It's a given that unit-level workplace culture influences patient care, but research is lacking on how culture connects with nursing-sensitive patient outcomes.1,2 Previous studies suggest that better patient outcomes are influenced by positive characteristics of the work environment and adequate staffing.3-6 The most studied patient outcomes are pressure injuries, falls, patient satisfaction, healthcare-associated infections, medical errors, mortality, and failure-to-rescue.7-9 Adverse outcomes not only increase the cost of care, but also inflict unnecessary harm to patients and relatives.10
The term workplace culture is defined as the unit-level culture that patients and staff experience every day.1 Nursing-sensitive outcomes are “those that are relevant, based on nurses' scope and domain of practice, and for which there is empirical evidence linking nursing inputs and interventions to the outcomes.”11 This study aims to investigate the connections between workplace culture and nursing-sensitive patient outcomes—specifically, those related to self-care, patient-centered care, complications, and adverse events.
There are countless ways to approach patient outcomes. They can be examined, for example, through desired outcomes such as self-care or patient-centered care. Another way to view these outcomes is to observe undesirable outcomes, such as complications and adverse events.
Self-care plays an important role in promoting recovery and the prevention of complications after hospitalization.12 Earlier research indicated that patient-centered care improves outcomes.13,14
Various studies find that an increase in staffing levels decreases the risk of healthcare-associated complications, and that lower levels of nursing care are linked to pressure injuries, medication errors, and patient falls.15-18 One study found that unit characteristics were associated with adverse events; nurses' perceptions of autonomy and collaboration were linked with high rates of pressure injuries, whereas a better level of nurse managerial support was related to lower rates of pressure injuries.10 Low levels of patient falls have been associated with moderate turnover rates in units and also with RN workgroup job satisfaction, RN skill mix, and RN unit tenure.19,20
Hospital care exposes patients to adverse events, such as medication errors, infections, and falls.21 These undesirable patient outcomes are often related to organizational characteristics.22-24 To be able to reduce the number of adverse events, it's necessary to understand organizational behavior, especially because most adverse events are considered preventable.21,25 Still, underreporting of adverse events is a well-recognized problem in healthcare, and an earlier U.S. study indicated that voluntary reporting or other commonly used methods fail to detect 90% of these incidents.25,26
Very little is known about the influence of workplace culture on patient outcomes. Previous studies have mostly focused on the influence of staffing levels, working environment, and skill mix.27,28 This study looks to reveal the connection between workplace culture and selected patient outcomes. These include patients' perceptions of care (self-care and patient-centered care) and complications such as pressure injuries, deep vein thrombosis, healthcare-associated infections, patient falls, and adverse events. Adverse event questions target medication; information; diagnosis; and operative or invasive procedure; and other treatment or follow-up, such as lab care, devices, asepsis, accidents, emergency care, violence, or deviation in procedures such as radiotherapy.29
Methods and data details
Data collection was carried out between November 2011 and March 2012 using a cross-sectional study design. The setting consisted of 14 inpatient acute care units in seven healthcare centers. Patients were older individuals, ranging from age 50 to 89, and stayed on the units for several weeks.30 (In Finland, primary healthcare is mainly tax-financed and organized by municipalities. The different healthcare specialists—physicians, nurses, dentists, and dental hygienists—provide care mainly in local healthcare centers.) In this study, the data were retrieved by questionnaires completed by patients (n = 53), RNs (n = 65), LPNs (n = 77), and nurse managers (n = 14). In each unit, the data were collected over a 1-month period. After the study month, the researcher returned to the units to collect questionnaires stored in sealed envelopes.
Nurses invited patients discharged during the study month to complete the questionnaire. Patients were informed that participation was strictly voluntary and anonymous. If the patient couldn't respond to the questions, a family member or other significant person was able to assist. Three questionnaires were completed by a family member; in two questionnaires, it wasn't possible to identify who had completed the questionnaire. Nursing personnel weren't allowed to assist patients in completing the questionnaire. Nurse managers also collected patient data from the different databases.
All unit RNs, LPNs, and nurse managers were included in the study, with the intention to gain a general view of the nursing personnel's perceptions of their workplace culture. Casual contract nurses were excluded. Staff members were verbally informed about the study, and their role in distributing the questionnaires to discharged patients who met the inclusion criteria was thoroughly explained. In addition, all participants received detailed written information.
The outcome questionnaire addressed patient background, discharge, and care instruments.31,14 Questions included information regarding unit, gender, age, marital status, education, reason for admission, and patient care experience. Self-care related activity after discharge was measured using a therapeutic self-care discharge instrument, which targeted several activities: taking medications, managing symptoms, performing activities of daily living, and addressing changes in condition.31 These were ranked using a 3-point response scale, with 0 corresponding to Not at all, 1 Somewhat, and 2 Very much. In addition, participants could select N/A Not applicable and U/A Unable to assess. The patient-centered care instrument consisted of 15 items ranked using a 5-point Likert scale, ranging from 1 corresponding to Strongly disagree to 5 corresponding to Strongly agree.
During the study month period, nurse managers were asked to gather patient outcome data (number of incidents) using the instrument developed for this study. To ensure reliability of the collected data, all concepts were discussed with the nurse managers, who also had the opportunity to contact the researcher whenever needed.
Outcome assessment targeted four complications: pressure injuries, deep vein thrombosis, healthcare-associated infections, and patients falls; 14 questions related to adverse events from medication administration; information delivery or documentation; diagnosis; operative or invasive procedures; and issues relating to other treatments or follow-up, such as lab care, devices, asepsis, accidents, emergency care, violence, or deviations in procedures.29
During the same month, nursing personnel assessed their unit workplace culture using the 78-item Nursing Context Index (NCI) questionnaire developed by Slater and McCormack.32 Three overarching factors represented nurses' stress (36 items), job satisfaction (18 items), and practice environment (24 items), comprising 19 constructs. A response rate of 60% was achieved. The hospital district's ethics committee and each of the participating organizations approved the study; all of the instruments were pilot tested before being administered.
Descriptive statistics were used to analyze sociodemographic data. Spearman's correlation, Kruskal-Wallis and Mann-Whitney tests were used to assess the correlation between the 19 constructs of workplace culture and the selected patient outcomes. Workplace culture was assessed using unit means, and selected patient outcomes were assessed at the individual level.
The mean patient age was 70 (range: age 30 to 94), nearly half of whom were older than age 70. Half (50.9%) of the patients were male, and over half (62%) of the participants had completed comprehensive school. Correlation analysis showed some negative associations between a patients' education level and stress, especially regarding workload, work-social life balance, and with the practice environment concerning adequate staffing and resources. (See Table 1.)
The nursing personnel (RNs, LPNs, and nurse managers) who answered the NCI questionnaire to measure the workplace culture represented 14 inpatient acute care units in seven healthcare centers of Finnish primary healthcare. More than half of the 152 participants answering the questionnaire were LPNs (50.7%, n = 77), 42.8% RNs (n = 65), and 6.6% head ward nurses (n = 10). The units per healthcare center ranged from one to five, and the number of participants per unit ranged from 7 to 15. Most of nursing personnel were female (97.9%), and half of them (50.3%) were over age 45. A large majority of the nursing personnel were employed full time in a rotating roster (81.6%, n = 115). The remainder worked part time in a rotating roster (12.8%, n = 18). Nearly all nurse managers (90%, n = 9) who completed the NCI questionnaire were over age 45 and all were female. All nurse managers were employed full time, either on set days (57.1%, n = 8) or in a rotating roster (14.3%, n = 2). Four nurse managers didn't return the NCI questionnaire.
Culture and patient perception of care
Patients weren't certain if the care they received was patient-centered. Some of the items showed rather high variations. The ability to engage in self-care after discharge was assessed as good. The ability to do everyday activities and carry out treatments were given the lowest scores. (See Table 2.)
Nurse stress, especially regarding inadequate preparation, was related to patients' higher perceptions of knowing who to call if they needed help with daily activities after discharge. The practice environment factor relating to a good physician-nurse relationship was linked to a higher prevalence of the patients' perceived capabilities to notice symptoms related to their health, to their knowledge of what medication they had to take, and why it should be taken.
Culture and patient complications
During the study period, 3 pressure injuries, 1 healthcare-associated infection, and 33 falls were documented. No deep vein thromboses were reported. Workplace culture revealed several associations with patient complications related to pressure injuries and patient falls. (See Table 3.) A relationship between the constructs of workplace culture and healthcare-associated infections couldn't be identified.
A higher prevalence of pressure injuries was associated with stress concerning workload, balance of work and social life, career development, and a lack of communication and support. The prevalence of pressure injuries was also related to the practice environment concerning an intention to leave. Satisfaction with pay and prospects, personal satisfaction, and professional satisfaction were associated with a lower prevalence of pressure injuries.
Lower levels of patient falls were linked with higher nurse stress levels from lack of staff support and uncertainty regarding treatments and their work environment. Lower stress levels regarding career development and satisfaction with the physician-nurse relationship and nursing management were linked with a lower prevalence of patient falls.
Culture and patient adverse events
The systematic monitoring system for adverse events was used on 64% of the units, whereas 36% of the units didn't yet use the system. During the study period, the majority of units (86.0%) reported adverse events related to medication. Half of the units (50.0%) reported adverse events related to patient accidents. Almost a third of the units (29%) reported adverse events related to communication and violence. Adverse events related to operative procedures were reported by one unit (two cases), and a device-related adverse event was reported by one unit (one case). No other types of adverse events were documented.
Only one adverse event showed an association with workplace culture. A higher prevalence of adverse events regarding communication was related to lower job satisfaction and, more precisely, to personal dissatisfaction and dissatisfaction toward the practice environment concerning lower organizational commitment. No other constructs of workplace culture were significantly related to adverse events.
The findings of this study demonstrate that workplace culture has some associated correlations with patient outcomes. A few of the constructs of workplace culture were related to a prevalence of complications (especially pressure injuries and patient falls), and likewise with adverse events concerning communication errors. Further, workplace culture impacted patients' self-care concerning their ability to manage after discharge, specifically taking medication, recognizing symptoms, and knowing who to contact if help was needed.
The results indicated that nurses' stress (especially with inadequate preparation to deal with the emotional needs of patients and their families) was related to patients' preparedness to know who to call if they needed help with daily activities after discharge. To avoid unnecessary readmissions, it's important that nurses have sufficient time and are well prepared to meet the psychosocial and emotional needs of the patient. This is in line with earlier research, which suggests that a good working environment and reduced workload of nurses are linked with fewer readmissions.33
The results of this study highlight the importance of a good physician-nurse relationship. Practice environment issues were related to a patient's ability to notice symptoms and their knowledge of what medication to take and why it was prescribed. Experts have suggested that if the relationship with physicians is satisfactory, then patients assess their care more positively, the job satisfaction of nurses is higher, and nurses remain longer in the workplace and the profession.34 Additional research suggests that nurses remain in their profession if the relationship between nurses and physicians is good. The results of this study and previous studies demonstrate that the physician-nurse relationship has an important impact on both patients and staff.35
The results of the significant associations between several constructs of workplace culture and complications are important. A higher number of pressure injuries was linked to stress with workload, an imbalance of work and social life, inadequate opportunities for career development, a lack of communication and support, and intention to leave the job. A lower prevalence of pressure injuries was related to satisfaction with pay and prospects, and with personal and professional satisfaction.
Unexpectedly, nurse stress related to a lack of staff support and uncertainty regarding treatments and their working environment wasn't linked to decreased patient complications such as falls. Lower stress levels relating to career development were linked with a lower prevalence of patient falls, as was satisfaction with practice environment (especially the physician-nurse relationship), empowerment, and nursing management. Previous research has demonstrated the relationship between patients' falls and omitted nursing care, decreased nurse staffing, and a decreased level of RN hours per patient day.36,37
The majority of units reported adverse events related to medication. This is consistent with earlier studies that showed medical errors occur on a daily or weekly basis.38 In our study, 42 medical errors were reported to cause actual harm, and 85 errors presented potential harm to patients. Nearly three quarters of the accidents reported in this study caused either actual harm (22 cases) or potential harm (8 cases). Communication errors were reported as causing potential harm (11 cases) and actual harm (1 case). Violence was reported as a cause of potential harm (8 cases) and actual harm (2 cases). However, it can be assumed that some of the adverse events weren't reported. It's essential that all patient safety issues are reported and addressed. A precondition for this is the presence of a nonpunitive culture that allows for process and system evaluations.
The study design allowed for a simultaneous comparison of patient and workplace culture outcomes. Patient outcomes were gathered directly from patients, and nurse managers also gathered certain patient data from the unit's databases. However, the study has some limitations that should be considered. First, the representativeness of the patient population is questionable in relation to the small number of respondents. The response rate of the patients is unknown because the total number of discharged patients wasn't available.
On the grounds of the pilot study, the number of respondents was expected to be much higher. It's also not known if a patient's condition may have affected his or her ability to engage with the questionnaire, and some of the patients may not have been informed about the study if this was overlooked during the discharge process. Therefore, future studies should be conducted with larger samples.
Second, nurse managers completed a self-administered questionnaire to assess the unit's patient outcomes. Standardized and valid patient outcome data weren't available in all of the facilities included in the study, so this raises the possibility of human error. Lastly, the study design, together with a rather small sample size, sets limits for generalizing the results. Therefore, the correlation analysis used in this study doesn't imply causation.
Workplace culture impacted patients' self-care regarding their ability to manage after discharge. Additionally, this study shows that specific constructs of workplace culture were related to the prevalence of complications, especially pressure injuries and patient falls, and to adverse events concerning communication errors in the primary healthcare setting. Due to limited study responses, any conclusions that may be drawn need to be considered carefully.
However, the results of this study have implications for both practice and research. It's clearly essential that healthcare organizations acknowledge the implications of a good workplace culture, which enhances safe and effective patient care. Also, it's essential that nurse managers use comparable data when evaluating patient outcomes. As such, further work to create standardized and easily accessible patient outcome information for nurse managers is recommended. Future research with larger sample sizes should also be conducted in different healthcare settings to broaden our understanding of the connections between workplace culture and patient outcomes.
The ethics committee of the hospital district and each of the participating organizations approved the study.
Source of funding
This study was financially supported by the Nurses' Education Foundation, University of Tampere, Finnish Cultural Foundation, Pirkanmaa Hospital District, and the Competitive State Research Financing of the Expert Responsibility area of Tampere University Hospital, Grant 9R048.