Professional practice environment and advanced nursing interventions associated with nurse-perceived quality of healthcare delivery in selected rural facilities in Saudi Arabia: a multisite cross-sectional correlational study

Background Rural Saudi health services face workforce shortages and geographical isolation, and nurses are often the principal providers of clinical care, patient education, and health promotion. This study examined whether the professional practice environment (RPPE) and engagement in advanced nursing interventions were associated with nurses' perceived quality of healthcare delivery (PQHD) in selected rural Saudi facilities. Methods This cross-sectional correlational study is reported according to STROBE. A total of 187 nurses from three rural healthcare facilities in three Saudi regions (South, North, East; one purposively selected facility per region) were recruited using proportional stratified random sampling within region × role strata. An online survey included the validated Revised Professional Practice Environment (RPPE) scale and two study-specific scales (advanced nursing interventions; PQHD) assessed for content validity and internal consistency. Analyses used Pearson correlations, t -tests, one-way ANOVA, and multivariable linear regression (IBM SPSS v26). Results PQHD was positively and significantly correlated with the RPPE total score ( r = 0.56, p < 0.001) and with advanced nursing interventions ( r = 0.47, p < 0.001); the two predictors were moderately intercorrelated ( r = 0.55, p < 0.001). In the multivariable model, the RPPE total score (β = 0.45, p < 0.001) and advanced nursing interventions (β = 0.25, p < 0.001) remained independently associated with PQHD after adjustment for nursing role, years of experience, and site (region); the model explained 43% of the variance ( R 2 = 0.43, adjusted R 2 = 0.40, F (7, 179) = 19.07, p < 0.001). In bivariate analyses, nurse practitioners reported higher PQHD than registered nurses, male nurses reported slightly higher PQHD than female nurses, and PQHD did not differ by age group, education, years of experience, or region; neither difference survived Holm adjustment. Conclusion A more favorable professional practice environment and more frequent engagement in advanced nursing interventions were independently associated with higher nurse-perceived quality of healthcare delivery in these rural Saudi facilities. Because the design is cross-sectional and the outcome is nurse-reported, causal and patient-level inferences cannot be drawn. These associations may inform efforts to strengthen rural practice environments and advanced practice roles, pending longitudinal, multi-source confirmation.