R E S E A R C H P A P E R
Nurses’ work environment and nursing outcomes:
A survey study among Finnish university hospital
registered nurses
Tarja Tervo-Heikkinen RN Researcher MNSc PhD(c)
Researcher, Department of Research, Kuopio University Hospital, Department of Nursing Science, University of Kuopio, Finland
Pirjo Partanen PhD RN
Senior Lecturer, Department of Nursing Science, University of Kuopio, Finland
Pirjo Aalto PhD
Chief Nursing Director, Pirkanmaa Hospital District, Tampere University Hospital, Finland
Katri Vehviläinen-Julkunen PhD RN
Professor, Department of Nursing Science, University of Kuopio, Department of Research, Kuopio University Hospital, Finland
Accepted for publication June 2008
Tervo-Heikkinen T, Partanen P, Aalto P, Vehviläinen-Julkunen K.International Journal of Nursing Practice2008;14: 357–365
Nurses’ work environment and nursing outcomes: A survey study among Finnish university hospital registered nurses
The aim was to assess the interrelationships between nurses’ work environment and nursing outcomes. A cross-sectional survey of 664 registered nurses (RN) on 34 acute care inpatient hospital wards was used to measure nurses’ perceptions. Patient data (n=4045) consisting of a total patient satisfaction indicator were collected simultaneously with the nurse data during year 2005. RN’s assessments of staffing adequacy, respect and relationships were the most important factors of work environment having an influence on job-related stress, job satisfaction, patient satisfaction and adverse events to patients and nurses. Some 77% of the RN reported adverse nurse events and 96% reported adverse patient events during a 3 month retrospective period. Ensuring sufficient and suitably qualified nurses’ availability in delivering nursing care is an important management issue. Nurses are concerned about the quality of care, and the concerns perceived by nurses can influence their clinical work.
Key words: cross-sectional studies, hospitals, nurses, nursing, questionnaire.
INTRODUCTION
Nurses’ work environment has been conceptualized and measured in various ways. According to Sleutel,1it is a set of related concepts described as ‘organizational’ factors that influence nursing practice. Aiken et al.2 have been theorizing a quality nurses’ work environment to a work setting that promotes nursing professional autonomy,
Correspondence: Tarja Tervo-Heikkinen, Kuopio University Hospital, Department of Research, PO Box 1777, FIN-70211 Kuopio, Finland. Email: tarja.tervo-heikkinen@kuh.fi
greater control over practice environment and better physician–nurse relationships, thus resulting in better outcomes for nurses and patients.
Economic changes affecting the whole western world in the 1990s (recessionary period and health-care staffing reductions), pressures for hospital restructuring and the decrease of the working age population have had an impact on the health-care systems and registered nurses’ (RN) work environments. A poor organizational climate and high workloads have been associated with increased levels of needlestick injuries.3The importance of optimal staffing levels has been confirmed recently by Rauhala
et al.,4connecting nurses’ work overload to increased sick leaves. Magnet hospital characteristics, such as progres-sive employment policies and organizational support for nurses, have been found to be associated with better nurse job satisfaction,5,6a safer work environment for nurses5 and also better patient safety outcomes7 than in non-magnet hospitals. Hospitals priorities and policies also influence nurses’ work environment, for example, in the use of nursing staff.
In summary, nurses’ work environment and its relation-ship to different nursing outcomes have been studied quite widely during recent years in the USA5,8and Canada.9,10 Research findings indicate a link between nurses’ job sat-isfaction and patient outcomes, such as mortality rates and patient satisfaction.11Also, numerous studies have linked organizational factors and factors related to work environ-ment to nurses’ job satisfaction.12As the shortage of nurses is an international problem, it is very important to examine whether there are differences in nurses’ work environment across different cultures and health-care systems. To date, relatively little is known about the nurses’ work environ-ment situation in European and Scandinavian hospitals. Raffertyet al.13studied the nurse environment situation in English hospitals, specifically the effects of staffing on patient outcomes (mortality and failure to rescue) and nurse retention outcomes, stating the same outcomes as in the USA. Also, a couple of other studies14,15 have been describing the European nurses’ work environment.
In measuring the nurses’ work environments staff nurse survey is a widely used method that has been developed and refined over the past decades.16In these surveys the most used instrument seems to be the Nursing Work Index (NWI) which was developed by Kramer and colleagues.17 NWI-revised (NWI-R) instrument was further developed by Aiken and Patrician18from the original one. NWI-R was far lighter for the respondent than the original version,
since only the presence of selected attributes was asked. After that the NWI-R has been largely used and modified. It is especially an instrument that has been used in the context of magnet hospitals as a satisfaction tool.19,20
The NWI-R findings on nurses’ work environment together with different nursing outcomes, such as adverse events to RN and patients3,7,21and RN’s assessed overall nursing care quality,22 have been studied by different researchers. Those studies showed the relationship between nurses’ work environment and outcomes; a better practice work environment brings better outcomes.
METHODS
Aim and research questions
The aim of this study was to assess the interrelationships of acute care hospital RN’s evaluations on their work environment and selected nursing outcomes. Specified research questions were: what is the relationship between nurses’ work environment and (i) nurses’ job-related stress and job satisfaction; (ii) patient satisfaction; (iii) adverse events to nurses; and (iv) adverse events to patients?
Design and sample
To examine the relationship between the nurses’ work environment and nursing outcomes, a conceptual frame-work based on earlier studies8,17,18was used (Fig. 1).
A cross-sectional questionnaire survey was carried out in April to May 2005 on 34 adult inpatient wards: 19 medical, 13 surgical and two joint medical-surgical wards, in four university hospitals in Finland. University hospitals are publicly funded tertiary care teaching hospitals. In Finland, altogether five university hospitals produce
ª55% of tertiary medical care patient days. Four of these hospitals participating in this study offer nearly three-quarters of all the university hospital beds (nª5540,
n=3753).23
The design of the data collection is presented in Fig. 2. The sample consisted of altogether 664 RN of whom 451 RN returned a completed questionnaire, giving a response rate of 68%. One ward was excluded from the ward-specific analysis because of its low response rate (11%). The outcome of patient satisfaction is derived from our patient survey (n=1730) via with a modified version (Humane Caring Scale-revised) of an earlier developed instrument24 from the study hospital wards during the same data collection period. In this study only the total satisfaction indicator was used.
Data collection
The data were collected via survey instruments sent to participating wards’ head nurses, who distributed them to the RN with a minimum working period of 1 month in the ward and working in clinical position (inclusion criteria). Our nurse survey instrument—the Registered Nurse Working Conditions Barometry Index-revised (RN-WCBI-R)—included the statements of the NWI-R. The instrument was based on a previously (2004) executed national survey of RN (a nationally representative random sample of 3000 RN) in Finland by the authors, and reported in a prior article,25 concerning RN’s views on their work environment as a whole across various different working settings. For this present study focusing on acute care hospital settings, we shortened the earlier wide instru-ment, removing some not relevant background questions to this study. The reliability of the instrument was between 0.737 and 0.838 as measured by Cronbach alpha (Table 1).
The NWI-R in this study
Our questionnaire included the NWI-R with 55 ments excluding two items from the 57 original
state-ments by Aiken and Patrician.18 The NWI-R scale was translated into Finnish language and independently back-translated by bilingual translators to validate the accu-racy of the translation. Of the NWI-R’s statements, 41 constituted five subscales (Table 1). These subscales were constructed by Exploratory Factor Analysis using survey material collected earlier (spring 2004) from members of the Finnish Nurses’ Association.25From that sample only those (n=162) who worked at university hospital inpatient wards were included in the factor analysis. The respondents were asked to rate items on a 4-point Likert scale (1=strongly agree, 4=strongly disagree) to indicate their level of agreement that the item being evaluated was present in their current work situation. The scores of all the items were reverse-coded, so that higher scores indicated perception of a positive statement.
Principal component analysis was used as an extraction method. All the items with lower communality than 0.300 were excluded from the final analysis.26,27A final description of the factors (subscales) was made from items that had higher loadings on the factor.
Figure 1. Conceptual framework of nurses’ work environment used in this study based on results of earlier studies.8,17,18RN, registered nurse; MD, doctor of medicine.
Outcomes
• Job-related stress
• Patient satisfaction
• RNs’ job satisfaction
• Adverse events to patients
• Adverse events to RNs
RNs’ Evaluation of the Work Environment
- Professional advancement and support of the TOP management
- Support of immediate superiors - Staffing and resource adequacy
- Nursing respect and RN–RN/RN–MD relationships - Standards of professional nursing
Figure 2. Design of the data collection. RN, registered nurse.
34 inpatient wards in four university hospitals
664 RNs survey 4045 patients survey Respond rate n=451, 68 % No respond n=213, 32 % Respond rate n=1730, 43 % No respond n=2315, 57 %
Table 1 Result of Exploratory Factor Analysis†(n=162): Five-factor solution of the Nursing Work Index-revised (NWI-R)
Subscales and component items Loading‡
1 Professional advancement (and support of the high managers) (a0.838, mean 2.23, SD 0.51, variance explained=43.8%)
Career development/clinical ladder opportunity. 0.675
A chief nursing officer is highly visible and accessible to staff. 0.646
An administration that listens and responds to employee concerns. 0.638
Opportunity for staff nurses to participate in policy decisions. 0.620
Opportunities for advancement. 0.611
Nursing staff is supported in pursuing degrees in nursing. 0.523
Active in-service/continuing education programmes for nurses. 0.482
Freedom to make important patient care and work decisions. 0.469
An active quality-assurance programme. 0.439
2 Support of immediate superiors (a0.765, mean 2.50, SD 0.51, variance explained=37.3%)
A nurse manager who is a good manager and leader. 0.607
A nurse manager backs up the nursing staff in decision-making. 0.599
Nurse managers consult with staff on daily problems and procedures. 0.583
Floating so that staffing is equalized among units. 0.566
The supervisory staff that are supportive of nurses. 0.511
Regular, permanently assigned staff nurses never have to float to another unit. -0.487
Flexible or modified work schedules are available. 0.479
The nursing staff participate in selecting new equipment. 0.401
Staff nurses are involved in the internal governance of the hospital. 0.354
3 Staffing (and resource) adequacy
(a0.799, mean 2.21, SD 0.61, variance explained=58.4%)
Enough registered nurses (RN) on staff to provide quality patient care. 0.800
Enough staff to get work done. 0.744
Adequate support services allow me to spend time with my patients. 0.726
Enough time and opportunity to discuss patient care problems with other nurses. 0.667
Primary nursing as the nursing delivery system. 0.522
4 Respect and relationships (Nursing respect and RN–RN/RN–doctor of medicine relationships) (a0.737, mean 3.16, SD 0.36, variance explained=33.3%)
Working with nurses who are clinically competent. 0.715
Opportunity to work on a highly specialized unit. 0.680
Physicians give high-quality medical care. 0.574
The contributions that nurses make to patient care are publicly acknowledged. 0.547
Working with experienced nurses who ‘know’ the hospital. 0.497
Physicians and nurses have good working relationships. 0.494
Not being placed in a position of having to do things that are against my nursing judgement. 0.492
Much teamwork between nurses and doctors. 0.491
High standards of nursing care are expected by the administration. 0.434
5 Standards of professional nursing
(a0.789, mean 2.64, SD 0.51, variance explained=37.9%)
Standardized policies, procedures and ways of doing things. 0.602
Nursing care is based on a nursing rather than a medical model. 0.600
A clear philosophy of nursing pervades the patient care environment. 0.596
A preceptor programme for newly hired RN. 0.566
A good orientation programme for newly employed nurses. 0.534
Use of nursing diagnoses. 0.531
Written up-to-date nursing care plans for all patients 0.507
Patient assignments foster continuity of care. 0.502
Total patient care as the nursing delivery system. 0.478
†Extraction method: principal component analysis. Rotation method: Varimax with Kaiser Normalization.‡Subscales theoretical variation was 1–4. Note: This table
contains the original NWI-R wording (Aiken and Patrician 2000).18Subscale, items, Cronbach alpha (a), mean of subscale, standard deviation (SD) and variance
Selected measures
The parameters collected by surveying RN and patients were aggregated to unit-level data so that items were summed to obtain a score for the unit. RN’s work envi-ronment was measured by NWI-R. Subscale data were used as an independent variable in relation to the different nursing outcomes.
Nursing outcomes
Five measures were used to quantify nursing outcomes in this study: (i) RN reported experience of job-related stress; (ii) job satisfaction; (iii) patient satisfaction with nursing care; (iv) adverse events to the RN; and (v) adverse events to the patients. RN’s experience of job-related stress constitutes of the reported number (%) of RN who experienced work stress quite a lot or exceed-ingly. Job satisfaction is RN’s reported experience of their satisfaction with their present job. A measure of the total patient satisfaction from the patient satisfaction survey24is used as patient outcome indicator in this study. The total patient satisfaction indicator was formulated from eight subscales of patient satisfaction with hospital care.
Nurse-assessed adverse RN events per 1000 RN working hours (adverse RN events) and adverse patient events per 1000 incoming patients (adverse patient events) were calculated from RN’s reported numbers of adverse events that occurred to the RN and patients during a 3 month retrospective period. Adverse events to RN were, respectively, proportioned to each ward’s total RN hours during the first quarter of 2005. RN were asked to evaluate the number of different work-related acci-dents during the past 3 months, such as sharp-device injuries, slipping, injuries caused by patients and injuries caused by lifting or moving patients. The number of adverse patient events was proportioned to each study ward’s incoming patients during the first quarter of 2005. Respectively, nurses were asked the number of adverse events that happened to their patients, namely patient falls, medication errors or nosocomial infection or pres-sure sores.
Ethical considerations
The study design was reviewed by the Northern Savo Ethical Committee and was given a national positive statement (number 154/2004, 9 November 2004). Per-mission for the RN survey was given by the Chief Director of Nursing and Director of Nursing of each participating
hospital. Permission to remodel and use the RN-WCBI questionnaire was given by the Finnish Nurses’ Associa-tion. Questionnaires with a return envelope were sent anonymously to the head nurses of the study wards, who gave them out to the RN fulfilling the study criteria. In an information sheet the researchers emphasized the re-spondents’ freedom to answer or not. The respondents answered anonymously, and there was no information that could be used to identify the respondents. Only infor-mation about the hospital and ward could be connected to the respondents. Permission for the patient satisfaction survey and use of administrative data was given by the chief executive medical directors and ethical committees according to each hospital’s standards.
Data analysis
All the statistical analyses (i.e. frequencies, percentages, correlations) were performed usingspssversion 14.0 for Windows. Principal component analysis and reliability analysis (Cronbach alpha) were used to formulate sub-scales from the survey data and to test the reliability of the modified version of the NWI-R scale. In the subscales a large number of statements are grouped into subareas linked by the principal component analysis on the basis of the given information.27,28The ward-specific values of the subscales were constructed using the means of the RN’s statements on each ward. Regression analysis was used to show how the independent variables interact with the dependent variables. Since regression analysis does not give the strength of the correlations, only the trend, sig-nificance (P-value), regression coefficients (b1) and total variance explanations (R2) were used.
RESULTS
Characteristics of RN
The respondents’ characteristics are shown in Table 2. Respondents worked on acute medical, surgical and medical-surgical inpatient wards. Their mean age was 39.3 years. In most cases the last received degree was RN (RN diploma or bachelor degree). Most of the respon-dents were tenured employees and worked full-time. Almost half of the respondents’ last work shift before answering the questionnaire was a day shift (43.6%); for one-quarter the last shift was an evening (26.9%) or night shift (26.2%). Only 3.3% reported having worked a long shift (12–15 h). Work experience was quite long so that more than two-thirds (73%) of the respondents had over 5 years of work experience as an RN.
Nurses job-related stress and
job satisfaction
Only 7% of the respondents answered that they did not feel any job-related stress. More than one-fifth parts (21%) of the respondents felt stress quite a lot or exceedingly (Table 3). Those who felt that respect and relationships were lower (P=0.013, b1=4.329, R2 =18.2%) and they also felt job-related stress rather much or exceedingly. The other subscales had the same direction, although those results were not statistically significant.
Every third RN was not satisfied with her present job. When the possibilities to professional advancement were evaluated to be better (P=0.009, b1=3.598, R2 =20%), staffing adequacy was satisfactory (P=0.001, b1=9.558, R2=28.9%), RN felt that nursing had respect and good working relation-ships (P=0.002, b1=7.376, R2 =27.6%), and also RN’s job satisfaction was better. The other subscales had the same direction although not statistically significant.
Patient satisfaction
All subscales (Table 3) and the patient satisfaction indicator correlated positively although not statistically significantly. When RN evaluations on standards of pro-fessional nursing increased (P=0.015, b1 = -0.117, R2=17.5%), staffing adequacy was also evaluated to be in good level (P=0.018, b1= -0.047, R2 =16.7%), nursing respect and relationships were felt well (P=0.039, b1= -0.053, R2=13.0%), and patients’ level of satisfaction also increased.
Adverse events to nurses
Almost every fifth respondent (16%) reported of an acci-dent at work during the last 3 month period. The mean was 1.7 accidents, with the total number fluctuating 1–6. Adverse events to all RN on the ward were also asked (Table 3). More than three-quarters (77%) of the re-spondents reported that accidents had happened to RN colleagues during the 3 month period. The regression analysis indicated a negative linear connection between all the subscales and adverse RN events; when the subscales’ positive effects increased, the rate of adverse RN events decreased linearly. However, the connection was statisti-cally significant only for standards of professional nursing (P=0.032, b1=0.270, R2 =14.4%) and staffing adequacy (P=0.004, b1=0.870, R2 =24.6%).
Adverse events to patients
The RN were also asked to estimate adverse patient events (Table 3). Only 4% answered that there were no any kind of adverse patient events during the 3 month period. The adverse patient events and subscales were analysed as above. There were also a negative linear con-nection between all the subscales and adverse patient events. The connection was statistically significant for respect and relationships (P=0.007, b1=2.793, R2=21.3%) and staffing adequacy (P=0.025, b1=2.994, R2 =15.2%).
DISCUSSION
Limitations of the study
There are some limitations in this study. First, our indi-cators of frequency of adverse events are subjective and may be biased, for example, by recall. This kind of inquiry had to be used since in Finland we do not have a nationally uniform system of reporting adverse events, but we wanted to calculate it. Because the number of adverse Table 2 Respondent (n=451) characteristics
Characteristics n %
Age (mean 39.3 years) (SD 22–63 years) Gender
Women 98
Men 2
Highest nursing degree
Registered nurses (RN)† 10
RN (diploma or bachelor)‡ 88
RN (+master degree) 2 Working situation
Worked as a nurse (mean 11.8 years) (SD 0–37 years) Full-time workers 93 Tenured employees 70 Work setting 451 Medical wards 228 51 Surgical wards 200 44 Medical-surgical wards 23 5
†RN education (2.5 years) which ended in 1980s.
‡RN (diploma or bachelor) education (3.5–4.5 years)
events is based on the RN survey, its reliability was improved by calculating unit-level figures from each ward’s RN data to minimize overlapping of adverse event figures in the survey.
The second limitation is the varying response rate across different wards (33–100%). Although the overall response rate (68%) was good, it fluctuated 11–100%, depending on the ward, being not very representative of all the wards. That’s why we decided to exclude one ward (response rate 11%) from the analysis due to scarce respondents.
Discussion of the results
It is already known that nurses’ work environment is a major determinant of patient and nurse welfare. In our study we used the NWI-R scale to measure the attributes
of the professional nursing environment. The five attributes we found were compared with different nursing outcomes to identify interrelationships summarized in Table 4. All the statistics were aggregated to the unit-level data and the items were summed to obtain a score for each ward.
It is notable that most of the RN reported themselves to be more or less stressed and every fifth RN even reported feeling stress quite a lot or exceedingly. However, when the professional nursing environment was reported to be better, nurses’ stress level decreased clearly. When com-paring the results obtained in this study, it seems that the level of satisfaction among Finnish RN is in many ways comparable to the results of the previous research22 con-taining RN surveys from the USA, Canada, England, Scotland and Germany, and reporting that 17.4–41% Table 3 Outcome measures of study wards in March 2005 (mean, SD, range)
Characteristics Mean SD Range of the measure
Registered nurses’ (RN) feeling job-related stress quite a lot or exceedingly (%)
21 12.76 0.0–43.8
RN with good job satisfaction (%) 65.9 17.65 25.0–100.0 Patients with good satisfaction (%) 69 9.51 44.45–84.91 Adverse RN events (number)† 0.4 0.18 0.03–0.76
Adverse patient events (number)‡ 11.3 7.61 1.4–43.3
†The ward-specific number of RN estimating adverse events happened in the unit during the last 3 months.
‡The ward-specific number of RN estimating adverse events happened to the patients in the unit during the last 3 months.
Table 4 Subscales and direction (↑or↓) of chosen surveyed figures when subscales increased (↑) by regression analysis and scatter plot figures. Statistically significant findings are marked (P-value)
When the subscale‡increased (↑)
the direction where figures moved
Direction of move and statistically significance (P-value)
Job-related stress§ RN job
satisfaction§ Patient satisfaction§ Adverse RN events§ Adverse patient events§ Professional advancement ↓† ↑0.009** ↑† ↓† ↓†
Support of immediate superiors ↓† ↑† ↑† ↓† ↓†
Staffing adequacy ↓† ↑0.001** ↑0.018* ↓0.004** ↓0.025*
Respect and relationships ↓0.013* ↑0.002** ↑0.039* ↓† ↓0.007**
Standards of professional nursing ↓† ↑† ↑0.015* ↓0.032* ↓†
*P<0.05; **P<0.01.†Finding was not statistically significant (P<0.050);‡Regression analysis as independent variable;§regression
of the study respondents were dissatisfied with their present job.22 In our study every third RN (33%) was dissatisfied. Our study confirmed that RN’s satisfaction with their present job was positively related to RN’s work environment.
All five nursing work environment variables that we studied—(i) professional advancement (and support of the top management), (ii) support of immediate superi-ors, (iii) staffing (and resource) adequacy, (iv) nursing respect and (RN–RN/RN–doctor of medicine) relation-ships and (v) standards of professional nursing—were found to be important predictors of the nursing outcomes explored in our study (Table 4). When professional envi-ronment attributes were evaluated to be better, also nurses’ work stress degreased and nurses’ satisfaction indicators increased linearly. Even the number of reported adverse events to RN and patients degreased. So, we can fairly claim that nurses’ professional environ-ment influences the nursing outcomes positively.
In this study the support given by managers at different levels did not make a major issue for a positive profes-sional environment. It seemed that more important was nurses’ perceptions of staffing adequacy, felt respect and good relationships and the standards of professional nursing. This finding differs from the Laschinger and Leiter7 and Gunnarsdottir et al.15 studies, for example, where they found that leadership played a fundamental role in the quality of work life environment. This might be a reflection of a cultural difference in Finnish health care, showing also RN’s worry about staffing adequacy in the future. These findings suggest that nurses are concerned about the quality of care they provide, and also that the concerns perceived by nurses can influence their clinical work and thereby their experience of the work environment.
CONCLUSION
In summary, the results of this study confirm earlier research on the importance of RN’s work environment to nursing outcomes and thus to health-care management and leadership. Additional longitudinal studies are needed to further clarify pathways linking organizational work environment issues and patient and staff outcomes. Staff-ing and other resources, like adequacy of support services, together with different nursing care quality indicators also need more studying.
In this study the staffing, nursing respect and relation-ships and also standards of professional nursing indicators
were strongly related to nurses’ job-related stress, job satisfaction, patient satisfaction and both RN and patient safety outcomes. The findings of this study provide useful information for health-care leaders and managers at different levels and also for policymakers to be used in decision-making on human resources planning in health care. Employing professional work environment for RN with adequate staffing levels is beneficial to RN’s health and satisfaction increasing also patient satisfaction and safety.
ACKNOWLEDGEMENTS
Financial support for this study was provided by the Kuopio University Hospital (EVO), the Kuopio Univer-sity Hospital Research Foundation, the Finnish Cultural Foundation (North Savo Foundation) and the Finnish Association of Nursing Research. We would also like to thank the Finnish Nurses’ Association for the opportunity to use and revise the questionnaire.
We want to thank statistician LicPhil Vesa Kiviniemi from Kuopio University Information Technology Centre for his abundant statistical and mathematical help. We are also most grateful to all the RN and head nurses who took part in this study by giving their time willingly in answer-ing our survey.
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