validity Index (CVI) between 0.90 and 0.95. Each dimension reflects critical aspects of nursing care, from technical execution to emotional support and patient safety. Scores are interpreted by computing the average, where higher mean scores reflect more frequent and consistent application of quality care practices.

The workplace support section was based on the Nurse Workplace Support Scale (NWSS) developed by Laschinger et al. (2001). This scale measures the level of support nurses perceive in their workplace environment. The NWSS uses a Likert scale with responses ranging from 1 to 5, where 1 denotes “Strongly disagree” and 5 denotes “Strongly agree.” Scores for each item are summed to produce a total score ranging from 20 to 100, with higher scores indicating higher perceived workplace support. The NWSS has demonstrated high reliability, with a Cronbach’s alpha of 0.91. The combined reliability of the entire questionnaire was assessed using Cronbach’s alpha, which indicated a high level of internal consistency across the three sections. The overall Cronbach’s alpha for the instrument was 0.93, confirming the instrument’s reliability for measuring clinical competence, patient care quality, and workplace support among nurses. This high level of reliability underscores the robustness of the instrument in capturing the nuanced aspects of clinical competence and the mediating role of workplace support in patient care quality.

Data Gathering Procedures

Necessary permissions were sought from institutional authorities including the Dean of the College of Allied Health Sciences, , and the Medical Chief of the partner hospital. Following these approvals, the research proposal underwent a design hearing with a panel of experts to evaluate the methodological soundness and ethical considerations of the study. Revisions based on the panel’s recommendations were incorporated, and the final version of the manuscript was submitted to the Institutional Ethics Review Committee for ethical clearance. Only upon receiving an approved ethical clearance and a Notice to Proceed did the actual data collection begin. The recruitment of respondents was conducted upon issuance of the Notice to Proceed. A probability sampling technique was utilized to ensure objective representation of the study population. A master list of qualified nurses employed in the hospital was obtained from the Human Resource Department. Using the table of random numbers, the participants were selected to avoid sampling bias. Data collection was executed through a face-to-face intercept approach during periods that did not interfere with work obligations, such as during break times, before shifts, or immediately after duty hours. Participation was voluntary, and respondents were given informed consent forms detailing the nature, scope, and confidentiality of the research. All collected data were encoded in an Excel file and prepared for statistical processing. Appropriate descriptive and inferential statistical analyses were applied to examine the level of nursing competence, the perceived quality of nursing care, workplace support, and their interrelationships. The data were organized into tables, with corresponding interpretations, theoretical implications, and supportive literature integrated in the discussion. To maintain ethical standards and respondent confidentiality, all physical copies of the completed questionnaires were securely shredded following data analysis and validation. Digital files were stored in a password-protected system accessible only to the researcher and adviser.

Statistical Treatment of Data

Means Score was used in determining the work values, organizational communication and collaboration of the nurses. Pearson r was used in assessing the significant relationship between the level of competence and satisfaction of quality nursing care and the level of competence mediated with workplace support and the satisfaction of the quality of nursing care, Mediation analysis was conducted using a path model approach to examine whether workplace support served as a mediating variable between nursing competence and quality of care. This analysis decomposed the total effect of competence on quality of care into direct and indirect effects, estimating the strength and significance of each pathway. The use of bootstrap confidence intervals and z-scores ensured robust estimation of the indirect effects.

Ethical Considerations

The study was approved by the University of the Visayas-Institution Review Board (IRB). See the appendices for the ethical considerations.

PRESENTATION, ANALYSIS, AND INTERPRETATION OF DATA

Table 1 Level of Competence of the Nurses

Dimensions	Mean score	SD	Interpretation
Helping role	92.06	5.91	Very competent
Teaching-Coaching	91.53	8.51	Very competent
Diagnostic functions	91.11	7.27	Very competent
Managing Situations	91.20	9.11	Very competent
Therapeutic interventions	90.40	8.24	Very competent
Ensuring quality	90.26	8.43	Very competent
Work role	92.34	7.22	Very competent
Grand mean	91.27	7.02	Very competent

Note: n-245.

Legend: A score of 0 -20 is not competent at all, 21 – 40 is low competence, 31 – 60 is fair competence, 61 – 80 is high competence, and 81 – 100 is very competent.

The overall level of competence was, interpreted as “very competent.” This result suggests that patients perceive nurses to be highly skilled across all evaluated areas of professional practice. However, it is important to recognize that the competence ratings were based on self-assessment by the nurses, which may have introduced central tendency bias or inflated ratings due to social desirability and self-perception bias. Self-rating often leads to higher evaluations because respondents may unconsciously overestimate their abilities, particularly in environments where competence is closely linked to professional pride and identity. Therefore, while the findings are highly encouraging, it is recommended that future studies incorporate multiple evaluators, such as peer reviews, supervisory assessments, and patient feedback, to provide a more comprehensive and triangulated view of nursing competence. Additionally, qualitative methods, such as focus group discussions or in- depth interviews, are suggested to explore deeper insights into the factors influencing perceived competence and to address any gaps that may not be captured by quantitative self-assessment alone.

Overall, the level of competence of the nurses at Caraga Regional Hospital was found to be very competent, carrying significant implications for patient care, professional development, and healthcare management. Highly competent nurses deliver safe, effective, and high-quality care, leading to better health outcomes and greater patient satisfaction (Aiken et al., 2018). Their skills in clinical decision-making, performing complex procedures, and responding to emergencies with confidence help minimize risks, prevent complications, and improve recovery rates (Benner, 2021).

However, sustaining this high level of competence requires continuous professional development. Even seasoned nurses need regular opportunities for training, mentorship, and exposure to updated best practices to keep pace with the rapidly evolving healthcare environment (Fukada, 2018). Furthermore, the workplace environment plays a crucial role in maintaining and enhancing competence. No matter how skilled a nurse is, a lack of support from leadership, colleagues, or institutional policies can eventually lead to burnout and performance decline (Laschinger et al., 2016).

This highlights the responsibility of healthcare administrators to invest in supportive workplace strategies—such as mentorship programs, leadership development initiatives, and access to professional resources to sustain nursing competence. Recognizing and rewarding nursing excellence through career advancement opportunities, fair compensation, and positive working conditions can help retain skilled nurses and further motivate them (Duchscher, 2017).

While this study confirms a strong level of competence among nurses, it also opens important avenues for further exploration. Future research could investigate other contributing factors to sustained competence, such as job satisfaction, emotional well- being, and organizational policies. Hospitals are encouraged to implement quality improvement initiatives, including hands-on simulation training, interdisciplinary team collaboration, and leadership engagement, to ensure that nurses continue to grow and adapt within an increasingly complex healthcare system (Fukada, 2018). By fostering a culture of continuous learning, supportive management, and professional growth, hospitals can strengthen not only the competence of their nursing workforce but also the overall quality and sustainability of healthcare services.

To further understand the areas contributing to the nurses’ overall competence, the findings were analyzed across seven core dimensions: helping role, teaching-coaching, diagnostic functions, managing situations, therapeutic interventions, ensuring quality, and work role. Each dimension represents a critical aspect of nursing practice and provides deeper insight into the specific strengths demonstrated by the nurses.

Helping role.

Nurse rated themselves to be very competent in the helping role. They believed that they were very competent in terms of planning patient care according to individual need, supporting patients’ coping strategies, evaluating critically own philosophy in nursing, modifying the care plan according to individual needs, utilizing nursing research findings in relationships with patients, developing the treatment culture of their unit, and decision-making guided by ethical values.

The data reveals that nurses are demonstrating their strong commitment to individualized, patient-centered care. They exhibit the ability to plan and modify care based on each patient’s unique needs, critically evaluate their own nursing philosophy, and integrate research findings into practice. This suggests a nursing workforce that prioritizes holistic and ethical care. Actual observations in the clinical setting support this, where nurses consistently revise care plans to reflect patient preferences and evolving conditions. Ethical decision-making is also evident in practice, especially during morally complex scenarios, indicating that nurses are guided by a solid framework of professional values.

According to Takase et al. (2016), nurses who deliver patient-centered care demonstrate greater job satisfaction and patient trust, particularly when ethical principles and individual needs are prioritized. However, Papastavrou et al. (2014) found that time constraints and staffing levels in some hospitals may compromise the delivery of personalized care, highlighting a potential gap between competence and actual clinical conditions.

Teaching-Coaching.

This was rated as very competent also. Nurses believed that they were very competent in mapping out patient education needs carefully, finding optimal timing for patient education, mastering the content of patient education, providing individualized patient education, coordinating patient education, and being able to recognize family members’ needs for guidance. Further they believed that they were very competent in terms of acting autonomously in guiding family members, taking student nurse’s level of skill acquisition into account in mentoring, supporting student nurses in attaining goals, and evaluating patient education outcome together with patient. Furthermore, they believed that they were very competent in terms of evaluating patient education outcomes with family, evaluating patient education outcome with care team, and taking active steps to maintain and improve their professional skills. Lastly, they were very competent in developing patient education in their unit, developing orientation programmes for new nurses in their unit, and coaching others in duties within their responsibility area.

The results revealed that nurses also display very competent performance in the teaching-coaching dimension. This reflects their ability to educate patients, mentor colleagues, and develop educational materials and strategies within the unit. Nurses effectively tailor patient education, determine optimal teaching moments, and provide individualized instruction to both patients and their families. Furthermore, they take proactive steps to support student nurses and novice staff through structured mentoring. These competencies are observed in real practice as nurses are seen engaging patients during discharge planning, facilitating unit-based learning sessions, and taking the initiative in orientation and professional development programs.

McCurry et al. (2010) emphasized that nurses who engage in active teaching roles improve patient outcomes and foster professional identity in nursing students. Conversely, Aliakbari et al. (2015) noted that while nurses are willing to teach, a lack of training in teaching methodologies may hinder the effectiveness of patient education.

Diagnostic functions

Respondents rated themselves as very competent in this area. They believed that they were very competent in analyzing patient’s well-being from many perspectives, being able to identify patient’s need for emotional support, being able to identify family members’ need for emotional support, arranging expert help for patient when needed, coaching other staff members in patient observation skills, coaching other staff members in use of diagnostic equipment and developing documentation of patient care.

The very competent rating in diagnostic functions indicates that nurses are capable of comprehensive assessments and early detection of patient issues. They analyze well- being from multiple perspectives and identify emotional support needs for both patients and families. Additionally, they arrange expert consultations when needed and assist other staff in observational skills. In actual clinical practice, nurses are often the first to detect subtle changes in a patient’s condition, prompting timely interventions. They also serve as emotional anchors for families and effectively coordinate referrals to psychological or specialized support services.

High scores in diagnostic functions highlight nurses’ ability to assess patients holistically and recognize emotional support needs. This is consistent with observations of nurses who escalate concerns early and involve allied professionals when needed. Bittner & Gravlin (2009) confirmed that strong assessment and critical thinking skills among nurses lead to earlier interventions and improved patient safety. However, Omani-Samani et al. (2018) suggest that diagnostic competence may vary depending on clinical experience, indicating that junior nurses may struggle in complex assessments without supervision.

Managing Situations.

They believed that they were very competent in terms of managing situations. They believed that they were very competent in being able to recognize situations posing a threat to life early, prioritizing their activities flexibly according to changing situations, acting appropriately in life-threatening situations, and arranging debriefing sessions for the care team when needed. Further, they believed that they were very competent in terms of coaching other team members in mastering rapidly changing situations, planning care consistently with resources available, keeping nursing care equipment in good condition, and promoting flexible team cooperation in rapidly changing situations.

Nurses show very competent abilities in managing situations, underscoring their readiness to respond to rapidly changing clinical environments. They exhibit flexibility in prioritizing care, act appropriately during life-threatening events, and promote teamwork under pressure. These competencies are reflected in real-time scenarios such as code situations, where nurses efficiently delegate tasks and provide leadership. Additionally, they conduct debriefings after critical events, showing reflective practice and a commitment to team learning. Their ability to adapt plans based on available resources further reflects practical and situational awareness in nursing management.

Seyedin et al. (2015) found that nurses’ ability to respond swiftly in emergency settings reduces mortality rates and improves patient outcomes, particularly when teamwork and protocols are well established. In contrast, Shields & Wilkins (2009) noted that in understaffed settings, nurses often experience burnout that can compromise their crisis management skills.

Therapeutic interventions.

This was rated as very competent. Nurses believed that they were very competent in terms of planning own activities flexibly according to clinical situation, making decisions concerning patient care taking the particular situation into account, coordinating multidisciplinary team’s nursing activities, coaching the care team in performance of nursing interventions, and updating written guidelines for care. Further, they believed that they were very competent in providing consultation for the care team, utilizing research findings in nursing interventions, evaluating systematically patient care outcomes, incorporating relevant knowledge to provide optimal care, and contributing to further development of multidisciplinary clinical paths.

With a mean score of 90.40, nurses were also found very competent in therapeutic interventions. They plan and implement interventions tailored to the clinical situation, incorporate evidence-based knowledge, and evaluate care outcomes systematically. This dimension also includes the ability to coordinate multidisciplinary care and provide coaching within the team. Observations support this as nurses take charge of implementing

care pathways, update guidelines based on new evidence, and act as resources for less experienced staff. Their involvement in case conferences and patient rounds demonstrates their leadership in clinical decision-making and integrated care.

Duffield et al. (2011) concluded that nurses’ involvement in therapeutic decision- making improves continuity of care and patient recovery rates. However, Aiken et al. (2012) pointed out that limited access to updated clinical guidelines and continuing education could hinder the optimal use of evidence-based interventions.

Ensuring quality.

They believed that they were very competent in being committed to their organization’s care philosophy, being able to identify areas in patient care needing further development and research, evaluating critically my unit’s care philosophy, and evaluating systematically patients’ satisfaction with care. Lastly, they believed that they were very competent in utilizing research findings in further development of patient care and making proposals concerning further development and research.

Nurses’ competence in ensuring quality reflects their dedication to sustaining high standards of care and fostering continuous improvement. They critically evaluate their unit’s care philosophy, utilize patient satisfaction feedback, and propose innovations based on research. In actual practice, this is evident through participation in quality improvement committees and implementation of changes based on audit results or incident reviews. Nurses are not only responsive to feedback but also act as initiators of practice development, aligning clinical operations with institutional goals and evidence-based standards.

Laschinger et al. (2014) found that autonomy and role clarity significantly enhance nurse empowerment and workplace engagement. On the contrary, Reid & Wills (2010) identified role strain as a risk when nurses are expected to manage multiple responsibilities without adequate staffing or support.

Work role.

Nurses believed that they were very competent in work role. They believed that they were very competent in terms of being able to recognize colleagues’ need for support and help, being aware of the limits of their own resources, that professional identity serves as resource in nursing, and in acting responsibly in terms of limited financial resources. Further, they believed that they were very competent in terms of being familiar with their organization’s policy concerning division of labor and coordination of duties. Further, they believed that they were very competent in terms of coordinating student nurse mentoring in the unit, mentoring novices and advanced beginners, providing expertise for the care team, acting autonomously , and guiding staff members to duties corresponding to their skill levels. Furthermore, they believed that they were very competent in terms of incorporating new knowledge to optimize patient care, ensuring smooth flow of care in the unit by delegating tasks, taking care of themselves in terms of not depleting their mental and physical resources, utilizing information technology in their work, and coordinating patients. Lastly, they believed that they were very competent in terms of orchestrating the whole situation when needed, giving feedback to colleagues in a constructive way, developing patient care in multidisciplinary teams, and developing work environment.

The highest among all dimensions, the work role domain underscores nurses’ very competent performance in fulfilling diverse responsibilities mentoring, coordinating, delegating, and self-care. They recognize colleagues’ needs for support, manage their physical and mental well-being, and guide staff based on skill levels. They also incorporate technology and serve as leaders within multidisciplinary teams. Real-life observations show nurses effectively managing unit workflow, guiding student nurses, and taking active roles in case management and task delegation. Their use of technology for documentation and communication further supports efficient patient care delivery. Laschinger et al. (2014) found that autonomy and role clarity significantly enhance nurse empowerment and workplace engagement. On the contrary, Reid & Wills (2010) identified role strain as a risk when nurses are expected to manage multiple responsibilities without adequate staffing or support.

Table 2 Quality of Care as Perceived by Nurses

Dimensions	Mean score	SD	Interpretation
Task‐oriented activities	2.75	0.377	Fair quality of care
Staff characteristics	2.81	0.379	Fair quality of care
Pre-condition	2.65	0.450	Fair quality of care
Physical environment	2.63	0.436	Fair quality of care
Patient outcomes	2.71	0.450	Fair quality of care
Human‐oriented activities	2.66	0.378	Fair quality of care
Grand mean	2.70	0.360	Fair quality of care

Note: n-245.

Legend: A score of 1.00 – 1.80 is very low quality of care (strongly disagree), 1.81 – 2.60 is low quality of care (disagree), 2.61 – 3.40 is fair quality of care (neither agree nor disagree), 3.41 – 4.20 is good quality of care (agree), and 4.20 – 5.00 is very good quality of care (strongly agree).

Overall, the quality of nursing was rated as fair by the nurses. The findings of this study present an interesting contrast between the perceived high level of competence among nurses and the fair level of quality of care they report delivering. The grand mean score for the level of competence was, interpreted as “very competent.” This indicates that nurses strongly believe they possess the necessary knowledge, skills, and attitudes across diverse domains of professional nursing practice. Their self- assessments reflect confidence in their ability to deliver individualized care, educate patients, manage clinical situations, apply diagnostic reasoning, and promote therapeutic interventions. Such high competence is a positive sign, implying that nurses are well-prepared, skilled, and motivated to deliver high standards of care.

However, when asked to rate the quality of care they actually provide, the grand mean was only interpreted as “fair quality of care.” This fair rating suggests that while the nurses believe they are capable, there are systemic, organizational, and contextual barriers that prevent them from fully translating their competence into consistently high-quality patient care. This discrepancy can be explained by several factors such as self-assessment bias: The competence scores are based on self-rating, which can be prone to central tendency and social desirability biases, leading nurses to perceive and report their abilities more favorably. Work environment constraints: Quality of care is a product not only of individual competence but also of organizational factors. Nurses working in high-pressure environments with heavy workloads, inadequate staffing, limited resources, and high patient acuity may struggle to apply their full range of skills effectively.

This contrast highlights an essential insight: competence alone is not enough to guarantee high-quality care. Environmental conditions, organizational culture, and institutional support systems significantly mediate the extent to which nurses can fully exercise their competencies to impact patient outcomes positively.

As supported by the literature, Aiken et al. (2018) and Laschinger et al. (2016) emphasize that workplace environments and leadership support play a crucial role in bridging the gap between nurse competence and actual patient care quality. Meanwhile, Fukada (2018) stresses that even highly skilled nurses require continuous professional development and systemic support to sustain high performance in practice.

Thus, it is essential for hospital administrators and policymakers to recognize that investments in staff development must be accompanied by investments in safe staffing levels, resource availability, positive work environments, and emotional support systems for nurses.

Moreover, the fair perception of care quality underscores the need for quality improvement initiatives, such as: Implementing interprofessional teamwork programs, Promoting patient-centered communication training, Enhancing hands-on clinical skills updates, conducting regular audits and patient feedback reviews, and fostering a culture of shared leadership where nurses are empowered to actively participate in care improvement decisions.

To better understand the specific areas contributing to the overall perception of fair quality of care, The following sections discuss the results for each dimension individually, highlighting key findings, providing clinical observations, and aligning interpretations with relevant literature to better explain the factors influencing the perceived quality of care.

Task‐oriented activities.

The table shows that this was rated as fair, supporting this finding, respondents neither agreed nor disagreed that they provided guidance to do self‐ care for their patients and provided the information to patient with effective communication. Also, they neither agreed nor disagreed that they provided sufficient information related to nursing care to patients’ relatives, they performed the standardized nursing service to patient according to their situation, and they informed their patients before providing any nursing intervention. Further, they neither agreed nor disagreed that they performed the good basic nursing care to patients, performed nursing duties in a professional manner, provided sufficient information to their patients about their care or treatment with clear word, and they immediately responded to patient and family’s problems. Furthermore, they neither agreed nor disagreed that they provided individualized care for patients, provided medication and treatment at the correct time, provides effective health education to patients, and provided nurse service on time despite being busy.  However, they disagreed that clearly explained to the patients about their questions related to medical expense.

Although nurses perceive themselves as fairly competent in task-related responsibilities, their responses suggest room for improvement in communication, timely interventions, and individualizing care. Neutral responses in most items may imply a lack of confidence or institutional barriers such as time constraints or high patient loads.

In practice, some nurses may be observed giving standardized health education rather than tailoring it to each patient’s context. Delays in medication administration and generalized communication styles could also reflect these neutral responses. Lin et al. (2021) found that task-focused nursing without effective patient communication often leads to reduced patient satisfaction, especially in time-pressured environments. Salem et al. (2020) emphasized that empowering nurses with better communication skills significantly improves quality of care delivery and patient understanding.

Staff characteristics.

This was also rated as fair, Respondents neither agreed nor disagreed that they carefully followed hospital rules and regulations, they were very cautious in performing their nursing duties, they were polite and pleasant to treat patient, and they smiled to patients when providing nursing service. Further, they neither agreed nor disagreed that they closely observed the patient condition, focusing on the dynamic change of the disease, they patiently listened to their patients, when they want to talk about their problems, they worked well with their team, and they patiently and repeatedly explained patients doubt.Nurses perceive their personal attributes such as politeness, teamwork, and cautiousness at a fair level. While they do not strongly agree on these traits, they recognize their presence, which could reflect a generally professional attitude that needs reinforcement through regular training and motivation. Nurses are likely seen working well in teams and communicating respectfully with patients. However, inconsistencies in expressions of empathy and emotional availability, such as smiling or listening attentively, may explain the neutral ratings. Shah et al. (2020) stated that positive staff attributes including empathy and teamwork significantly influence patients’ perception of care. Alamer et al. (2022) linked emotional intelligence and nurse professionalism with improved patient interaction and clinical effectiveness.

Pre-condition.

This was rated as fair. Respondents neither agreed nor disagreed that they managed drugs well, they participated in the ward quality management, their professional experience was helpful for their nursing job, and they intended to help patients whenever the help was needed. However, they disagree that they mastered the clinical technical operations to meet the needs of nursing care, they can up‐to‐data their theoretical knowledge to meet the needs of nursing care, and mastered operating process of basic nursing care and special nursing care.

This dimension reflects concerns about the nurses’ perceived readiness in terms of clinical skills, theoretical knowledge, and participation in quality management. Disagreement on mastering technical and theoretical aspects suggests a need for competency-based training and continuous professional development. Discrepancies between theory and practice might be evident such as hesitation in managing complex clinical procedures or underutilization of evidence-based guidelines. Some nurses might rely more on routine practice than on updated clinical standards. Yilmaz & Duyan (2021) emphasized that a lack of technical proficiency and continuing education hampers quality nursing care. Nguyen et al. (2023) found that knowledge gaps, especially among less experienced nurses, negatively affect patient outcomes.

Physical environment.

A fair rating was given on this dimension. Respondents neither agreed nor disagreed that they provided the hygienic room to the patients, provided a comfortable environment for patient to rest in, kept patient room has the good ventilation, provided safe environment to patients for their treatment, and provided the quiet ward environment for patients staying in the hospital. However, they disagreed that they immediately disposed patients’ reflection environment problems.

The perceived quality of the physical environment is moderate, suggesting that nurses recognize challenges in maintaining hygiene, ventilation, safety, and quietness in hospital settings. Disagreement in addressing environment-related patient complaints implies institutional or logistical limitations. Nurses may be seen attempting to maintain cleanliness and patient comfort but may struggle due to overcrowded wards, understaffing, or limited infrastructure. Prompt resolution of environmental concerns (e.g., noise, room temperature) may not always be feasible. Alotaibi et al. (2020) stressed that a therapeutic physical environment enhances recovery and overall patient experience. Liu et al. (2022) confirmed that environmental factors significantly influence patient satisfaction, and nurses often feel restricted in addressing these without institutional support.

Patient outcomes. This was also rated as fair. Respondents neither agreed nor disagree that they avoided patient physical damage, they never got complains from the patients and their relatives, avoided patient chemical and biological damage, and ensured that the provided service would meet patient’s satisfaction criteria. However, they disagreed that they ensured to provide safety service to patient.

Nurses show modest confidence in preventing harm (physical, chemical, or biological) and ensuring patient satisfaction. The “disagree” rating on providing safety services suggests issues with systems or processes that affect overall care safety. Despite best efforts, nurses might experience near-miss incidents, medication errors, or infection control breaches especially in high-stress units. Though complaints are not frequent, patient satisfaction may vary depending on workload and resource availability. Chen et al. (2019) reported that nurse-led patient safety initiatives decrease incidents such as falls and medication errors. Thapa et al. (2021) found that perceived lack of support in staffing and safety protocols directly affects how nurses evaluate their influence on patient outcomes.

Human‐oriented activities.

This was rated as fair. Supporting this finding, respondents neither agree nor disagree that they ensured to provide services that would meet patient individual needs, helped their patients to relieve their fear about treatment and procedure, and they protected patient’s privacy when provide nursing service. However, they disagreed that they helped their patients to relive their worry about illness, built confidence to overcome the disease, provided humanity services to patients based on their characteristics, and they analyzed the patient psychological feelings to provide care.

Nurses report difficulty in fully addressing emotional, psychological, and individualized care needs. Disagreement on helping patients relieve fear, build confidence, or analyze psychological needs implies that psychosocial support is undervalued or underutilized. In many settings, nurses may focus primarily on physiological care, with less time or training allocated for emotional support. Patient anxiety or psychological distress may not be systematically assessed or managed by nurses. Cai et al. (2020) emphasized that humanistic care significantly contributes to patients’ emotional well-being but is often overlooked due to workload and task prioritization. Zhou et al. (2022) indicated that training in holistic and humanistic nursing care improves both nurse satisfaction and patient trust.

Table 3 Extent of Workplace Support as Perceived by the Nurses

Dimensions	Mean score	SD	Interpretation
Manager or supervisor	2.41	0.801	Low
Co-workers	2.26	0.479	Low
Company, business, or organization	2.23	0.468	Low
Grand mean	2.30	0.451	Low

Note: n-245.

Legend: A score of 1.00 – 1.80 is very low (strongly disagree), 1.81 – 2.60 is low (disagree), 2.61 – 3.40 is fair (neither agree nor disagree), 3.41 – 4.20 is high (agree), and 4.20 – 5.00 is very high (strongly agree).

The findings of the study revealed that the overall extent of workplace support perceived by nurses was low, with a grand mean of 2.30 and a standard deviation of 0.451. This result suggests that nurses feel they receive insufficient support across key areas, including support from their managers or supervisors, co-workers, and the organization itself. The perception of low workplace support is a critical concern as it directly impacts nurses’ well-being, motivation, and capacity to deliver high-quality patient care. Supportive work environments are strongly associated with higher job satisfaction, better patient outcomes, and greater professional engagement (Laschinger et al., 2016; Aiken et al., 2018). However, a lack of perceived support has been consistently linked to higher levels of burnout, emotional exhaustion, turnover intention, and decreased quality of nursing care (Twigg et al., 2019).

Several factors may explain the low workplace support ratings observed: Managerial Gaps: Nurses may feel that their supervisors are overly focused on operational demands, leaving little room for empathy, flexibility, or individualized support. Weak Peer Support Structures: Although interpersonal conflicts appear minimal, there may be a lack of strong collaborative relationships and emotional solidarity among co-workers. Limited Organizational Flexibility: Institutional policies may prioritize clinical and operational efficiency over employee well-being, creating environments where personal needs are overlooked.

These challenges can have serious implications. When nurses feel unsupported, they are more likely to experience stress, reduced morale, and professional dissatisfaction, which in turn can affect patient safety, team collaboration, and institutional efficiency (Dempsey et al., 2018). Importantly, low workplace support can also undermine the maintenance and application of clinical competence. Even highly skilled nurses require continuous mentorship, access to resources, and a psychologically safe environment to fully realize their professional potential and adapt to the evolving demands of healthcare (Fukada, 2018; Aiken et al., 2018). Without these supports, nurses may experience skill stagnation, hesitation in clinical decision-making, and emotional disconnection from their roles.

To further understand the sources of the perceived low workplace support, the following sections present the detailed findings and discussions for each dimension, highlighting specific strengths, gaps, and relevant observations supported by literature.

Manager or supervisor.

The support was low. Respondents strongly disagreed that their manager does not understand that there are times when employees’ personal needs have to come before their work, that in organizing meeting times or work hours, their manager showed little concern for employees’ personal needs, and their manager does what she or he can to make things easier when employees were having difficulties. Also, they neither agreed nor disagreed that their manager does things to help employees balance their work and their personal life.

The low score suggests that nurses perceive inadequate support from their immediate supervisors in balancing personal and professional responsibilities. This could potentially lead to lower job satisfaction, increased stress, and even turnover if not addressed. In many hospitals, nurse supervisors are often focused on staffing and operational targets, which may overshadow their ability to empathize or support subordinates’ personal challenges. Nurses report difficulty in requesting shift changes or leaves without feeling penalized or judged, especially in understaffed facilities. Boamah et al. (2018) found that transformational leadership and supportive supervision are significantly associated with higher nurse engagement and reduced burnout. Laschinger et al. (2014) noted that supervisor support correlates positively with nurse job satisfaction and retention. However , contrary to the study by Morsiani et al. (2017) suggested that many nurse managers demonstrate high levels of emotional intelligence and relational skills, leading to perceived supportiveness in some contexts, particularly in magnet hospitals.

Co-workers.

The support was low also in terms of co-workers. Respondents strongly disagreed that their co-workers did not really care about how things were going for them personally, their coworkers did not pitch in and help them out in practical ways, and they did not depend on their coworkers for practical help. Also, they neither agreed nor disagreed that they there are coworkers who would fill in for me as much as they could, they had co-workers who go out of their way to help then at work, if they were having difficulties of a personal nature, there were coworkers who would show concern for them, and they had co-workers who would support them through difficult personal issues. They disagreed that they cannot talk about personal matters with their co-workers.

Nurses feel that while overt conflict may not exist, genuine interpersonal support among peers is limited. The lack of strong peer support may hinder collaboration, especially in high-pressure environments like emergency or critical care units. Co-worker support can be highly dependent on unit culture. In some departments, competition or hierarchy may reduce openness to offering help or emotional support. Some nurses express hesitation to share personal matters or ask for help due to fear of judgment or gossip. Heaney, Price, & Rafferty (2020) emphasized that coworker support is a critical buffer against work stress and emotional exhaustion. Speroni et al. (2015) found that strong peer networks significantly reduce the likelihood of workplace incivility and improve team effectiveness. However, some studies like McVicar (2016) report moderately high perceived support among co-workers, especially in teams with long-standing tenure or shared trauma experiences (e.g., during COVID-19 surges), suggesting that context and crisis periods can foster solidarity.

Company, business, or organization.

Support on this area was low. They strongly disagreed that people with personal needs did not do as well in the company, the company frowned on employees who cut back on their hours of work for personal reasons, and the company believed that employees who take a leave of absence for personal needs are not serious about their jobs. Also, they neither agreed nor disagreed that the company had a way of showing that it supports people who have personal needs and the company tried to help employees make work arrangements that suit their personal needs. However, they disagree that to succeed in the company employees must put their personal needs second and that the company gave out a message that employees should not allow their personal needs to interfere with their work. The low organizational support score indicates a perceived lack of systemic and policy-level recognition of employees’ personal needs. It may contribute to disengagement, decreased morale, and intention to leave, especially among younger nurses valuing work-life integration. Many organizations prioritize clinical outcomes and operational efficiency over employee welfare, resulting in minimal flexibility in scheduling or lack of wellness programs. Requests for flexible shifts, mental health days, or parental leave are often met with bureaucratic delays or disapproval.

Eisenberger et al. (2006) coined the concept of Perceived Organizational Support (POS), which has since been linked with greater organizational commitment and lower turnover. Moody (2020) highlights that nurses who perceive high organizational support are more resilient and committed, particularly in resource-constrained hospitals. However, some private or magnet-status hospitals have implemented progressive HR policies, such as flexible scheduling and wellness initiatives, which resulted in higher perceived support (Aiken et al., 2011), suggesting institutional culture plays a crucial role.

Overall, the workplace support was low. The findings that nurses perceive workplace support as low raises important concerns for both their well-being and the quality of patient care. A supportive work environment is essential for job satisfaction, professional growth, and the ability to provide high-quality care (Laschinger et al., 2016). When nurses feel unsupported, they may experience stress, burnout, and decreased motivation, all of which can negatively impact their performance and, ultimately, patient outcomes (Aiken et al., 2018). Lack of workplace support can take many forms, including staff shortages, weak leadership engagement, limited access to training, and a lack of recognition for nurses’ efforts (Twigg et al., 2019). These challenges can lower morale, increase the risk of errors, and reduce overall efficiency, making it harder for nurses to deliver safe and effective care (Dempsey et al., 2018).

This highlights the urgent need for healthcare leaders and policymakers to address workplace support issues. Studies show that when nurses feel valued and supported, they are more engaged, provide better care, and experience greater job satisfaction (Fukada, 2018). Hospitals can improve workplace support by ensuring adequate staffing levels, strengthening leadership involvement, creating mentorship programs, and providing continuous learning opportunities (Laschinger et al., 2016). Additionally, fostering a collaborative and respectful work environment where nurses feel heard, appreciated, and empowered can significantly boost morale and job performance.

Moreover, low workplace support can also hinder nurses’ ability to develop and maintain clinical competence. Without proper guidance, resources, and training, it becomes challenging for nurses to keep up with advancements in healthcare and refine their skills (Aiken et al., 2018). Healthcare institutions must invest in leadership development, peer support networks, and structured training programs to strengthen workplace support and help nurses perform at their best.

Future research should explore why nurses feel unsupported whether it’s due to leadership gaps, teamwork challenges, or limited career growth opportunities. Additionally, hospitals should conduct regular assessments of nurse satisfaction and working conditions to identify problem areas and implement targeted improvements. By creating a culture of support, recognition, and continuous professional development, hospitals can boost nurse retention, improve job satisfaction, and enhance the overall quality of patient care. A strong, well-supported nursing workforce is essential for a resilient and efficient healthcare system.

Table 4 Relationship between the Level of Competence and Quality of Nursing Care

Variables	r value	p value	Decision	Interpretation
helping role	.051	.431	Failed to reject Ho	Not significant
teaching-coaching	.105	.101	Failed to reject Ho	Not significant
diagnostic functions	.092	.150	Failed to reject Ho	Not significant
managing situations	.118	.065	Failed to reject Ho	Not significant
therapeutic interventions	.113	.077	Failed to reject Ho	Not significant
ensuring quality	.124	.052	Failed to reject Ho	Not significant
work role	.064	.318	Failed to reject Ho	Not significant
overall competence	.110	.087	Failed to reject Ho	Not significant

Legend: Significant if p value is < .05. Dependent Variable: Quality of Nursing Care. Pearson r interpretation: A value greater than .5 is strong (positive), between .3 and .5 is moderate (positive), between 0 and .3 is weak (positive), 0 is none, between 0 and –.3 is weak (negative), between –.3 and –.5 is moderate (negative), and less than –.5 is strong (negative).

Overall Quality of Nursing Care.

The table shows that the p values for the independent variables of helping role, teaching-coaching, diagnostic functions, managing situations, therapeutic interventions, ensuring quality, work role, overall competence were greater than the significant value of .05. These values were interpreted as not significant which led to the decision of failing to reject the null hypothesis. Thus, helping role, teaching-coaching, diagnostic functions, managing situations, therapeutic interventions, ensuring quality, work role, overall competence were not significantly correlated with overall quality of nursing care. This further means that, a high overall quality of nursing care can still be achieved despite the low helping role, teaching-coaching, diagnostic functions, managing situations, therapeutic interventions, ensuring quality, work role, overall competence.

The finding that clinical competence does not significantly impact the quality of nursing care challenges the common belief that more skilled nurses automatically provide better patient outcomes. This suggests that while nurses may be highly trained and knowledgeable, other factors may have a stronger influence on the actual quality of care they deliver. Research shows that organizational factors such as staffing levels, workload, hospital policies, and resource availability can sometimes outweigh individual competence in determining patient care quality (Aiken et al., 2018). Even the most competent nurses may find it difficult to provide the best care if they are overworked, unsupported, or lack the time and resources to apply their skills effectively (Twigg et al., 2019).

This highlights the need to look beyond individual skill levels when working to improve patient care quality. Hospital administrators and policymakers should prioritize improvements in nurse-topatient ratios, workplace culture, and access to essential medical supplies, as these factors can significantly impact how care is delivered (Laschinger et al., 2016). Additionally, teamwork, strong leadership, and interdisciplinary collaboration can help bridge the gap between competence and realworld patient outcomes (Dempsey et al., 2018).

Moreover, this finding suggests that competence alone is not enough—nurses need the right environment to apply their expertise effectively. Professional development should not only focus on clinical skills but also on critical thinking, communication, and adaptability, which are essential for delivering high-quality care in fast-paced healthcare settings (Fukada, 2018). Future research should explore other key factors influencing care quality, such as emotional intelligence, resilience, and hospital support systems, to gain a deeper understanding of what truly improves patient outcomes.

Ultimately, this study reinforces the idea that ensuring high-quality patient care requires more than just competent nurses. Addressing workplace challenges, improving hospital systems, and fostering a supportive and well-resourced environment are just as— if not more important in making sure patients receive safe, effective, and compassionate care.

Table 5 Relationship between the Level of Competence and Quality of Nursing Care when Mediated by Workplace Support

Type	Effect	Estimate	SE	Lower	Upper	β	z	p
Indirect	Competence ⇒ Support ⇒ Care	0.0117	0.0106	-0.00899	0.0324	0.0121	1.11	0.267
Component	Competence ⇒ Support	0.0951	0.0763	-0.05442	0.2445	0.0794	1.25	0.213
	Support ⇒ Care	0.1232	0.0507	0.02387	0.2226	0.1526	2.43	0.015
Direct	Competence ⇒ Care	0.1168	0.0607	-0.00219	0.2358	0.1208	1.92	0.054
Total	Competence ⇒ Care	0.1285	0.0614	0.00823	0.2488	0.1329	2.09	0.036

Legend: Significant if p value is < .05.

Mediation analysis was performed to assess the mediating role of workplace support on the linkage between level of competence and quality of nursing care. The results revealed that the total effect of the level of competence on the quality of nursing care was significant (β = 1.1329, z = 2.09, p = .036).

With the inclusion of the mediating variable—workplace support, the impact of the level of competence on the quality of nursing care became insignificant (β = .1208, z = 1.92, p = .054).

The indirect effect of the level of competency on the quality of care through the workplace support was found insignificant (β = .0121, z = 1.11, p = .267). This shows that the relationship between level of competency and quality of care is not mediated by workplace support Path Model.

The table shows that the level of competence was found to be not significant with quality of care (Level of competence → Quality of Nursing Care) (p < 0.213). Also, compatibility revealed a not significant relationship with workplace support (Level of competence → Workplace support) (p < 0.054). In addition, workplace support had no significant linkage with quality of nursing care (Workplace support → Quality of nursing care) (p < 0.001).

Moreover, the table indicated that indirect effect was also found not significant significant (β = 0.0121, p < 0.267) between the level of competence and quality of care (Level of competence → Quality of care). Hence, it concludes that level of competence and quality of care is not partially mediated (0.267) by workplace support.

These results suggest that while competence initially appears to influence care quality, workplace support does not function as a significant bridge that explains or enhances this relationship. In simpler terms, the nurses’ self-perceived competence does not translate into better quality of care through the pathway of feeling supported at work.

However, an important contextual factor must be considered: The findings throughout the study indicated that workplace support was perceived as low this low level of support may explain why nurses’ high self-assessed competence does not result in high quality of care.

Without strong workplace support structures such as responsive leadership, cohesive teamwork, access to adequate resources, and flexible work arrangements even highly competent nurses may be unable to perform optimally or consistently deliver high- quality care. Thus, the absence of a mediating effect may be due not to the irrelevance of support, but rather to insufficient support in the workplace to make a meaningful difference.

In clinical practice, competent nurses often struggle to apply their skills fully when faced with organizational barriers, heavy workloads, inadequate staffing, and limited time for patient interaction. Despite their knowledge, training, and technical skills, their ability to translate competence into effective patient care may be restricted by an unsupportive environment. This insight is consistent with the findings of Swiger et al. (2021) and He et al. (2022), who suggest that support systems must be operational and structural not just perceived emotionally to truly enhance care outcomes. Moreover, Alfuqaha et al. (2023) emphasized that perceived support has only an indirect and weak association with quality unless accompanied by broader system-level changes .While workplace support may not directly mediate the competence-to-care relationship in this study, it still plays a critical role in sustaining nurse well-being, job satisfaction, motivation, and long-term retention— all of which indirectly contribute to the overall quality and resilience of the healthcare system.

The finding that workplace support did not partially mediate the relationship between clinical competence and quality of nursing care suggests that nurses’ competence alone has the most direct impact on patient care quality, regardless of the level of support they receive. This means that while a supportive work environment is beneficial, it may not be the key factor influencing how well competent nurses perform. Research has consistently shown that highly skilled nurses are capable of delivering safe, efficient, and high-quality care because of their advanced clinical knowledge, critical thinking, and decision-making abilities (Fukada, 2018). Even when workplace support is lacking, nurses who possess strong competence may still be able to provide excellent patient care by drawing on their expertise and training (Aiken et al., 2018).

These findings imply that organizational interventions focused solely on providing generalized support and may not be sufficient to bridge the gap between competence and care delivery. The translation of competence into quality care may depend more on functional system-level enablers like staffing ratios, clinical protocols, access to continuing education, and practical autonomy, rather than the broad perception of being supported in the workplace. Additionally, this may reflect variability in how workplace support is experienced. For instance, nurses may feel emotionally or socially supported, but if they lack concrete structural support (e.g., adequate staffing, time for patient interaction, or safe working conditions), their ability to practice at a high level remains constrained.

In clinical settings, it is often observed that even highly competent nurses become overwhelmed by systemic pressures. For example: A nurse may have strong clinical judgment but is unable to respond to patient needs promptly due to heavy caseloads. Though peer and supervisor support exist informally, policies or bureaucratic delays may prevent timely decisions, such as adjusting medication schedules or implementing care plans. Nurses often report being recognized for their skills but feel unsupported in staffing or task delegation, resulting in missed opportunities for quality care interventions. These examples underscore that support must be operational and actionable, not merely perceived, to make a measurable difference in care quality.

However, this does not mean that workplace support is unimportant. While it may not significantly impact the direct link between competence and care quality, it plays a vital role in nurse well-being, job satisfaction, and retention (Laschinger et al., 2016). Without proper support, even the most competent nurses may experience stress, burnout, and decreased motivation, which could eventually impact their ability to sustain high-quality care (Twigg et al., 2019). The absence of a mediating effect in this study may suggest that other factors, such as personal resilience, ethical commitment, and intrinsic motivation, have a stronger influence on how competence translates into nursing care quality.

Swiger et al. (2021) found that nurse competence is a critical driver of care quality, but emphasized that unless systemic issues like resource availability and role clarity are addressed, competence alone does not yield improved outcomes. In a study by He et al. (2022), workplace support had a moderating not mediating effect, meaning it buffered the impact of stress but did not directly improve care quality or translate competence into better care. Alfuqaha et al. (2023) reported that perceived support from supervisors and peers was positively associated with job satisfaction, but had only an indirect and weak relationship with care quality, further suggesting that support systems need to be integrated with structural and procedural change to be truly effective. By contrast, Wei et al. (2020) showed that in settings with strong transformational leadership and high psychological safety, workplace support significantly enhanced the impact of competence on outcomes indicating that the context and type of support matter greatly.

This finding highlights the importance of continuing investments in programs that develop and maintain nurses’ clinical competence, as this has the most direct effect on patient care outcomes. Hospitals should prioritize ongoing education, hands-on training, simulation-based learning, and evidence-based practice initiatives to help nurses refine and expand their skills (Dempsey et al., 2018).

Additionally, future research could explore other possible mediators, such as leadership effectiveness, teamwork, and emotional resilience, to gain deeper insights into the workplace dynamics that influence nursing care quality. Ultimately, while workplace support may not directly mediate the connection between competence and patient care, it still plays a crucial role in ensuring nurses feel valued, motivated, and capable of maintaining excellence over time. A combination of strong clinical competence and a supportive work environment can help create a resilient and high-performing nursing workforce one that consistently delivers safe, compassionate, and high-quality patient care.

CONCLUSION AND RECOMMENDATIONS

Conclusions

This study highlights the importance of not only developing nursing competence but also ensuring that nurses are supported in ways that allow them to fully apply their skills in patient care. While nurses view themselves as highly competent, this does not always result in consistently high-quality care. This reinforces the idea that competence alone is not enough it must be practiced in a supportive environment.

The results affirm Dee Fink’s Competence Theory, which suggests that meaningful learning and performance require both ability and opportunity. Even the most skilled nurses need conditions that allow them to act on what they know. Likewise, the study reflects Eisenberger’s Organizational Support Theory, where the lack of strong workplace support weakens the connection between competence and performance. When nurses do not feel adequately supported by their organization, their ability to deliver excellent care may be limited. In line with Lee Schmidt’s Quality of Nursing Care Model, quality nursing care is more than just technical skill it includes communication, compassion, teamwork, and system support. These elements must work together for patients to truly benefit from the care provided. Therefore, improving care quality requires a dual focus: strengthening nursing skills and creating conditions that help nurses apply those skills with confidence, consistency, and compassion.

Recommendations

Based on the findings of the study, the following recommendations are given:

Practice.

As part of research utilization, a Nursing Care Quality Enhancement Plan is recommended for implementation in the hospital where the study was conducted. This plan may serve as a foundation for improving nursing care by strengthening the alignment between nurse competence and care quality. It may also prompt the review and revision of current operational, quality assurance, and staff development plans to incorporate targeted interventions identified in this study. Other healthcare institutions may also adopt or adapt this plan in response to similar concerns in care delivery and workplace support.

Policy.

The findings of this study support the need to reinforce hospital policies that promote a supportive work environment, particularly for nursing professionals. Policies should be directed toward ensuring structured mentorship, safe staffing levels, and ongoing competence-based evaluations. Institutional policy revisions may also focus on embedding quality nursing care principles, aligned with both technical and human-oriented aspects of service, into continuous quality improvement frameworks.

Education.

This study may serve as a valuable reference for discussions on the application of nursing competence in clinical practice, the dynamics of workplace support, and their effects on care quality. It may also be used as a supplemental material in nursing administration, leadership, and research courses, particularly in areas concerning the development and implementation of enhancement plans, ethics in research, and statistical analysis. Faculty and students alike may benefit from this study when examining competency-based education and system-based practice.

Research.

To ensure dissemination of the findings, the study abstract will be posted on the hospital’s bulletin board and social media platforms, including the institution’s official Facebook page. The study will be submitted for publication in local or international peer-reviewed journals and for presentation at professional research congresses in oral or poster format. These efforts aim to foster broader discussions and practical applications of the findings in nursing management and healthcare quality.

Also, the following research titles are suggested for future researchers to embark on:

A Qualitative Study on the Lived Experiences of Nurses in Applying Clinical Competence in Constrained Work Environments;

An Intervention Study on the Effectiveness of a Structured Workplace Support Program in Enhancing the Quality of Nursing Care; and

A Mixed-Methods Study on the Alignment of Nursing Education Outcomes with Hospital-Based Competency Expectations.

NURSING CARE QUALITY ENHANCEMENT PLAN

Rationale

The delivery of high-quality nursing care is a cornerstone of patient safety, satisfaction, and recovery. While the study revealed that nurses possess a very high level of competence across all professional dimensions including diagnostic functions, therapeutic interventions, and patient education the findings also highlighted a disconnect between competence and perceived quality of care. In particular, areas such as patient-centered communication, emotional support, and the application of competence in task-oriented care received only “fair” ratings from patient satisfaction scores. Moreover, while workplace support was considered important, it was found not to significantly mediate the relationship between competence and care quality, indicating the need for more actionable and structured support systems. Given these findings, this Nursing Care Quality Enhancement Plan was developed to address identified performance gaps and sustain strengths in environmental care and safety. The plan provides a framework of interventions that integrate capacity- building, workplace system improvements, and environmental monitoring, all grounded in both evidence-based practice and the real- time experiences of frontline nurses. It aims to ensure that nurses are not only clinically skilled but also enabled and empowered to deliver holistic, safe, and responsive care in every patient encounter.

General Objective

To enhance the overall quality of nursing care through the development of competency aligned systems, improved patient- centered communication, structured workplace support, and sustained environmental safety standards.

Specific Objectives

To improve the translation of nurses’ clinical competence into actual care outcomes by aligning protocols and workflows with observed skill sets.

To enhance nurses’ patient-centered communication and emotional care through targeted education and feedback-based interventions.

To strengthen structured workplace support systems that enable and motivate nurses to apply their competencies effectively under optimal conditions.

To sustain a high standard of environmental safety and cleanliness by involving nursing staff in routine monitoring, reporting, and compliance activities.

Areas of Concern	Specific Objectives	Activities	Persons Responsible	Resources	Time Frame	Success Indicators
Need to increase the translation of competence into quality care outcomes	To enhance alignment between nurses’ competence and actual care delivery processes.	Personally- initiated: ·       Attend webinars and      training        on translating knowledge         into clinical action. ·       Read evidence- based guidelines and clinical case studies. Hospital-initiated: ·       Conduct reviews of SOPs and workflows. ·       Implement cross-checks between documented competence       and patient outcomes. Common: ·       Conduct periodic interdisciplinary reviews and care audits.	Nursing Quality Officer, Department Heads	Updated SOPs, training kits, care audit forms	3rd quarter of 2025	Revised SOPs implemented; 20% improvement in outcome alignment indicators
Need         to                 increase patient-centered communication                 and emotional support	To improve the ability of nurses to engage                         in empathetic, clear, and                    therapeutic communication.	Personally- initiated: •                        Complete modules               on communication and            empathy   in nursing. Hospital-initiated: •                              Conduct simulation-based communication training. •           Hold seminars on                 cultural competence and therapeutic interactions. Common: •               Collect     and review communication- related           patient satisfaction   data quarterly.	Nurse Educators, Clinical Supervisors, QA Committee	Simulation labs,                case vignettes, feedback forms	3rd–4th Quarter 2025	At least 85% of staff                    complete communication training;                           patient scores on empathy improve by 15%
Need to increase structured workplace support to enable care delivery	To                              strengthen workplace                  systems that enable nurses to apply                 their                                   skills effectively                     under supportive conditions.	Personally- initiated: •            Participate in peer support and feedback sessions. •       Attend resilience and wellness workshops. Hospital-initiated: •         Formalize unit- based mentorship programs. •               Train nurse leaders                 on proactive support strategies. Common: •                              Conduct monthly           team check-ins           and feedback forums.	HR             Officer, Unit Supervisors, Chief Nurse	Mentorship logs, wellness materials, meeting platforms	3rd–4th Quarter 2025	Mentorship engagement   rate above                        75%; positive shift in support survey scores
Need to sustain compliance with environmental safety and healing standards	To maintain high levels of compliance in cleanliness, safety, and  environmental responsiveness in patient care areas.	Personally- initiated: •                       Complete refresher courses on                  infection control and safety protocols. Hospital-initiated: •                              Monthly environment audits with nurse engagement. •        Safety drills and updates      on emergency readiness. Common: •                          Distribute environmental feedback forms to patients                     and families.	Infection Control Team, Environmental           Services, Nurse Managers	Audit tools, environmental survey forms,campaign posters	Ongoing every quarter	Audit compliance maintained at ≥ 90%;                        patient feedback  reflects satisfaction                        with environment

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