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Cracking the Code for Quality

The Interrelationships of Culture, Nurse Demographics, Advocacy, and Patient Outcomes

DiCuccio, Margaret Hardt PhD, RN, NEA-BC; Colbert, Alison M. PhD, RN, PHCNS-BC, FAAN; Triolo, Pamela Klauer PhD, RN, FAAN; Schreiber, James B. PhD; Dean, Bonnie PhD, RN

Author Information
JONA: The Journal of Nursing Administration: March 2020 - Volume 50 - Issue 3 - p 152-158
doi: 10.1097/NNA.0000000000000859


Although it has been nearly 30 years since Leape's1 landmark study reported that two-thirds of mistakes in hospitals were preventable, hospitals still lag behind other industries in discovering the complex formula for quality. A recent, albeit controversial, study reported that medical errors should rank as the third leading cause of death in the United States and posits that tracking vital statistics may hinder research, minimize the problem, and keep the issue hidden from the public eye.2

When the Institute of Medicine (IOM) released the 1st report on the state of quality in 1999, it was a call to action. The IOM got the attention of those in the “C-suite” by citing the lack of administrative focus on a culture of safety as 1 of the primary reasons for poor quality found in systemic hospital-acquired conditions (HACs). The IOM rapidly followed with more reports, called the “Quality Chasm Series,” which sent shock waves through healthcare. Numerous studies have reported the progress, or lack thereof, of these issues and recommendations.3 The Agency for Healthcare Research and Quality followed by providing education and research tools to assist healthcare entities to assess their safety culture and to correct cultural issues that lead to poor patient outcomes.4

While attention to patient safety has greatly increased since the IOM reports, nurse-sensitive HACs continue to occur at unacceptable rates.5,6 Because the nurse is the pivotal practitioner on the frontline of care, constantly interacting with the patient and the healthcare team, serving as translator and advocate, this role has the greatest potential to improve quality and patient safety. The negative ramifications of substandard care are a public health crisis, affecting both patients and families and contributing to the rising costs of healthcare.

Patient advocacy has been defined as “the act or process of pleading for, supporting, or recommending a course of action.”7(p41) After years of focus on creating a culture of safety with limited success, the role of nursing advocacy is not clear. The purpose of this study was to examine safety culture, advocacy, nurse demographic characteristics, and nurse-sensitive patient outcomes to determine if relationships existed that could provide insight into this issue.


The multifactorial nature of patient safety demands research and inquiry from various perspectives to identify effective interventions. Symphonology, the theoretical foundation of this research, is a bioethical framework that considers both the context of the organizational culture and the individual's choice to advocate as an ethical decision.8 Such an approach is supported by the American Nurses Association's inclusion of advocacy in the Nursing Code of Ethics as a primary nursing function.7 Research has validated advocacy as an ethical construct within the nurse-patient relationship.9-11 Husted et al,8 the authors of symphonology, determined that the core of the ethical process hinged on the formation of agreements. Husted et al derived 6 bioethical standards that were important to consider in the ethical decision-making process: autonomy, freedom, self-assertion, objectivity, beneficence, and fidelity. Agreement and the use of the standards occur within the overall context of knowledge, awareness, and the situation (Figure 1).

Figure 1
Figure 1:
Husted ethical decision making model.

Patient care does not occur in isolation, and cultural norms and other influences affect the nurse's conscious or subconscious decision to choose to act on behalf of the patient.9,10 Although nurses graduate with knowledge of the accountability to advocate,7 as they assimilate into the culture of the practice environment, they adopt the decision-making processes and values of the organization and their colleague senior nurses.12 The Husted model provides a theoretical basis for understanding the complex interaction between nurse decision making (to advocate) and culture of practice.

A summary of the literature is detailed in Supplemental Digital Content 1 ( The review demonstrates that as the culture of safety evolved, nurse-sensitive outcomes, specifically patient experience, hospital-acquired pressure ulcers (HAPUs), and incidence of falls, improved.6,13-15 However, while the literature suggests that safety culture and patient outcomes are correlated, the potential role of patient advocacy was not clear.9-11 The published work has focused on the experience that nurses had when advocating for patients, the cultural and organizational impediments to advocacy, and the nurse's perception of the impact to patient outcomes. The advocacy and culture studies indicate a connection between the organizational culture and other care providers that act as gatekeepers, influencing the nurse's desire and ability to satisfactorily advocate for the patient. The conceptual framework, developed by the researchers) for this study, is illustrated in Figure 2.

Figure 2
Figure 2:
Conceptual framework schematic.


To answer the research questions (Table 1), this retrospective correlational cross-sectional–designed study utilized a subset of data previously collected by the health system in December 2015 and January 2016 to assess the safety culture. The parent study surveyed 12 047 health system employees; 4199 (35%) completed the patient safety culture survey, whereas the advocacy survey was completed only by RNs. The secondary data analysis was conducted in 2017 using a subsample of 1045 staff RNs who practiced on 40 medical/surgical or telemetry units throughout 7 hospitals in the system. Institutional review board approval, exempt status, was obtained for the study from Duquesne University and the health network.

Table 1
Table 1:
Research Questions

The measurement tools are outlined in Table 2. The choice of nurse-sensitive patient outcome variables was determined following a literature review of research on patient safety culture and patient outcomes. The variables of patient experience, HAPUs, and falls were selected because of significance in past studies including medical/surgical unit populations.6

Table 2
Table 2:
Measurement Methods


Units with a 20% or greater response rate were included in the study. The final sample consisted of 23 medical/surgical units and 211 nurses from 7 hospitals. Listwise deletion was used for the 34 study participants with missing data on the advocacy survey. α was set at the traditional P ≤ .05. IBM SPSS (version 24.0, Armonk, NY) was used to perform the statistical analysis. The relationship between safety culture and advocacy was tested using a Pearson correlation. Descriptive statistics for participant demographics were expressed in percentages and means. The relationships between the demographic characteristics, safety culture, and advocacy were tested using a 1-by-1 best-case-scenario multiple-regression approach. Specifically, each demographic variable of interest, level of education, hospital unit, hospital, employment length in unit, employment length in hospital, and length of time as an RN, was examined independently with advocacy scores as the outcome variable. Four exploratory multiple regression models were run to test the relationship between perceptions of safety culture, advocacy, and the patient outcomes.


Descriptive Statistics

Most study participants were female and worked in the hospital and their unit for 5 years or less, and their highest level of education was an associate degree (Table 3). The mean of the 211 completed safety culture scale was 20.67 (SD, 9.88). The mean of the 177 completed advocacy scales was 88.94 (SD, 12.59), with scores ranging between 17 and 102. The means of the 5 patient outcomes variables were as follows: nurse communication 76.0% (4.2), call light response 59.8% (7.1), pain management 66.1% (5.3), fall rate 3.5 (1.3), and HAPU rate 1.2 (0.8).

Table 3
Table 3:
Demographic Characteristics

Perceptions of Safety Culture and Advocacy

To examine the relationship between safety culture and advocacy, 2 bivariate Pearson correlations were run between the composite of the 42-item safety culture scores and both a composite of the advocacy scores and the log transformation of the composite of advocacy scores. The composites were used because a principal component analysis with oblique rotation indicated 1 component for each survey data set. The log transformation was conducted because the distribution was skewed to the high end of the advocacy scale. The raw Pearson correlation was r = 0.33 and r = 0.29 after the log transformation, a statistically significant finding. Following the log transformation, higher scores on the advocacy scale indicated lower advocacy values. The correlation between the 2 was small to moderate, with approximately 9% shared variance. The correlations between advocacy and the total safety culture score and the 12 subscales are provided in Table 4.

Table 4
Table 4:
Correlations of PSC With APAS

Relationships Among Nurse Demographic Characteristics, Safety Culture, and Advocacy

A 1-by-1 best-case-scenario approach using 1-way analysis of variance was used to examine the relationships among nurse demographic characteristics, safety culture, and advocacy. Education level, a categorical variable, did not vary statistically significantly by advocacy scores (F3,170 = 2.24, P = .09). Lengths of tenure in the unit, in the hospital, and as a nurse were statistically significantly associated with advocacy scores (F5,171 = 2.26, P = .05; F5,171 = 2.69, P = .02; F5,168 = 2.83, P = .02, respectively), which indicated that longer tenure was associated with lower advocacy scores. Based on those results, using multiple linear regression model, safety culture scores, tenure in the hospital, and tenure as a nurse as independent variables and log of the advocacy scores as the outcome variable were examined and found to be statistically significant at the P ≤ .025 level (Table 5). For every unit increase in the safety culture score, there was a −0.23 drop in the advocacy scores. For every 1-unit increase in length as an RN (a 1 category move), there was a 0.18 increase in the advocacy scores, indicating length of time as a nurse was predictive of a less positive attitude toward patient advocacy.

Table 5
Table 5:
ABP, PSC, and Years of Tenure

Relationships Among Perceptions of Safety Culture, Attitudes Toward Advocacy, and Patient Outcomes

Four exploratory multiple regression models were run with safety culture and advocacy as the predictor variables and a nurse-sensitive patient outcome as the outcome. Each analysis included 1 of the outcome variables (nurse communication, call light response, pain management, falls, or HAPUs), as well as patient safety and advocacy. None yielded statistically significant results.


This study was one of the 1st to examine the relationships between and among safety culture, advocacy, and patient outcomes. While a positive relationship was found between safety culture and advocacy, a more noteworthy relationship was found between the tenure of the nurse and the nurse's perception of both safety culture and advocacy. As the nurse's tenure increased, the perception of both safety culture and advocacy appeared to erode. Although the relationship between safety culture and advocacy was significant, the results including patient outcomes were not significant, contrary to the published literature.6,13-15

The correlation between patient safety culture and the nurse's attitude toward advocacy indicated that there was a positive relationship between the context of the nurse's work environment, the safety culture, and their attitudes toward advocacy, which was consistent with the conceptual framework. The results of this study were consistent with research studies that have linked advocacy and culture.9,11

In this study, moderate negative correlations were found between safety culture and tenure of the nurse as well as advocacy and tenure as a nurse. This finding was unexpected; therefore, a review of the literature was conducted to relate the findings within what is already known. Although no studies were found directly linking these specific concepts (culture, advocacy, and tenure of the nurse), there have been studies in the work environment satisfaction literature comparing the experience level of the nurse and satisfaction with the work environment.21-23 When considering the current study within the context of the available literature on senior medical/surgical nurses and medical/surgical nursing in general, the results are more understandable. The key contributor found in the literature was the additional workload pressure faced by senior medical/surgical nurses that led to patient safety concerns. A nurse's perceived ability to deliver high-quality care has been found to be directly related to workload, staffing, and the nurse-to-patient ratio.15,24-26 Research has shown that high-quality care is perceived as more important by senior nurses, and therefore, these nurses place a higher emphasis on quality of care than younger nurses.21,22 It has been reported that more senior nurses reported quality-of-care issues related to workload pressure as they cared for patients while serving as a resource to younger nurses.21 In addition, 60.7% of the nurses had 5 or fewer years of experience in the current study. This ratio would place senior medical/surgical nurses in an adverse situation, as noted in the literature, where they are often charge nurses responsible for the overall quality of patient care provided by their less experienced colleagues while also caring for their own patients.21

The nonsignificant results among patient safety culture, advocacy, and patient outcomes were not anticipated, as previous studies had reported significant results in the medical/surgical patient population related to patient safety culture.5,6,15 The lack of variation in unit falls, HAPUs, and patient experience data might have explained the nonsignificant results between patient safety culture, attitude toward advocacy, and patient outcomes. The study inclusion criteria of units that had 20% or greater respondents to the safety culture survey could also have contributed to the nonsignificant results because smaller units were included that had only a few respondents. Therefore, the study could be underpowered for the unit-level analysis of patient outcomes.

The nonsignificant results in the comparison between education level, safety culture, advocacy, and patient outcomes were also not expected, as previous studies reported significant results related to education level and patient outcomes.26,27 One study compared the nurse's perception of the nursing work environment (nurse perceptions of manager, unit, and peer support) with the educational preparation of the nurse.23 The results indicated that nurses with more than 15 years of experience and prepared at the baccalaureate level had statistically significantly greater nurse satisfaction and perceived greater support than did their colleagues who were prepared at the associate-degree level. In the current study, the majority of nurses were prepared at the associate- and diploma-degree levels, which may explain why tenured nurses perceived less teamwork and support in the work environment than younger nurses.


Units with 20% or greater participation were included in the study, meaning smaller units could have had a low number of participants, which could have influenced the nonsignificant findings between safety culture, advocacy, and the patient outcomes included in the study. The nesting effect of the data (nurses within units) resulted in the data being used at multiple levels, which could have an impact on the power of the study. This study is limited in generalizability due to the use of a convenience sample within 1 hospital system in 1 area of the United States. Nurses in this study also self-reported their perception of safety culture and advocacy, which can be influenced by many factors outside the variables under study. The higher than national average associate degree in nursing response rate could also be a limitation.

Implications for Nurse Executives

This research has implications for nurse leader practice and future inquiry. As nurse leaders, it is imperative that within our practice we not only educate our teams and colleagues on the critical advocacy role of the nurse and the prevention of negative patient consequences, but also reinforce and reward advocacy in performance management and career ladders. The correlation between safety culture and advocacy provides a starting point for a conversation among nursing and medical staff leadership. Providers count on nurses to keep their patients safe; however, they may not understand their own role in creating a positive culture in which nurses can freely advocate. Nurse leaders are in the position to improve the safety culture of all units, and in specific medical/surgical units, by enabling and expecting all staff to practice advocacy.

Finally, the results of this research indicate that several opportunities exist for additional inquiry particularly in the relationship between safety culture and advocacy, safety culture and nurse tenure, and safety culture and patient outcomes. Further investigation of the relationship between safety culture and advocacy in critical care and perioperative departments is warranted as these clinical areas care for some of the most vulnerable. Interventional research related to strategies to improve safety culture and the work environment for medical/surgical nurses and the associated financial and clinical outcomes achieved would benefit nurses and the organizations in which they practice. Additional research is needed to better understand the complex relationship between the safety culture, advocacy, and the patient outcomes achieved.


To Gladys Husted, who shaped my perspective. MHD


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