The Imperative to Improve Hospital Work Environments

Study suggests hospitals should pursue improved nurse education and staffing, but those investments do not significantly reduce patient mortality in the absence of a good work environment.

    • December 18, 2011

“One of the largest categories in hospital budgets is nursing,” said Linda Flynn, PhD, RN, FAAN. “It accounts for at least a quarter of annual operating expenses and up to 40 percent of direct care costs, but we don’t know much about which investments in nursing do the most to improve care and how to maximize those investments. There is significant scientific evidence that increasing nurse staffing improves patient care and reduces mortality, but in what conditions does this approach work best? In which circumstances might it not work and what other conditions should exist to maximize the improvements in quality of care?”

A study recently published Medical Care, and funded in part by the Robert Wood Johnson Foundation (RWJF), reveals that higher nurse-to-patient staffing ratios, a good work environment and a greater proportion of nurses with bachelor’s degrees are all important factors in improving outcomes for general surgical patients. The combination of all three provides the best results.

Flynn, associate dean and professor of graduate education at Rutgers University College of Nursing was an investigator on a team of researchers headed by Linda Aiken, PhD, FAAN, FRCN, RN, who surveyed nurses in California, Florida, New Jersey and Pennsylvania about: nurse workloads; nurse education; the nurse work environment; nurse demographics; burnout; job dissatisfaction; intent to leave; quality of care; patient safety indicators; and frequency of adverse events on their units. They also analyzed American Hospital Association data and patient discharge data for 665 hospitals in those four states, focusing on mortality and failure-to-rescue for surgical patients ages 19 to 89.

The research team found that increased nurse workloads, as measured by a decreased nurse-to-patient ratio, decreased the odds of failure-to-rescue and patient deaths by 3 percent. Better work environments and having 10 percent more nurses with bachelor’s degrees decreased the odds of patients dying by 7 percent and 4 percent, respectively.

They also found, however, that in hospitals with poor work environments, higher patient-to-nurse ratios had no effect on numbers of deaths and failure-to-rescue, but increased the odds of both outcomes in hospitals with average or good work environments. The effect was greatest in hospitals with good work environments.

Good work environments lowered the odds of deaths and failure to rescue in hospitals regardless of the levels of nursing staffing, but the effect was most pronounced in the hospitals with the best staffing ratios.

For each 10 percent increase in the number of BSN-prepared nurses, the researchers noted a 4 percent decrease in the odds of patients dying. Hospitals with 40 percent more BSN-prepared nurses had a 15 percent decrease in the risk of patient mortality.

“It’s clear from our findings that the impact on surgical patient outcomes of improving nurse staffing—while widely recognized as improving patient care—depends on the quality of the nurse work environment,” Aiken said. “Absent a good work environment, expending the resources to increase the number of nurses may not yield the desired improvement in patients’ mortality and the rate of failure incidents. Increasing the number of nurses with bachelor’s degrees or trying to improve the work environment through changing interprofessional culture and giving nurses more authority for decisions about care management are also effective, and less costly measures that could be pursued first.”

The researchers also noted that their findings on the impact on quality of patient care of nurses with bachelor’s degrees also support the recommendation of the Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, to increase the proportion of nurses with bachelor’s degrees to 80 percent by 2020.

In addition to Aiken and Flynn, the research team includes: Jeannie Cimiotti, DNSc, RN; Douglas Sloane, PhD; Herbert Smith, PhD; and Donna Neff, PhD, APRN.