The purpose of a systematic review is to attempt to find, evaluate and synthesize high quality research relevant to the research question. A systematic review uses carefully developed data collection and sampling procedures that are put in place in advance as a protocol. (Polit, 2012). A systematic review must contain the following: a clear inclusion and exclusion criteria, an explicit search strategy, systematic coding and analysis of included studies, and a meta-analysis if possible. (Hemingway & Brereton, 2009). Systematic reviews are conducted by nurse researchers to avoid reaching incorrect or misleading conclusions that could arise from a biased study. Systematic reviews are perceived by many as the cornerstone of evidence-based practice. (Polit, 2012). The issue of concern that this article addresses is “to systematically evaluate nurse working conditions and to review the literature dealing with their association with patient outcomes.” (Bae, 2011). “The aim of this study is to fulfill two objectives: a systematic evaluation of nurse working conditions and a review of the literature dealing with the association between nurse working conditions and patient outcomes. The innovative review of research on working conditions focused on the relationships between nurse working conditions and patient outcomes.” (Bae, 2011).
The author of this systematic review, Dr. Sung-Hei Bae, is currently an Assistant Professor of Nursing in the Graduate Program in Nursing Administration and Healthcare Systems Management at the University of Texas at Austin. Dr. Bae received her BSN and MPH from Seoul National University and PhD from the University of North Carolina at Chapel Hill. Dr. Bae is a health services researcher and focuses on nursing workforce policy, state mandatory overtime policy, comprehensive nurse staffing characteristics, and nursing sensitive patient outcomes. Dr. Bae’s research includes 4 studies and she has 16 publications. At the time of this review, Dr. Bae was a Professor at the School of Nursing University at Buffalo, State University of New York. (University of Texas at Austin, 2014). As one can see, Dr. Bae has a great deal of experience in research. The purpose of this systematic review is to synthesize concepts of the working conditions in nursing and to evaluate which of these working conditions are associated with patient outcomes. This review will also identify the strength of evidence for each of the working conditions related to the patient outcomes. (Bae, 2011).
The instrument used for this review for the quality appraisal is the Quality Assessment and Validity Tool for Correlation Studies. The search strategy for this review was guided by a preliminary literature review. The literature review identified relevant research terms. Terms included nurse working conditions, work structure, care environment, work context, and organizational context. The articles reviewed were from January 2000 to October 2009. The articles had to meet the following inclusion criteria: “the study population consisted of nurses working in health care facilities, papers had to report primary research; studies reported a measure of analysis of the relationship between working conditions and patient outcomes; the studies had a quantitative design; and the direct measure of patient outcomes were operationalized as the dependent variable and working conditions as independent variables.” (Bae, 2011). 194 articles met the inclusion criteria. Out of these 194 articles, only eleven met criteria and were assessed for the methodological quality. For the quality appraisal, fourteen questions were used to evaluate the design, sample, measurement and statistical analysis. The total number of points that the study scored was divided by 14.
Those studies that scored 0.75 were rated as strong. The results were: one strong, nine moderate and one weak. From the eleven studies, the following data were extracted in the final inclusion: author, country, year of publication, setting, participants/sample, framework/theoretical model design, definitions of working conditions, instruments of working conditions, measures of patient outcomes, analysis and the significance of the associations with favorable working conditions. (Bae, 2011). Seven studies used the Practice Environment Scale of the Nursing Work Index to measure nurse working conditions, one used the Work Environment Survey, and the remaining three used a variety of instruments from prior studies. In examining the association between working conditions and patient outcomes, the eleven studies contained a total of fourteen different patient outcome variables. The association between autonomy and patient outcomes were examined in two studies. Six studies measure the philosophy emphasizing the quality of clinical care and the association with patient outcomes. Nurse participation was examined in regards to the relationship between nurse participator and the patient outcomes, as well as the association between supportive managers and patient outcomes.
Other areas that were examined were collaborative relationships with physicians, supportive relationships with peers, staffing and decentralization, patient-centered climate and busyness. The findings of this systematic review suggest that evidence supporting a positive relationship between better nurse working conditions and improved patient outcomes is inconclusive. It is recommended that further studies be conducted in a variety of settings with more diverse and randomly selected samples. (Bae, 2011). In the review of this study, over half of the relationship outcomes examined were not significant. Recent studies have proven and documented a significant relationship between nurse working conditions and reduction in mortality rates in the hospital setting. (Aiken, Clarke, Sloane, Lake & Cheney, 2008). Recent studies have also proven a reduction in catheter-associated urinary tract infections. (Stone, Mooney-Kane & Larson, 2007). Conclusion
As stated earlier, the findings of this review suggest that the evidence supporting relationships between nurse working conditions and patient outcomes is inconclusive. Further studies need to be done to expand the knowledge of influences among nurse working conditions and patient outcomes. Efforts in doing so should occur in various health-care settings. The use of other search terms would also encompass even more studies related to this topic. Through this particular review, the study does show an increase in nurse participation in hospital affairs, philosophy emphasizing quality of clinical care, supportive managers, nurse staffing and collaborative relationships between nurses and physicians do have a positive relationship to the reduction of adverse events. Although the general review of the literature supports the concept that nurse care environments that foster better nursing care are associated with better patient outcomes, there is a lack of evidence to support it. (Bae, 2011).
Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, E.T. & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration 38(5), 223-229.
Bae, S.H. (2011). Assessing the relationships between nurse working conditions and patient
outcomes: systematic literature review. Journal of Nursing Management, 19, 700-713. Hemingway, P. & Brereton, N. (2009). What is a systematic review?. Evidence-based Medicine.
(2nd ed.). What is…? Series. Retrieved on September 7, 2014 from
Polit, D.F. (2012). Nursing Research: Generating and Assessing Evidence for Nursing Practice.
(9th ed.) Wolters Kluwer Health Inc.
Stone, P.W., Mooney-Kane, C., & Larson, E.L. (2007). Nurse working conditions and patient
safety outcomes. Medical Care 45(6), 571-578.
The University of Texas at Austin. (2014). Retrieved from http://utexas.edu/nursing/faculty/profiles/baes