The working environment of nurses appears to have a correlation with patient safety and quality, with recent research finding that scores improve when hospitals improve working conditions.

The research was led by Linda H. Aiken, PhD, FAAN, FRCN, the Claire M. Fagin Leadership Professor of Nursing, professor of sociology, and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Philadelphia. She and her colleagues studied 535 hospitals in four states between 2005 and 2016.

They determined that patient safety “remains a serious concern.” In the study period, 21% of study hospitals showed improvements of more than 10% in work environment scores, and 7% had worse scores.

Although the percentage of hospitals improving their working environments was small, those facilities also saw improvements in patient safety indicators as rated by nurses and patients.

The number of patients rating their hospital favorably improved by 11%, and the number saying they would definitely recommend the hospital improved by 8%. The number of nurses reporting excellent quality of care rose by 15%, and those giving the hospital a favorable grade on patient safety increased 15%.

In hospitals where work environments deteriorated, the number of nurses giving a favorable grade on patient safety fell by 19%. (An abstract of the study is available online at:

Little Progress Since IOM Report

The study results suggest that patient safety and the hospital work environment are intertwined, Aiken says. The research is significant because of the scale, involving 53,000 nurses and 800,000 patients, she says.

“This has never been done in the safety world, looking at a host of hospitals over time to see how they have changed since the Institute of Medicine’s [IOM’s] 1999 To Err is Human report, and whether safety improved at the hospitals,” Aiken says. “The IOM made the point way back in 1999 that nursing was foundational to patient safety, meaning that if nursing itself was not safe, it would be almost impossible to implement any meaningful patient safety interventions over a dysfunctional nursing framework.”

IOM — now known as the National Academy of Medicine — published a series of guides on improving safety after the 1999 report, including Keeping Patients Safe: Transforming the Work Environment of Nurses, which “lays out guidelines for improving patient safety by changing nurses’ working conditions and demands.” (The guide is available online at:

“There is a consensus in the healthcare community that safety has not improved as much or as rapidly as we hoped, and it is not distributed evenly across institutions. We’re not where we thought we might be after two decades of focusing on patient safety,” Aiken says. “Seventy-one percent have not changed at all, and 7% decreased, when comparing each hospital to their own baselines. We found exactly what the IOM predicted, that hospitals that improved their own work environments made much greater gains in quality and patient safety than hospitals that had not changed at all or that 7% that slipped down.”

In hospitals that improved their work environments, safety metrics improved by 15%. Those hospitals saw significant gains in nurse satisfaction and patient satisfaction scores.

“This means that the priorities we set and pursued in the first 20 years were not exactly the right priorities,” Aiken says.

Nurses Key to Improvement

Hospitals have made some improvements in identifying interventions and showed that they worked to prevent harm to patients. The evolution of surgical checklists and the use of bundled care for the prevention of central line infections are examples, she notes.

“But it turns out that for that bundled care to work as intended, there has to be a fidelity to the implementation of the bundles of care at a 95% reliability level,” Aiken says. “In the work environments we have at hospitals, nothing can be done at a 95% reliability level. Therein lies the problem of why we haven’t made more progress in patient safety.”

The work environment for nurses is critical for two reasons, Aiken says.

First, nurses are there at the bedside with closer contact to patients than anyone else. If there aren’t enough nurses, the whole surveillance system that allows early intervention for patients’ issues falls apart, she says.

The second reason is that there is “as much chaos in hospitals as there was 20 years ago,” Aiken says.

“There is research showing that every clinical nurse at the bedside is interrupted on average once an hour by an operational failure that in and of itself seems inconsequential but makes the nurses stop mid-task,” Aiken says. “That task might be preparing medications, giving medications, changing sterile dressings. The failure that interrupts them might be the lack of proper dosages of a medication, broken equipment, the blood bank being closed at night. The operational failures are creating a safety hazard and making the clinical care very inefficient.”

Make Nursing a Safety Concern

Improving the nursing work environment typically is not considered a safety intervention, Aiken says.

“Until we define the adequacy of nursing as a critical safety intervention, patient safety cannot improve. [Nurses are] somebody else’s business,” Aiken says. “They don’t fall in the sweet spot of quality improvement professionals, so they are not addressed as a safety intervention, when in fact they are key to making any other interventions effective.”

Quality improvement professionals should work to address the work environment issues that prevent nurses from improving safety, Aiken says. That will mean motivating management to address the operational failures that are well known to nurses on the floor.

She also encourages quality improvement leaders to consider how nurses and physicians are involved in committees that make any types of decisions for the hospital.

“They are now missing in many of those committees. You need to ask if there are enough nurses, in particular, involved in all these quality and safety committees that are giving us feedback and driving our strategic plan for reducing harm,” Aiken says. “Try to increase the staff engagement and diminish the idea that hospitals are hierarchical institutions where administrators are the most important and the people providing patient care are the least important.”

Little Confidence in Management

Seventy-five percent of the nurses in the study said they had no confidence that management will respond to the work environment issues they cited as influential on patient care.

“There’s a disconnect between the nurses at the bedside who see what’s wrong and the management who can fix it,” Aiken says.

“Nurses and doctors are doing workarounds all the time, like hoarding pillows because there are never enough pillows to keep patients from getting pressure ulcers and positioning them after surgery. The workarounds enable management and support services in not doing their work, but it’s not the way to provide good, quality care,” she adds.

Another continuing problem is how nurses continue feeling personally blamed for the failings of the healthcare system.

Fifty percent of nurses say they feel mistakes are held against them, indicating that little progress has been made on the implementation of Just Culture or any other movement away from personal blame since the 1999 IOM report, Aiken says.

The likelihood of personal blame means clinicians still are afraid to report errors or concerns about the work environment, she says.

“Clearly, the reported errors are only the tip of the iceberg, and we have this developing syndrome of the secondary victim, meaning the clinician who has some role in the error. Because there is no safe way to report the error and learn from the experience, this increases the burnout and turnover at the bedside,” Aiken says.

“The loss of these experienced healthcare professionals is expensive and takes some of the best people away from patient care, continuing a cycle in which patient safety is degraded.”