journal

HEALTH POLICY AND SYSTEMS

The Relationship Between Nurses’ Perception of WorkEnvironment and Patient Satisfaction in Adult Critical CareChristine Boev, PhD, RN, CCRN

Assistant Professor of Nursing, Wegmans School of Nursing, St. John Fisher College, Rochester, NY

Key wordsWork environment, patient satisfaction, patient

outcomes, multilevel modeling

CorrespondenceDr. Christine Boev, St. John Fisher College,

3690 East Ave., Rochester, NY 14618.

E-mail: [email protected]

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 amajor impact on hospital reimbursement. The critical care setting is character-ized by high patient acuity and a fast-paced work environment. Nurses’ per-ception of work environment in relation to various patient outcomes includingpatient satisfaction has not been explored exclusively in critical care.Objectives: (a) Examine patient’s perception of nursing care associated withtheir hospitalization in the intensive care unit. (b) Describe nurses’ percep-tion of work environment within a defined 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 environmentand patient satisfaction in adult critical care.Methods: This study used existing data to address the study aims. Unit-levelcomparisons were examined using analysis of variance. The final aim was ex-amined using multilevel modeling for longitudinal data.Results: Patients were very satisfied with their hospitalization (4.48 out of5.0). Significant differences were noted among all unit level comparisons (p <

.001). Nurses also reported moderate satisfaction with work environment asmeasured by the PES-NWI, with perception of the role of their nurse man-ager receiving the highest scores. Perception of nurse manager leadership andability was significantly related to patient satisfaction (p = .018). Favorableperception of the nurse manager was associated with a .424 point increase inpatient satisfaction.Conclusions: This study offers preliminary support for the relationship be-tween nurses’ perception of work environment and patient satisfaction in crit-ical care. It also highlights the pivotal role of the nurse manager in both nurseand patient satisfaction.Clinical Relevance: This study examines two important aspects that are bothrelevant and important to clinical nursing. The first aspect is the healthy workenvironment. Multiple studies have linked the nursing work environment topatient outcomes and this is an area that deserves further attention. The secondaspect, patient satisfaction, is now associated with hospital reimbursement. Therelationship between the nursing work environment and patient satisfactionhighlights an important link to improving patient care.

Healthcare systems across the United States now includepatient and family centered care (PFCC) as a priorityin their care delivery models. This initiative to incor-porate both patients and their family members as part-

ners in healthcare decision making comes on the heelsof the Institute of Medicines’ pivotal report, Crossing theQuality Chasm, where PFCC was identified as one of thesix priority areas for improving healthcare in the United

368 Journal of Nursing Scholarship, 2012; 44:4, 368–375.C© 2012 Sigma Theta Tau International

Boev Work Environment and Patient Satisfaction

States (Institute of Medicine, 2007). The Institute for Pa-tient and Family Centered Care (2012) identified four keyprinciples related to PFCC: dignity and respect, informa-tion sharing, participation, and collaboration. In recogni-tion of the importance of PFCC, the Centers for Medicareand Medicaid Services (CMS) developed a survey, theHospital Consumer Assessments of Healthcare Providersand Systems (HCAHPS), which is administered to hos-pitalized patients to assess level of patient satisfaction.Completion of this survey is mandated by the CMS, withthe consequence of noncompliance resulting in a 2% re-duction in payment from CMS (2011). Of concern to re-searchers is the newness of the HCAHPS survey and itslimited psychometric history, making its usefulness formeasuring care delivery outcome suspect until additionalreliability and validity testing is done.

Patient satisfaction in critical care is rarely measuredand is increasingly important to patients, who are theprimary external consumer and focus of customer ser-vice within the healthcare setting. Most patient satisfac-tion surveys are administered to patients after they havebeen discharged and reflect the care they received fromthe unit from which they were discharged. Because fewpatients are discharged to home from the intensive careunit (ICU), data pertaining to patient satisfaction withICU nursing care are limited. In addition, ICU patientstypically receive high doses of narcotics and sedativesand may have limited recall of the time spent in theICU. Due to the vulnerability and complexity of ICU pa-tients, critical care nurses bear a tremendous responsi-bility to optimize the patient’s well-being in a complexwork environment. Acutely ill patient populations arealso associated with higher nurse burnout and job dissat-isfaction (Embriaco, Papzian, Kentish-Barnes, Pochard,& Azoulay, 2007). Several researchers examined the re-lationship between the nursing work environment andadverse patient outcomes as well as patient satisfaction(Boyle, 2004; Manojlovich, Antonakos, & Ronis, 2009;Manojlovich & DiCicco, 2007).

The link between nurses’ perception of work envi-ronment and nurse-sensitive patient outcomes, nurseturnover, and burnout has been demonstrated in acutecare 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 aconcern in light of the projected nursing shortage, whichis estimated at 1 million nurses by the year 2020 (HealthResources Services Administration, 2004) and is expectedto hit critical care and other specialty areas the hardest.Because of the unique, fast-paced, and high-stress envi-ronments in critical care units, ICUs are disproportion-ately affected by high vacancy and turnover (AmericanNurses Association, 2009). This has a major impact on

the cost of health care, where the cost to replace oneacute care nurse is estimated to be $62,100 to $67,100(Jones, 2005). This instability also has significant poten-tial for negative impact on care delivery outcomes, withvacancy rates greater than 12% resulting in higher inci-dences of adverse effects (Aiken, Clarke, Sloane, Sochal-ski, & Silber, 2002). In addition, critical care nurses aremore prone to burnout, which has been linked to de-creased patient satisfaction and increased morbidity andmortality (Embriaco et al., 2007; Vahey et al., 2004). As aresult, strategies are needed to improve overall job satis-faction, thereby increasing nurse retention and commit-ment to the organization (Ingersoll, Olsan, Drew-Cates,Devinney, & Davies, 2002).

Patient satisfaction has been linked to nursing work en-vironment. One group of researchers examined patientsatisfaction data from HCAHPS surveys and found thatthe nurse work environment was positively related toall HCAHPS patient satisfaction measures (Kutney-Lee,McHugh, Sloane, Cimiotti, Neff, & Aiken, 2009). Thisfinding is an important indication of how the patients’negative perceptions of the nursing work environmentcan influence their overall level of dissatisfaction withtheir hospital experience. In addition, this study illus-trated the importance of perception of work environmentand its impact on patient satisfaction. It is important tofurther explore this relationship in critical care wherevery little was known about patient satisfaction.

The present study has three aims. The first was toexamine patients’ perception of nursing care associatedwith their hospitalization in the ICU using the IntensiveCare Unit Patient Satisfaction Survey. The second aimwas to describe nurses’ perception of work environmentwithin a defined sample of adult critical care units, usingthe Practice Environment Scale of the Nursing Work In-dex (PES-NWI). The final aim was to explore the relation-ships between nurses’ perception of work environmentand patient satisfaction in adult critical care using multi-level modeling (MLM) as the basis for statistical analysis.

Data and Methods

This secondary data analysis of longitudinal data exam-ined the relationship between nurses’ perception of workenvironment and patient satisfaction in adult critical care.A portion of the data used for this research was part of alarger study funded by the U.S. Department of Health andHuman Services (USDHHS) that instituted several inter-ventions aimed at improving the work environment offour adult ICUs in one hospital (Ingersoll, 2003). In ad-dition to nurse perception data, patient satisfaction datawere collected from patients discharged from one of the

Journal of Nursing Scholarship, 2012; 44:4, 368–375. 369C© 2012 Sigma Theta Tau International

Work Environment and Patient Satisfaction Boev

Table 1. Aggregated Nursing Demographics by Unit for Entire Study

Period

Unit A Unit B Unit C Unit D p (ANOVA)

Age

20–30 49 33 28 27 < .001∗

31–40 42 55 38 50

41–50 24 36 28 31

> 50 14 5 34 2

Race

American

Indian/Alaskan

1 3 1 1 < .001∗

Asian 0 4 0 3

Native Hawaiian 0 0 1 0

Black 2 0 0 1

White 122 121 120 103

More than one 3 1 3 1

Ethnicity

Hispanic/Latino 0 1 3 1 < .001∗

Non-Hispanic/Latino 101 95 92 81

Education

Diploma 6 7 10 4 < .001∗

AAS 20 7 30 19

BS/BA/BSN 24 31 28 23

BSN 54 68 40 45

MS, Nursing 12 13 17 18

MS, MA, not nursing 13 2 0 2

Doctoral degree 0 0 0 0

Level in CAS

Level 1 0 0 3 5 < .001∗

Level 2 130 76 105 82

Level 3 16 36 26 20

Level 4 18 15 14 15

Level 5 8 17 4 22

Level 6 0 2 0 0

LPN 0 0 12 0

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.

Significant if p < .05∗.

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

Sample

Six hundred seventy-one PES-NWIs were completedduring the study period. All nurses who completed thePES-NWI as part of the larger study were included in thisstudy. The sample of nurses consisted predominantly ofWhite women with Bachelor of Science degrees rangingin age from 20 years to over 60 years (Table 1). Othernurse characteristics included in the analysis were nurs-ing demographics such as age, race, highest level of ed-ucation, and level in the Clinical Advancement System.Unit-level comparisons were made using analysis of vari-

ance (ANOVA), with significant differences noted for allnursing characteristics among units.

All patients admitted to the critical care units duringthe study period were approached to complete the PatientSatisfaction Survey. If the patient was not able to com-plete the survey, a family member or healthcare proxywas approached. A total of 1,532 patient satisfactionsurveys were completed during the 5-year (2005–2009)study period, with 50.6% of the surveys completed bypatients. Patient satisfaction was measured using a newinstrument developed by Ingersoll (2004). Patient satis-faction was ranked by either the patient or a family mem-ber using a 5-point Likert scale, with 1 corresponding tostrongly disagree and 5 corresponding to strongly agree.

Setting

The setting for the study was a 750-bed university-affiliated tertiary hospital in Western New York. This hos-pital contained four adult ICUs, with sizes ranging from10 to 22 beds each. Included in the study were a medicalICU, a surgical ICU, a cardiothoracic ICU, and a burn-trauma ICU, all of which required specialized orientationand continued demonstration of competency for nursesworking in the units.

Measures

Practice Environment Scale of the Nursing WorkIndex. The PES-NWI, designed to measure character-istics within the nursing practice environment (Lake,2002), was a modification of the original NWI developedby Kramer and Hafner (1989). The NWI was based onthe original magnet hospital characteristics described byMcClure, Poulin, Sovie, and Wandelt (1983). These in-vestigators explored common attributes of hospitals thatwere successful in recruiting and retaining nurses amidsta serious nursing shortage in the 1980s. In 2002, Lakerevised the original NWI using a five-stage approach toshorten the scale from 66 to 31 items (Ingersoll, 2004).The PES-NWI has been used in multiple studies and set-tings and is considered a highly reliable and valid measureof 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 Percep-tion Survey (NPS), which contained five instruments thatmeasure various aspects of the work environment. Theoriginal PES-NWI is a 31-item instrument that uses a4-point Likert scale format (Ingersoll 2004). When in-corporated into the NPS, four items from the original in-strument (the collaborative practice items) were deletedand the Likert scale was modified to a 6-point scale. The



Table 2. Comparison of Reliability Analysis of the Practice Environment

Scale of the Nursing Work Index for This Study and Original

Internal Internal

consistency consistency

reliability reliability

Subscale (this study) (Lake, 2002)

Staffing and resource adequacy .85 .80

Nurse manager ability, leadership,

and support

.67 .84

Participation in hospital affairs .76 .83

Foundations for quality care .81 .80

Overall .91 .82

focus of the referent was changed from the organizationlevel to the unit level, and the collegial subscale was elim-inated because of the inclusion of a collaborative practicesubscale elsewhere in the survey. Table 2 summarizesthe internal consistency reliability results for the subscaleof the PES-NWI for this study compared with those re-ported by Lake (2002). The nurse manager subscale hadthe lowest Cronbach’s α (0.66), which was acceptable fora revised instrument (Devellis, 2003). This psychometricanalysis provides preliminary evidence of the validity ofthis instrument for measuring nurses’ perception of workenvironment in this sample.

Patient Satisfaction Survey. Patient satisfaction inthe ICU was measured by a survey constructed by In-gersoll (2004) and completed by patients and their fam-ily members (if the patient was unable to complete it).The 26-item instrument, which rates satisfaction withthe nurse, physician, and facilities, has been tested forinternal consistency reliability only. The coefficient α

is .92 for the overall scale and .92 for the 12-item nursesubscale. Internal consistency reliability estimates werecalculated using all patient satisfaction surveys collectedduring the original study (2005–2009). This survey wasused instead of the hospital’s Press Ganey patient satis-faction surveys, which were sent to patients according tothe unit from which they were discharged. Three of thefour ICUs did not typically discharge patients from theirunits. This study only examined 12 of the 26 items spe-cific to patients’ satisfaction with nursing care.

Data Analysis

Data were cleaned and checked for errors and miss-ing data prior to any analysis procedures. SPSS Windows(SPSS Version 17.0, SPSS Inc., Chicago, IL, USA) wasused for data analysis, with data from existing sources se-curely transferred into data files for protection of sourceand subjects’ rights. Data analysis procedures were di-rected to address each specific aim.

The independent variables of this study were nurses’perception of work environment as measured by thePES-NWI as well as unit-level covariates, includingregistered nurse (RN) skill mix, RN hours per pa-tient day, and voluntary turnover. Other indepen-dent variables included nursing demographics andeducation. The dependent variable was patient satisfac-tion.

Evaluation of the nurses’ perception of work envi-ronment was completed by examining data collectedby the PES-NWI from 2005 to 2009. Patient satisfac-tion data were examined by data collected using the Pa-tient Satisfaction Survey in the same ICU units duringthe same study period (2005–2009). Descriptive statisticswere used. Unit-level comparisons were examined usingchi-square, paired t-test, and ANOVA.

The final aim was examined using MLM for longitu-dinal data. This analysis accounted for longitudinal ef-fects over time (multiple observations from the sameunit). MLM was used to examine the potential rela-tionship between nurses’ perception of work environ-ment and patient satisfaction. The following process wasused to construct all multilevel models (Hox, 2002). First,multicollinearity among independent variables was in-vestigated, as well as examination of other assumptionsof MLM, including normally distributed dependent vari-ables, linear relationship between dependent and inde-pendent variables, and homoscedasticity (Tabachnick &Fidell, 2007). The assumptions of normally distributeddependent variables, linearity, and homoscedasticitywere met.

Bivariate analysis of both dependent and indepen-dent variables were examined to explore these relation-ships and investigate potential issues of multicollinearityamong independent variables. All independent variableswere entered into a multiple regression equation for eachdependent variable. Criteria to determine multicollinear-ity between independent variables was examined by as-sessing tolerance, variance inflation factor (VIF), and con-dition index. Variables with a tolerance level less than0.1 (Norusis, 2000), VIF greater than 10, and conditionindex greater than 30 (Belsley, Kuh, & Welsch, 1980),were taken out of the model because of suspected mul-ticollinearity. A final decision regarding which variablesto include in the final model was made based on sup-port in the literature regarding a potential relationshipand theoretical framework. Bivariate analyses were per-formed using SPSS mixed models for each independentvariable and each outcome. Independent variables signifi-cantly related to the outcome (p > .20) were then enteredin the final model for each outcome. An unstructuredcovariance structure was used for each model (Bickell,2007).



Table 3. Subscales of the Practice Environment Scale of the Nursing Work Index by Unit for Total Sample 2005–2009 (N = 671)

Unit A Unit B Unit C Unit D p

Subscale (mean/SD) (mean/SD) (mean/SD) (mean/SD) (ANOVA)

Staffing and resource adequacy 3.8/.97 3.7/.94 3.7/1.01 3.0/1.97 <.0001∗

Nurse manager ability 4.6/.99 4.7/.83 4.8/.80 4.4/1.71 .082

Participation 4.4/.77 4.5/.66 4.5/.76 4.6/1.20 .460

Foundations for quality 4.7/.51 4.6/.60 4.8/.57 4.6/.70 .087

Note. ANOVA = analysis of variance. Significant if p < .05∗.

Table 4. Subscales of the Practice Environment Scale of the Nursing Work Index by Year by Unit for Total Sample 2005–2009 (N = 671)

2005 2006 2007 2008 2009 p

(mean/SD) (mean/SD) (mean/SD) (mean/SD) (mean/SD) (ANOVA)

Staffing and resource adequacy 3.4/.90 3.9/.90 3.6/1.1 3.2/1.06 3.9/1.0 <.0001∗

Nurse manager ability 4.9/.82 4.7/.82 4.6/.93 4.5/1.10 4.6/1.90 .07

Participation 4.6/.73 4.5/.72 4.4/.82 4.3/.88 4.4/1.2 .14

Foundations for quality 4.8/.58 4.8/.49 4.6/.62 4.5/.65 4.6/.59 .001∗

Note. ANOVA = analysis of variance. Significant if p < .05∗.

Results

Table 3 summarizes scores on each subscale of thePES-NWI for each unit. For all units, the nurses’ percep-tion of their nurse manager and foundations for qualitycare received the highest scores. Significant differencesbetween units were noted for the staffing and resourceadequacy subscales. The subscales of the PES-NWI wereexamined for significant differences over the study pe-riod. Significant differences existed over time for thestaffing and resource adequacy and foundations for qual-ity care subscales (Table 4).

Table 5 lists the means and standard deviations foreach item for the entire sample. Overall quality of nursingcare received the highest score, with patient’s satisfactionof pain control receiving the second highest score. Pa-tient’s satisfaction with preparation for transfer from theICU received the lowest scores. A total patient satisfactionscore was computed for each survey, with higher scoresindicating higher levels of satisfaction. Significant differ-ences in patient satisfaction score were noted betweenunits for 2007 and 2008 (Table 6). In addition, significantdifferences were noted between units (which were theunit of analysis) for the total 5 years of the study period.

The final aim of this study was evaluated by examiningthe relationship between patient satisfaction and nurses’perception of work environment. A two-level multilevelmodel assessed the effect of nurses’ perception of workenvironment (as measured by the PES-NWI) on pa-tient satisfaction (Table 7). The level 1 variable includedperception of work environment measured by the NPSaggregated by unit by year. Level 2 was the unit. Percep-tion of nurse manager leadership and ability was signifi-

Table 5. Total Scores for Each Item of Patient Satisfaction Survey

(N = 1,532)

Item Mean SD

Overall quality of nursing care 4.5 3.15

Friendliness and courtesy of nursing staff 4.4 .80

Willingness of nurses to listen to your concerns and

options about your condition and treatment

4.3 .85

Availability of nursing staff to discuss your needs 4.2 .88

Clarity and completeness of answers to questions 4.3 .82

Control of pain 4.4 .79

Communication with others about your needs 4.2 .83

Preparation for transfer from intensive care unit 4.1 .89

The way health team members communicate and

work together

Inclusion of our family in decisions about your care 4.2 .93

Responsiveness of the nursing staff to your family’s

needs and concerns

4.3 .84

Responsiveness of the nursing staff to your personal

needs and concerns

4.2 .93

cantly related to patient satisfaction (p = .018). Favorableperception of the nurse manager was associated with a.424 point increase in patient satisfaction. The final modelhad nonsignificant intercepts and significantly differentresiduals between units. “Nonsignificant intercepts” sug-gests that the means do not vary more than what wouldbe expected by chance (Tabachnick & Fidell, 2007). “Sig-nificant residuals” means the occurrence of unexplained(error) variance remained at the unit quarter level on pa-tient satisfaction after adjusting for both level 1 and level2 predictors (Tabachnick & Fidell, 2007).



Table 6. Total Patient Satisfaction Scores Compared by Unit and Year (N = 1,532)

Unit A Unit B Unit C Unit D p

Year Mean (SD) Mean (SD) Mean (SD) Mean (SD) (ANOVA)

2005 4.2 (.23) 4.3 (.25) 4.2 (.26) 4.5 (.04) .26

N = 51 N = 72 N = 37 N = 86

2006 4.3 (.21) 4.3 (.34) 4.3 (.24) 4.1 (.39) .42

N = 93 N = 166 N = 130 N = 131

2007 4.2 (.25) 4.4 (.19) 4.1 (.19) 4.3 (.19) .009∗

N = 91 N = 93 N = 89 N = 79

2008 4.1 (.16) 4.4 (.21) 4.1 (.30) 4.3 (.34) .002∗

N = 92 N = 99 N = 87 N = 88

2009 4.0 (NA) 4.7 (NA) 4.4 (NA) 4.3 (NA) .09

N = 14 N = 14 N = 13 N = 12

Total 4.2 (.28) 4.4 (.26) 4.2 (.26) 4.2 (.29) <.001∗

N = 341 N = 444 N = 356 N = 348

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

Table 7. Results of Final TwoLevelMultilevelModel of Patient Satisfaction

(Practice Environment Scale [PES] of the Nursing Work Index)

CI CI

(lower (upper

Estimate bound) bound) p

PES Staffing subscale −.007 −.151 .136 .920

PES Nurse Manager subscale .424 .074 .775 .018∗

PES Participation subscale −.496 −1.13 .141 .102

PES Quality Care subscale .017 −1.31 .141 .127

Estimates of covariance

parameters residual

.066 .052 .083 <.0001

Intercept (random) .040 .002 .678 .487

−2 Log likelihood 37.32

Note. CI = confidence interval. Significant if p < .05∗.

Discussion

This study is one of the first toexamine patient satis-faction specifically in adult ICUs, where patient acuity ishigh and patients are often unable to complete surveys.Patient satisfaction in critical care is a relatively under-studied phenomenon because most measures of satisfac-tion have focused on the care delivery from which thepatient is discharged. Recent policy changes by the CMS,however, have attracted great interest in this topic be-cause patient satisfaction is now linked to hospital reim-bursement (CMS, 2011). A recent study examined familymembers’ (n = 729) perception of ICU care and reportedthat family members were most satisfied with nursingskill and less so with ICU atmosphere, control over care,and support for decision making (Osborn et al., 2012).The present study had similar findings that indicated apatient population that was very satisfied with the nurs-ing care. One of the highest scoring items in the patientsatisfaction survey was friendliness and courtesy of nurs-

ing staff. This is an important finding, which supports ini-tiatives aimed at improving customer service. Patients arenot always aware of a nurse’s technical ability or intelli-gence, but what is important is incorporating a smile andkindness into one’s nursing practice.

In addition to high patient satisfaction scores, this sam-ple of nurses reported favorable perception of their workenvironment as measured by the adapted PES-NWI. Thisfinding is consistent with the literature, where nursesworking in a magnet-designated hospital reported beingvery satisfied with their work environment (Ulrich, Nor-man, Beurhaus, Dittus, & Donelan, 2007). In fact, oneof the units was recently awarded the Beacon Awardthrough the American Association of Critical Care Nurses,which recognizes excellence in leadership, communica-tion, best practices, and patient outcomes (Ulrich, Woods,et al., 2007). Significant differences were noted overthe study period for the staffing and resource adequacysubscale as well as the foundations for quality of care.Concurrent analysis of these subscales revealed that thescores mirrored each other in terms of increases and de-creases. Nurses cannot provide high-quality patient carewithout sufficient resources.

In this study, nurses’ perception of the role of theirnurse manager was significantly related to patient satis-faction. Favorable perception of the nurse manager wasassociated with higher patient satisfaction scores. Thisfinding was consistent with a study by Kutney-Lee et al.(2009), who found that patient satisfaction, as measuredby the HCAHPS patient satisfaction survey, was signifi-cantly related to nurses’ perception of work environmentas measured by the PES-NWI, although the managerability subscale was not reported separately (Kutney-Lee,McHugh, Sloane, Cimiotti, Neff, & Aiken, 2009).

Interesting trends in both nursing and patient satis-faction scores were noted in one of the units. Trends in



patient satisfaction scores in Unit A showed a steady de-cline over the study period. Interestingly, nurses’ percep-tion of work environment also steadily declined over thestudy period for this unit. Further investigation of thisunit revealed changes in management over the course ofthe study period, with scores on the nurse manager sub-scale of the PES-NWI steadily decreasing over time. Thistrend was supported by an overall positive relationshipbetween favorable nurse perception of the nurse managerand favorable rating of patient satisfaction (p = .019).

Implications for Policy and Practice

This study provides preliminary support of the impor-tance of PFCC in acute care settings. Patient satisfactionhas become increasingly important, and hospitals muststrategize on how to best meet the needs of this acutelyill patient population. This sample of patients reportedhighest satisfaction with overall nursing care and thefriendliness and kindness of the nursing staff. It is im-portant to remind nurses that even on the most diffi-cult and overwhelming days, a kind gesture and a smilego a long way in improving patient satisfaction. The sig-nificant relationship between nurses’ perception of theirnurse manager and overall patient satisfaction suggeststhat hospitals may want to consider investing in improv-ing the nursing work environment and providing oppor-tunities to advance the leadership skills of nurse man-agers. As demonstrated in other studies, leadership andability of the nurse manger has been found to improvenursing satisfaction, yet the relationship between the ef-fective role of the nurse manager and patient outcomesrequires further exploration (Anthony et al., 2005; Boyle,Bott, Hansen, Woods, & Taunton, 1999; Hall, 2007).

The hierarchical data structure coupled with moder-ate intraclass correlation coefficients made MLM the mostappropriate choice for statistical analysis. MLM is a rela-tively newer form of statistical analysis, and strict guide-lines in terms of the process for model building and anal-yses are not yet in place. One potential limitation is thatthere were only four patient care units used in this anal-ysis. Despite this small number of units, MLM was themost appropriate statistical analysis to account for theclustering effect of observations over time within units.

Limitations

The research design of a secondary data analysis is alimitation because the data were not collected originallyto address the specific aims of the proposed study. An-other potential limitation is that this study is potentiallyunderpowered. Each variable was measured at a differ-ent frequency, resulting in various numbers of observa-

tions. The nature of this secondary analysis does not al-low this researcher to increase the sample size; therefore,sample size is a limitation of this study. Future studiesexploring the relationship between nurse perception andpatient outcomes should include a multisite longitudinalstudy with a larger number of units.

Other limitations include the fact that the nurse surveydata had some of the same nurses completing the surveyfor more than 1 year, which could potentially influencethe results. The patient satisfaction instrument has notbeen tested fully for psychometric characteristics and hasbeen used in one setting only. Overall generalizability ofthe findings is limited due to the study being restrictedto one setting. Despite these limitations, this study wasable to provide preliminary support for the relationshipbetween nurses’ perception of work environment and pa-tient satisfaction in adult critical care.

Acknowledgments

The study was approved by the University ofRochester Research Subject’s Review Board (Study #RSRB00032837) and supported by and American Asso-ciation of Critical Care Nurses and Sigma Theta Tau largecritical care grant.

Clinical Resources� American Nurses Credentialing 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-A-New-Health-System-for-the-21st-Century.aspx

� Institute for Patient and Family Centered Care:www.ipfcc.org

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