Effects of Work Environments on Nursing and Patient Outcomes

Nurses are leaving the profession due to high levels of job dissatisfaction arising from current working conditions characterized by heavy workloads, limited participation in decision making and lack of development opportunities (Canadian Health Services Research Foundation [CHSRF], 2006a). To gain organizational support for workplace improvements and thereby improve nursing retention, evidence is needed to demonstrate the impact of the work environment on patient care. The purpose of this study was to determine the relationship between nurses\u27 perceptions of their work environment and the quality and risk outcomes for both the patient and the nurse. Kanter\u27s (1977, 1993) theory of structural empowerment guided the study. Empowering work environments for nurses were hypothesized to impact group processes and thereby work effectiveness as reflected in patient outcomes (patient satisfaction, therapeutic self care, falls and nurse-assessed risks). Empowering workplaces were also hypothesized to enhance the nurse\u27s psychological empowerment and, in turn, engagement in empowering behaviours that lead to quality care and job satisfaction. A multi-level cross-sectional design was used to test the study model. Self-report surveys were used for a sample of nurses (n=679) and discharged patients (n=1005) affiliated with medical and surgical units from 21 hospitals in Ontario. Unit characteristics and falls data were obtained from existing hospital databases. Using multilevel structural equation modeling, the hypothesized model fit well with the data (χ2=21.074, df=10, CFI=.985, TLI=.921, RMSEA=.041, SRMR .002[within] and .054[between]). Empowering workplaces had positive effects on nurse-assessed quality of care and predicted fewer falls and nurse-assessed risks as mediated through group processes. These conditions positively impacted individual psychological empowerment which, in turn, had significant direct effects on empowered behaviour, job satisfaction and care quality. Theoretically, evidence supported the further evolution of structural empowerment theory to include group processes and empowered behaviour as mediators to various nurse and patient outcomes. The evidence from this study also reinforced the critical need to invest in improving nursing work environments for the benefit of patients and nurses. Theory-informed strategies for changes to the workplace have the potential to mitigate against projected nursing shortages and ensure a sustainable workforce to meet future demands for care