Work Environment Factors Related to Nurses' Attitude about Roles in Quality Improvement

Human factors and organizational culture have been two of the most frequently identified root causes of sentinel events as stated by The Joint Commission (2016). In an organizational culture of safety, errors and potential problems are viewed by administration through a lens of system-wide vulnerabilities. Healthcare workers feel less threatened when speaking up about patient care safety risks and have better attitudes about quality improvement efforts in an environment where openness and transparency are treasured as key elements. It was perceived that a blame-free work environment which enabled individuals to not only value competencies of safety and quality improvement, but voice concerns about errors or risks for error without reprimand or punishment (Barensteiner, 2011; Davis et al., 2016; AHRQ, 2014; Lyndon et al., 2015) would enable nurses to feel a sense of unity and perceive common values toward a culture of safety. Additionally, nurses who felt united in their efforts toward quality improvement could have a more positive fulfilling work related state of mind allowing them to engage in work activities with vigor and dedication.

A non-experimental correlational design was used to explore the relationships between quality improvement attitudes of nurses (belief in the value of safety and quality improvement competencies and feelings about the ability to voice concerns in the process toward quality improvement efforts) and two work environment factors of social capital (specifically perceived common values and trust and sense of unity) and work engagement. The study sample (n=69) were registered nurses in a southeastern United States hospital.

Data were collected utilizing an online web survey. Quality improvement attitude was measured using a reliable (Cronbach’s alpha coefficient of 0.93) and valid tool which was developed by the investigator. Social capital with respect to perceived common values and trust and sense of unity was measured using the reliable and valid Social Capital Scale (Ernstmann et al., 2012). Work engagement was measured using the reliable and valid Utrecht Work Engagement Scale (Schaufeli and Bakker, 2006).

Using correlational analysis, statistically significant relationships between quality improvement attitudes of nurses, social capital, and work engagement were found. Nurses who valued competencies of safety and quality improvement (QSEN, 2016), and felt their voice was heard while working in a culture of safety, had a positive fulfilling work relationship and perceived a sense of unity and trust among workers.

The study implied nurses who not only valued competencies of safety and quality improvement but also felt they were a part of a transparent environment where they could report errors and risk for patient safety had a greater sense of unity, perceive trust and common values, and had a greater positive and fulfilling work related state of mind. Previous studies indicated nurses who did not feel comfortable voicing concerns for risks of safety (Davis, Harris, Mahishi, Bartholomew, & Kenward, 2016; Lyndon et al., 2015) had not reported clinical situations in which patients were put at risk (Maxfield et al., 2013) suggesting their voice in the process of quality improvement might not have been heard. In addition, organizational cultures and nurses have accepted problems as common occurrences and feel powerless to influence practice of other nurses who deviate from standards of care (Lyndon et al., 2015). When healthcare workers feel organizational goals indicate patient safety as a priority, behaviors and attitudes which supported quality outcomes were evident and motivation to voice concerns is manifested (Weaver et al., 2013).

The full scope of this presentation is far reaching into the areas of nursing practice, education, and research. Clinical nursing administrators would find this interesting because it implies nurses have a greater sense of unity and more positive work state of mind when they perceive they have a voice in quality improvement efforts potentially leading to higher nurse retention rates. Nursing educators would be interested in knowing that teaching nursing students to value the QSEN competencies and to speak up when competencies are not being followed leads to positive attitudes toward quality outcomes and a fulfilling work experience. A limited amount of research is available which seeks to explore nursing attitudes about quality improvement efforts. Further studies should be conducted to explore factors centered around quality improvement nursing attitudes.