Identification of elements of the practice environment that influence both nurse satisfaction and patient outcomes is an important area for nursing research. Several valid and reliable tools to measure the components of the practice environment have been developed by nurse researchers. The Practice Environment Scale and Job Enjoyment Scale are included in the National Database of Nursing Quality Indicators® (NDNQI®) RN Satisfaction Survey. In addition the NDNQI provides a database for participating hospitals to collect nurse-sensitive quality outcome data including catheter-associated urinary tract infection rates (CAUTI) for internal use and external benchmarking. All data are collected at the unit level providing opportunity for researchers to explore associations between the nurse work environment and measured quality outcomes.
Leiter and Laschinger (2006) posited the Nursing Worklife Model (NWLM) to explain how the elements identified in the practice environment are interrelated in the complex system of the nurse practice environment with subsequent work that extended the model to include association of nurse perception of patient adverse events. To date, researchers have primarily evaluated the impact of the practice environment on clinical outcomes using administrative data at the hospital or individual nurse level using nurse perceived adverse patient outcomes.
Exploration of the practice environment using the NWLM with catheter-associated urinary tract infections (CAUTI), an identified never event, is an important area for research. Care occurs at the work unit level where practice environments may vary. Study of relationships at the unit level with a measured clinical outcome extended previous hospital-level NWLM research. The purpose of this two-phased study was to fit the NWLM to unit level data, validate the fit of a modified NWLM from the first phase and extend the model to evaluate the association with CAUTI rate at the work unit level in acute care settings.
Methods:
A secondary data analysis of a national sample (N= 3,023) of critical care, step-down, medical, surgical, and combined medical-surgical units from the 2011 NDNQI® was used to fit the NWLM to the unit level data. The modified NWLM was then validated using a national sample, (N=1,106), of medical, surgical, and combined medical-surgical unit level data from the 2012 NDNQI® data. Using structural equation modeling (SEM), a modified NWLM of job enjoyment was confirmed and extended to include a unit level outcome measure, the annualized CAUTI rate from the matched units in the 2012 NDNQI® data.
Results:
Following indicated modifications to the NWLM pathways in the analysis of the 2011 data, additional significant paths were added to job enjoyment, staffing and resource adequacy, and foundations for quality care resulting in good model fit to the unit level data (CFI=.999; RMSEA=.059 [95% CI=.034 -.089]; SRMR=.002). Using the a priori model from 2011 data analysis, the modified NWLM at the unit level showed an excellent model fit (CFI =.995, RMSEA=.041 [95% CI=.028-.056]; SRMR=.020) to the 2012 NDNQI® unit level data. The results of the extension of the model to include the clinical outcome revealed a significant (p= <.01) negative pathway from job enjoyment to CAUTI rates (β= -.08). There were significant positive association of CAUTI rate with hospital characteristics that included Academic Medical Centers (β=.13) and hospitals greater than 500 beds (β=.07), indicating both had higher CAUTI rates.
Conclusion:
The validated model using unit level data supported the importance of the nurse practice environment in reducing negative clinical outcomes (i.e., CAUTI rates). The results demonstrated the importance of the unit practice environment based on the NWLM, for improving quality of care. In addition to emphasis on best clinical practice, strategies to support a culture of professional practice are indicated.
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