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Med Care. 2019 May;57(5):353-361. doi: 10.1097/MLR.0000000000001109.

A Meta-Analysis of the Associations Between the Nurse Work Environment in Hospitals and 4 Sets of Outcomes.

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Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA.
University of Vermont Medical Center, Burlington, VT.
Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, Philadelphia, PA.



The nurse work environment is theorized to influence the quality of nursing care, nurse job outcomes, and patient outcomes.


The aim of this meta-analysis was to evaluate quantitatively the association of the work environment with job and health outcomes.


Relevant studies published through September 2018 were identified. Inclusion criteria were use of a nationally endorsed work environment measure and reporting of odds ratios (ORs) and 95% confidence intervals from regression models of 4 outcome classes: nurse job outcomes, safety and quality ratings, patient outcomes, and patient satisfaction. Pooled ORs and confidence intervals were estimated for each outcome using fixed or random effects models.


Of 308 articles reviewed, 40 met inclusion criteria. After excluding 23 due to sample overlap or too few observations to meta-analyze, a set of 17 articles, comprising 21 independent samples, was analyzed. Cumulatively, these articles reported data from 2677 hospitals, 141 nursing units, 165,024 nurses, and 1,368,420 patients, in 22 countries.


Practice Environment Scale of the Nursing Work Index, a National Quality Forum nursing care performance standard.


Consistent, significant associations between the work environment and all outcome classes were identified. Better work environments were associated with lower odds of negative nurse outcomes (average OR of 0.71), poor safety or quality ratings (average OR of 0.65), and negative patient outcomes (average OR of 0.93), but higher odds of patient satisfaction (OR of 1.16).


The nurse work environment warrants attention to promote health care quality, safety, and patient and clinician well-being.

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