Abstract & Commentary
Quality of Critical Care Work Environment Linked to Fewer Health Care-Associated Infections
By Leslie A. Hoffman, RN, PhD
Professor Emeritus, Nursing and Clinical & Translational Science, University of Pittsburgh
SYNOPSIS: Nurses working in critical care environments that were perceived as more positive were less likely
to report frequent health care-associated infections.
SOURCE: Kelly D, et al. The critical care work environment and nurse-reported health care-associated infections. Am J Crit Care 2013;22:
This study investigated the influence of the critical care work environment on nurse-reported health care-associated infections. Respondents were selected from nurses who participated in a survey by the American Hospital Association that included acute care hospitals in four states (New Jersey, Pennsylvania, California, and Florida). The sample for this study included 3217 critical care nurses working in 320 hospitals. Most (53%) had a bachelor’s degree or higher, 54% were certified, and 11% were men. Mean nursing experience was 12.7 ± 11.1 years and the mean number of patients cared for was 2.2 ± 0.4. The hospitals represented a wide range of bed size (< 250 to > 500); slightly more than half (54%) were teaching hospitals. Nurses were asked to rate the frequency of ventilator-associated pneumonia, catheter-associated bloodstream infections, and urinary tract infections on a 7-point Likert scale (never to every day). Infections were categorized as "frequent" if the event occurred more often than once a month. The Practice Environment Scale of the Nursing Work Index was used to assess work environment.
Results indicated that the odds of nurses who worked in hospitals with a better critical care work environment reporting frequent health care-associated infections were 36-41% lower than the odds for those who worked in worse nurse work environments.
The Centers for Disease Control and Prevention (CDC) estimates that each year approximately 1.7 million hospitalized patients will acquire an infection, and that 1 in 17 will die as consequence of the infection.1 A substantial body of research supports that how nursing care is delivered influences the likelihood that patients will acquire an infection. Several factors, including high nurse patient ratios, fewer hours of nursing care per patient-day, and nurse burnout have been linked to a greater frequency of acquired infections. A prior study by this research team reported that nurse burnout was significantly associated with a greater number of urinary tract and surgical site infections.1 Hospitals in which burnout was reduced by 30% had fewer infections and an annual cost savings of up to $68 million.1
Findings of this recent study extend these results to the ICU environment. Scores on the instrument used for this study showed the most variability on ratings of nurse manager ability, leadership and support, staffing resources and support, nurse participation in hospital affairs, and collegial nurse-physician relations, suggesting that these are areas that can be investigated for improvement in perceptions of the work environment and, therefore, improved patient care. How perceptions of the work environment influence infection rates remains unclear. The authors hypothesize that detachment associated with high levels of burnout may result in inadequate hand hygiene practices and lapses in other infection control procedures. In addition, inadequate staffing and/or perceptions of limited nurse manager support can influence nurse commitment and, therefore, practice. Critical care nurses are sensitive to the amount of collaboration in the delivery of patient care and may hesitate to question if the attending physician or housestaff disregard their concerns. Evidence from this and other studies suggests that simple-to-implement changes can greatly impact the incidence of health care-associated infections and positively impact patient outcomes.
1. Cimiotti JP, et al. Nurse staffing, burnout and health care-associated infections. Am J Infect Control 2012;40:486-490.