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Association of Nurse Engagement and Nurse Staffing on Patient Safety

Brooks Carthon, J. Margo, PhD, APRN, FAAN; Hatfield, Linda, PhD, RN, NNP-BC; Plover, Colin, MSN, RN, MPH; Dierkes, Andrew, BSN, RN; Davis, Lawrence, BSN, RN; Hedgeland, Taylor, BSN, RN; Sanders, Anne Marie, BSN, RN; Visco, Frank, BSN, RN, RN-BC; Holland, Sara, DNP, RN; Ballinghoff, Jim, MSN, MBA, RN, NEA-BC; Del Guidice, Mary, MSN, RN, CENP; Aiken, Linda H., PhD, RN, FAAN, FRCN

doi: 10.1097/NCQ.0000000000000334
Original Article: PDF Only

Background: Nurse engagement is a modifiable element of the work environment and has shown promise as a potential safety intervention.

Purpose: Our study examined the relationship between the level of engagement, staffing, and assessments of patient safety among nurses working in hospital settings.

Methods: A secondary analysis of linked cross-sectional data was conducted using survey data of 26 960 nurses across 599 hospitals in 4 states. Logistic regression models were used to examine the association between nurse engagement, staffing, and nurse assessments of patient safety.

Results: Thirty-two percent of nurses gave their hospital a poor or failing patient safety grade. In 25% of hospitals, nurses fell in the least or only somewhat engaged categories. A 1-unit increase in engagement lowered the odds of an unfavorable safety grade by 29% (P < .001). Hospitals where nurses reported higher levels of engagement were 19% (P < .001) less likely to report that mistakes were held against them. Nurses in poorly staffed hospitals were 6% more likely to report that important information about patients “fell through the cracks” when transferring patients across units (P < .001).

Conclusions: Interventions to improve nurse engagement and adequate staffing serve as strategies to improve patient safety.

Center for Health Outcomes and Policy Research, and School of Nursing, University of Pennsylvania, Philadelphia (Drs Brooks Carthon, Hatfield and Aiken and Messrs Dierkes and Plover); Pennsylvania Hospital, Philadelphia (Dr Hatfield, Mss Sanders and Del Guidice and Mr Visco); and Penn Presbyterian Medical Center, Philadelphia, Pennsylvania (Dr Holland, Messrs Davis and Ballinghoff, and Ms Hedgeland).

Correspondence: J. Margo Brooks Carthon, PhD, APRN, FAAN, Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia PA 19104 (

This research was supported by the National Institute of Nursing Research (NR14855-NR04513, T32-NR0714; L. Aiken, Principal Investigator).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Accepted for publication: February 12, 2018

Published ahead of print: June 8, 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved