Almost everyone agrees that nurses play an important role in the healthcare industry but no one cares about the environment within which the nurses work. Traditionally, the role of nurses was to help in disease prevention efforts and advise individuals on practices that keep them at bay with diseases. However, the role of nurses has changed with time. It is because new diseases are arising while new techniques of managing the diseases are also being developed. Seemingly, studies are being conducted with the aim of building an all-round nurse, who can attend to the increasing needs of the healthcare industry. Particularly, most researchers are interested in how nurses can be taught to communicate better with patients while emphasizing on their work ethics. It is understandable because nurses come into contact with patients more than any other health worker in the hospital environment. However, many experts forget or deliberately refuse to recognize that the environment within which a nurse works influences his or her output in regard to enhancing the wellbeing of patients.
First, it is important to understand all the elements and the factors that make up the nursing environment. According to Kelly et al. (2014), the work environment refers to the organizational attributes of the workplace which either enhance or limit professional nursing practice. However, this seems to be a general definition of the topic. Shang et al. (2013) attempt to delve into the specifics by highlighting some of the variables that make up the nurses work environment. One of the factors concerns the leadership of the hospital. These are people who have the responsibility of being in charge of the healthcare facility and coming up with directions on how things ought to be done in the facility. The decisions of these people to a large extent define what nurses ought to do and what they are not supposed to do. It is common knowledge that some managers are stricter than others. While some hospital managers may involve nurses to take part in making decisions that affect them, some may employ the autocratic type of leadership where the participation of nurses is limited.
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The second component of the nurse environment are the physical structures. That means the wards, as well as other places where nurses spend time with patients or other people in the particular healthcare facility. The manner in which the various spaces are designed or arranged influences the output of a nurse (Hunsaker et al. 2015). Third, the nursing environment is also defined by the various people that the nurse interacts with. The most prominent ones are the patients, followed by the other specialists such as physicians and doctors. The physicians and doctors usually spend short durations with patients and require that nurses conduct checks on the progress of the patients (Hutchinson & Jackson, 2013). That means that the nurse will ensure that the patient takes his or her medication as prescribed by the doctor. Additionally, the nurses also keep records of the patients so that they avail them to the doctors or physicians when required. The interaction between the doctors or physicians with the nurses defines greatly how a nurse discharges his or her duties.
Lastly, the equipment within the hospital environment also forms an integral part of the nursing environment. Some health facilities are adequately equipped while others are under-equipped. Conventionally, nurses will work best in facilities that have better equipment than those that are under-equipped or have outdated equipment (Kelly et al. 2014). It is not just about equipping the facilities, but it is also about ensuring that the nurses are trained on how to use the equipment. This working paper investigates the literature available on how the work environment affects the output of nurses in regard to the wellbeing of patients. As already mentioned, the profession of nursing is multifaceted, hence the literature review is also dynamic. The literature review involved one qualitative study (Hutchinson & Jackson, 2013) and five quantitative studies (Cho et al. 2015; Flyn et al.2012; Kirwan, Mathews & Scott, 2013; Bogaert et al. 2013; Stimpfel & Aiken, 2013)
Qualitative Study
Hutchinson and Jackson’s (2013) study dubbed “Hostile clinician behaviors in the nursing work environment and implications for patient care” attempts to investigate how the interaction of professionals in the hospital environment influence the output of nurses. The study, in an attempt to conduct a conclusive investigation, comes up with four themes. The themes include, nurse-nurse bullying, intimidation and patient care, physician-nurse relations and patient care, nurses and physicians implicating patients directly in hostile clinician behaviors, and reduced performance of the nurse related to exposure to clinician behaviors that are hostile. In its methodology, the study reviewed papers that were published from 1990 to 2011 (Hutchinson &Jackson, 2013). The time frame was chosen because there were studies that reported the emergence of hostile clinician behaviors in the 1980s but some of the findings were published in the 1990s papers. Additionally, since there are relatively few primary studies carried out on hostile behavior of clinicians, the study used a mixed studies design. That means that the research involved qualitative, quantitative, and other mixed methods.
Still on the Hutchinson and Jackson (2013) study, the researchers first defined patient care and hostile clinician behavior. Patient care is described as the care processes and events. The processes involve the impact of the behavior and attitudes of the clinicians and interventions on clinical, safety, care, and quality. On the contrary, hostile clinician behavior involves all the different forms of aggressive, harassing, or disruptive behaviors that occur between clinicians. In regard to the nursing lexicon, when these behaviors occur, they are popularly referred to as oppressed group behavior and lateral or horizontal violence. In regard to nurse-physician relation and patient care, the study noted that good interaction between physicians and nurses led to improved quality of care and minimized undesirable patient outcomes.
On the contrary, Hutchinson and Jackson established that physician intimidation contributed significantly to medication errors, as well as failure of nurses to seek clarification on medication orders on which they have concerns. Concerning nurse-nurse bullying, from two qualitative studies and three survey studies, it was established that hostility caused individuals to feel overwhelmed and unable to ask for assistance from their colleagues. In four survey studies and three qualitative studies, respondents reported that there was tendency to ignore assistance requests from colleagues, particularly in situations that needed help to safeguard the safety of the patient. In regard to the third theme, reduced nurse performance related to exposure hostile clinician behaviors, the study established that nurse avoidance and communication delays place patients at risk or delay treatment. These adverse impacts arise because of communication breakdown between the physician and the nurses (Hutchinson & Jackson, 2013). That means that the flow of clinical information is hampered by the bad relationship. For instance, in two of the surveys, nurses who had previously experienced hostile clinician attitudes said that the conduct distracted them from their work and reduced their capacity to concentrate. The low concentration consequently resulted into some of the nurses making minor to major errors to patients. The last theme was the direct implication of the nurses and physicians hostile behavior to patients. The research established that both physicians and nurses were reported to use verbal abuse in relating with other nurses in front of patients. If the physicians abuse nurses in front of the patients, the nurses’ confidence reduces. The nurses could also replicate the hostile behavior and use verbal abuse on the patients.
Quantitative Studies
Cho et al. (2015) investigate the relationship between the nurse staffing level and the performance of the particular nurses. The researchers use a cross-sectional study which incorporates nurse survey data (N= 4, 864 nurses), patient hospital discharge data (N= 113,426 patients), and facility data (N= 58 hospitals). It is also important to note that the study is conducted in South Korea. According to the study, a total of 4,864 registered nurses participated in the survey. All the participants were young with a mean age of 28.7 years and with work experience of averagely 6.2 years as registered nurses. Most of the participants were female (n= 4,617) and 2,124 of them had at least a bachelor’s degree or higher in nursing. Also, most of the participants worked on a full-time basis.
According to the study, most nurses reported that they had cared for over 17 patients on their latest shift. Also, about 40 percent of the nurses who were interviewed worked in health facilities that had favorable nursing practice environments while only about 23.2 percent worked in healthcare facilities that had poor or deplorable nursing practice environment. Additionally, the study revealed a positive relationship between high nurse overload and patient undesirable events. For instance, the study established that an increase of one patient per nurse was linked with a 1 percent rise in the probability of administering the wrong dose or medication, a 2 percent rise in falls with injury and a 1 percent rise in pressure ulcer. On the contrary, nurses in hospitals with good nurse work environments reported relatively lower rates of dose or medication error, fewer falls with injury, and fewer pressure ulcer.
Flyn et al. (2012) study uses a non-experimental design to investigate the relationship between the nursing practice environment, the level of staffing of nurses, the error interception practices of nurses, and non-intercepted medication error rates in acute care hospitals. The study was carried out in a sample of 82 medical surgical units selected from 14 U.S. acute care hospitals. Additionally, a sample of 686 staff nurses was chosen after all registered nurses in the 82 units were surveyed. The study was carried out for eight months and the data collected comprised of the number of medication errors for every 1,000 patient days, as well as the number of hours per patient day done by the registered nurses. According to the study, the practices that nurses use to identify and intercept errors have a considerable impact on the rate of errors of medication on the medical-surgical units in hospitals that deal with acute care. On a positive note, frequent nurse engagement in interception practices was linked to fewer medication errors per 1,000 patient days.
On the contrary, the study established that there was no prominent relationship between registered nurse staffing levels and medication errors. Flyn et al. (2012) contend that one possible reason is that using registered nurse hours per patient day as a way of measuring staffing is recorded and reported by the informatics systems of hospitals. The measure, therefore, may portray total paid hours and not productive hours hence may be an inaccurate measurement of staffing. The findings of this study are in tandem with other literature which contend that a supportive practice environment is related to higher quality of nursing care (Ball et al. 2013). Errors associated with medication are expensive to both hospitals and patients but when provided with the necessary assistance, nurses can use practices which help to interrupt those errors before reaching the patient.
Another important literature review is a study carried out by Kirwan, Mathews, and Scott (2013) dubbed “The impact of the work environment of nurses on patient safety outcomes.” It is important to note that the research was a cross-sectional quantitative study carried out in Ireland. The objective of the study was to investigate the relationship between the environment of the ward within which the nurses work and the patient safety outcomes using the nurse and ward level variables. The nurses involved in the study were those in direct contact with patients in the study wards and consequently, data from 1397 nurses was used to carry out the analysis. In the methodology, the survey was conducted using a questionnaire that incorporated the Practice Environment Scale of the Nursing Work Index (PES-NWI).
In the Kirwan, Mathews and Scott (2013) study, it was established that the nurse work environment is associated with their adverse event reporting rates. To go into specifics, the study found out that a positive work environment leads to higher levels reporting of adverse events by nurses. Furthermore, the researchers reveal that most of the time nurses fear to report adverse events because they think that managers will punish them. Using a report from the Department of Health and Human Services in the USA that investigates 195 hospitals, the researchers suggest that 86 percent of undesirable events that happen to patients are not reported. However, reporting of adverse events does not indicate that the events will not occur again but only indicates a move away from under reporting, which is a limitation of the safety of patients. Increased reporting by nurses is seen as a demonstration of better understanding of the system approach to safety, willingness to facilitate organizational learning, and an open way of investigating incidents.
Bogaert et al. (2013) study, “The relationship between nurse practice environment, nurse work characteristics, burnout and job outcome and quality of nursing care” is another equally important study. This study also used a cross-sectional approach and was conducted in Belgium. The survey was carried out in two hospitals in the Dutch speaking region of Belgium and one hospital in the French speaking region of Belgium. The participants in the study were professional nurses that were registered and involved in direct care and worked in surgical, medical, intensive care units, adult or pediatric care units, and operating theatres. The questionnaires of the respondents were screened for incomplete responses. Questionnaires totaling up to 1201 from 116 nursing units were incorporated in the final sample for analysis.
In the findings of the study, the independent variable of the nurse practice environment had an impact on the mediating variables of burnout dimensions and job outcomes such as satisfaction of the job, intention to stay at the health facility, intention to continue practicing the nursing profession, and assessment of quality of care at the unit. Additionally, decision latitude, workload, and social capital were found to have a relationship between the nurse practice environment and the dimensions of burnout. The relationship between the nurse and the physician, as well as with the hospital management had an impact on the nurse management at the unit level. Consequently, the management of nurses at the ward level affected the manner in which they carried out their duties. More specifically, hospital management or organizational support affected personal accomplishment of the nurses directly. On the contrary, the relationship between the nurse and the physician had an indirect impact on the outcomes through decision latitude.
The last study is that of Stimpfel and Aiken (2013) which investigates the relationship between the length of nurses’ shifts with the safety and quality of care. The study used an approach of secondary analysis that incorporated observational, administrative hospital data and cross-sectional nurse survey data. The nurse survey questioned the nurses who participated on the length of their shifts, scheduling characteristics, demographics, characteristics of the work environment, work break patterns, and the way they perceived quality of care and safety within their particular hospitals. The sample that was analyzed involved 22,275 hospital staff registered nurses from 577 nonfederal hospitals that dealt with acute care in four states. The four states included California, Pennsylvania, New Jersey, and Florida. On average, 39 nurses in every hospital responded in the study. That nurses that were incorporated in the study reported that they worked between 1 and 24 hours on their last shift and took care of 1 to 19 patients from various inpatient medical-surgical units. It is also important to note that only direct care nurses were involved in the study.
According to the study, there was poor quality of care, as well as a poor safety grade in nurses who worked for 10 hours or longer in comparison with nurses who worked for 8 to 9 hours. Although a significant number of nurses reported that they were satisfied with the long working shifts, the study found out that the quality of care and safety was often compromised. The study also found out that most nurses are less likely to take a break during their work shift. Consequently, the lack of a break was found to have a significant impact on the quality and safety of the patients. For instance, the researchers noted that nurses who took longer breaks had a 10 percent decrease in the probability of making errors.
Strengths of the Studies
To begin with the Hutchinson & Jackson (2013) study, the review of papers that were published between 1990 and 2011 is a sufficient time-frame for a conclusive study. Perhaps the other important aspect of the duration of the study is that it compares the nurse work environment of the 20 th century and the 21 st century. Individuals can establish whether there has been any significant improvement in the work environment from the 20 th century to the 21 st century. Concerning Chong et al. (2015) study, the nurses that were involved in the study had a mean age of approximately 28 years. These are relatively young nurses and their responses are important to establish whether the working environment facilitates fast adaptation to their new careers or not.
Flyn et al. (2012) study uses a sample of 14 US acute care hospitals which is a satisfactory sample of providing a better view of the nurse environment. The strength of Kirwan, Mathews & Scott (2013) study is that it simplifies the quantitative analysis into presents it into a descriptive language that is easy to understand. Bogaert et al. (2013) study emphasized on involving only professional nurses in the survey. The other studies did not see such a factor as being important. Professional nurses attach a lot of commitment to their career more than those who are unregistered. That means that they depend on the nursing career for their income and most probably do not have any peripheral activities. Therefore, their responses have a higher level of reliability and consistency. Lastly, the Stimpfel & Aiken (2013) study used secondary analysis techniques such as observation to find out how the nurses worked in their environment. Such techniques are important to verify and ascertain whether the responses provided by the nurses are accurate. From this analysis, the study conducted by Hutchinson & Jackson (2013) and that conducted by Stimpfel & Aiken (2013) seem to be stronger than the others.
Contradictory Methodologies and Findings
Most of the studies with the exception of Hutchinson & Jackson (2013) study use questionnaires to get data from the respondents. The demerit of using such methodology is that respondents tend to give positive responses rather than stating the truth. Looking at a study such as the one conducted by Bogaert et al. (2013), the objective was to investigate the impact of the nurse work environment to the burnout of nurses. However, Bogaert et al. (2013) carry out a quantitative analysis but do not provide significant quantitative data. Instead, the researchers decide to analyze the data using a descriptive format. Bogaert et al. (2013) could have used secondary sources to investigate their topic.
Additionally, some of the samples stated in some studies are unrealistic. For instance, Stimpfel & Aiken (2013) state that their survey involved a sample of 22,275 registered nurses taken from 577 hospitals. The sample is too high and it is uncertain whether the researchers analyzed all the responses provided by the respondents. The most prominent reason that would make one doubt are the logistics involved. One, the research would require many people to administer the questionnaires. Two, the costs involved in moving across four states in the US are too high. It is unlikely that individual researchers can analyze such a huge sample spread over a large geographical area without external intervention.
Conclusion
According to the studies provided, the nurse environment has an impact on the quality care of the patients. A positive environment makes the nurses to attend to the patients as desired. One of the studies that supports this assertion if that of Hutchinson and Jackson’s (2013). It is qualitative and relies on publications sampled from 1990 to 2011. Most studies analyzed in the literature review allude that increased workload among the nurses reduces their output. Most of the nurses in the various hospitals where the studies are carried out may report that they are satisfied with their work for fear of retribution. However, their responses may not be in tandem with the actual situations in the healthcare facilities. Seemingly, the only exception seems to be in the emergency departments in the US because the nurses who are employed are often older and experienced. As such, they may be more concerned about their career development than the younger nurses.
Nevertheless, there is more need for stakeholders in the healthcare industry, particularly those under the nursing department to publish more books that concern nurses. A lot of information of information that concern the nurses is found in sources that present a challenge in regard to verification and reliability. Additionally, most of the studies that are available aim at guiding the nurses on how to carry themselves out when performing various duties but relatively few studies try to investigate their work environment. Most prominently, a significant number of studies interpret the work environment of the nurses to mean their level of staffing and the number of work hours provide, ignoring that other professionals such as doctors and physicians constitute the nurse work environment.
Concerning the literature gaps that exist in the literature review, there are relatively few qualitative studies. Additionally, no studies conduct a survey of the patients to investigate their experiences in various hospitals. Since it is the patients who receive the services of the nurses, studies that seek to present their responses are a good way of demonstrating feedback. Analysis of nurses only while other people also influence their work environment risks providing studies that are biased.
References
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