The Impact of Nursing Work Environments on Nurse Perceptions of Quality of Care and Patient Safety: A Qualitative Evidence Synthesis and Systematic Review with Meta-Analysis

The report is a product of the VA/HSR Evidence Synthesis Program.

The Impact of Nursing Work Environments on Nurse Perceptions of Quality of Care and Patient Safety: A Qualitative Evidence Synthesis and Systematic Review with Meta-Analysis

Takeaway: Nurses play an essential role in providing high-quality healthcare and ensuring patient safety. Investigators with HSR's Evidence Synthesis Program (ESP) reviewed the evidence on the relationship between nurses' work environment and their evaluations of healthcare quality and patient safety. The review's findings underscore the importance of the nurse work environment in nurses' quantitative ratings and qualitative perceptions of healthcare quality and patient safety. Aspects of the nurse work environment are likely to be interconnected and influenced by the overall culture of the organization; changing just one element of the nurse work environment is likely not sufficient to robustly impact nurses' evaluation of healthcare quality and patient safety. Several common qualitative themes across individual workplace factors point to the importance of shared cultural beliefs, norms, and values. Findings suggest approaches that healthcare administrators and nursing leaders may pursue to create supportive nurse work environments that foster quality care and patient safety. The review's results should be interpreted with some caution due to the inconsistency and risk of bias across studies.

The nursing workforce is a key component of healthcare and is essential in ensuring high-quality care and patient safety. Multiple studies have reported a significant association between objective measures of healthcare quality and nurse-rated quality of care. In response to a request from the VA Office of Nursing Services, HSR's Evidence Synthesis Program (ESP) Center in Durham, NC, reviewed the literature that has examined the relationship between the nurse work environment and nurse evaluations of healthcare quality and patient safety. To identify relevant articles, the ESP team searched MEDLINE, Scopus, and CINAHL Ultimate for studies published between January 1, 2014, and December 16, 2024. The ESP investigators considered 14 aspects of the nursing work environment: teamwork, leadership, nurse autonomy, staffing adequacy, clarity of roles and goals, recognition, physical comfort, flexible scheduling, organizational stability or culture, professional development opportunities, salary, participation in decision making, innovation, and workplace safety and violence.

Summary of Findings

• ESP investigators identified 110 eligible studies. Of those, 76 quantitatively examined the associations between the nurse work environment and nurse-rated quality and safety of care, 25 used qualitative methods to explore how the nurse work environment impacted nurses' perceptions of quality and safety of care, and 9 assessed the effectiveness of interventions designed to improve nurse work environments. No eligible studies were conducted within the VA healthcare system.
• Findings should be interpreted with some caution as inconsistency and risk of bias across studies led to very low certainty of evidence.
• Multidimensional measures that combined two or more aspects of the nurse work environment as a single exposure were significantly and positively associated with nurse-rated healthcare quality and patient safety.
• Compared to multidimensional measures, individual measures of the nurse work environment (e.g., innovation, leadership, organizational culture, staffing adequacy, teamwork) demonstrated smaller associations with nurse-rated healthcare quality and patient safety.
  • Four individual work environment factors (staffing adequacy, professional development, participation in decision making, and workplace safety and violence) were significantly associated with nurse-rated healthcare quality.
  • Of the 12 individual workplace factors with patient safety outcomes, 10 were significantly associated with nurse-rated patient safety.
• Key features of staffing adequacy that are important to nurses in delivering high-quality care and ensuring patient safety include nurse experience, patient-to-nurse ratios, patient acuity, use of overtime, and staffing mix during shifts.
• Leadership played a pivotal role in nurses' perceptions of quality and safety, with effective leaders facilitating quality and safety by securing needed resources, setting a tone that supports quality care and patient safety, and trusting frontline nursing staff.
• Nurse work environment interventions commonly targeted three or more work environment factors.

Implications

This review's findings underscore the importance of the nurse work environment in nurse evaluations of healthcare quality and patient safety. Results suggest many promising approaches that healthcare administrators and nursing leaders may pursue to create supportive nurse work environments that foster quality care and patient safety. Changing just one workplace factor is likely not sufficient to robustly impact quality and safety outcomes. Qualitative findings support this assumption; several common qualitative themes across individual workplace factors point to the importance of shared cultural beliefs, norms, and values. Results suggest that nurse work environment factors are likely to be interconnected and influenced by the overall culture of the organization.

Limitations

The qualitative and quantitative studies included in this review had multiple methodological limitations. In addition, there was a paucity of research in outpatient settings, and only one study described the impact of electronic health records on nurse-rated quality and patient safety. The ESP team's taxonomy of nurse work environment factors might have excluded some aspects of the nurse workplace. Also, the outcomes included in this review were nurses' self-reports of patient safety and healthcare quality. Finally, nurse work environments and scope of practice may vary by region within the U.S., and the identified literature may not be generalizable to every health system in the country.

Future Research

Future interventional research should focus on pragmatic approaches that leverage the assets of VA's learning health systems to assess strategies to foster healthy nurse work environments and combine multiple workplace factors that demonstrated significant or salient findings in this report. Additional qualitative research is needed to understand nurses' perspectives on their workplace and its relationship with quality and safety.

Citation

Dick T, Pope C, Rushton S, et al. The Impact of Nursing Work Environments on Nurse Perceptions of Quality of Care and Patient Safety: A Qualitative Evidence Synthesis and Systematic Review with Meta-Analysis. Washington, DC: Evidence Synthesis Program, Health Systems Research, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-010; 2026.

To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/nursing-qoc.cfm (This report is available via intranet only.)