Nursing Resources, Workload, the Work Environment and Patient Outcomes

Purpose:
The study was designed to link nursing resources (staffing, skillmix) with workload (acuity, casemix), the work environment (NWI-R and other measures) to patient outcomes at the ward level.

Background/Significance:
Understanding the relationship between nursing and patient outcomes requires understanding the pressures on nursing work and the environment within which it takes place, at the ward level where hospital operations play out.

Methods:
We designed a study which combined longitudinal analysis using administrative data (5 years; >10 million patient records; 286 nursing wards; >250,000 nurse schedule or payroll records) combined with primary data collect from 80 randomly selected wards in 19 hospitals in New South Wales, Australia. Patient outcomes were measured as 11 negative OPSN (Outcomes Potentially Sensitive to Nursing),in the longitudinal study and falls and medication errors in the cross sectional study. Ward environment was measured with NWI-R, the Environmental Complexity scale, and a survey of nurses' perceptions of violence in the working environment.

Results:
Greater Registered Nurse resources were associated with decreased rates of seven OPSN and, in conjunction with increased nursing workload occasioned by patient turnover and unstable working environment, were associated with other negative outcomes. Wards showed considerable variability in nearly all measures of interest.

Conclusions and Implications for Practice:
This study supports the understanding that staff nurses and nurse managers have about how nursing is associated with negative patient outcomes through a pathway that includes workload and characteristics of the working environment.