20 Jun 2022


Access, Cost and Quality of Environments for Advanced Practice Nurses

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The intervention of Advanced Nursing Practitioners has consistently been seen to result in reduced health care costs and improved patient outcomes across patient groups. The optimal timing and number of telephone contacts and post-discharge home visits by advanced practice nursing practitioners or APNs, re-hospitalization patterns and acute care visits however vary across different patient groups. To keep patients healthier over time, APNs need to not only have the interpersonal skills and deep knowledge and excellence in clinical matters, but they also need to be exposed to quality environments that will allow them to produce optimal results. Quality practice environments have therefore been described on the basis of access, cost and quality as a means of determining their impact on nursing practice and in turn on patient outcomes. 

Quality Work Environments 

The maintenance of a safe working environment reflects a degree of compassion and of vigilance for the welfare of patients that is just as important as other aspects of competent healthcare. Because of this, policymakers, researchers and providers have intensified efforts to not only understand but to change organizational components, conditions and processes within the healthcare system as they relate to patients and those working to serve them. Existing research provides the results of current evidence that has been found following the examination of the relationships among organizational climates and the overall quality of worker outcomes. Worker outcomes include job satisfaction and turnover. The organizational climate attributes will on many occasions vary from composite measures of organizational climate to morale ( Chiou-Fen, et al., 2020)

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Job satisfaction directly affects nurses’ morale and consequently affects patient outcomes. There are several factors affecting job satisfaction among nurses. The most important and over-arching factor is work environment. Work environment touches on several areas including the organizational culture, work policies, nurses’ welfare, payment, appreciation, and other factors such as promotion. Highly motivated nurses tend to be highly effective in their work with the results being reflected on the patient outcomes. Quality work environment also takes into consideration issues such as interpersonal communication and accommodation to new ideas and views. Considering that most workplaces are highly diverse, it is important to explore how employees embrace diversity and accommodate differing views, beliefs and attitudes. Cultural competence is among the skills needed in nursing practice. It should be practiced when dealing with other healthcare workers before practicing it when handling patients. A conducive work environment creates a great platform for nurses to apply their practical skills and help improve patient outcomes. In the era of evidence-based practice, nurses have an opportunity to implement new management approaches to holistically address patients’ health challenges. 

While most studies around the quality of work environments in healthcare surround nurses, it is also important to consider other healthcare workers that work closely with nurses and could affect patient outcomes such as mental health workers and outpatient case workers. Chiou-Fen, et al., (2020) report that a positive organizational climate is related to increased job satisfaction among workers. While the results of studies relating to turnover are not as strong, there is visible evidence that job satisfaction can mediate the effect of organizational climate on employee turnover. 


Leaders in many healthcare facilities have reported facing chronic challenges in their attempts to retain an adequate supply of certified nursing assistants and qualified nurses to manage the chronic and acute care needs of their patient populations. Many health centers and nursing homes continuously fail to meet the nurse staffing levels that are recommended and expected by the Centers for Medicare and Medicaid Services. This problem is then exacerbated by the high turnover among members of this population resulting from a lack of access to quality working environments which is prevalent in the industry. 

In institutions with low access to quality working environments and high turnover are linked to having poor quality care culminating in additional costs related to labor such as hiring, training and loss of productivity. These additional costs are problematic for this industry considering that the industry is heavily dependent on Medicaid to reimburse and that is currently operating under a series of tight budgetary constraints. 

Job dissatisfaction and staff burnout are also barriers to access to a quality working environment. They are key drivers of nurse turnover and therefore pose a significant threat to the safety of patients. Research as shown that registered nurses in nursing homes report higher job dissatisfaction that RNs who are employed in other medical settings such as hospitals (Fawaz, et al., 2018). This is due to the fact that nurses working in these facilities lack access to quality working environments due to factors such as understaffing while caring for increasingly frail patients. Nursing home RNs have also recorded higher rates of missed care and burnouts than CNAs and LPNs. Nurses in nursing homes have reported often leaving necessary care unattended to because of lack of resources and time. This missed care is also largely linked to job dissatisfaction and burnout (Chiou-Fen, et al., 2020). 

From the above, it is evident that sufficient staffing is an important part of quality and safe practice environments. However, access to this cannot be assured by staffing improvements alone. Without other organizational elements present, staffing improvements will have a limited impact on access to quality working conditions. Nurse leaders and advocates for nursing play an important role in campaigning and advising polices that ensure that nurses have access to quality working environment. An example of such a policy is a nurse to patient ration that is evidence-based and will provide optimum outcomes for both nurse and patient (Silber, et al., 2016). 


Research has recognized that quality nursing environments that have above average levels of staffing provide better value as compared to those that do not recognize the quality of their nursing environments by having staffing levels that are below-average. In this context, value is characterised my lower costs, reduced readmission and lower mortality. It is important however to notice that staffing comes at a cost and said costs are often eventually catered for by the end user which is the patient (Silber, et al., 2016). However, by improving the nursing environment of healthcare facilities, other costs associated with low quality working environments can be mitigated. The resources that would otherwise be used to offset the costs associated to poor quality care, and high turnover can cater for improved staffing among nurses (Dyrbye, et al., 2017). 


There is a statistically significant positive association between quality nurse working environments and job satisfaction among nurses. Many studies have described quality work environments as being composed of teamwork, professional specialization caring and support and have been seen to have a positive association with job satisfaction after the adjustment has been made for personal demographic characteristics ( Fawaz, et al., 2018)

The quality measures and evaluation described above are also directly linked to role development among nurses. Advanced Practice Nurses and nurse leaders are actively taking up leadership roles that will allow them to advocate for and enhance the quality of working environments among nurses. On the advocacy front APRNs carry out research endeavours to establish evidence-based practice which will then advise policymakers to enact legislation and procedures that will ultimately improve the quality of working environments among nurses. 

Without effective quality measures in place, the roles of APRNs will be impacted. By definition, APRNs are nurses that have achieved advanced clinical and educational practice requir3ements. Their roles are therefore often extended to the provision of services in community-based settings. However, if working environments for nurses are of poor quality, APRNs may be required to regress back to focusing on clinical settings. This will be due to the gaps left by nurses who leave the profession, nurses who offer poor quality care due to burnout and overall understaffing among nurses. The gap left by APRNs will leave the nursing population with less than optimum representation in leadership and policy making positions (Dyrbye, et al., 2017)


The concept of the iron triangle of healthcare was introduced to explain the concept that quality, cost and access to healthcare cannot be improved simultaneously. The premise in this case refers to patient care and is that an improvement in one of these areas will result in an expected decline at either one or both of the others. Through research, this is now understood to be the case as pertains to quality working environments for nurses. Quality working environments in healthcare settings are for example linked to job satisfaction. Job satisfaction is in turn linked to high staffing ratios among nurses. However, increasing staffing will cause an increase in costs while also increasing quality. Nursing managers therefore need to improve workspaces and work satisfaction by caring and supporting for nurses, creating better development of their careers as well as enhancing teamwork through planning and job training. While this will increase costs, it will also improve both the quality of their work but also the quality of care offered. It can therefore be said that in the iron triangle of healthcare, cost will have to be the opportunity cost if nurses are to get quality work environments (Fawaz, et al., 2018). 


Chiou-Fen, L. I. N., Fu-Chih, L. A. I., Huang, W. R., Huang, C. I., & Hsieh, C. J. (2020). Satisfaction with the quality nursing work environment among psychiatric nurses working in acute care general hospitals. Journal of Nursing Research, 28(2), e76. DOI: 10.1097/jnr.0000000000000350 

Dyrbye, L. N., Shanafelt, T. D., Sinsky, C. A., Cipriano, P. F., Bhatt, J., Ommaya, A., ... & Meyers, D. (2017). Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. NAM perspectives. Retrieved from https://iuhcpe.org/file_manager/1501524077-Burnout-Among-Health-Care-Professionals-A-Call-to-Explore-and-Address-This-Underrecognized-Threat.pdf 

Fawaz, M. A., Hamdan-Mansour, A. M., & Tassi, A. (2018). Challenges facing nursing education in the advanced healthcare environment. International journal of Africa nursing sciences, 9, 105-110. 

Silber, J. H., Rosenbaum, P. R., McHugh, M. D., Ludwig, J. M., Smith, H. L., Niknam, B. A., ... & Aiken, L. H. (2016). Comparison of the value of nursing work environments in hospitals across different levels of patient risk. JAMA surgery, 151(6), 527-536. doi: 10.1001/jamasurg.2015.4908 

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StudyBounty. (2023, September 16). Access, Cost and Quality of Environments for Advanced Practice Nurses.


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