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Bishwajit Mazumder
Nursing Instructor
Dhaka Nursing College, Dhaka
E. mail: mbishwa@rocketmail.com

Working condition and patient outcome

Introduction:
The working condition in which nurses provide care to patients can
determine the quality and safety of patient care. As the largest health care workforce,
nurses apply their knowledge, skills, and experience to care for the various and
changing needs of patients. A large part of the demands of patient care is centered on
the work of nurses. When care falls short of standards, whether because of resource
allocation (e.g., workforce staffing, workflow design and physical environment) or
lack of appropriate policies and standards, nurses shoulder much of the responsibility.
This reflects the continued miss understanding of the greater effects of the numerous,
complex health care systems and the work condition factors. Understanding the
complexity of the work condition and engaging in strategies to improve its effects is
paramount to higher-quality, safer care. High-reliability organizations that have
cultures of safety and capitalize on evidence-based practice offer favorable working
conditions to nurses and are dedicated to improving the safety and quality of care.
Emphasis on the need to improve health care systems to enable nurses to not be at the
sharp end so that they can provide the right care and ensure that patients will benefit
from safe, quality care. Working conditions are viewed either as resources that
improve work quality or as demands that impede work quality. Working conditions
potentially affect patient safety, which leads to patient outcomes.

Definitions of Working Conditions:

Working conditions refers to the working environment and all existing

circumstances affecting labor in the workplace, including job hours, physical aspects,
legal rights and responsibilities.
Or,
Working conditions refers to the working environment and aspects of an
employees terms and conditions of employment. This covers such matters as: the
organization of work and work activities; training, skills and employability; health,
safety and well-being; and working time and work-life balance.

Component of working condition:

Workforce Staffing:
Workforce staffing refers to the job assignments of healthcare workers. The
volume of work assigned to individuals. This has been defined in different ways
depending on the nature of the job assignment. For pharmacists it has been defined as
the number of prescription orders filled per day. For nursing staff, it has been defined
as the numberof patients cared for during a work shift. For physicians, it has been
defined as the number of a certain procedure (such as coronary arteriography or
resection of a gastric carcinoma) performedper year. The most common hypothesis is
that higher workload is associated with a larger rate of errors and/or adverse
outcomes.
Workflow Design:
Workflow design focuses on the process of delivering health care. Workflow
design encompasses the interactions among workers and also between workers and
the workplace. It also includes the nature and scope of the work as tasks are
completed.

Personal/Social staffing:
This category of working conditions is concerned with the personal,
professional, and social aspects of the healthcare work environment. The personal
factors include stress, burnout, dissatisfaction, motivation, and control over work..

Physical Environment:
Physical environment working conditions include direct physical
characteristics such as light, aesthetics, noise, air quality, toxic exposures,
temperature, and humidity. This category also includes basic workplace design
features, such as obstacles, physical layout, and distance from nursing stations.
Organizational Factors:
Organizational factors are structural and process aspects of the organization
as a whole. For example, work structures such as the use of teams and the division of
labor are organizational factors with potential influences on patient safety. Other
organization- level factors include size, funding mechanisms (e.g., profit, not- forprofit), hospital type (e.g., teaching, private), and culture
.

Importance of working condition:

Working condition is the essential element for nurses decision making.
Because Nurses provide leadership in nursing assessment, planning, implementation
and evaluation for the purpose of promoting, maintaining or restoring health,
preventing illness, injury and disability or supporting a peaceful death. The nurses
develop professional relationships for the purpose of providing care in collaboration
with the patient and family, other nurses and health team members throughout all
stages of health and complexities of illness. The nurses independently provide safe,
competent, compassionate, ethical nursing care to stable, predictable and
unpredictable populations, and ensures the goals and needs of the patients and

families are prioritized and individualized. Using nursing knowledge, critical thinking
and clinical judgment, the nurses engage in independent, interdependent and
dependent functions to provide healthcare focusing on comprehensive assessment,
patient/family education, and coordination of care. These functions may be selfdetermined, or assigned by physician, nurse practitioner or other nurses.

a. For patients:
1. Quality outcomes:
Nursing plays a dominant role in the determination of overall patient
satisfaction with healthcare (Abramowitz, Cote & Berry, 1987; Clark, Leddy, Drain
&Kaldenberg, 2007). Patient satisfaction has been defined as the degree to which the
patients expectations for care are met in a care episode (Laschinger& Almost, 2003).
Meeting patient expectations are influenced by their personal characteristics (e.g.
gender, age), structural factors (e.g. service delivery model, provider competence,
cleanliness of physical environment) and the quality of nurse-patient interactions (e.g.
caring, pleasant attitude, prompt responses; Larrabee and Bolden (2001).

2. Risk outcomes:
Falls are one of the two most common risk-related patient outcomes
occurring in hospital settings (Mark et al., 2008) and fall rates are a key nursing
metric used to evaluate patient safety and quality (Donaldson, Brown, Aydin,
Burnes-Bolton & Rutledge, 2005). Falls, defined as an unintentional movement to
the floor or otherevaluate patient safety and quality (Donaldson, Brown, Aydin,
Burnes-Bolton & Rutledge, 2005). Falls, defined as an unintentional movement to
the floor or other level that results in the need for intervention or treatment (White
&McGillis Hall, 2003; Mulvey Boyle, 2004), are a type of adverse event that is
preventable through nursing actions

b. For Nurse :
1. Psychological empowerment:

Spreitzer (1995/1996) suggested that structural conditions alone do not

result in the experience of empowerment. It is the reaction to these conditions that
generates a psychological response whereby the individual interprets their work as
having impact and meaning. The motivational potential of empowering conditions
also includes the individuals perception of competence or self-efficacy whereby they
believe that they areable to meet the demands of the job.
2. Empowered behavior:
While the relationship between empowered nursing workplaces and work
effectiveness has been established, the mechanism by which this occurs has not been
elucidated. Laschey (2000) argued that employee empowerment is a multi-stage
process whereby structural changes to the work conditiont may lead to employees
feeling empowered, that feelings of personal efficacy may change work behavior and
these empowered behaviors may lead to improved business performance.
3. Job satisfaction:
Characteristics of the work environment that are associated with nursing job
satisfaction include some of the key dimensions of structural and psychological
empowerment. McNeese-Smith (1999) conducted a qualitative study of acute care
nurses to determine factors that created job satisfaction and dissatisfaction. They
found that the environment, pace and variety of patients in acute care, professional
opportunities, a balanced workload and the ability to meet patients needs influenced
job satisfaction. The overall goal of nursing is to provide quality care.

Patient Outcomes:
Work effectiveness for nurses is manifested in the quality of care received
by patients. Patient outcomes that are sensitive to nursing care include both qualityrelated outcomes (patient satisfaction, ability to perform self care activities on
discharge from hospital, functional status and symptom management) and risk-related
or patient safety outcomes (falls, pressure ulcers/sounds, nosocomial infections,

medication errors and mortality) (Doran, 2003). While excessive workloads and
inadequate staffing have been implicated in the incidence of these risk outcomes
(Aiken, Clarke, Sloane, Sochalski&Silber, 2002; Blegen, Goode, & Reed, 1998;
Kovner&Gergen, 1998), less is known about other workplace factors such as access to
resources, supports, information, and opportunities for development and their effect
on quality and risk patient outcomes. Lowe (2002), Vahey, Aiken and Sloan (2003)
and Mulvey Boyle (2004) suggest that future research should focus on the
mechanisms through which work environment factors affect nurses and patient
outcome.
Access to empowering conditions in the working condition leads to the
experience of psychological empowerment which is defined as ones work being
perceived as meaningful, that it has impact on organizational outcomes, there is
feeling of control over ones work and that the individual is confident in their ability
to meet work expectations (Spreitzer, 1995). Psychological empowerment is a
significant predictor of job satisfaction, productivity /effectiveness and decreased
intent to leave the organization (Koberg, Boss, Senjem& Goodman, 1999; Laschinger,
Finegan, Shamian&Wilk, 2004). For perceptions of empowerment to translate into
work effectiveness, a set of behaviors arising from feeling empowered must be
enacted. The literature suggests that empowered behavior includes proactive, focused
efforts that are self-initiated (Kuokkanen, Leino-Kilpi&Katajisto, 2003; Thomas
&Velthouse, 1990) but there is little research to empirically test the link between
empowering work conditions and the occurrence of empowered behavior.

Working condition affect patient outcome:

1. Working Conditions Affect Patient Outcomes that are Related to Patient
Safety:
Many observational studies have examined a variety of working conditions and
patient outcomes related to adverse events, such as in- hospital mortality, nosocomial
infections, and decubitus ulcers. A common finding across multiple studies examine
that the evidence is strongest for such non-fatal outcomes as newly acquired

infections and short-term re-hospitalizations.Evidence for a direct effect of any

working condition upon patient death issuggestive but relatively weak.
2. Working Conditions Affect the Rate of Recognition of Medical Errors
after they Occur:
Recognition and reporting of medical errors have been emphasized as part of
patient safety improvement programs. Many researcher has shown systematic
literature review yielded only limited evidence that working conditions are related to
error recognition and reporting. Some aspects of workforce staffing (shift scheduling)
and organizational factors were found to affect error reporting.
3. Working Conditions Affect the Rate of MedicalErrors:
The evidence about the relationships between individual working conditions and
rates of medical errors is diverse. Based on evidence from cross-sectional studies that
measured error rates and retrospective analyses of reported medical errors, we
concluded there is sufficient evidence that some working conditions, including
patient-to-nurse ratios and workplace interruptions, affect rates of certain medical
errors. There is also highly suggestive evidence that other factors, such as
environmental lighting, affect error rates. Most evidence pertains to medication
administration and dispensing errors by nurses and pharmacists. There has been very
little research conducted on many other important areas of error, including breaks in
precautions to prevent worker-involved transmission of infectious agents among
patients and technical errors in operative procedures. Studies of error rates among
physicians have mostly been conducted in simulated care delivery settings. A common
feature of nearly all studies of error rates is that the errors involve simple
calculationand recording tasks. Potentially important but more complex types of error,
such as prioritizing clinical tasks or developing diagnostic assessments, have not been
studied in the context of working conditions
4. Working Conditions Affect the Probability that Adverse Events will
Occur Following Detected or Undetected Medical Errors:

The ideal study of working conditions would be a prospective evaluation that

examined healthcare delivery sites with systematically different working conditions
and recorded both medical errors and relevant clinical outcomes. Such a study would
test whether working conditions influenced the relationships among errors and patient
outcomes. There have been studies that examined both medical errors and adverse
outcomes, but they have not provided the detail of results to evaluate whether medical
errors led directly to adverse outcomes.
5. The Complexity of the Plan of Care AffectWhether Working Conditions
Affect Patient Outcomes that areRelated to Patient Safety:
The body of research on working conditions research has been conducted in a
wide variety of settings and has examined a large number of clinical problems. For
selected working conditions, there is sufficient evidence to answer this question.
Many researcher has found that the effect of patient to nurse ratios on adverse event
rates has been sufficient to conclude that the magnitude of the effect differs between
intensive care and general inpatient care settings.
6. Working Conditions Affect Measures of ServiceQuality in Industries
Other than Health Care:
Research in non-healthcare settings provides useful evidence for evaluating
several areas of working conditions. Research on the effects of ambient noise in
factories has provided evidence comparable to that from healthcare settings and has
permitted us to judge the evidence to be sufficient to conclude that ambient noise does
not affect patient safety. Most research on workplace colors and aesthetics has been
conducted outside of healthcare but is sufficiently comparable to conclude that these
factors also do not affect patient safety.

Theory Related Nursing Working Condition and Patient Outcomes :

Conceptual Framework:

Donabedian defined quality healthcare along 3 basic dimensions: structure,

process, and outcomes of care. The structures of care include the adequacy of
facilities and equipment, and the administrative structure and operations related
toprograms providing care. The processes of care are actions/services involved with
direct care. The outcomes are consequences that can be attributed to the structure and
processes of care. Patient characteristics affect these relationships.Working condition
nursing-sensitive patient outcomes reflect the nurses scope of practice, inputs and
interventions for which there is empirical evidence linking these activities to patient
outcomes (Doran, 2003). Hackman (1987) identified three criteria to assess team
effectiveness: actual group output, capabilities of members to work together on
subsequent tasks or goals and the groups ability to meet the needs of its members.
Based on this theoretical framework and previous research evidence, we developed a
conceptual model (Fig. 1). The structures of care included both covariates and
characteristics that may be directly related to organization of nursing services (ie,
profit margin and magnet status). Administrative processes related to nurse working
conditions included work force staffing, work flow design, personal/ social working
condition, physical environment, organizational factor. We examined outcomes
thought to be sensitive to nursing care. The quality of work in turn affects patient
safety and patient outcomes.We adjusted for patients underlying risk for disease
using comprehensive sets of variables to decrease selection bias. We hypothesized that
elderly patients being cared for better working conditions would have better safety
outcomes.
Figure 1.This figure guided the empirical analyses. The covariates on the left impact
both the independent and dependent variables shown on the right. The covariates were
controlled for in all analyses. The extent to which individual clinicians performed
specific technical processes (eg, catheter care) was not measured in this study.

Future Research:
For several specific working conditions, there is evidence that the working
condition affects patient safety, but the evidence comes from few studies and is

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insufficient to draw clear conclusions. Further research to clarify and confirm the
findings from existing studies will permit judgments to be made about the importance
of these working conditions. The areas in which such targeted research is indicated
include workplace stress, workplace lighting conditions, and several aspects of
organizational factors. With the exception of selected work processes pertaining to
workflow design, most of the evidence on the relationship of working conditions to
patient safety is derived from non experimental studies. Thus, there remain
unanswered questions about the magnitude of improvement in patient safety that can
be achieved by improving working conditions. There is a need for significant future
research that evaluates how specific workplace interventions will affect patient
outcomes. Such research could be conducted as clinical trials or as carefully designed
demonstration projects and program evaluation studies.

Conclusion:
Safe patient management is a very important issue for establishing trusting
relationships between patients, their families and healthcare providers. This is also
related to lower medical costs. Although several theories and methods have been
proffered to prevent incidents, some of them are not easily understandable nor
applicable. We may need to consider instituting systems solutions for creating a better
working condition for nurses, efforts to improve by developing organizational
policies that support autonomy, participation in decision-making and relational
coordination may be an economically viable means to accomplish such an objective.
By achieving this, we could reduce the number of patient safety incidents, falls, and
nurses burnout, especially in the era. Organizations need to examine the problem
solving process carefully in order to determine a well suited model that will offer the
best predisposition for success. System approaches, such as improving working
conditions, have been advocated to improve patient safety.

Reference:

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