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Work environment factors other than staffing associated with nurses’ ratings of patient care quality

Djukic, Maja; Kovner, Christine T.; Brewer, Carol S.; Fatehi, Farida K.; Cline, Daniel D.

doi: 10.1097/HMR.0b013e3182388cc3

Background: The impact of registered nurse (RN) staffing on patient care quality has been extensively studied. Identifying additional modifiable work environment factors linked to patient care quality is critical as the projected shortage of approximately 250,000 RNs over the next 15 years will limit institutions’ ability to rely on RN staffing alone to ensure high-quality care.

Purpose: We examined the association between RNs’ ratings of patient care quality and several novel work environment factors adjusting for the effects of two staffing variables: reported patient-to-RN ratios and ratings of staffing adequacy.

Methodology: We used a cross-sectional, correlational design and a mailed survey to collect data in 2009 from a national sample of RNs (n = 1,439) in the United States. A multivariate logistic regression was used to analyze the data.

Findings: Workgroup cohesion, nurse–physician relations, procedural justice, organizational constraints, and physical work environment were associated with RNs’ ratings of quality, adjusting for staffing. Furthermore, employment in a Magnet hospital and job satisfaction were positively related to ratings of quality, whereas supervisory support was not.

Practice Implications: Our evidence demonstrates the importance of considering RN work environment factors other than staffing when planning improvements in patient care quality. Health care managers can use the results of our study to strategically allocate resources toward work environment factors that have the potential to improve quality of care.

Maja Djukic, PhD, RN, is Assistant Professor, College of Nursing, New York University, New York. E-mail:

Christine Kovner, PhD, RN, is Professor, College of Nursing, New York University, New York. E-mail:

Carol S. Brewer, PhD, RN, is Professor, School of Nursing, University at Buffalo, New York. E-mail:

Farida K. Fatehi, MS, is Junior Research Analyst, College of Dentistry, New York University, New York. E-mail:

Daniel Cline, MSN, RN, CRNP, is PhD Candidate and John A. Hartford Foundation BAGNC Scholar 2010–2012, College of Nursing, New York University, New York. E-mail:

This work was supported by the Robert Wood Johnson Foundation. Permission to conduct the study was granted by the New York University and the University at Buffalo Institutional Review Boards.

This paper was presented on April 2011 at the American Association of Nurse Executives 44th Annual Meeting and Exposition Meeting in San Diego, California.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

© 2013 Lippincott Williams & Wilkins, Inc.