Conditions for care : factors in the nurse work environment related to safe and high quality care in acute care hospitals

Shortages of registered nurses (RNs) intensify challenges for healthcare service providers in matching an increasing demand for care with a sufficient healthcare workforce. Poor working conditions have been recognized to often precede RNs’ decision to leave the profession prematurely. Since job dissatisfaction has been shown to be related to negative outcomes for patients, investigating working conditions may provide valuable insights for healthcare service providers in their efforts to improve recruitment and retention of RNs to sustain care quality and safety for patients. However, there was limited knowledge in research about the work conditions needed for care provision from the perspective of RNs themselves.

The overarching aim of this thesis is to investigate RNs’ experiences of their work environment – as persons, as professionals, and as employees – and how their experiences are related to patient safety, quality of care, and conditions for patient care delivery. This thesis is based on data derived from the Swedish component of the cross-sectional, multi-national EU 7th framework project Registered Nurse Forecasting (RN4CAST). Swedish data include survey responses from a national sample of 11 015 RNs working in inpatient care on medical/surgical wards in all acute care hospitals in Sweden, patient data from the national discharge register, and data on hospital characteristics.

Results show that hospital structural factors such as size, geographical location, and teaching status, had relatively little influence on RNs’ assessments of their work environment, work situation and the quality of care. Factors with the most influence on RNs’ assessments of patient safety on their ward were modifiable, related to their perception of adequate staffing and resources, hospital management prioritizing patient safety, supportive nurse leadership, and good working relations with physicians. RN-assessments of excellent patient safety and quality of care on their ward related to considerably lower odds of patients dying within 30 days of admission. In their own accounts, RNs described experiencing expectations and demands – from management, patients and their families, other staff groups, the RN profession as well as their own individual ambitions – to uphold standards of safe, high quality care. However, they also described working in an environment with little means of influencing the conditions needed to meet these demands. The tensions between expectations and demands on one hand, and lack of influence on the other, seemed to lead to RNs’ lacking a sense of agency, on both individual and collective levels.

This thesis indicates that RN-assessments of excellent patient safety and quality of care can be useful as valid hospital-level indicators to inform policy-decisions on patient care. However, inadequacy of important conditions for providing safe care (e.g. adequate staffing and resources) as well as the lack of a sense of agency suggests organizational factors might impede RNs’ ability to use their entire range of professional competence in care provision and to govern their own scope of practice. In efforts to improve RN retention and to ensure safe, high-quality care to patients, hospital organizations could use these research findings to identify and foster organizational conditions that support RNs’ full professional contribution to patient care.

List of scientific papers

I. Lindqvist R, Smeds Alenius L, Griffiths P, Runesdotter S, Tishelman C. Structural characteristics of hospitals and nurse-reported care quality, work environment, burnout and leaving intentions. J Nurs Manag. 2015 Mar;23(2):263-74.
https://doi.org/10.1111/jonm.12123

II. Smeds Alenius L, Tishelman C, Runesdotter S, Lindqvist R. Staffing and resource adequacy strongly related to RNs' assessment of patient safety: a national study of RNs working in acute-care hospitals in Sweden. BMJ Qual Saf. 2014 Mar;23(3):242-9.
https://doi.org/10.1136/bmjqs-2012-001734

III. Smeds-Alenius L, Tishelman C, Lindqvist R, Runesdotter S, McHugh MD. RN assessments of excellent quality of care and patient safety are associated with significantly lower odds of 30-day inpatient mortality: A national cross-sectional study of acute-care hospitals. Int J Nurs Stud. 2016 Sep;61:117-24.
https://doi.org/10.1016/j.ijnurstu.2016.06.005

IV. Smeds Alenius L, Lindqvist R, Ball J, Sharp L, Lindquist O, Tishelman C. Between a rock and a hard place: RNs' descriptions of their work situation in cancer care in Swedish acute care hospitals. [Manuscript]