Evaluating Individual, Professional, and Work Environment Characteristics That Impact Intensive Care Nurses' Attitudes Toward Wasteful Behaviors

ABSTRACT

This study aims to examine the relationships between intensive care nurses' individual, professional, and work environment characteristics and their attitudes toward wasteful behaviors. The cross‐sectional study was carried out with 346 intensive care nurses in a multicenter setting between August and October 2025 in two provincial centers. While attitudes toward wastefulness correlated positively with age, working hours, years of working in the institution and profession, status of loving the profession, and satisfaction with the unit, they correlated negatively with the number of patients cared for daily. The scores for staffing and resource adequacy and nursing foundations for quality of care positively affected the perception of wastefulness, individual attitude, use of resources, and organizational culture of wastefulness scores. On the other hand, the scores for collegial nurse–physician relations and nurse participation in hospital affairs negatively affected the perception of wastefulness, individual attitude, use of resources, and organizational culture of wastefulness scores. Furthermore, the scores for collegial nurse–physician relations negatively impacted the score for non‐value adding processes. In conclusion, addressing all dimensions of wastefulness, improving the work environment, organizing continuous training and awareness programs, and motivating intensive care nurses are essential for developing positive attitudes toward wastefulness. It is crucial to adopt an organizational culture and provide training and motivation for intensive care nurses, who are at the center of care, in order to improve their attitudes toward wastefulness as a part of nursing services management. This study adheres to the STROBE guideline of reporting.

1. Introduction

Healthcare expenditures are increasing with each passing day in Türkiye and worldwide (Peter 2023). This poses serious risks to the equity and financial sustainability of countries' healthcare systems (Olivares‐Tirado and Zanga 2023).

According to Organisation for Economic Co‐operation and Development (OECD) data from 2019, healthcare expenditures in OECD countries corresponded to 8.8% of gross domestic product on average, while this rate increased to 9.2% in 2021 (OECD 2022). In the United States of America (USA), healthcare expenditures reached a total of $4.3 trillion in 2021, corresponding to an average of $12,900 per capita (Peter 2023). These findings indicate that health expenditures have increased significantly both in total and on a per capita basis (OECD 2022; Peter 2023).

Reports from the World Health Organization (WHO) (2010) stated that approximately 20%–40% of global healthcare expenditures are wasted, resulting in squandered resources (World Health Organization 2010). In their study, Shrank et al. (2019) reported that the estimated cost of waste in the USA healthcare system ranged from $760 billion to $935 billion. This figure represents a waste rate of approximately 25% of total healthcare spending, which is consistent with average rates observed in other sectors/countries. According to the 2018 Turkey Waste Report, healthcare expenditures rank 11th (6.2%) among the items that should be reduced to lower monthly expenses (Republic of Tükriye Ministry of Trade 2018).

Waste in healthcare refers to high costs that can be prevented by eliminating harmful or ineffective services and processes and by using lower‐cost alternatives that deliver the same or better outcomes. It also includes expenditures on services for which there is no evidence that they provide better health outcomes compared to lower‐cost alternatives, as well as costs associated with the treatment of preventable medical harm (such as hospital‐acquired infections) resulting from the inefficient delivery of healthcare services (Peter 2023; Lallemand 2012).

In 2010, the Institute of Medicine (IOM) performed a study to determine the level of waste in healthcare expenditures in the USA. In this study, six areas of waste were identified, including failure of care delivery, failure of care coordination, overtreatment and low‐value care, failure of pricing, fraud and deception, and administrative complexity (Berwick and Hackbarth 2012; Institute of Medicine (US) 2010; Shrank et al. 2019).

Leading countries, including Germany, the USA, Canada, and China, have undertaken diverse reform initiatives to improve educational practices, clinical guidelines, and evidence‐based policies for reducing waste in healthcare services (Brown et al. 2021; Himmelstein et al. 2020; Göpffarth et al. 2016; Olivares‐Tirado and Zanga 2023; Zhou et al. 2021). The above‐mentioned initiatives have focused on identifying the basic causes of waste in healthcare services, reducing unnecessary practices, and aligning clinical decision‐making processes with evidence‐based standards (Brown et al. 2021; Himmelstein et al. 2020; Göpffarth et al. 2016; Olivares‐Tirado and Zanga 2023; Zhou et al. 2021). In this way, resources are used more efficiently, which results in substantial economic savings (Olivares‐Tirado and Zanga 2023).

Reducing waste in healthcare not only leads to economic savings (Himmelstein et al. 2020; Olivares‐Tirado and Zanga 2023) but also improves the quality of care provided to patients and strengthens the overall performance of the healthcare system (Zhang et al. 2020; Parishani et al. 2021). From a nursing perspective, reducing waste can enable nurses to focus more effectively on care processes; this can contribute to improving care quality and patient safety. Indeed, it has been demonstrated that nursing workload and the time allocated to care are associated with patient outcomes (Griffiths et al. 2018; Dall'Ora et al. 2022). Furthermore, initiatives to reduce waste can help reduce health inequities by redirecting resources toward interventions that strengthen social determinants of health, and ultimately contribute to improved health outcomes (Olivares‐Tirado and Zanga 2023). For this reason, it is critical for policymakers as well as health administrators to systematically evaluate the sources, scope, and impacts of waste in healthcare services.

Nurses play a direct role in healthcare services and are at the center of healthcare. Since the time of Florence Nightingale, the founder of modern nursing, nurses have been recognized for their competence in environmental issues and their essential roles in reducing environmental burdens and waste originating from healthcare delivery, as well as providing healthcare services (Gürgen Şimşek and Özsoy 2024). Nurses are in a unique position to observe and identify the elements of waste, including unnecessary tests, overtreatment, and administrative complexities. Identifying waste through nurse participation ensures the optimized resource use and the improved quality and safety of care (Baykara Mat and Baykal 2024; Parishani et al. 2021).

Nurses not only participate in sustainable healthcare practices but also lead, guide, and initiate change (Luque‐Alcaraz et al. 2024). Every conscious intervention exhibited by nurses functions as a critical mechanism that alleviates the economic burden on the healthcare system. Especially owing to their knowledge, attitudes, and behaviors, nurses contribute to reducing resource waste and play a key role in achieving sustainability goals (Luque‐Alcaraz et al. 2024; Sundberg et al. 2024).

Intensive care units are areas in the healthcare system with high costs and intensive resource use. Intensive care units are the areas with the highest risk of waste in healthcare facilities due to the use of advanced technology, expensive pharmacological treatments, and high volume of supplies (Domico et al. 2025; Tatsis et al. 2025). In this high‐cost and dynamic environment, nurses' attitudes toward waste will play a crucial role in maintaining the delicate balance between the rational management of limited resources and the sustainability of clinical care standards.

This study aims to examine the relationships between intensive care nurses' individual, professional, and work environment characteristics and their attitudes toward wasteful behaviors. The research question is as follows:

• Is there a relationship between nurses' individual and professional characteristics and their attitudes toward waste?

• Are the perceived characteristics of the work environment by nurses a statistically significant predictor of the variance in their attitudes toward waste scores?

Job Demands‐Resources (JD‐R) Theory explains that physical, organizational, and social factors in the work environment have an impact on employees' psychological and behavioral outcomes (Bakker and Demerouti 2007). From the JD‐R perspective, fostering these factors in the work environment increases nurses' sense of organizational belonging and responsibility (Antoinette Bargagliotti 2012; Schaufeli and Taris 2014). This situation will provide an opportunity to develop a professional level of rigor in resource utilization in business processes. Therefore, this study aims to analyze the relationship between individual and professional characteristics and attitudes toward waste, while also validating the mechanism by which the work environment makes waste prevention a professional norm through a path analysis. The model established in the research is presented in Figure 1.

Figure 1.

The research model.

2. Methods

2.1. Study Design

This study was conducted on intensive care nurses between August and October 2025 using a cross‐sectional survey design.

This cross‐sectional study followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines (von Elm et al. 2014).

2.2. Sample and Setting

The current research was done on intensive care nurses in five public hospitals that operate in two cities in Turkey. These hospitals included two city hospitals, one university hospital, one state hospital, and one private specialized hospital. The study was conducted in tertiary healthcare facilities, each with a total bed capacity exceeding 500 and an intensive care bed capacity exceeding 40. These facilities provide a robust environment for evaluating nursing practice standards by offering a wide range of critical care services, including adult, pediatric, neonatal, surgical, and internal medicine units.

In this study, the power of the regression model, which was established to test the effect of nurses' perceived work environment characteristics on their attitudes toward waste, was determined using the semPower package. The sample size (n) for the present study was calculated to be 317 in the R Studio (2024.04.2) software program by the “semPower” Package. The power analysis is based on testing the null hypothesis (β = 0), which argues that work environment characteristics do not predict attitudes toward waste. The path analysis parameters using the effect size for the root mean square error of approximation (RMSEA) value (d) = 0.07, degree of freedom (df) = 20 [k × (k + 1)/2−p; k: observed variables, p: parameters (path + variance)], type I error (α) = 0.05, and type II error (β) = 0.05 and 95% power (1–β) (Ellis 2010; Moshagen and Bader 2024; Rigdon 1994; Raykov and Marcoulides 2012). Based on these determined parameters and the expected effect size (RMSEA) of 0.07, the minimum sample size required to prove the structural validity of the model by rejecting the null hypothesis was calculated. This approach aims to test not only the significance of the coefficients but also the model's ability to represent the theoretical framework as a whole. To maintain the study's power, the research was completed with a sample size approximately 10% larger, considering possible losses.

The eligibility criteria were as follows: (1) Working as an intensive care nurse between August and October 2025, and (2) having at least 3 months of professional experience in intensive care, and volunteering to take part in the research.

2.3. Data Collection and Ethical Considerations

The present study was examined and approved by the Non‐Interventional Clinical Research Ethics Committee of Istanbul Aydin University (26/03/2025; 69/2025). The research was performed following the ethical principles of the Declaration of Helsinki. Institutional permissions were received from the provincial health directorates with which the hospitals in the two cities are affiliated. Additionally, the head nurses of the intensive care units where the study was carried out were contacted, informed about the research, and nurse lists were obtained. Informed consent was obtained from the nurses who volunteered to participate in the study. While some nurses completed and submitted the survey on the same day, others submitted it a week later due to workload.

2.4. Instruments

Research data were collected using the “Nurse Descriptive Information Form,” the “Practice Environment Scale of the Nursing Work Index,” and the “Nurses' Wasteful Behaviors Attitude Scale.”

2.4.1. Nurse Descriptive Information Form

The form was specifically developed for this study by the researchers, in line with the literature, to determine the relevant sociodemographic and occupational characteristics (such as age, sex, marital status, education level, experience, and unit of employment) of the participants.

2.4.2. Nurses' Wasteful Behaviors Attitude Scale (NWBAS)

Baykara Mat and Baykal (2024) developed the above‐mentioned scale, which comprises five sub‐dimensions: “(1) Perception of Wastefulness,” “(2) Individual Attitude,” “(3) Use of Resources,” “(4) Non‐Value Adding Processes,” and “(5) Organizational Culture of Wastefulness.” During scale scoring, the arithmetic mean is used to calculate the overall scale and sub‐dimension scores, and the possible scores range from 1 to 5. An increase in the scores indicates that attitudes toward wastefulness increase in a positive sense (Baykara Mat and Baykal 2024). NWBAS had a content validity index above 0.80. The explained variance for the five‐factor structure was determined to be 58.17%. The scale's overall internal consistency Cronbach's ⍺ value is 0.93, ranging from 0.76 to 0.85 for the sub‐dimensions, and the test−retest reliability coefficient is above 0.90 for the overall scale and its sub‐dimensions (Baykara Mat and Baykal 2024).

Perception of wastefulness examines healthcare professionals' tendencies toward wasteful behaviors and what waste means to them; Individual attitude reflects nurses' individual attitudes and behaviors regarding wasteful behaviors in the hospital; Use of resources examines wasteful behaviors encountered in the use of materials and equipment provided by hospitals; Non‐value adding processes examines internal hospital processes; and Organizational culture of wastefulness reflects the relevant organization's attitude toward wasteful behaviors (Baykara Mat and Baykal 2024).

2.4.3. Practice Environment Scale of the Nursing Work Index (PES‐NWI)

The scale in question was developed by Lake (2002) and adapted into Turkish by Türkmen et al. (2011). The scale comprises 31 items and five subscales in total: “(1) Nurse Participation in Hospital Affairs,” “(2) Nursing Foundations for Quality of Care,” “(3) Nurse Manager Ability, Leadership, and Support of Nurses,” “(4) Staffing and Resource Adequacy,” and “(5) Collegial Nurse–Physician Relations.” The PES‐NWI is a four‐point Likert scale (4 = strongly agree to 1 = strongly disagree). The scale and subscale scores are averaged, and a score between 1 and 4 is obtained. Individuals perceive the work environment positively as their scores on the scale increase (Türkmen et al. 2011). PES‐NWI had a content validity index of 0.82. The correlation reliability coefficients of the items were between r = 0.33 and 0.69. The scale's overall internal consistency, Cronbach's ⍺ value, is 0.94, ranging from 0.80 to 0.87 for the sub‐dimensions. In the test−retest evaluation, the Pearson's Product‐Moment Correlation coefficient was determined to be between r = 0.36 and 0.78 (Türkmen et al. 2011).

2.5. Data Analysis and Synthesis

In this study, statistical analysis was carried out using R Studio (2024.04.2) software program. We used packages with “tidyverse,” “lavaan,” “psych,” “GGally,” “corrplot,” and “ggplot2” in R. We drew diagrams by using lavaangui (Karch 2025). First, we presented descriptive statistics of demographic characteristics. Cronbach's ⍺ should be over 0.70 for good internal consistency (Bland and Altman 1997). Cronbach's ⍺ was used to examine the internal consistency of each scale. For the correlation analysis, the strength of the correlation ranges as follows: 0–0.19 very weak, 0.20–0.39 weak, 0.40–0.59 moderate, 0.60–0.70 strong, and 0.80–1.00 very strong (Dunn 2001).

Path analysis was chosen to test the complex interactions between variables and the overall validity of the model. The weighted least squares (WLS) estimation method was used to predict the models with several fit indices. These indices were noted as the ratio of the chi‐square to degrees of freedom (${\chi }^2/\mathit{df}$), “RMSEA,” “Standardized Root Mean Squared Residual (SRMR),” “Normed Fit Index (NFI),” “Non‐Normed Fit Index (NNFI),” “Comparative Fit Index (CFI),” “Goodness of Fit Index (GFI).” For the path analysis models to be acceptable, ${\chi }^2/\mathit{df}$ ratio needs to be smaller than 5, the RMSEA and SRMR need to be under 0.08, and all other fit indices to be over 0.95 (Jöreskog and Sörbom 1993; Schumacker and Lomax 2010). Unlike regression analysis, this method allowed for verification of the relationship between work environment and attitudes toward waste with the theoretical model through the RMSEA = 0.07 and other fit indices. Since the Henze−Zirkler multivariate and Shapiro−Wilk univariate normality test results indicated that the scores were not normally distributed (p < 0.001), non‐normal estimation techniques were employed for both correlation and path analysis. Prior to analysis, the data set was examined for missing values, and no missing data were found. Results were evaluated at p < 0.05 and p < 0.01 at the significance level.

3. Results

The data were collected from 346 intensive care nurses working at hospitals in two cities in Turkey. Participants were aged between 20 and 55 years, with a mean age of 29.05 ± 5.70 years. Years of working in the profession ranged from 3 months to 34 years, with a mean of 6.09 ± 5.78 years. Years of working in the unit ranged from 3 months to 30 years, with a mean of 3.86 ± 3.99 years. Years of working in the institution ranged from 3 months to 34 years, with a mean of 4.84 ± 4.91 years. The participants had an average of 0.34 ± 0.62 children (range: 0–3). Their weekly working hours averaged 54.65 ± 14.40 h, with a range of 30 to 128 h. Furthermore, the number of patients cared for per shift ranged from 0 to 60, with a mean of 6.02 ± 9.81 patients.

Unit satisfaction ranged from 1 to 10 score, with a mean of 6.82 ± 2.70 persons. Hospital satisfaction ranged from 0 to 10 score, with a mean of 5.54 ± 2.93 persons. Labor of love ranged from 0 to 10 score, with a mean of 6.98 ± 2.55 person. The other demographic characteristics are given in Table 1.

Table 1.

Demographic characteristics.

Variables	Frequency (N = 346)	Percent (%)
Gender
Female	231	66.80
Male	115	33.20
Marital status
Single	213	61.60
Married	133	38.40
Education
High school	17	4.90
Associate degree	31	9.00
Undergraduate	251	72.50
Postgraduate	47	13.60
Unit
Adult intensive care	145	41.90
Pediatric intensive care	53	15.30
Neonatal intensive care	12	3.50
Coronary intensive care	33	9.50
Cardiovascular surgery intensive care	31	9.00
Anesthesia intensive care	5	1.40
Emergency intensive care	49	14.20
Neurology intensive care	7	2.00
Other	11	3.20
Having children
Yes	90	26.00
No	256	74.00
The way of work
Day	56	16.20
Night	4	1.20
Day/night shift	286	82.70
Staff status
Regular	134	38.70
Contractual	205	59.20
Fee‐earning	7	2.00
The status of having willingly chosen the nursing profession
Yes	255	73.70
No	91	26.30
Perceived workload
Balanced	85	24.60
Severe	261	75.40
Income status
Very low	24	6.90
Low	94	27.20
Middle	213	61.60
High	15	4.30

Variables	$\overline{\mathit{X}}$ ± SD	M (Min.−Max.)
Age	29.05 ± 5.70	28 (20–55)
Years of working in the profession	6.09 ± 5.78	5 (3 months−34 years)
Years of working in the unit	3.86 ± 3.99	3 (3 months−30 years)
Years of working in the institution	4.84 ± 4.91	4 (0–34)
Number of children	0.34 ± 0.62	0 (0–3)
Working hours	54.65 ± 14.40	48 (30–128)
Number of patients	6.02 ± 9.81	2 (1–60)
Unit satisfaction	6.82 ± 2.70	7 (1–10)
Hospital satisfaction	5.54 ± 2.93	5 (0–10)
Labor of love	6.98 ± 2.55	7.50 (0–10)

Abbreviations: M (Min.−Max.), median (minimum−maximum); $\overline{\mathit{X}}$ ± SD, mean ± standard deviation.

In this study, the overall Cronbach's ⍺ coefficients were 0.98 and 0.96 for NWBAS and PES‐NWI, respectively. On the other hand, wasteful behaviors attitude scale sub‐scales were between 0.91 and 0.97 for “Perception of Wastefulness” (α = 0.96), “Individual Attitude” (α = 0.97), “Use of Resources” (α = 0.98), “Non‐Value Adding Processes” (α = 0.91), “Organizational Culture of Wastefulness” (α = 0.95). The PES‐NWI sub‐scales were between 0.80 and 0.90 for “Staffing and Resource Adequacy” (α = 0.85), “Collegial Nurse–Physician Relations” (α = 0.80), “Nurse Manager Ability, Leadership, and Support of Nurses” (α = 0.85), “Nursing Foundations for Quality of Care” (α = 0.89), “Nurse Participation in Hospital Affairs” (α = 0.90). The high Cronbach's ⍺ coefficients indicate excellent internal consistency, though values above 0.95 may also suggest potential item redundancy within the scales.

The mean scores for NWBAS and PES‐NWI were 3.51 ± 1.14 and 2.53 ± 0.60, respectively. The mean scores for the sub‐scales of the NWBAS were 3.51 ± 1.33 for Perception of Wastefulness, 3.57 ± 1.33 for “Individual Attitude,” 3.60 ± 1.39 for “Use of Resources,” 3.31 ± 1.01 for “Non‐Value Adding Processes,” and 3.56 ± 1.24 for “Organizational Culture of Wastefulness.” The mean scores for the sub‐scales of the PES‐NWI were 2.23 ± 0.74 for “Staffing and Resource Adequacy,” 2.63 ± 0.68 for “Collegial Nurse–Physician Relations,” 2.49 ± 0.74 for “Nurse Manager Ability, Leadership, and Support of Nurses,” 2.69 ± 0.60 for “Nursing Foundations for Quality of Care,” and 2.47 ± 0.67 for “Nurse Participation in Hospital Affairs.”

The correlation analysis of variables was evaluated between age, years of working in the profession, years of working in the unit, years of working in the institution, working hours, number of patients, unit satisfaction, hospital satisfaction, labor of love, “Perception of Wastefulness,” “Individual Attitude,” “Use of Resources,” “Non‐Value Adding Processes,” “Organizational Culture of Wastefulness,” “Nurse Participation in Hospital Affairs” “Nursing Foundations for Quality of Care,” “Nurse Manager Ability, Leadership, and Support of Nurses,” “Staffing and Resource Adequacy,” and “Collegial Nurse–Physician Relations” as shown in Figure 2. There was a range from −0.44 to 0.95.

Figure 2.

Spearman's Rho correlation coefficients among variables.

The model estimation values and fit indices among sub‐dimension variables are presented in Table 2. “Nurse Manager Ability,” “Leadership, and Support of Nurses” has not statistically effect on PW (p > 0.05), other variables demonstrated substantial influence. “Staffing and Resource Adequacy” has a statistically significant positive effect on “Perception of Wastefulness” (β = 0.42, p < 0.01), whereas “Collegial Nurse–Physician Relations” has a significant negative effect (β = −0.57, p < 0.01). “Nursing Foundations for Quality of Care” has a statistically significant positive effect on “Perception of Wastefulness” (β = 0.80, p < 0.01), whereas “Nurse Participation in Hospital Affairs” has a significant negative effect (β = −0.53, p < 0.05). “Nurse Manager Ability, Leadership, and Support of Nurses” has not statistically effect on “Individual Attitude” (p > 0.05). “Staffing and Resource Adequacy” has a statistically significant positive effect on “Individual Attitude” (β = 0.38, p < 0.01), whereas “Collegial Nurse–Physician Relations” has a significant negative effect (β = −0.58, p < 0.01). “Nursing Foundations for Quality of Care” has a statistically significant positive effect on IA (β = 0.80, p < 0.01), whereas “Nurse Participation in Hospital Affairs” has a significant negative effect (β = −0.51, p < 0.05). “Nurse Manager Ability, Leadership, and Support of Nurses” has not statistically effect on “Use of Resources” (p > 0.05). “Staffing and Resource Adequacy” has a statistically positive effect on “Use of Resources” (β = 0.37, p < 0.05), whereas “Collegial Nurse–Physician Relations” has a significant negative effect (β = −0.58, p < 0.01). “Nursing Foundations for Quality of Care” has a statistically positive effect on “Use of Resources” (β = 0.89, p < 0.01), whereas “Nurse Participation in Hospital Affairs” has a significant negative effect (β = −0.56, p < 0.05). “Staffing and Resource Adequacy,” “Nurse Manager Ability,” “Leadership, and Support of Nurses, Nursing Foundations for Quality of Care and Collegial Nurse–Physician Relations” have not statistically effect on “Non‐Value Adding Processes” (p > 0.05). “Collegial Nurse–Physician Relations” has a statistically significant negative effect on “Non‐Value Adding Processes” (β = −0.38, p < 0.01). “Nurse Manager Ability,” “Leadership, and Support of Nurses” has not statistically effect on “Organizational Culture of Wastefulness” (p > 0.05). “Staffing and Resource Adequacy” has a statistically significant positive effect on “Organizational Culture of Wastefulness” (β = 0.32, p < 0.05), whereas “Collegial Nurse–Physician Relations” has a significant negative effect (β = −0.57, p < 0.01). “Nursing Foundations for Quality of Care” has a statistically statistically positive effect on “Organizational Culture of Wastefulness” (β = 0.71 p < 0.01), whereas “Nurse Participation in Hospital Affairs” has a significant negative effect (β = −0.47, p < 0.05). The fit index value of ${\chi }^2/\mathit{df}$ = 14.15 is not acceptable, but the other fit index values of RMSEA = 0.00, SRMR = 0.00, NFI = 1.00, NNFI = 1.00, CFI = 1.00, and GFI = 1.00, which are within the range of good fit, indicate that the model is well fitted. Since ${\chi }^2/\mathit{df}$ is a highly sensitive indicator of sample size (Kaplan 1988), the imbalance between the limited sample size in the present study and the parameter density of the model resulted in this index not fully reflecting the model fit. Furthermore, path diagram among sub‐scale variables has shown in Figure 3. Also, we have presented the comparisons of NWBAS scales with demographic characteristics in Table 3. Analysis of the unit‐based distribution of scores reveals that nurses employed in the emergency intensive care unit exhibited significantly lower attitudes toward wastefulness (mean = 1.84 ± 0.56) compared to their colleagues in other departments (Table 3).

Table 2.

The path analysis among sub‐scale variables.

Model	Beta	Std. beta	Std. error	t	p	R 2	Fit index
SRA → Perception of wastefulness	0.416	0.230	0.149	2.783	0.005**	0.074	${\chi }^2/\mathit{df}$ = 14.15 RMSEA = 0.00♯ SRMR = 0.00♯ NFI = 1.00♯ NNFI = 1.00♯ CFI = 1.00♯ GFI = 1.00♯
CNPR → perception of wastefulness	−0.568	−0.289	0.142	−3.992	< 0.001
NMALSN → Perception of wastefulness	−0.146	−0.081	0.195	−0.746	0.455
NFQC → Perception of wastefulness	0.803	0.362	0.212	3.796	< 0.001
NPHA → Perception of wastefulness	−0.529	−0.268	0.236	−2.242	0.025*
SRA → Individual attitude	0.379	0.210	0.145	2.609	0.009**	0.071
CNPR → Individual attitude	−0.577	−0.294	0.138	−4.179	< 0.001
NMALSN → Individual attitude	−0.113	−0.062	0.182	−0.618	0.537
NFQC → Individual attitude	0.796	0.359	0.201	3.966	< 0.001
NPHA → Individual attitude	−0.512	−0.259	0.226	−2.259	0.024*
SRA → Use of resources	0.371	0.197	0.154	2.414	0.016*	0.072
CNPR → Use of resources	−0.583	−0.284	0.148	−3.943	< 0.001
NMALSN → Use of resources	−0.130	−0.069	0.196	−0.666	0.505
NFQC → Use of resources	0.885	0.382	0.207	4.282	< 0.001
NPHA → Use of resources	−0.563	−0.273	0.245	−2.296	0.022**
SRA → Non‐value adding processes	0.206	0.150	0.117	1.766	0.077	0.038
CNPR → Non‐value adding processes	−0.388	−0.260	0.107	−3.612	< 0.001
NMALSN → Non‐value adding processes	−0.008	−0.006	0.133	−0.062	0.950
NFQC → Non‐value adding processes	0.213	0.126	0.176	1.212	0.225
NPHA → Non‐value adding processes	−0.084	−0.056	0.180	−0.467	0.641
SRA → Organizational culture of wastefulness	0.320	0.190	0.136	2.360	0.018*	0.077
CNPR → Organizational culture of wastefulness	−0.570	−0.310	0.140	−4.076	< 0.001
NMALSN → Organizational culture of wastefulness	−0.123	−0.073	0.171	−0.720	0.472
NFQC → Organizational culture of wastefulness	0.707	0.341	0.206	3.438	0.001**
NPHA → Organizational culture of wastefulness	−0.467	−0.253	0.225	−2.073	0.038*

Note: ♯: Good fit, ^┼: Acceptable fit; Weighted least squares estimation.

Abbreviation: CNPR, Collegial Nurse–Physician Relations; NFQC, Nursing Foundations for Quality of Care; NMALSN, Nurse Manager Ability, Leadership, and Support of Nurses; NPHA, Nurse Participation in Hospital Affairs; SRA, Staffing and Resource Adequacy.

^* p < 0.05

^** p < 0.01.

Figure 3.

Path diagram among sub‐scale variables.

Table 3.

Comparisons of participants' wasteful behaviors attitude sub‐scale variables with demographic characteristics.

			PW		IA		UR		NVAP		OCW		NWBAS
Variables		N	$\overline{\mathit{X}}$ ± SD	p	$\overline{\mathit{X}}$ ± SD	p	$\overline{\mathit{X}}$ ± SD	p	$\overline{\mathit{X}}$ ± SD	p	$\overline{\mathit{X}}$ ± SD	p	$\overline{\mathit{X}}$ ± SD	p
Gender	Female	231	3.58 ± 1.28	0.451b	3.63 ± 1.28	0.467b	3.65 ± 1.35	0.648b	3.33 ± 0.95	0.940b	3.59 ± 1.21	0.833b	3.55 ± 1.11	0.514a
	Male	115	3.39 ± 1.41		3.44 ± 1.42		3.49 ± 1.46		3.29 ± 1.13		3.50 ± 1.31		3.42 ± 1.21
Marital status	Single	213	3.30 ± 1.36	< 0.001b	3.37 ± 1.40	0.001** , b	3.39 ± 1.47	0.002** , b	3.24 ± 1.05	0.054b	3.38 ± 1.32	0.003** , b	3.34 ± 1.22	0.003**
	Married	133	3.86 ± 1.20		3.88 ± 1.15		3.93 ± 1.17		3.45 ± 0.93		3.85 ± 1.06		3.78 ± 0.96
Education	High school	17	3.76 ± 1.38	0.033* , d	3.97 ± 1.37	0.002** , d	3.82 ± 1.47	0.011* , d	3.45 ± 0.99	0.019* , d	3.78 ± 1.10	0.021* , d	3.75 ± 1.12	0.012* , c
	Associate degree	31	2.75 ± 1.55		2.73 ± 1.50		2.75 ± 1.56		2.66 ± 1.25		2.84 ± 1.41		2.75 ± 1.40
	Undergraduate	251	3.54 ± 1.32		3.59 ± 1.30		3.63 ± 1.36		3.37 ± 0.99		3.58 ± 1.24		3.54 ± 1.12
	Postgraduate	47	3.79 ± 1.00		3.83 ± 1.15		3.91 ± 1.20		3.44 ± 0.80		3.87 ± 1.03		3.76 ± 0.91
Unit	Adult intensive care	145	4.08 ± 0.93	< 0.001d	4.14 ± 0.90	< 0.001d	4.21 ± 0.95	< 0.001d	3.56 ± 0.86	< 0.001d	4.06 ± 0.88	< 0.001d	3.99 ± 0.75	< 0.001c
	Pediatric intensive care	53	3.42 ± 1.28		3.35 ± 1.25		3.39 ± 1.29		3.35 ± 0.86		3.44 ± 1.07		3.39 ± 1.03
	Neonatal intensive care	12	3.86 ± 1.12		3.96 ± 1.05		4.10 ± 1.05		3.64 ± 0.70		4.13 ± 0.78		3.95 ± 0.66
	Coronary intensive care	33	3.81 ± 1.33		3.92 ± 1.27		3.88 ± 1.34		3.20 ± 1.00		3.81 ± 1.15		3.71 ± 1.10
	Cardiovascular surgery intensive care	31	3.34 ± 1.36		3.37 ± 1.41		3.48 ± 1.46		3.30 ± 1.27		3.44 ± 1.44		3.39 ± 1.30
	Anesthesia intensive care	5	3.00 ± 1.25		3.33 ± 1.56		3.34 ± 1.70		3.57 ± 1.05		3.51 ± 1.21		3.40 ± 1.23
	Emergency intensive care	49	1.61 ± 0.49		1.68 ± 0.59		1.62 ± 0.69		2.34 ± 0.87		1.81 ± 0.76		1.84 ± 0.56
	Neurology intensive care	7	4.43 ± 0.16		4.55 ± 0.43		4.27 ± 0.67		4.31 ± 0.57		4.37 ± 0.58		4.37 ± 0.49
	Other	11	3.91 ± 1.37		3.97 ± 1.41		3.96 ± 1.35		3.73 ± 1.16		3.87 ± 1.30		3.88 ± 1.27
Having children	Yes	90	3.90 ± 1.18	0.001** , b	3.90 ± 1.22	0.004** , b	3.99 ± 1.19	0.002** , b	3.47 ± 0.93	0.093b	3.88 ± 1.01	0.013* , b	3.82 ± 0.99	0.002** , a
	No	256	3.38 ± 1.35		3.45 ± 1.35		3.46 ± 1.43		3.26 ± 1.03		3.45 ± 1.30		3.40 ± 1.18
The way of work	Day	56	3.48 ± 1.48	0.083d	3.47 ± 1.55	0.145d	3.55 ± 1.51	0.111d	3.23 ± 1.13	0.740d	3.52 ± 1.36	0.317d	3.45 ± 1.31	0.202c
	Night	4	1.92 ± 1.42		2.17 ± 1.29		2.07 ± 1.32		2.86 ± 1.35		2.43 ± 1.27		2.34 ± 1.25
	Day/night shift	286	3.54 ± 1.29		3.60 ± 1.28		3.63 ± 1.36		3.34 ± 0.98		3.58 ± 1.22		3.54 ± 1.10
Staff status	Contractual	134	3.28 ± 1.37	0.005** , d	3.30 ± 1.40	0.001** , d	3.33 ± 1.48	0.003** , d	3.14 ± 1.11	0.013* , d	3.32 ± 1.34	0.012* , d	3.27 ± 1.25	0.004** , a
	Regular	205	3.71 ± 1.25		3.79 ± 1.22		3.82 ± 1.27		3.46 ± 0.91		3.75 ± 1.13		3.70 ± 1.01
	Fee‐earning	7	2.33 ± 1.54		2.24 ± 1.41		2.29 ± 1.44		2.61 ± 1.12		2.55 ± 1.46		2.42 ± 1.33
The status of having willingly chosen the nursing profession	Yes	255	3.52 ± 1.34	0.592b	3.57 ± 1.36	0.574b	3.59 ± 1.41	0.953b	3.31 ± 1.05	0.566b	3.53 ± 1.23	0.269b	3.50 ± 1.16	0.798a
	No	91	3.48 ± 1.31		3.55 ± 1.24		3.61 ± 1.34		3.36 ± 0.90		3.64 ± 1.28		3.53 ± 1.12
Perceived workload	Balanced	85	3.25 ± 1.46	0.102b	3.35 ± 1.47	0.265b	3.35 ± 1.48	0.165b	3.19 ± 1.14	0.332b	3.28 ± 1.32	0.020* , b	3.29 ± 1.28	0.180a
	Severe	261	3.60 ± 1.27		3.64 ± 1.28		3.68 ± 1.35		3.36 ± 0.97		3.65 ± 1.21		3.58 ± 1.09
Income status	Very low	24	3.79 ± 1.50	0.164d	3.87 ± 1.28	0.100d	3.77 ± 1.45	0.258d	3.67 ± 1.18	0.192d	3.94 ± 1.27	0.012** , d	3.81 ± 1.20	0.075c
	Low	94	3.67 ± 1.27		3.75 ± 1.30		3.78 ± 1.33		3.38 ± 0.93		3.80 ± 1.17		3.67 ± 1.06
	Middle	213	3.42 ± 1.33		3.47 ± 1.34		3.51 ± 1.40		3.26 ± 1.01		3.43 ± 1.25		3.42 ± 1.15
	High	15	3.47 ± 1.45		3.34 ± 1.41		3.44 ± 1.46		3.18 ± 1.12		3.29 ± 1.37		3.33 ± 1.32

Abbreviations: IA, individual attitude; NVAP, non‐value adding processes; NWBAS, nurses' wasteful behaviors attitude scale; OCW, organizational culture of wastefulness; PW, perception of wastefulness; UR, use of resources; $\overline{X}$±SD, mean ± standard deviation.

^* p < 0.05

^** p < 0.01.

^a Independent t‐test.

^b Mann−Whitney U test.

^c One‐way ANOVA.

^d Kruskal−Wallis test.

4. Discussion

Since nurses are at the center of patient care, they have the opportunity to affect patient care outcomes while also influencing the cost of care through efficient care. Although numerous factors affect healthcare costs, nurses can change inefficiencies in resource management and material waste (Graves et al. 2024). Therefore, the current research was conducted as a multicenter study to assess the individual, professional, and work environment characteristics impacting intensive care nurses' attitudes toward wasteful behaviors. The study revealed that attitudes toward wastefulness closely correlated with individual, professional, and work environment dynamics and had a multifaceted structure. Likewise, a study on healthcare professionals found that wasteful behaviors correlated with employee, patient, and institutional behaviors in a multifaceted way (Baykara Mat and Baykal 2022).

The present study determined that nurses had a positive attitude toward wastefulness, displaying the most positive attitude toward the use of institutional resources and the least positive attitude toward non‐value adding processes. Likewise, a study conducted in intensive care reported that nurses were aware of wasteful stocking practices and made efforts to establish and maintain waste management (Al‐Shamaly 2021). The finding above is essential for implementing sustainable health practices since conservation of resources enables the delivery of safe, accessible, economical, and environmentally friendly healthcare services in the long run. Hence, transforming this positive attitude into a culture and supporting it through appropriate strategies is crucial.

At the individual level, waste is closely associated with a person's values, habits, beliefs, economic status, and level of awareness (Shi et al. 2019). The current research data also showed that life events influencing values, habits, and economic status (e.g., age, marital status, and the status of having children) impacted attitudes of intensive care nurses toward wastefulness. This shows that implementing individual strategies is important to reduce wastefulness.

The present work clearly demonstrated the impact of education on attitudes toward wastefulness. Nurses with an associate degree had the lowest attitudes toward wastefulness. Undoubtedly, education is critical to reducing wastefulness since it both raises individual awareness and fosters behavioral change (Badawy et al. 2025). Integrating sustainability training into nursing curricula in recent years has contributed to raising environmental awareness among nurses and has provided them with knowledge and skills on this issue (Badawy et al. 2025). Therefore, it is crucial to restructure nursing curricula and shape them in line with sustainable development goals. Raising awareness of lifelong learning and providing regular training to employees by managers on wasteful behaviors is necessary.

The current study found that nurses working in emergency intensive care units displayed lower attitudes toward wastefulness compared to those working in other intensive care units (e.g., adult, pediatric, neonatal, coronary, cardiovascular, anesthesia, emergency, and neurology). This is thought to be related to the high level of uncertainty and time pressure in emergency intensive care units. Nurses working in these units face multifaceted challenges, including role ambiguity, time constraints, and limited resources. In this context, nurses have to manage complex clinical decision‐making processes under conditions such as time pressure, multitasking, and high patient turnover (Akbaş Uysal and Ekiz 2025). This is thought to be related to the high level of uncertainty and time pressure in emergency intensive care units. Operational processes, human factors, and systemic necessities make the use of resources unavoidable to a particular extent (Spencer and Howard 2025). However, all of these do not mean that strategies to reduce wastefulness cannot be developed. It is possible to reduce wastefulness, especially through enhanced process management, training and leadership, staff participation, monitoring and tracking systems, and triage awareness.

The present research found that the adequacy of workforce and resources in the institution and the nursing resources necessary for quality care positively affected nurses' perception of wastefulness, their individual attitude toward wastefulness, use of resources, and Organizational culture of wastefulness. In case of a shortage of workforce and resources, employees may experience time pressure, leading to the need for quick decision‐making. This hinders the optimal use of resources and can cause wastefulness. Thus, this result confirms another finding from the current study, that is, the negative correlation between the number of patients cared for daily and waste consumption. Likewise, Badawy et al. (2025) indicated resource scarcity as one of the challenges faced by nurses when attempting to incorporate environmental sustainability into their work environments. The nurse‐focused project by Graves et al. (2024) aimed at reducing material waste produced in intensive care units determined that the implementation of bedside material carts to assist in delivering patient care could significantly decrease unnecessary hospital waste in intensive care units. Hence, improving the number and quality of human resources, planning resources rationally, and establishing innovative resource tracking and monitoring systems are crucial for reducing wastefulness.

The study found that the relationship between physicians, nurses, and colleagues within the institution and nurses' participation in management and representation adversely affected nurses' perception of wastefulness, their individual attitude toward wastefulness, use of resources, and the organizational culture of wastefulness. Moreover, the physician‐nurse‐colleague relationship negatively impacts non‐value‐added processes. Collaborative relationships between professions are also vital for reducing stress in the workplace. There is a negative correlation between nurse‐physician relationships and burnout (Ayed et al. 2024). The creativity, innovations, and renewed collegial spirit brought about by the COVID‐19 pandemic have created an opportunity to eliminate waste arising from unnecessary nursing tasks, uncoordinated care activities, ineffective task delegation, and unnecessary administrative complexity (Weston 2022). It has been stated that while waste generation is inevitable in healthcare services and nursing care interventions, considering sustainable care without material waste and properly disposing of waste should be a part of healthcare professionals' daily lives (Ferreira et al. 2024).

4.1. Limitations

The present study determined individual, professional, and work environment characteristics impacting intensive care nurses' attitudes toward wasteful behaviors using self‐report instruments. The research was conducted in a sample of public hospitals (city and state, training, and research hospitals) and does not reflect the sample of private hospitals, which differ in terms of work environment characteristics. Another limitation of the study is that it included nurses with at least 3 months of experience in intensive care units. While this period allows for initial clinical adaptation, it may be insufficient for the full stabilization of professional attitudes and perceptions regarding complex organizational processes.

Although data for the study were collected from five different hospitals, the analyses were conducted using path analysis rather than hierarchical modeling. In the future, using multilevel linear mixed models in research will allow for a more detailed understanding of variance at the institutional level.

5. Conclusion and Recommendations

The study revealed that nurses had a positive attitude toward wastefulness, displaying the most positive attitude toward the use of resources in the institution and the least positive attitude toward non‐value adding processes. Nurses' individual, professional, and work environment characteristics affect their attitudes toward wasteful behaviors. The findings indicate that the factors influencing waste are multidimensional and provide fundamental data for addressing all these dimensions in efforts to reduce waste. Regularly measuring nurses' wasteful behaviors and thoroughly investigating the reasons behind them in the work environment, conducting root cause analysis at both organizational and individual levels, and then examining the causes and sharing them with health policymakers and professional associations is crucial.

5.1. Implications for Nursing Practice

As a part of nursing services management, it is essential that care is paid to procedures, instructions, and assessments within the institution to positively develop the attitudes of intensive care nurses, who are at the center of care, toward wastefulness. Furthermore, these practices should be adopted as a part of corporate culture, and training and motivation should be provided to nurses. It is recommended that comprehensive studies and projects on wasteful behaviors be carried out in nursing management. It is crucial to adopt an organizational culture and provide training and motivation for intensive care nurses, who are at the center of care, in order to improve their attitudes toward wastefulness as a part of nursing services management.

Author Contributions

Study design: Cennet Çi̇ri̇ş Yildiz and Seda Deği̇rmenci̇ Öz. Data collection: Cennet Çi̇ri̇ş Yildiz, Seda Deği̇rmenci̇ Öz, Ece Uysal Kasap, and İrem Korkmaz. Data analysis: Cennet Çi̇ri̇ş Yildiz and Ali Mertcan Köse. Study supervision: Cennet Çi̇ri̇ş Yildiz. Manuscript writing: Cennet Çi̇ri̇ş Yildiz, Seda Deği̇rmenci̇ Öz, Ece Uysal Kasap, İrem Korkmaz, and Ali Mertcan Köse. Critical revisions for important intellectual content: Cennet Çi̇ri̇ş Yildiz, Seda Deği̇rmenci̇ Öz, Ece Uysal Kasap, İrem Korkmaz, and Ali Mertcan Köse. Ali Mertcan Köse's area of expertise is statistics.

Funding

The authors have nothing to report.

Ethics Statement

The present study was examined and approved by the Non‐Interventional Clinical Research Ethics Committee of Istanbul Aydin University (26/03/2025; 69/2025). The research was performed following the ethical principles of the Declaration of Helsinki.

Conflicts of Interest

The authors declare no conflicts of interest.

Patient or Public Contribution

This study did not include patient or public involvement in its design, conduct, or reporting.

Data Availability Statement

Data supporting the findings of this study are available upon reasonable request from the corresponding author [C.C.Y.]. Due to ethical considerations, the data is not publicly available.