¶ … Environment Affects Nurses Over and again, literature reviews show the consistent relationship and association between nurse working environment and patient outcome as well as superior nurse performance (Aiken et al., 1999; Aiken et al., 1994; Lake, 2004). Better environments result in better nurse care as this case model shows. The case model was based on the study popularized in our institution that was directed by Aiken et al. (2008) who sought to examine whether better hospital nurse care environments were associated with lower patient mortality and better nurse outcomes irrespective of nurse education and the quality and quantity of nurse staffing.

In 1999, the researchers had sampled 168 hospitals, which was 80% of the 210 adult acute care hospital in Pennsylvania in 1999. 60 nurses from each hospital completed the survey, with half of the hospitals having more than 50 nurses who responded. Other nurses who worked outside the hospitals also received surveys and altogether 40,000 nurses both in and out of medical institutions completed the questionnaires. The measures used were the 1999 American Hospital Association Annual Survey and the 1999 Pennsylvania Department of Health Hospital Survey which provided data on medical environment that were to be used as control variables.

The measure of the patient care environment itself was based on the PES-NWI. According to results were hospitals categorized as having "better," "mixed," or "poor" care environments.

The nurse job outcomes and their quality of care was then assessed by six survey measures that rated variables such as their job satisfaction, burnout, and intention to leave their job within the next year. Three additional questions asked nurses about their perception on their quality of care. Nurse burnout was assessed using the 9-item emotional exhaustion scale of the Masslach Burnout inventory. This is a widely standardized tool. Researchers used the Cronbach assessment to gauge outcome and set their scores o f 27 or above to indicate high burnout.

In addiction to the Maslach measure, the researchers also focused on whether patient mortality could be traced to environment and the patients' deaths within the last 30 days were analyzed. This, however, goes beyond the topic of our essay. Wanting to gauge the results of nurses environment on nursing practice, we focused on results of Aiken et al.'s (2008) study, whether, in other words, the medical environment significantly impacted or had no significant impact on nurse practical behavior.

In Aiken et al.'s study, 43 (26%) of the hospital were shown to have poor environment. This meant that the nurses were working in stressful, disorderly, disorganized, noisy, and constantly changing environments (amongst toehr negative variables). 83 (49%) of the hospitals studied were in a mixed category, and 42 ranked in top quality (this meant that they were organized, calm, quiet, and demonstrated a friendly orderly atmosphere amongst other positive qualities). Interestingly enough, Aiken et al. (2008) discovered that the highest percentage of nurse burnout and turnover occurred in hospitals with poor care environments where there was also reported dissatisfaction with their jobs. The percentage of nurses who reported that their quality of performance was poor or fair (and assessment amongst patients ratified this) was twice as high in hospitals with lower and poor environment than with hospital with superb environment. It was also observed that nurses who worked in poor environments had less confidence in their abilities to succeed and perform optimum work and also indicated less confidence in the ability of management to deal with the hospital problems. This was likely due to the disorganization of the general environment. These same nurses working in the poor environment distrusted management's ability to resolve patient problems and also were skeptical of patient ability to function independently once discharged. Apparently, poor organizational patterns promoted a discouraging effect throughout the ward leaving nurses to wonder whether the disorganization extended from environment to the managers' ability to cope and to adequately perform...

As a peripheral observation, nurses working in these hospitals refrained from recommending treatment of these hospitals to friends or family members who needed treatment, whilst nurses working in better hospital environments usually rated the care of their hospitals more highly to others. More so, it was discovered that above all conditions sampled (e.g., long hours, nurse staffing, pay etc.) it was primarily the environment that caused nurse burnout and resolve to leave. This sounds questionable to me, but after observing it in terms of my colleagues, I see how environment (and I would add temperature conditions too as well as aestheticism) hugely impacts out performance. Finally, the rate of nurses who reported concern on patient care was about 42% to 69% higher in poor environment hospitals than in those that had a better care environment.
As an aside, but to reinforce the importance of quality environment on nursing, the rate of patients dying in hospitals with poor care environments within 30 days of admission as 14% higher than the same rate dying within 30 days of admission in better care environments. This may have been due to the negative variables of the environments such as constant change, sterility, inadequate heart, stress, disorganization, and so forth (as, for instance, Shen and Qin (2010) have discovered that unfamiliar and disorganized hospital or nursing environment can encourage fatal falls) or it may have been generated by poor nursing performance that was instigated by these negative conditions. The nurses may have treated the patients in poor fashion due to induced stress and conflict that were environmentally induced. To an extreme, patient death may even have been accidentally caused due to some outcome of the negative environment such as patient slipping on floor, pills being misplaced or mislabeled, or some other casualty of medical disorganization. Again, the determinants of patient mortality may have been a configuration of both factors: nurse impacted by environment and patient affected by it. Nonetheless, nurse performance is strongly affected by the environment and the nurse's attitude in turn has huge repercussions on patient outcome.

The authors concluded that:

if all hospitals had better care environments, a 4:1 patient-to-nurse ratio, and 60% BSN-prepared staff nurses, the overall mortality rate would have been 15.6 per 1,000 admissions, and the failure-to-rescue rate would be 68.2 per 1,000. Under the worst case scenario (a poor care environment, 8:1 patient-to-nurse ratio, and 20% BSN-prepared staff nurses), the mortality rate would have been 25.1 per 1,000 admissions, and the failure-to-rescue rate would be 105.9 per 1,000. All else being equal, hospitals that ranked poorly on all 3 factors had mortality rates and failure-to-rescue rates that were 61% and 55% higher, respectively, than hospitals that ranked high on all 3. (p.28)

In short, it seems as though a calculated approximation of 40,000 deaths could be prevented per year in hospitals if hospital environments were to be improved.

In our hospital based upon this research and similar research, we implement the guidance outlines printed by the American Burses Credentialing Center Magnet ordinances that reach for certain improvements in practice environments (Aiken et al., 2005). Apparently many hospitals that inculcate and incorporate the guidelines of the magnet system (they are often called "magnet hospitals") show better nurse and patient outcomes. Aiken et al.'s (2008) study as case study indicates the same results too.

In our hospital, we strive, according to the Magnet principles, to implement a positive environment. We find that the underlying principles of the Magnet system are excellent enabling us to feel better about ourselves and building up our confidence and, by finding our stuff, raising the quality of our work with patients. The improvement in the work environment has, by the way -- and I am convinced of this -- also succeeded in attracting a better caliber of nurses who choose to work for us rather than work elsewhere. Whether it is the pay that attracts them or the quiet and peace of the ward that leads to less…