title: Associations between characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals: a systematic review of literature.
abstract: OBJECTIVE
  To systematically review the literature on relationships between characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals.
  
  
  METHODS
  The search was performed in Medline (PubMed), Cochrane, Embase, and CINAHL.
  
  
  METHODS
  Included were quantitative studies published from 2004 to 2012 that examined associations between work environment and the following patient outcomes: delirium, malnutrition, pain, patient falls and pressure ulcers. The Dutch version of Cochrane's critical appraisal instrument was used to assess the methodological quality of the included studies.
  
  
  RESULTS
  Of the initial 1120 studies, 29 were included in the review. Nurse staffing was inversely related to patient falls; more favorable staffing hours were associated with fewer fall incidents. Mixed results were shown for nurse staffing in relation to pressure ulcers. Characteristics of work environment other than nurse staffing that showed significant effects were: (i) collaborative relationships; positively perceived communication between nurses and physicians was associated with fewer patient falls and lower rates of pressure ulcers, (ii) nurse education; higher levels of education were related to fewer patient falls and (iii) nursing experience; lower levels of experience were related to more patient falls and higher rates of pressure ulcers. No eligible studies were found regarding delirium and malnutrition, and only one study found that favorable staffing was related to better pain management.
  
  
  CONCLUSIONS
  Our findings show that there is evidence on associations between work environment and nurse-sensitive patient outcomes. However, the results are equivocal and studies often do not provide clear conclusions. A quantitative meta-analysis was not feasible due to methodological issues in the primary studies (for example, poorly described samples). The diversity in outcome measures and the majority of cross-sectional designs make quantitative analysis even more difficult. In the future, well-described research designs of a longitudinal character will be needed in this field of work environment and nursing quality.
authors: St. Antonius Academy, St. Antonius Hospital, Nieuwegein, The Netherlands. Electronic address: d.stalpers@antoniusziekenhuis.nl.
authors: Dewi
authors: D
authors: Stalpers
authors: Scientific Institute for Quality of Healthcare, St. Radboud University, Nijmegen, The Netherlands.
authors: Brigitte J M
authors: BJ
authors: de Brouwer
authors: National Health Care Institute, Diemen, The Netherlands.
authors: Marian J
authors: MJ
authors: Kaljouw
authors: University Medical Centre Utrecht, Department of Nursing Science, Utrecht, The Netherlands.
authors: Marieke J
authors: MJ
authors: Schuurmans
mesh_terms: D000058:Accidental Falls; D006801:Humans; D009741:Nursing Staff, Hospital / Q000523:psychology*; D010561:Personnel Staffing and Scheduling; D003668:Pressure Ulcer; D016896:Treatment Outcome; D017132:Workplace
keywords: Hospitals; Nurse-sensitive patient outcomes; Quality of care; Review; Work environment