Good Work Environment for Nurses Correlates to Lower ICU Admission, Study Says

Hospitals with better nurse work environments appear to be more effective in providing surgical patient care in a lower acuity setting, analysis reveals.

Surgical patients in hospitals that offer better nurse work environments were less likely to end up in the intensive care unit (ICU) and less likely to die, according to a new study published in AACN Advanced Critical Care.

“Intensive Care Unit Utilization Following Major Surgery and the Nurse Work Environment,” which analyzed nearly 270,000 patient records in 453 hospitals, is the first study to directly link the nurse work environment to ICU use.

Its findings suggest that efforts to improve the work environment for nurses may reduce ICU utilization and avoid risks associated with ICU admissions.

Researchers examined Medicare beneficiaries undergoing general, orthopedic, or vascular surgical procedures between January 2006 and October 2007 and found that surgical patients in hospitals with good nurse work environments had:

• 16% lower odds of ICU admission
• 12% lower odds of in-hospital mortality
• 11% lower odds of dying within 30 days of hospital admission than patients in hospitals with mixed or poor nurse work environments.

"Hospitals with better nurse work environments may be better equipped to provide complex patient care in a lower acuity setting without compromising a patient’s odds of mortality," said co-author Anna Krupp, PhD, MSHP, RN, an assistant professor, University of Iowa College of Nursing.

"A key difference between ICUs and lower acuity units is the staffing ratio of patients to nurses. In the context of the COVID-19 pandemic, our findings suggest that a limiting factor in a hospital’s capacity to respond to the COVID-19 surges of critically ill patients is likely related to the quality of the nurse work environments prior to the pandemic," Krupp said. "Fewer additional ICU beds may have been needed if hospitals had good nurse work environments prior to the pandemic, with enough nurses to safely care for patients in lower acuity settings."

The nurse work environment was measured using the 31-item Practice Environment Scale of the Nursing Work Index, which is endorsed by the National Quality Forum, according to a press release from the American Association of Critical-Care Nurses.

Hospitals were then categorized as good (top 25%), poor (bottom 25%) or mixed, which were the 50% between the high and low scales.

Patients in the best nurse work environments had the lowest occurrence of ICU admission or 30-day mortality, while patients in hospitals with poor nurse work environments had the highest occurrence, according to the study.

Surgical patients in hospitals with good versus poor nurse work environments had:

• 29% lower odds of being admitted to an ICU
• 23% lower odds of in-hospital mortality
• 21% lower odds of 30-day mortality
• 28% lower odds of being admitted to an ICU or experience 30-day mortality.

Admission to an ICU varied significantly by surgical group, with vascular surgical patients having the highest use of ICUs (47.4%), followed by general (18.2%) and orthopedic (5.9%), the study said.

While hospital characteristics—number of beds, teaching status, and technology capabilities—varied significantly, the analysis revealed that those with the best nurse work environments were nonteaching hospitals with more than 250 beds.