HEALTH POLICY AND SYSTEMS

The Relationship Between Nurses Perception of Work Environment and Patient Satisfaction in Adult Critical Care
Christine Boev, PhD, RN, CCRN
Assistant Professor of Nursing, Wegmans School of Nursing, St. John Fisher College, Rochester, NY

Key words Work environment, patient satisfaction, patient outcomes, multilevel modeling Correspondence Dr. Christine Boev, St. John Fisher College, 3690 East Ave., Rochester, NY 14618. E-mail: cboev@sjfc.edu Accepted: August 12, 2012 doi: 10.1111/j.1547-5069.2012.01466.x

Abstract
Background: Patient satisfaction in critical care is rarely measured yet has a major impact on hospital reimbursement. The critical care setting is characterized by high patient acuity and a fast-paced work environment. Nurses perception of work environment in relation to various patient outcomes including patient satisfaction has not been explored exclusively in critical care. Objectives: (a) Examine patients perception of nursing care associated with their hospitalization in the intensive care unit. (b) Describe nurses perception of work environment within a dened sample of adult critical care units, using the Practice Environment Scale of the Nursing Work Index (PES-NWI). (c) Explore the relationships between nurses perception of work environment and patient satisfaction in adult critical care. Methods: This study used existing data to address the study aims. Unit-level comparisons were examined using analysis of variance. The nal aim was examined using multilevel modeling for longitudinal data. Results: Patients were very satised with their hospitalization (4.48 out of 5.0). Signicant differences were noted among all unit level comparisons (p < .001). Nurses also reported moderate satisfaction with work environment as measured by the PES-NWI, with perception of the role of their nurse manager receiving the highest scores. Perception of nurse manager leadership and ability was signicantly related to patient satisfaction (p = .018). Favorable perception of the nurse manager was associated with a .424 point increase in patient satisfaction. Conclusions: This study offers preliminary support for the relationship between nurses perception of work environment and patient satisfaction in critical care. It also highlights the pivotal role of the nurse manager in both nurse and patient satisfaction. Clinical Relevance: This study examines two important aspects that are both relevant and important to clinical nursing. The rst aspect is the healthy work environment. Multiple studies have linked the nursing work environment to patient outcomes and this is an area that deserves further attention. The second aspect, patient satisfaction, is now associated with hospital reimbursement. The relationship between the nursing work environment and patient satisfaction highlights an important link to improving patient care.

Healthcare systems across the United States now include patient and family centered care (PFCC) as a priority in their care delivery models. This initiative to incorporate both patients and their family members as part368

ners in healthcare decision making comes on the heels of the Institute of Medicines pivotal report, Crossing the Quality Chasm, where PFCC was identied as one of the six priority areas for improving healthcare in the United
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States (Institute of Medicine, 2007). The Institute for Patient and Family Centered Care (2012) identied four key principles related to PFCC: dignity and respect, information sharing, participation, and collaboration. In recognition of the importance of PFCC, the Centers for Medicare and Medicaid Services (CMS) developed a survey, the Hospital Consumer Assessments of Healthcare Providers and Systems (HCAHPS), which is administered to hospitalized patients to assess level of patient satisfaction. Completion of this survey is mandated by the CMS, with the consequence of noncompliance resulting in a 2% reduction in payment from CMS (2011). Of concern to researchers is the newness of the HCAHPS survey and its limited psychometric history, making its usefulness for measuring care delivery outcome suspect until additional reliability and validity testing is done. Patient satisfaction in critical care is rarely measured and is increasingly important to patients, who are the primary external consumer and focus of customer service within the healthcare setting. Most patient satisfaction surveys are administered to patients after they have been discharged and reect the care they received from the unit from which they were discharged. Because few patients are discharged to home from the intensive care unit (ICU), data pertaining to patient satisfaction with ICU nursing care are limited. In addition, ICU patients typically receive high doses of narcotics and sedatives and may have limited recall of the time spent in the ICU. Due to the vulnerability and complexity of ICU patients, critical care nurses bear a tremendous responsibility to optimize the patients well-being in a complex work environment. Acutely ill patient populations are also associated with higher nurse burnout and job dissatisfaction (Embriaco, Papzian, Kentish-Barnes, Pochard, & Azoulay, 2007). Several researchers examined the relationship between the nursing work environment and adverse patient outcomes as well as patient satisfaction (Boyle, 2004; Manojlovich, Antonakos, & Ronis, 2009; Manojlovich & DiCicco, 2007). The link between nurses perception of work environment and nurse-sensitive patient outcomes, nurse turnover, and burnout has been demonstrated in acute care settings (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Stone et al., 2007; Vahey, Aiken, Sloane, Clarke, & Vargas, 2004), but not exclusively in critical care. This is a concern in light of the projected nursing shortage, which is estimated at 1 million nurses by the year 2020 (Health Resources Services Administration, 2004) and is expected to hit critical care and other specialty areas the hardest. Because of the unique, fast-paced, and high-stress environments in critical care units, ICUs are disproportionately affected by high vacancy and turnover (American Nurses Association, 2009). This has a major impact on
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the cost of health care, where the cost to replace one acute care nurse is estimated to be $62,100 to $67,100 (Jones, 2005). This instability also has signicant potential for negative impact on care delivery outcomes, with vacancy rates greater than 12% resulting in higher incidences of adverse effects (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). In addition, critical care nurses are more prone to burnout, which has been linked to decreased patient satisfaction and increased morbidity and mortality (Embriaco et al., 2007; Vahey et al., 2004). As a result, strategies are needed to improve overall job satisfaction, thereby increasing nurse retention and commitment to the organization (Ingersoll, Olsan, Drew-Cates, Devinney, & Davies, 2002). Patient satisfaction has been linked to nursing work environment. One group of researchers examined patient satisfaction data from HCAHPS surveys and found that the nurse work environment was positively related to all HCAHPS patient satisfaction measures (Kutney-Lee, McHugh, Sloane, Cimiotti, Neff, & Aiken, 2009). This nding is an important indication of how the patients negative perceptions of the nursing work environment can inuence their overall level of dissatisfaction with their hospital experience. In addition, this study illustrated the importance of perception of work environment and its impact on patient satisfaction. It is important to further explore this relationship in critical care where very little was known about patient satisfaction. The present study has three aims. The rst was to examine patients perception of nursing care associated with their hospitalization in the ICU using the Intensive Care Unit Patient Satisfaction Survey. The second aim was to describe nurses perception of work environment within a dened sample of adult critical care units, using the Practice Environment Scale of the Nursing Work Index (PES-NWI). The nal aim was to explore the relationships between nurses perception of work environment and patient satisfaction in adult critical care using multilevel modeling (MLM) as the basis for statistical analysis.

Data and Methods

This secondary data analysis of longitudinal data examined the relationship between nurses perception of work environment and patient satisfaction in adult critical care. A portion of the data used for this research was part of a larger study funded by the U.S. Department of Health and Human Services (USDHHS) that instituted several interventions aimed at improving the work environment of four adult ICUs in one hospital (Ingersoll, 2003). In addition to nurse perception data, patient satisfaction data were collected from patients discharged from one of the
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Table 1. Aggregated Nursing Demographics by Unit for Entire Study Period Unit A Unit B Unit C Unit D p (ANOVA) Age 2030 3140 4150 > 50 Race American Indian/Alaskan Asian Native Hawaiian Black White More than one Ethnicity Hispanic/Latino Non-Hispanic/Latino Education Diploma AAS BS/BA/BSN BSN MS, Nursing MS, MA, not nursing Doctoral degree Level in CAS Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 LPN < .001

49 42 24 14 1 0 0 2 122 3 0 101 6 20 24 54 12 13 0 0 130 16 18 8 0 0

33 55 36 5 3 4 0 0 121 1 1 95 7 7 31 68 13 2 0 0 76 36 15 17 2 0

28 38 28 34 1 0 1 0 120 3 3 92 10 30 28 40 17 0 0 3 105 26 14 4 0 12

27 50 31 2 1 3 0 1 103 1 1 81 4 19 23 45 18 2 0 5 82 20 15 22 0 0

< .001

ance (ANOVA), with signicant differences noted for all nursing characteristics among units. All patients admitted to the critical care units during the study period were approached to complete the Patient Satisfaction Survey. If the patient was not able to complete the survey, a family member or healthcare proxy was approached. A total of 1,532 patient satisfaction surveys were completed during the 5-year (20052009) study period, with 50.6% of the surveys completed by patients. Patient satisfaction was measured using a new instrument developed by Ingersoll (2004). Patient satisfaction was ranked by either the patient or a family member using a 5-point Likert scale, with 1 corresponding to strongly disagree and 5 corresponding to strongly agree.

< .001

Setting
The setting for the study was a 750-bed universityafliated tertiary hospital in Western New York. This hospital contained four adult ICUs, with sizes ranging from 10 to 22 beds each. Included in the study were a medical ICU, a surgical ICU, a cardiothoracic ICU, and a burntrauma ICU, all of which required specialized orientation and continued demonstration of competency for nurses working in the units.

< .001

< .001

Measures
Practice Environment Scale of the Nursing Work Index. The PES-NWI, designed to measure characteristics within the nursing practice environment (Lake, 2002), was a modication of the original NWI developed by Kramer and Hafner (1989). The NWI was based on the original magnet hospital characteristics described by McClure, Poulin, Sovie, and Wandelt (1983). These investigators explored common attributes of hospitals that were successful in recruiting and retaining nurses amidst a serious nursing shortage in the 1980s. In 2002, Lake revised the original NWI using a ve-stage approach to shorten the scale from 66 to 31 items (Ingersoll, 2004). The PES-NWI has been used in multiple studies and settings and is considered a highly reliable and valid measure of the nursing practice environment (Aiken & Sloane, 1997; Warshawsky & Havens, 2011). For the original study where these data were drawn, the PES-NWI was incorporated into the Nurse Perception Survey (NPS), which contained ve instruments that measure various aspects of the work environment. The original PES-NWI is a 31-item instrument that uses a 4-point Likert scale format (Ingersoll 2004). When incorporated into the NPS, four items from the original instrument (the collaborative practice items) were deleted and the Likert scale was modied to a 6-point scale. The
Journal of Nursing Scholarship, 2012; 44:4, 368375. C 2012 Sigma Theta Tau International

Note. AAS = Associates of Applied Sciences; BS = Bachelor of Science; BA = Bachelor of Arts; MS = Master of Science; MA = Master of Arts; CAS = Clinical Advancement System; LPN = Licensed Practical Nurse. Signicant if p < .05 .

four ICUs. Data for the original study were collected from January 1, 2004, through June 30, 2009.

Sample
Six hundred seventy-one PES-NWIs were completed during the study period. All nurses who completed the PES-NWI as part of the larger study were included in this study. The sample of nurses consisted predominantly of White women with Bachelor of Science degrees ranging in age from 20 years to over 60 years (Table 1). Other nurse characteristics included in the analysis were nursing demographics such as age, race, highest level of education, and level in the Clinical Advancement System. Unit-level comparisons were made using analysis of vari370

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Table 2. Comparison of Reliability Analysis of the Practice Environment Scale of the Nursing Work Index for This Study and Original Internal consistency reliability (this study) .85 .67 .76 .81 .91 Internal consistency reliability (Lake, 2002) .80 .84 .83 .80 .82

Subscale Stafng and resource adequacy Nurse manager ability, leadership, and support Participation in hospital affairs Foundations for quality care Overall

focus of the referent was changed from the organization level to the unit level, and the collegial subscale was eliminated because of the inclusion of a collaborative practice subscale elsewhere in the survey. Table 2 summarizes the internal consistency reliability results for the subscale of the PES-NWI for this study compared with those reported by Lake (2002). The nurse manager subscale had the lowest Cronbachs (0.66), which was acceptable for a revised instrument (Devellis, 2003). This psychometric analysis provides preliminary evidence of the validity of this instrument for measuring nurses perception of work environment in this sample. Patient Satisfaction Survey. Patient satisfaction in the ICU was measured by a survey constructed by Ingersoll (2004) and completed by patients and their family members (if the patient was unable to complete it). The 26-item instrument, which rates satisfaction with the nurse, physician, and facilities, has been tested for internal consistency reliability only. The coefcient is .92 for the overall scale and .92 for the 12-item nurse subscale. Internal consistency reliability estimates were calculated using all patient satisfaction surveys collected during the original study (20052009). This survey was used instead of the hospitals Press Ganey patient satisfaction surveys, which were sent to patients according to the unit from which they were discharged. Three of the four ICUs did not typically discharge patients from their units. This study only examined 12 of the 26 items specic to patients satisfaction with nursing care.

Data Analysis
Data were cleaned and checked for errors and missing data prior to any analysis procedures. SPSS Windows (SPSS Version 17.0, SPSS Inc., Chicago, IL, USA) was used for data analysis, with data from existing sources securely transferred into data les for protection of source and subjects rights. Data analysis procedures were directed to address each specic aim.
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The independent variables of this study were nurses perception of work environment as measured by the PES-NWI as well as unit-level covariates, including registered nurse (RN) skill mix, RN hours per patient day, and voluntary turnover. Other independent variables included nursing demographics and education. The dependent variable was patient satisfaction. Evaluation of the nurses perception of work environment was completed by examining data collected by the PES-NWI from 2005 to 2009. Patient satisfaction data were examined by data collected using the Patient Satisfaction Survey in the same ICU units during the same study period (20052009). Descriptive statistics were used. Unit-level comparisons were examined using chi-square, paired t-test, and ANOVA. The nal aim was examined using MLM for longitudinal data. This analysis accounted for longitudinal effects over time (multiple observations from the same unit). MLM was used to examine the potential relationship between nurses perception of work environment and patient satisfaction. The following process was used to construct all multilevel models (Hox, 2002). First, multicollinearity among independent variables was investigated, as well as examination of other assumptions of MLM, including normally distributed dependent variables, linear relationship between dependent and independent variables, and homoscedasticity (Tabachnick & Fidell, 2007). The assumptions of normally distributed dependent variables, linearity, and homoscedasticity were met. Bivariate analysis of both dependent and independent variables were examined to explore these relationships and investigate potential issues of multicollinearity among independent variables. All independent variables were entered into a multiple regression equation for each dependent variable. Criteria to determine multicollinearity between independent variables was examined by assessing tolerance, variance ination factor (VIF), and condition index. Variables with a tolerance level less than 0.1 (Norusis, 2000), VIF greater than 10, and condition index greater than 30 (Belsley, Kuh, & Welsch, 1980), were taken out of the model because of suspected multicollinearity. A nal decision regarding which variables to include in the nal model was made based on support in the literature regarding a potential relationship and theoretical framework. Bivariate analyses were performed using SPSS mixed models for each independent variable and each outcome. Independent variables signicantly related to the outcome (p > .20) were then entered in the nal model for each outcome. An unstructured covariance structure was used for each model (Bickell, 2007).
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Table 3. Subscales of the Practice Environment Scale of the Nursing Work Index by Unit for Total Sample 20052009 (N = 671) Unit A (mean/SD) 3.8/.97 4.6/.99 4.4/.77 4.7/.51 Unit B (mean/SD) 3.7/.94 4.7/.83 4.5/.66 4.6/.60 Unit C (mean/SD) 3.7/1.01 4.8/.80 4.5/.76 4.8/.57 Unit D (mean/SD) 3.0/1.97 4.4/1.71 4.6/1.20 4.6/.70 p (ANOVA) <.0001 .082 .460 .087

Subscale Stafng and resource adequacy Nurse manager ability Participation Foundations for quality

Note. ANOVA = analysis of variance. Signicant if p < .05 . Table 4. Subscales of the Practice Environment Scale of the Nursing Work Index by Year by Unit for Total Sample 20052009 (N = 671) 2005 (mean/SD) Stafng and resource adequacy Nurse manager ability Participation Foundations for quality 3.4/.90 4.9/.82 4.6/.73 4.8/.58 2006 (mean/SD) 3.9/.90 4.7/.82 4.5/.72 4.8/.49 2007 (mean/SD) 3.6/1.1 4.6/.93 4.4/.82 4.6/.62 2008 (mean/SD) 3.2/1.06 4.5/1.10 4.3/.88 4.5/.65 2009 (mean/SD) 3.9/1.0 4.6/1.90 4.4/1.2 4.6/.59 p (ANOVA) <.0001 .07 .14 .001

Note. ANOVA = analysis of variance. Signicant if p < .05 .

Results
Table 3 summarizes scores on each subscale of the PES-NWI for each unit. For all units, the nurses perception of their nurse manager and foundations for quality care received the highest scores. Signicant differences between units were noted for the stafng and resource adequacy subscales. The subscales of the PES-NWI were examined for signicant differences over the study period. Signicant differences existed over time for the stafng and resource adequacy and foundations for quality care subscales (Table 4). Table 5 lists the means and standard deviations for each item for the entire sample. Overall quality of nursing care received the highest score, with patients satisfaction of pain control receiving the second highest score. Patients satisfaction with preparation for transfer from the ICU received the lowest scores. A total patient satisfaction score was computed for each survey, with higher scores indicating higher levels of satisfaction. Signicant differences in patient satisfaction score were noted between units for 2007 and 2008 (Table 6). In addition, signicant differences were noted between units (which were the unit of analysis) for the total 5 years of the study period. The nal aim of this study was evaluated by examining the relationship between patient satisfaction and nurses perception of work environment. A two-level multilevel model assessed the effect of nurses perception of work environment (as measured by the PES-NWI) on patient satisfaction (Table 7). The level 1 variable included perception of work environment measured by the NPS aggregated by unit by year. Level 2 was the unit. Perception of nurse manager leadership and ability was signi372

Table 5. (N = 1,532) Item

Total Scores for Each Item of Patient Satisfaction Survey

Mean 4.5 4.4 4.3 4.2 4.3 4.4 4.2 4.1

SD 3.15 .80 .85 .88 .82 .79 .83 .89

Overall quality of nursing care Friendliness and courtesy of nursing staff Willingness of nurses to listen to your concerns and options about your condition and treatment Availability of nursing staff to discuss your needs Clarity and completeness of answers to questions Control of pain Communication with others about your needs Preparation for transfer from intensive care unit The way health team members communicate and work together Inclusion of our family in decisions about your care Responsiveness of the nursing staff to your familys needs and concerns Responsiveness of the nursing staff to your personal needs and concerns

4.2 4.3 4.2

.93 .84 .93

cantly related to patient satisfaction (p = .018). Favorable perception of the nurse manager was associated with a .424 point increase in patient satisfaction. The nal model had nonsignicant intercepts and signicantly different residuals between units. Nonsignicant intercepts suggests that the means do not vary more than what would be expected by chance (Tabachnick & Fidell, 2007). Signicant residuals means the occurrence of unexplained (error) variance remained at the unit quarter level on patient satisfaction after adjusting for both level 1 and level 2 predictors (Tabachnick & Fidell, 2007).
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Table 6. Total Patient Satisfaction Scores Compared by Unit and Year (N = 1,532) Unit A Mean (SD) 4.2 (.23) N = 51 4.3 (.21) N = 93 4.2 (.25) N = 91 4.1 (.16) N = 92 4.0 (NA) N = 14 4.2 (.28) N = 341 Unit B Mean (SD) 4.3 (.25) N = 72 4.3 (.34) N = 166 4.4 (.19) N = 93 4.4 (.21) N = 99 4.7 (NA) N = 14 4.4 (.26) N = 444 Unit C Mean (SD) 4.2 (.26) N = 37 4.3 (.24) N = 130 4.1 (.19) N = 89 4.1 (.30) N = 87 4.4 (NA) N = 13 4.2 (.26) N = 356 Unit D Mean (SD) 4.5 (.04) N = 86 4.1 (.39) N = 131 4.3 (.19) N = 79 4.3 (.34) N = 88 4.3 (NA) N = 12 4.2 (.29) N = 348 p (ANOVA) .26 .42 .009 .002 .09 <.001

Year 2005 2006 2007 2008 2009 Total

Note. ANOVA = analysis of variance; NA = not available. Signicant if p < .05 .

Table 7. Results of Final Two Level Multilevel Model of Patient Satisfaction (Practice Environment Scale [PES] of the Nursing Work Index) CI CI (lower (upper Estimate bound) bound) PES Stafng subscale PES Nurse Manager subscale PES Participation subscale PES Quality Care subscale Estimates of covariance parameters residual Intercept (random) 2 Log likelihood .007 .424 .496 .017 .066 .040 37.32 .151 .074 1.13 1.31 .052 .002 .136 .775 .141 .141 .083 .678

p .920 .018 .102 .127 <.0001 .487

Note. CI = condence interval. Signicant if p < .05 .

Discussion
This study is one of the rst toexamine patient satisfaction specically in adult ICUs, where patient acuity is high and patients are often unable to complete surveys. Patient satisfaction in critical care is a relatively understudied phenomenon because most measures of satisfaction have focused on the care delivery from which the patient is discharged. Recent policy changes by the CMS, however, have attracted great interest in this topic because patient satisfaction is now linked to hospital reimbursement (CMS, 2011). A recent study examined family members (n = 729) perception of ICU care and reported that family members were most satised with nursing skill and less so with ICU atmosphere, control over care, and support for decision making (Osborn et al., 2012). The present study had similar ndings that indicated a patient population that was very satised with the nursing care. One of the highest scoring items in the patient satisfaction survey was friendliness and courtesy of nursJournal of Nursing Scholarship, 2012; 44:4, 368375. C 2012 Sigma Theta Tau International

ing staff. This is an important nding, which supports initiatives aimed at improving customer service. Patients are not always aware of a nurses technical ability or intelligence, but what is important is incorporating a smile and kindness into ones nursing practice. In addition to high patient satisfaction scores, this sample of nurses reported favorable perception of their work environment as measured by the adapted PES-NWI. This nding is consistent with the literature, where nurses working in a magnet-designated hospital reported being very satised with their work environment (Ulrich, Norman, Beurhaus, Dittus, & Donelan, 2007). In fact, one of the units was recently awarded the Beacon Award through the American Association of Critical Care Nurses, which recognizes excellence in leadership, communication, best practices, and patient outcomes (Ulrich, Woods, et al., 2007). Signicant differences were noted over the study period for the stafng and resource adequacy subscale as well as the foundations for quality of care. Concurrent analysis of these subscales revealed that the scores mirrored each other in terms of increases and decreases. Nurses cannot provide high-quality patient care without sufcient resources. In this study, nurses perception of the role of their nurse manager was signicantly related to patient satisfaction. Favorable perception of the nurse manager was associated with higher patient satisfaction scores. This nding was consistent with a study by Kutney-Lee et al. (2009), who found that patient satisfaction, as measured by the HCAHPS patient satisfaction survey, was signicantly related to nurses perception of work environment as measured by the PES-NWI, although the manager ability subscale was not reported separately (Kutney-Lee, McHugh, Sloane, Cimiotti, Neff, & Aiken, 2009). Interesting trends in both nursing and patient satisfaction scores were noted in one of the units. Trends in
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patient satisfaction scores in Unit A showed a steady decline over the study period. Interestingly, nurses perception of work environment also steadily declined over the study period for this unit. Further investigation of this unit revealed changes in management over the course of the study period, with scores on the nurse manager subscale of the PES-NWI steadily decreasing over time. This trend was supported by an overall positive relationship between favorable nurse perception of the nurse manager and favorable rating of patient satisfaction (p = .019).

Implications for Policy and Practice

This study provides preliminary support of the importance of PFCC in acute care settings. Patient satisfaction has become increasingly important, and hospitals must strategize on how to best meet the needs of this acutely ill patient population. This sample of patients reported highest satisfaction with overall nursing care and the friendliness and kindness of the nursing staff. It is important to remind nurses that even on the most difcult and overwhelming days, a kind gesture and a smile go a long way in improving patient satisfaction. The signicant relationship between nurses perception of their nurse manager and overall patient satisfaction suggests that hospitals may want to consider investing in improving the nursing work environment and providing opportunities to advance the leadership skills of nurse managers. As demonstrated in other studies, leadership and ability of the nurse manger has been found to improve nursing satisfaction, yet the relationship between the effective role of the nurse manager and patient outcomes requires further exploration (Anthony et al., 2005; Boyle, Bott, Hansen, Woods, & Taunton, 1999; Hall, 2007). The hierarchical data structure coupled with moderate intraclass correlation coefcients made MLM the most appropriate choice for statistical analysis. MLM is a relatively newer form of statistical analysis, and strict guidelines in terms of the process for model building and analyses are not yet in place. One potential limitation is that there were only four patient care units used in this analysis. Despite this small number of units, MLM was the most appropriate statistical analysis to account for the clustering effect of observations over time within units.

tions. The nature of this secondary analysis does not allow this researcher to increase the sample size; therefore, sample size is a limitation of this study. Future studies exploring the relationship between nurse perception and patient outcomes should include a multisite longitudinal study with a larger number of units. Other limitations include the fact that the nurse survey data had some of the same nurses completing the survey for more than 1 year, which could potentially inuence the results. The patient satisfaction instrument has not been tested fully for psychometric characteristics and has been used in one setting only. Overall generalizability of the ndings is limited due to the study being restricted to one setting. Despite these limitations, this study was able to provide preliminary support for the relationship between nurses perception of work environment and patient satisfaction in adult critical care.

Acknowledgments
The study was approved by the University of Rochester Research Subjects Review Board (Study # RSRB00032837) and supported by and American Association of Critical Care Nurses and Sigma Theta Tau large critical care grant.

Clinical Resources r American Nurses Credentialing

r r r

Center: http:// www.nursecredentialing.org/Magnet.aspx Center for Medicare and Medicaid Services: http://www.hcahpsonline.org/home.aspx Institute of Medicine: http://www.iom.edu/ Reports/2001/Crossing-the-Quality-Chasm-ANew-Health-System-for-the-21st-Century.aspx Institute for Patient and Family Centered Care: www.ipfcc.org

References
Aiken, L. A., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse stafng and patient mortality, nursing burnout and job dissatisfaction. Journal of the American Medical Association, 288, 19871993. doi:10.1001/jama.288.16.1987 Aiken, L. A., & Sloane, D. M. (1997). Effects of specialization and client differentiation on the status of nurses: The case of AIDS. Journal of Health and Social Behavior, 38, 203222. American Nurses Association. (2009). Nursing facts: Nursing shortage. ANA Nursing World. Retrieved from http://
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Limitations
The research design of a secondary data analysis is a limitation because the data were not collected originally to address the specic aims of the proposed study. Another potential limitation is that this study is potentially underpowered. Each variable was measured at a different frequency, resulting in various numbers of observa374

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www.nursingworld.org/MainMenuCategories/ ThePracticeofProfessionalNursing/workplace/Workforce/ ShortageStafng/Shortage.aspx Anthony, M. K., Standing, T. S., Glick, J., Duffy, M., Paschall, F., Sauer, M. R., Dumpe, M.L. (2005). Leadership and nurse retention. The pivotal role of nurse managers. Journal of Nursing Administration, 35, 146155. Belsley, D. A., Kuh, E., & Welsch, R. E. (1980). Regression diagnostics: Identifying inuential data and sources of collinearity. New York: John Wiley & Sons. Bickell, R. (2007). Multilevel analysis for applied research. New York: Guilford Press. Boyle, D. K., Bott, M. J., Hansen, H. E., Woods, C. Q., & Taunton, R. L. (1999). Managers leadership and critical care nurses intent to stay. American Journal of Critical Care, 8, 361371. Boyle, S. M. (2004). Nursing unit characteristics and patient outcomes. Nursing Economic$, 22, 111123. Centers for Medicare and Medicaid Services. (2011). HCAHPS fact sheet. Retrieved from: http://www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments/ HospitalQualityInits/Downloads/ HospitalHCAHPSFactSheet201007.pdf Devellis, R. F. (2003). Scale development (2nd ed.). Thousand Oaks, CA: Sage. Embriaco, N., Papzian, L., Kentish-Barnes, N., Pochard, F., & Azoulay, E. (2007). Burnout syndrome among critical care healthcare workers. Current Opinion in Critical Care, 13, 482488. doi:10.1097/MCC.0b013e3282efd28a Hall, D. S. (2007). The relationship between supervisor support and registered nurse outcomes in nursing care units. Nursing Administration Quarterly, 31, 6880. Health Resources Services Administration. (2004). What is behind HRSAs projected supply, demand, and shortage of registered nurses? Retrieved from ftp://ftp.hrsa.gov/bhpr/ workforce/behindshortage.pdf Hox, J. J. (2002). Multilevel analysis. Mahwah, NJ: Lawrence Erlbaum Associates. Ingersoll, G. L. (2003). Transforming ICUs to retain staff & improve unit outcome. Project summary submitted to U.S. Department of Health and Human Services. Ingersoll, G. L. (2004). Intensive care unit patient satisfaction survey. Unpublished survey used with permission from author. Ingersoll, G. L., Olsan, T., Drew-Cates, J., Devinney, B., & Davies, J. (2002). Nurse satisfaction, affective commitment and career intent. Journal of Nursing Administration, 32, 250263. Institute for Patient and Family Centered Care. (2012). Basic principles for patient and family centered care. Retrieved from: http://www.ipfcc.org/advance/topics/basic.html Institute of Medicine. (2007). Preventing medication errors: Quality chasm series. Washington, DC: National Academies Press.
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Jones, C. (2005). The cost of nurse turnover, part 2. Journal of Nursing Administration, 35, 4149. Kramer, M., & Hafner, L. (1989). Shared values: Impact on staff nurse job satisfaction and perceived productivity. Nursing Research, 38(3), 172177. Kutney-Lee, A., McHugh, M.D., Sloane, D.M., Cimiotti, J.P., Neff, D.F., & Aiken, L.H. (2009). Nursing: A key to patient satisfaction. Health Affairs, 28, w669-w677. doi:10.1377/hlthaff.28.4.w669 Lake, E. (2002). Development of the Practice Environment Scale of the Nursing Work Index. Research in Nursing & Health, 25, 176188. doi:10.1002/nur.10032 Manojlovich, M., Antonakos, C. L., & Ronis, D. L. (2009). Intensive care units, communication between nurses and physicians, and patients outcomes. American Journal of Critical Care, 18, 2130. doi:10.4037/ajcc2009353 Manojlovich, M., & DiCicco, B. (2007). Health work environments, nurse-physician communication, and patients outcomes. American Journal of Critical Care, 16, 536543. McClure, M. L., Poulin, M. A., Sovie, M. D., & Wandelt, M. A. (1983). Magnet hospitals: Attraction and retention of professional nurses. Kansas City, MO: American Nurses Association. Norusis, M. J. (2000). SPSS advanced statistics users guide. Chicago: SPSS Inc. Osborn, T. R., Curtis, J. R., Nielson, E. L., Back, A. L., Shannon, S. E., & Engelberg, R. A. (2012, May 20). Identifying elements of ICU care that families report as important but unsatisfactory: Decision-making, control and ICU atmosphere. Chest (Online First). Retrieved from http://journal.publications.chestnet.org/article.aspx? articleid=1216061#tab1 doi:10.1378/chest.113277 Stone, P. W., Mooney-Kane, C., Larson, E. L., Pastor, D. K., Zwanziger, J., & Dick, A. W. (2007). Nurse working conditions, organizational climate, and intent to leave in ICUs: An instrumental variable approach. Health Services Research, 42, 10851104. doi:10.1111/j.14756773.2006.00651.x Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th ed.). Boston, MA: Pearson Education. Ulrich, B. T., Norman, L., Beurhaus, P. T., Dittus, R., & Donelan, K. (2007). Magnet status and registered nurse views of work environment and nursing as a career. Journal of Nursing Administration, 37, 212220. Ulrich, B. T., Woods, D., Hart, K. A., Lavandero, R., Leggett, J., & Taylor, D. (2007). Critical care nurses work environments value of excellence in beacon units and magnet organizations. Critical Care Nurse, 27, 6877. Vahey, D. C., Aiken, L. H., Sloane, D. M., Clarke, S. P., & Vargas, D. (2004). Nurse burnout and patient satisfaction. Medical Care, 42, II-57II-66. doi:10.1097/01.mlr.0000109126.50398.5a Warshawsky, N. E., & Havens, D. S. (2011). Global use of the Practice Environment Scale of the Nursing Work Index. Journal of Nursing Administration, 60, 1731. doi:10.1097/NNR.0b013e3181ffa79c
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