NUR 651 Module 2 Work Environment Paper Example

The Nursing Practice Environment as Strategy: Measuring It, What It Predicts and Where to Act

[Student Name]

Southern New Hampshire University

NUR 651: Advanced Concepts for Nurse Executive Leaders

Module Two Work Environment Paper

[Instructor Name]

[Date]

The Nursing Practice Environment as Strategy: Measuring It, What It Predicts and Where to Act

Health systems measure their finances monthly and their patient outcomes quarterly, but many measure the conditions in which nurses work only when a crisis forces the question. The practice environment, meaning the organizational features that support or constrain professional nursing practice, is often treated as a matter of morale. The research treats it as a driver of patient outcomes and workforce stability. Northfield Health System, a composite system of four hospitals, has never measured its practice environment in a standardized way. This paper describes the first system-wide measurement, explains what the scores predict according to the research and proposes where to act. It argues that the practice environment should be measured annually with a validated instrument, reported to the board alongside financial and quality results and improved through targeted actions on the weakest dimensions.

Measuring the Practice Environment

Lake (2002) built the Practice Environment Scale, usually shortened to PES-NWI, out of an older Nursing Work Index that had been assembled from the features of hospitals known for attracting and keeping nurses. Working with a large sample of nurses, she settled on 31 items that fall into five groups: (1) how much nurses take part in hospital affairs, (2) the nursing foundations that support quality, (3) the ability, leadership and support of nurse managers, (4) whether staffing and resources are adequate and (5) how collegially nurses and physicians work together. Nurses rate each item on a four-point scale from strongly disagree to strongly agree. The instrument has been used in many large studies, which allows an organization to compare its scores with published results, and its subscales point to different kinds of action, which makes it useful for management as well as research.

Northfield surveyed all registered nurses in direct care, and 58% responded. System-wide, the composite score was 2.61, near the midpoint of the scale. Nursing foundations for quality of care and collegial nurse-physician relations scored highest, at 2.86 and 2.84. Staffing and resource adequacy scored lowest, at 2.18, followed by nurse participation in hospital affairs at 2.39. Scores varied across hospitals: the smallest rural hospital scored highest overall, while the largest, the system's tertiary center, scored lowest on staffing and resource adequacy.

What Better Environments Predict

The research gives the scores meaning. Cimiotti et al. (2012) linked nurse surveys with infection data from Pennsylvania hospitals and found that higher patient-to-nurse ratios were associated with more urinary tract and surgical site infections, and that nurse burnout was also associated with infections, suggesting that the conditions nurses work in affect the vigilance that prevents harm. They estimated that reducing burnout could prevent thousands of infections a year across the state's hospitals.

Improvement is possible and pays off. Kutney-Lee et al. (2015) followed a group of hospitals over time and compared those that achieved Magnet recognition with those that did not. Hospitals that became Magnet-recognized showed greater improvements in their work environments and in the proportion of nurses with baccalaureate degrees, and larger reductions in surgical mortality and failure to rescue, than the comparison hospitals. The study suggests that a deliberate effort to improve the practice environment can change patient outcomes, not only nurses' opinions.

Connecting the Scores to Northfield's Outcomes

To make the case locally, the chief nursing officer's team linked unit-level survey results to the system's own data. Units in the lowest quartile on staffing and resource adequacy had first-year nurse turnover of 31%, compared with 17% in the highest quartile, and a higher rate of central line-associated bloodstream infections over the previous two years. The relationship does not prove cause, since units with more turnover may rate their staffing lower, but it matches the published evidence and gives the board a picture of what the scores mean in Northfield's own terms.

Where to Act

Actions are matched to the two weakest subscales. For staffing and resource adequacy, Northfield will review staffing plans on the ten lowest-scoring units with their managers and staff, fund a system float pool to cover predictable gaps, and add unit support roles to remove nonnursing tasks such as transport and supply stocking. For nurse participation in hospital affairs, the system will establish unit practice councils and a system nursing congress with authority over nursing practice standards, include staff nurses on committees that choose equipment and design units and give the chief nursing officer a standing report at every board meeting. The manager subscale, while not the weakest, will receive attention through a manager development program, since managers translate system decisions into daily working conditions.

Involving Nurses in the Response

Survey results lose credibility if nurses never hear what happened to them. Within a month of the survey, each unit will receive its own scores alongside the hospital and system results, and managers will hold a short meeting with staff to discuss the two lowest-scoring items and agree on one change the unit can make itself and one it needs the hospital to make. The system nursing congress will review the unit requests and report back on which were funded. This closes the loop that many engagement surveys leave open and is itself a demonstration of the participation subscale that Northfield most needs to improve. Response rates on the next survey will be treated as a signal of whether nurses believe their answers matter.

Targets and Reporting

The survey will be repeated annually. The target is to raise the staffing and resource adequacy subscale from 2.18 to 2.40 and the participation subscale from 2.39 to 2.55 within two years, with no hospital scoring below 2.20 on any subscale. Results will be reported to the board with turnover, vacancy and nurse-sensitive quality indicators, so trustees see the environment and its consequences together. Whether to pursue Magnet recognition will be decided after the first repeat survey; the Kutney-Lee evidence suggests the process can drive improvement, but its cost and staff time must be weighed against the system's other priorities.

Conclusion

The practice environment can be measured with a validated instrument, it predicts outcomes that matter to patients and to the balance sheet and it can be improved. Northfield's first survey shows where its environment is weakest. Treating those scores as strategic measures, acting on the weakest subscales and reporting results to the board will turn the practice environment from a matter of morale into a managed part of the system's strategy.

References

Cimiotti, J. P., Aiken, L. H., Sloane, D. M., & Wu, E. S. (2012). Nurse staffing, burnout, and health care-associated infection. American Journal of Infection Control, 40(6), 486-490. https://doi.org/10.1016/j.ajic.2012.02.029

Kutney-Lee, A., Stimpfel, A. W., Sloane, D. M., Cimiotti, J. P., Quinn, L. W., & Aiken, L. H. (2015). Changes in patient and nurse outcomes associated with Magnet hospital recognition. Medical Care, 53(6), 550-557. https://doi.org/10.1097/MLR.0000000000000355

Lake, E. T. (2002). Development of the practice environment scale of the nursing work index. Research in Nursing & Health, 25(3), 176-188. https://doi.org/10.1002/nur.10032