Improving patient care by improving nurses' work environment

While nurse-to-patient ratios are widely recognized as an important factor in determining the quality of patient care, those ratios are not always easy to change without significant cost and investment of resources. What's more, the projected nursing shortage will make it even more difficult for hospitals to increase nurse staffing. A study published in the current issue of Health Care Management Review indicates that there are other aspects of registered nurses' (RNs) work environments that RNs perceive can also have a significant impact on the quality of care they deliver. In order of influence, those factors are: physical work environment, workgroup cohesion, nurse-physician relations, procedural justice and job satisfaction. Nurses' ratings of patient care quality were also higher in hospitals with Magnet® recognition programs, and lower in work settings with greater organizational constraints such as lack of equipment and supplies.

Maja Djukic, PhD, RN, assistant professor at the New York University College of Nursing (NYUCN); Christine Kovner, PhD, RN, FAAN, professor at NYUCN; Carol Brewer, PhD, RN, FAAN, professor at the School of Nursing, University at Buffalo; Farida Fatehi, BDS, MS, junior research analyst at the New York University College of Dentistry (NYUCD); and Daniel Cline, MSN, RN, CRNP, PhD candidate, and the John A. Hartford Foundation Building Academic Geriatric Nursing Capacity scholar, at NYUCN, were the investigators for the published study. The study is based on a 98-question survey of 1,226 RNs, which is part of RN Work Project, a nationwide, 10-year longitudinal survey of RNs begun in 2006 by Kovner and Brewer, and supported by a grant from the Robert Wood Johnson Foundation.

"There has been a great deal of research into the impact of staffing on patient care, but we know that increasing nurse-to-patient ratios isn't always possible," said Djukic. "What we found in our study is that administrators can improve a variety of work environment factors that are also likely to improve the quality of patient care, without having to change nurse-to-patient ratios. Improvements need to be strategic, because our work shows that the value of enhancing work environment varies across different factors."

For example, the researchers found that Magnet recognition has nearly the same impact on nurses' ratings of patient care quality as workgroup cohesion, but investing in workgroup cohesion is significantly less costly and complicated than applying for and earning Magnet recognition. Additionally, improvements in physical are likely to yield a greater benefit for quality of patient care, as perceived by RNs, than improvements in nurse-physician relations. Then again, implementing a team building program is likely to be less costly than remodeling a hospital unit. Nonetheless, if a hospital is planning to remodel, incorporating RNs' preferences into the physical environment design could result in changes that improve the quality of patient care.

"Health care managers need to think about how they can best redesign RNs' work environments to promote high quality patient care," said Kovner. "They need to examine their resources and determine which changes are possible and which will have the most impact on improving ."

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