December, 2010 - SUPPORT Summary of a systematic review | print this article |

Improving the nursing work environment: identifying effective interventions

Nurses are an indispensable part of healthcare systems. The Nursing Work Environment (NWE) is defined as the context within which nurses provide their services, and includes infrastructural, management and social components. NWEs are vulnerable to the negative side-effects of restructuring and cost-saving drives, which may result in decreased levels of staff satisfaction and potentially negative patient outcomes. Although interventions for the improvement of NWEs have been proposed, few have been evaluated in terms of their effectiveness. 

Key messages

  • Interventions to improve the NWE may:
    - Improve leadership, autonomy, workload, clarity (degree of role specificity), professional development opportunities, innovation, participation in decision making, and recognition (respect, reward systems)
    - Improve or worsen teamwork
    - Improve or worsen workplace safety

Who is this summary for?

People making decisions concerning improvements of the nursing work environment.

This summary includes:

  • Key findings from research based on a systematic review
  • Considerations about the relevance of this research for low income countries

Not included:

  • Recommendations
  • Additional evidence not included in the systematic review
  • Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

Schalk DMJ, Bijl MLP, Halfens RJG, Hollands L, Cummings GG. Interventions aimed at improving the nursing work environment: a systematic review. Implement Sci 2010; 5:34. See in Implementation Science

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

Nurses are vital to the provision of safe care in healthcare systems. While NWEs offer opportunities for professional autonomy, recognition and development, cost-cutting exercises in healthcare systems or individual institutions may impact negatively. These negative impacts may include, for example, higher nurse/patient ratios, reduced professional and clinical support, increases in the number of non-nursing tasks undertaken, and the delegation of nursing tasks to nurses who have not yet been trained to perform them. Interventions to improve NWEs typically target one or a small number of the elements which constitute an NWE. While many interventions have been proposed, few have been evaluated in terms of their effectiveness.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.



About the systematic review underlying this summary

Review Objectives: To identify which interventions have been implemented to improve NWEs and how effective they were at improving them
/ What the review authors searched for What the review authors found
Interventions Interventions to improve the NWE

11 controlled intervention studies including:
8 before-after studies
3 intervention-control studies
Participants Nurses

Registered/licensed nurses (also: student nurse extenders, secretaries, unit leaders)
5 studies conducted in hospital settings
3 studies conducted in nursing homes
1 study conducted in a community healthcare institution
1 study conducted in a psychogeriatric clinic
1 study conducted in several healthcare workplaces
Settings Nursing workplace

5 studies from the United States of America (USA)
2 studies from the Netherlands
3 studies from Sweden
1 study from Norway
Outcomes

Teamwork; leadership; autonomy; workload; clarity; recogni-tion; physical comfort; flexible scheduling; organisational policies; professional development opportunities; salary, participation in decision making; innovation; workplace safety

Teamwork; leadership; autonomy; workload; clarity; recognition; professional development opportunities; participation in decision making; innovation; workplace safety
Date of most recent search: April 2008 (latest date of publication)

Limitations: This review has important limitations.
1. Only published studies (except doctoral dissertations) in English were included, the Cochrane Library was not searched and authors/experts were not contacted.
2. Results reporting and discussion are by intervention, not by outcome, and the effect size is not reported.

Schalk DMJ, Bijl MLP, Halfens RJG, Hollands L, Cummings GG. Interventions aimed at improving the nursing work environment: a systematic review. Implement Sci 2010; 5:34. See in Implementation Science

About the certainty of the 
evidence (GRADE)


High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.


Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.


Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.


Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

Eleven studies were included and these had been conducted in different types of healthcare institutions in the USA and Northern Europe. All studies were controlled intervention studies, and most used a before-after design. A variety of interventions and outcome manifestations were reported. In the findings overview, the outcomes were categorised using the NWE taxonomy proposed by the authors.

  • Teamwork may be improved through short-term participatory interventions, social support training, and individualised care and regular systematic clinical supervision. Teamwork may be improved or worsened by primary nursing (assignment of patients to a primary nurse), and may be worsened by shared governance
  • Leadership may be improved as a result of social support training, and by the educational toolbox of practical instruments for use at elderly care workplaces
  • Autonomy (empowering, professional identity) may be increased by primary nursing, the educational toolbox, and individualised care and regular systematic clinical supervision
  • The Workload of nurses (adequate staffing, work pressure) may be decreased by primary nursing, short-term participatory interventions, and the nursing practice quality circle (regular meetings of nurses to identify and discuss problems, and suggest solutions).
  • Clarity (degree of role specificity) may be improved by primary nursing and short-term participatory interventions
  • Professional development opportunities may be improved by short-term participatory interventions, the educational toolbox, and individualised care and regular systematic clinical supervision
  • Innovation (technological demands) may be improved by the nursing practice quality circle
  • Participation in decision making may be improved by the educational toolbox
  • Recognition (respect, reward system) may be improved by individualised care and regular systematic clinical supervision
  • Workplace safety may be improved or worsened by interventions to prevent violence

 

Interventions to improve the nursing work environment
Patients or population:  Nurses
Settings:  Nursing workplace (e.g. hospitals, other healthcare institutions)
Intervention: An intervention to improve the NWE (primary nursing, shared governance, social support and stress inoculation training, short-term participatory interventions, nursing practice quality circle, educational toolbox, individualised care and regular systematic clinical supervision, violence prevention intervention)
Comparison: No intervention (before intervention or control group)
Outcomes

Impact
Intervention: +/- outcome manifestation

 No of Participants
(studies)		 Quality of the evidence
(GRADE)		 Comments
Teamwork

Primary nursing, short-term participatory interventions:
+ Social support
Primary nursing: - Communication
Shared governance: - Intrapersonal conflicts
Social support and stress inoculation training: + Peer Cohesion
Individualised care and regular systematic clinical supervision:
+ Cooperation

424
(5 studies)

+ Significant improvement
- Significant deterioration
Leadership

Social support and stress inoculation training:
+ Supervisor support
Educational toolbox: + Leadership; + Performance feedback

317
(2 studies)
+ Significant improvement
Autonomy

Primary nursing: + (Job) Autonomy
Educational toolbox: + Participation
Individualised care and regular systematic clinical supervision:
+ Autonomy

 632
(4 studies)		 + Significant improvement
Workload

Primary nursing and Short-term participatory interventions:
+ Job demands
Nursing practice quality circle: + Work pressure

 286
(3 studies)		 + Significant improvement
Clarity

Primary nursing: + Resident assignment
Short-term participatory interventions:
+ Guidelines on how to do the job

 

 223
(2 studies)		 + Significant improvement
Professional development opportunities

Short-term participatory interventions: + Opportunity to develop
Educational toolbox: + Skills development
Individualised care and regular systematic clinical supervision:
+ Professional growth

 385
(3 studies)		 + Significant improvement
Innovation

Nursing practice quality circle:
+ Innovation

 63
(1 study)		 + Significant improvement
Participation in decision making Educational toolbox: + Participation 270
(1 study)		 + Significant improvement
Recognition

Individualised care and regular systematic clinical supervision:
+ Recognition

 39
(1 study)		 + Significant improvement
Workplace safety

Violence prevention intervention:
- Registration violent events;
+ Awareness of risk situations for violence;
+ Avoidance of potential dangerous situations;
+ Dealing with aggressive patients; + Perceived knowledge
+ Self-efficacy; + Violence prevention skills

 824
(2 studies)		 + Significant improvement
- Significant deterioration
p: p-value     GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
  • All included studies were conducted in HICs.  
  • NWE components, such as infrastructure, may be structurally different in LMICs and HICs. This may be due, for example, to resource constraints in LMICs or cultural differences. Evidence from HICs may therefore not be directly applicable to LMICs.
  • Nurses in LMICs often provide a wider range of services and have more responsibility than their peers in HICs.
  • The measured outcomes are very relevant to LMICs.
EQUITY
  • The review did not examine effects of the interventions on equity.
  • Nurses often lack authority within staff hierarchies, particularly female nurses in male-dominated societies. Interventions to improve NWEs should therefore be expected to improve equity.
  • Differences in baseline conditions in healthcare settings in LMICs (private vs. public; primary vs. secondary vs. tertiary level of care) will have an impact on the relative effectiveness of any intervention and its potential benefits.
ECONOMIC CONSIDERATIONS
  • The review did not provide information on the costs or cost-effectiveness of interventions.
  • The funds required to implement many interventions to improve NWEs may be unavailable in many LMICs. Funds to sustain them may also be lacking.
  • Nurse staffing costs are low in LMICs relative to other NWE budget costs (e.g. for drugs or infrastructure). In HICs, by contrast, nurse staffing costs often considerably higher. Therefore achieving cost-savings by cutting nursing staff numbers would be a lower priority in LMICs and a higher priority in HICs. Thus, there is limited scope for increased workloads due to staff cuts due to cost saving requirements.
MONITORING & EVALUATION
  • The review found that the effectiveness of interventions targeting salary, flexible scheduling and organisational policies has not been assessed.
  • The (cost-)effectiveness of interventions to improve NWEs needs to be formally evaluated.
  • The (cost-)effectiveness of interventions in LMICs to improve NWEs needs to be evaluated.
  • Interventions to improve NWEs should be monitored and the casuses of any negative effects identified.
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with
researchers and policymakers in low- and middle-income countries. For additional details about how these judgements were made see: http://supportsummaries.org/support-summaries/how-support-summaries-are-prepared/

Additional information

Related literature

Cummings G, Estabrooks CA: The effects of hospital restructuring that included layoffs on individual nurses who remained employed: A systematic review of impact. International Journal of Sociology and SocialPolicy 2003, 23:8-53.

Kennerly SM: Effects of shared governance on perceptions of work and work environment. Nursing Economics 1996, 14:111-116.

Latham L, Hogan M, Ringl K: Nurses supporting nurses. Creating a mentoring program for staff nurses to improve the workforce environment. Nurse Administration Quarterly 2008, 32:27-39.

Moos RH, Schaefer JA: Evaluating healthcare work settings. A holistic conceptual framework. Psychology and Health 1987, 1:97-122. 

O'Brien-Pallas L, Baumann A: Quality of nursing worklife issues – a unifying framework. Canadian Journal of Nurs-ing Administration 1992, 5:12-16. 

Van Wyk BE, Pillay – van Wyk . Preventive staff support interventions for health care workers. Cochrane Database of Systematic Reviews 2010, 3:CD003541. 

This summary was prepared by

Peter Steinmann, Swiss Tropical and Public Health Institute, Switzerland

Conflict of interest

None declared. For details, see: Conflicts of interest

Acknowledgements

This summary has been peer reviewed by: Greta Cummings, Canada and Victoria Pillay-van Wyk, South Africa

This summary should be cited as

Steinmann P. Improving the nursing work environment: which interventions work? A SUPPORT Summary of a systematic review. December 2010



About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

To receive e-mail notices of new SUPPORT summaries or provide feedback on this summary, go to: www.supportsummaries.org/contact

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