Abstract
The rapidly aging population and their frequent use of hospital services will create substantial quality challenges in the near future. Redesigning rural hospital work environments is the key to improving the quality of care for older adults. This study explored how the work environment influences registered nurses’ (RNs’) perceived quality of geriatric care in rural hospitals. We used an exploratory mixed-methods research design emphasizing the qualitative data (in-depth, semi-structured interviews). Quantitative data (questionnaire) measuring the RN work environment were also collected to augment qualitative data. Four themes emerged: (a) collegial RN relationships, (b) poor staffing/utilization, (c) technology benefits/challenges, and (d) RN–physician interactions, which were identified as key factors influencing the quality of geriatric care. We concluded that rural hospital work environments may not be optimized to facilitate the delivery of quality geriatric care. Targeted interventions are needed to improve overall quality of care for hospitalized older adults in rural settings.
Keywords
The rapidly growing older adult population will create unique and significant challenges for the U.S. health care system overall, especially for small, rural hospitals with limited resources and health care providers (Institute of Medicine [IOM], 2005). Approximately 50% of all rural hospital inpatient admissions are comprised of older adults, and the number of discharges in rural hospitals for those aged 85 years or older is almost double the rate of urban hospitals (Hall, Owings, & Shinogle, 2006). Rural hospitals face challenges due to their small size, financial constraints, low volume of procedures, and lack of information technology (IT) infrastructure (Moscovice & Rosenblatt, 2000). Hospitalized older adults are at a high risk of adverse events and the shortage of registered nurses (RNs) and poorly designed systems and models of care contribute to these events (IOM, 2004, 2008). A better understanding of how rural hospital work environments influence and contribute to quality geriatric care is essential for the development of innovative, affordable, and sustainable care models that improve the care for our vulnerable and rapidly growing older adult population.
The nurse work environment is a complex and multidimensional construct (Lake, 2002). Redesigning rural hospital work environments is the key to improving the quality of care for hospitalized older adults. One example of how to redesign the hospital work environment to improve care is to create and implement nursing care models that better address the needs of hospitalized older adults—the primary consumers of hospital services. Redesigning and transforming the work environment of hospitals with a focus on the needs of hospitalized older adults can have a positive impact on the quality of care they receive (Guthrie, Edinger, & Schumacher, 2002; Inouye, Bogardus, Baker, Leo-Summers, & Cooney, 2000; Pfaff, 2002). To redesign rural hospital work environments, a better understanding of how the work environment influences and contributes to quality geriatric care in these unique settings is needed.
A significant body of evidence demonstrates the important relationships between the work environment and nurse, patient, and organizational outcomes (Aiken et al., 2011; Baernholdt & Mark, 2009; Djukic, Kovner, Brewer, Fatehi, & Cline, 2011). Qualitative studies have identified work environment themes such as (a) teamwork, (b) access to resources, (c) time constraints, and (d) technologies that support communication and documentation as important for the delivery of quality patient care (Baernholdt, Jennings, Merwin, & Thornlow, 2010; Cline, Rosenberg, Kovner, & Brewer, 2011). Quantitative studies have demonstrated that positive perceptions of the work environment are associated with higher perceived quality of care (Aiken, Clarke, & Sloane, 2002; Djukic et al., 2011).
Unfortunately, many of these studies do not examine the work environment specific to quality care of older adults. Older adults are at an increased risk of adverse events (Anpalahan & Gibson, 2008; Sager et al., 1996) and may be particularly sensitive to the work environment; therefore, research is needed to examine work environment factors specific to quality care of hospitalized older adults. Limited studies have examined the work environment and perceived quality of geriatric care (Boltz et al., 2008; Kim, Capezuti, Boltz, & Fairchild, 2009). A study by Boltz et al. (2008) examined relationships between work environment factors specific to quality geriatric care using a sample of nurses from non-rural hospitals (community hospitals and metropolitan hospitals). In this study, they found significant, positive relationships between the geriatric-specific work environment factors and perceived quality of geriatric care.
Kim et al. (2009) examined relationships between constructs of the work environment and perceived quality of geriatric care using a sample of non-rural nurses. Work environment measures for this study were dichotomized into the general work environment, measured by the Practice Environment Scale of the Nursing Work Index (PES-NWI; Lake, 2002), and the geriatric-specific work environment, measured by the Geriatric Care Environment Scale (GCES; Boltz et al., 2008), an emerging measure of the work environment specific to quality care of older adults. Kim and colleagues (2009) found that the general work environment was negatively related to quality geriatric care (p < .001; r2 = .24), but the geriatric work environment was positively related to quality geriatric care (p < .001; r2 = .39) and explained about 15% more of the variability in quality. Only one of the general work environment subscales was positively related to quality geriatric care and two subscales were negatively related; all three geriatric work environment subscales were positively related to the perceived quality of geriatric care. This may indicate that the work environment required to deliver quality care to older adults is different from the work environment needed to deliver quality of care to younger and middle-aged adults.
These studies (Boltz et al., 2008; Kim et al., 2009) provide evidence regarding the relationships between the geriatric-specific work environment and perceived quality of geriatric care in non-rural hospitals. However, a gap in the literature still exists regarding the work environment of rural hospitals and the quality of geriatric care. Understanding how the work environment influences the quality geriatric care in rural hospitals is important as more than half of all inpatient admissions are comprised of older adults and the number of discharges for patients aged 85 years or older is almost double that of urban hospitals (Hall et al., 2006).
Another gap in many studies of the nurse work environment is the limited number of constructs measured. Many studies examining the work environment and quality of care examine constructs found in the PES-NWI: (a) nurse manager ability, (b) collegial nurse–physician relations, (c) staffing and resource adequacy, (d) nurse participation in hospital affairs, and (e) nursing foundations for quality of care. Given the complex nature of the work environment, additional measures of the work environment allow for a more complete understanding of how the work environment influences the quality of care. Important findings from a 10-year longitudinal study of organizational factors affecting newly licensed RNs’ work behaviors (Kovner et al., 2007; Kovner, Brewer, Greene, & Fairchild, 2009) have shown that job satisfaction, organizational commitment, procedural justice, organizational constraint, and workgroup cohesion are also related to perceived quality of care (Djukic et al., 2011). Investigations of the work environment and quality of care would benefit from having these constructs included to provide a better understanding of the complex nature of the work environment.
Purpose
Limited evidence exists related to how the work environment influences the quality of geriatric care in rural hospitals. Focusing specifically on RNs working in rural hospitals, the purpose of the study was to explore how the work environment influences nurse perceived quality of geriatric care. The study used a mixed-methods approach with an emphasis on the qualitative data. The qualitative component of the study sought to answer the following research questions:
The quantitative component of the study sought to measure work environment factors associated with quality care using valid and reliable instruments that would augment the primary qualitative data.
Method
Overview of Mixed-Methods Design
A concurrent, embedded mixed-methods research design that emphasized the qualitative interview data (QUAL) over the quantitative questionnaire data (quan) was used. The mixed-methods research design, QUAL + quan, allowed the research team to augment and supplement the qualitative data with quantitative data adding value to the findings that would be absent if only one type of research approach were used (Creswell & Plano-Clark, 2007).
Setting and Sample
Three rural New York hospitals participated in the study as recruitment sites. The hospitals ranged in size from 50 to 150 staffed beds and the number of Medicare inpatients ranged from approximately 1,100 to 1,500 per year. Total patient revenues for the hospitals ranged from US$80 million to US$170 million (American Hospital Directory, 2011). Each hospital offered a range of clinical services including radiology, emergency, intensive care, orthopedics, general medical, and general surgical units. All three hospitals were located in counties with an urban influence code of 8, meaning that the counties were not adjacent to a metropolitan area and contained a town of between 2,500 and 9,999 residents (Hart, Larson, & Lishner, 2005). A purposive sample of nurses, working on either general medical, general surgical, or mixed use medical/surgical units within each hospital, were invited to participate in the study. The study was approved by the New York University Committee on Activities Involving Human Subjects.
Qualitative Data Collection and Analysis
Consistent with the aims of this mixed-methods study, QUAL data were prioritized. Qualitative descriptive methods were used to collect and analyze the data (Sandelowski, 2000). After obtaining signed informed consent, semi-structured interviews with nurses were conducted on-site at each hospital. We used a maximum variation sampling approach to facilitate a broad and diverse range of participants’ views. The goal was to interview at least one nurse at each hospital who (a) had less than 2 years of experience (Benner, 1984)—nurses with more experience and skills perceive clinical situations differently than novice nurses; (b) held a bachelor’s degree in nursing (Aiken et al., 2011)—there have been associations identified with quality of care and level of education; (c) had worked at a large urban medical center (Baernholdt & Mark, 2009)—rural practice has unique challenges and culture; and (d) was in a leadership position (Gormley, 2011)—leaders often perceive quality different from bedside nurses. Field notes supplemented the recorded interviews and data collection continued until saturation was achieved, which occurred with a sample size of 31.
Interviews focused on how the work environment influenced the quality of geriatric care on nurses’ respective units. Open-ended questions and probes were used to gather data, clarify responses, and go deeper into the meaning of comments. Interview included statements and questions such as, “Tell me about the quality of geriatric care on you unit” and “Can you tell me about a time when an older adult received quality care on your unit?” Interviews lasted approximately 25 to 55 min, were recorded for accuracy, and reviewed by the first author (D.D.C.) daily to ensure that the interview guide and techniques elicited deep, rich responses. Any identifying information received during the interview process, such as names and telephone numbers, were not transcribed.
Interviews were tape recorded and transcribed verbatim, with 100% accuracy. Qualitative content analysis (Krippendorff, 2004) was used to analyze the narratives of each participant. Transcripts were read multiple times so that the first author (D.D.C.) became well acquainted with the data, getting a sense of the whole. Coding of the data began using a priori codes derived from the quality of care framework developed by Aiken, Sochalski, and Lake (1997) and modified by Boltz et al. (2008), which links organizational characteristics, the nurse work environment, and quality of geriatric care. A priori codes included such codes as nurse manager ability, IT, staffing and resources, and institutional values regarding older adults. A priori coding was followed by open coding techniques to discover new patterns and emerging themes. Codes were grouped into subthemes with similar characteristics or meaning and then synthesized to create more abstract themes. Qualitative analysis software ATLAS.ti (Scientific Software Development, 2006) facilitated coding and clustering of the data.
Several procedures were followed to increase the trustworthiness of the qualitative findings (Lincoln & Guba, 1985) and provide an audit trial, including reflexivity, field notes, expert/peer review, and use of analytic memos. In addition, independent coding of a subset of interview data by a second researcher was conducted. These codes were compared with the principal investigator’s coding and discussed until agreement was reached on a final coding scheme. The second coder also independently coded another subset of interview data using the agreed upon codes, and greater than 80% intercoder agreement was achieved.
Quantitative Data Collection and Analysis
At the conclusion of each interview, participants were given a packet with instructions on how to complete and return the questionnaire using the self-addressed, return envelope. The questionnaire contained 34 multiple-choice and Likert-type questions, four fill in the blank questions, and one open-ended question.
General work environment
The general work environment was measured using the PES-NWI (Lake, 2002). The instrument has good validity and internal reliability, with Cronbach’s alpha scores for all subscales above .71(Lake, 2002). The original PES-NWI contains 31 items and five subscales: (a) nurse manager ability, (b) collegial nurse–physician relations, (c) staffing and resource adequacy, (d) nurse participation in hospital affairs, and (e) nursing foundations for quality of care. A new subscale for the PES-NWI was developed in 2010 that measures (f) nurses’ perceptions of IT (Moorer, Meterko, Alt-White, & Sullivan, 2010). The Information Technology scale was used to ensure that this emerging area of the work environment was captured in the study. Subscale responses ranged from 1 = strongly disagree to 4 = strongly agree.
The study also included five additional measures of the work environment: job satisfaction, organizational commitment, organizational constraint, workgroup cohesion, and procedural justice. Each scale has good validity and reliability (Kovner et al., 2007) and is frequently used in research exploring the work environment and nurse work behaviors (see www.rnworkproject.org).
Geriatric-specific work environment
The geriatric work environment is a specific component of the overall work environment and is conceptualized as unique aspects of the work environment that contribute specifically to quality geriatric care (Abraham et al., 1999).The geriatric work environment was measured using the GCES of the Geriatric Institutional Assessment Profile (GIAP; Abraham et al., 1999). The GIAP measures a hospital’s readiness to provide high-quality geriatric care, whereas the GCES “represents a healthcare professional’s perceptions of how care provided to older adults reflects age-sensitive principles and the organizational practice environment that supports or hinders care delivery” (Kim et al., 2007, p. 341). The GCES contains four subscales: (a) institutional values regarding older adults (0 = strongly disagree, to 4 = strongly agree), (b) capacity for collaboration (0 = does not interfere, to 4 = greatly interferes), (c) geriatric resource availability (0 = somewhat interferes, to 4 = greatly interferes), and (d) aging sensitive care delivery (ASCD; 0 = not very satisfied, to 4 = very satisfied; Kim et al., 2007). Previous studies (Boltz et al., 2008; Kim et al., 2009) have used only the institutional values regarding older adults, capacity for collaboration, and geriatric resource availability subscales as a composite described as the Geriatric Nurse Practice Environment.
The subscale institutional values regarding older adults measures nurses’ perceptions of “leadership support for staff involvement in decision-making, respect for the rights of older patients, collegial decision making between staff and administration, and support for the personal growth of nurses” (Boltz et al., 2008, p. 284). Capacity for collaboration measures nurses’ perceptions of “geriatric knowledge among all disciplines, use of interdisciplinary aging-specific protocols, and the degree of conflict around care of older patients” (Boltz et al., 2008, p. 284). Geriatric resource availability measures nurses’ perceptions of "staffing, availability of equipment and services specific to the needs of older adults, and management support in communicating with families and older patients” (Boltz et al., 2008, p. 284). Aging-sensitive care delivery measures the extent to which nurses perceive that care is “geriatric-specific, evidence-based, individualized care that promotes informed decision-making and is continuous across settings” (Boltz et al., 2008, p. 285). The subscales have demonstrated good reliability with Cronbach’s alpha scores (Kim et al., 2007) above .83.
Quality of care
General quality of patient care was measured with two Likert-type questions (Aiken et al., 2002). Participants were asked to rate (a) whether patients received high-quality care at their hospital (1 = strongly disagree to 4 = strongly agree) and (b) whether patients received high-quality care on their units (1 = strongly disagree to 4 = strongly agree). The ASCD subscale of the GCES was used as a measure of the quality of geriatric-specific care.
Analysis
Quantitative data were analyzed using IBM SPSS Statistics 19 (2010). Missing data were imputed using simple mean imputation methods. Screening of the data began with univariate descriptive statistics of the variables, including frequencies, measures of central tendency, and dispersions. This was followed by calculation of scores for each of the scales and subscales.
Integrating Quantitative Data With Qualitative Data
Qualitative and quantitative data were analyzed independently, followed by triangulation and integration of the data. The integrated analysis began by entering each type of data (qualitative and quantitative) into an informational matrix to portray the data together (Creswell & Plano-Clark, 2007). Using triangulation methods, the quantitative scores from the PES-NWI and the GCES subscales were examined in relation to the primary themes that emerged from the qualitative data exploring how the work environment influences the quality of geriatric care in rural hospitals.
Results
A total of 26 (84%) nurses who participated in an interview completed and returned the questionnaire. Demographics and quantitative results are based on returned questionnaires (n = 26; see Table 1), while qualitative results are based on the completed interviews (N = 31). The emphasis of the study was on the qualitative data. There were no substantive differences in themes that emerged among the three hospitals and all data, both qualitative and quantitative, were analyzed in aggregate. The average age of the participants was 41 years and the majority of the participants identified themselves as a White, non-Hispanic (96%), and female (92%).
Participant Demographics (N = 31).
Qualitative Themes
Four themes emerged from the qualitative data: (a) collegial RN relationships, (b) poor staffing/utilization, (c) technology benefits/challenges, and (d) RN–physician interactions. All themes emerged in response to how the nurse’s work environment influenced the quality of geriatric care.
Collegial RN relationships
The importance of strong, collegial relationships and a sense of community were viewed as essential to quality geriatric care, “ . . . Everyone is very willing to help each other out. I think nurses take very good care of their elderly patients.” When nurses were asked, “What works best on your unit?” the sense of community as it related to better patient care was expressed:
We help each other out. We are not like, “Oh I am not going to answer your call light.” I think that’s probably the most important thing. We don’t only stick to our patients; we help each other out for sure.
Camaraderie and teamwork that extend to extramural activities (e.g., dinners, team sports) also indicated a sense of community, “It’s like coming to work with your family,” and fostered a sense of workplace support. This theme was also reflected in expressions of satisfaction and commitment to their units, “I just enjoy where I work and the people I work with so much . . . ” Community and collegial relationships also influenced the quality of geriatric care, because it allowed nurses to feel comfortable asking for help and reassured them, because they knew help was always available. One nurse stated,
. . . I am confident that if I come into trouble, all I got to do is yell and somebody is there. I also know that if a patient is in trouble all I have to do is yell and someone is there.
Nurses also talked about teamwork in non-urgent situations that improved quality by facilitating continuity of care.
Poor staffing/utilization
Staffing was considered important to the quality of geriatric care and was seen by many participants to be inadequate in two ways: (a) too few staff for the acuity of the patients and (b) too few nurse aides. For example, one participant noted what she liked least about her unit was “the patient loads.” Nurses described frustration in the perception that “administration” staffed units according to the number of patients rather than acuity of patients: “ . . . Patients are becoming more complex and this affects the bedside nurse . . . we’re seeing a lot of patients that need more intense nursing care . . . ”
The importance of nurse aides was frequently mentioned as critical to staffing needs, the quality of geriatric care, and assistance with activities of daily living (ADL): “ . . . the 80 year old patient who maybe can’t get out of bed by themselves . . . who really needs assistance or supervision for ambulation or going to the bathroom . . . ” The nurses also recognized the presence of a nursing aide as instrumental in keeping patients safe: “It definitely affects [quality of care], because [the patient] will either lay there in bed needing us, or try to get up and move and fall.” When nurse aides were absent, quality of care was perceived as diminished because there is “ . . . not enough time to spend with the patients to make sure that their teeth are brushed and hair combed, the wrinkles taken out of their bed.”
Nurse aides were also seen as important team members who changed the work environment by facilitating the nurses’ ability to perform high-level critical thinking processes essential to quality care of older adults. One nurse explained the contribution that nurse aides make in the following way: It’s imperative to have aides . . . every elderly person needs to walk to the bathroom . . . might need extra skin care . . . as an RN doing the meds you are trying to forward think if they are crashing or not!
Technology benefits/challenges
Two topics emerged related to the work environment, quality geriatric care, and IT: (a) improved quality and (b) impact on efficiency. Nurses’ perceived IT to improve quality; however, they also felt that the current technology had not been optimized for nursing, their work environment, or interactions with older adults. The potential for IT to improve quality was identified in relation to medication administration and safety as it “decreases the risk of a patient getting a wrong medication,” as well as “decreasing the chance of giving the patient a wrong medication.”
Although the nurses felt that IT could improve quality, they were also concerned with how it decreases efficiency and impacted the time it takes to accomplish tasks, “If you need IV Lopressor, you need it quick. So who’s going to go to the computer, “Can I please use the computer? It’s just very time-consuming . . . we need more computers and easier access!” The nurses also perceived IT and bedside computers to have a negative impact on the quality of geriatric care related to the effect on nurse–patient interactions, “We’ve become depersonalized.” Nurses noted that computers hinder developing and fostering meaningful relationships with patients because “you are putting your face in the technology all the time . . . the patient gets lost.” They also noted that for older adults, nurses’ use of the computers to improve quality and safety may be misinterpreted as behavior that is not patient centered because older patients perceive nurses as only caring about “doing their computer thing, ‘they don’t ever look at me.’”
RN–physician interactions
Nurses identified interactions with physicians as positive, respectful, and collegial; however, they also noted occasional negative interactions that caused them to feel belittled and disrespected. Nurses spoke specifically to the value of hospitalists, finding them responsive to their needs, and bringing expertise and collegiality to their units. This created a sense of pride, because hospitalists were considered part of the nursing unit’s own team. Negative physician interactions were perceived as contributing to poor quality of geriatric care because it led to nurses avoiding or delaying contacting physicians, “I think it makes the nurse hesitant to even go to the doctor to tell him that something is wrong, which can be extremely dangerous because you are delaying that process.” A history or pattern of poor interactions with specific physicians was concerning because of the complex care needs of geriatric patients.
Quantitative Results
Nurses reported favorable perceptions of the general work environment, which was demonstrated by mean subscale scores greater than 2.5 in the PES-NWI composite score and all the five PES-NWI subscales: (a) nurse manager ability (2.95 ± 0.60), (b) collegial nurse–physician relations (2.91 ± 0.63), (c) nurse participation in hospital affairs (2.88 ± 0.46), (d) nursing foundations for quality of care (2.93 ± 0.35), (e) nursing IT (2.91 ± 0.51). However, nurses did not have favorable perceptions of staffing and resource adequacy (2.44 ± 0.57). Of the five additional work environment scales, nurses felt a strong sense of workgroup cohesion (4.04 ± 0.85, range = 1-5), were satisfied with their job (5.48 ± 1.22, range = 1-7), and committed to their organization (3.74 ± 0.69, range = 1-5). They had favorable views of procedural justice (i.e., the degree to which RNs feel involved with decision making; 3.20 ± 0.65, range = 1-5), and few organizational constraints (i.e., work situations that interfere with performance, 2.83 ± 0.83, range = 1-6).
The geriatric-specific work environment was perceived as (a) institutional values regarding older adults (2.03 ± 0.59) indicating that nurses somewhat agree that there is support for staff involvement in decision making and respect for older adults, (b) capacity for collaboration (2.68 ± 0.71) indicating that a lack of geriatric-specific knowledge and protocols somewhat interferes with geriatric care, (c) geriatric resource availability (2.03 ± 0.59) indicating that staffing, equipment and services for older adults, and support for family communication somewhat interfere with geriatric care, and (d) aging-sensitive care delivery (2.28 ± 0.64) indicating that nurses are only somewhat satisfied with the quality of geriatric care. Nurses also agreed or strongly agreed that patients receive high-quality care in their hospital (96.1%), and on their units (92.0%).
Integrated Results
The exploratory nature of this study emphasized the prioritization of the qualitative data. The integration of quantitative data with the study’s primary qualitative findings was the final step in this analysis (see Figure 1). In mixed-methods studies, the integrated data demonstrate concordance when qualitative and quantitative data agree, and discordance when qualitative and quantitative data disagree. Concordant findings provide strong evidence, whereas discordant findings indicate a need for further exploration and investigation.
Integrated results.
Concordant Findings
Two qualitative themes, collegial RN relationships and poor staffing/utilization, were found to have concordant quantitative data. The theme collegial RN relationships demonstrated concordance with three quantitative scales, workgroup cohesion, job satisfaction, and organizational commitment. Qualitative data, nurses’ narrative stories of how collegial relationships enhance the quality of geriatric care were augmented and strengthened by the relatively high mean scores measuring their workgroup cohesion (4.04 ± 0.85), satisfaction with their jobs (5.48 ± 1.22), and strong commitment to their organizations (3.74 ± 0.69).
The theme poor staffing/utilization demonstrated concordance with two of the quantitative subscales, staffing and resource adequacy from the PES-NWI, and geriatric resource availability from the GCES. The resource adequacy subscale was the only PES-NWI subscale to be scored unfavorably, with a score of <2.5, and the GCES subscale was viewed as somewhat interfering with the quality of geriatric care. Both quantitative subscales indicated deficiencies in staffing and utilization of resources, which supported the qualitative data, nurses’ stories of staffing inadequacies and resource allocation that impaired the quality of geriatric care.
Discordant Findings
The two remaining themes, technology benefits/challenges and RN–physician interactions demonstrated discordant findings, meaning that the quantitative data highlighted discrepancies from the qualitative findings. Although nurses articulated clear inefficiencies and challenges with IT, technology was rated favorably on the PES-NWI subscale. The qualitative data also demonstrated that interactions with physicians could negatively impact the quality of geriatric care. However, nurse–physician relations were rated favorably on the PES-NWI subscale.
Discussion
The findings from this study provide insights into how the work environment influences the quality of geriatric care in rural hospitals. Nurses identified work environment factors of collegial RN relationships, poor staffing/utilization, technology benefits/challenges, and RN–physician interactions as influencing the quality of geriatric care in rural hospitals. Overall, nurses believed that patients received high-quality care at their hospital and on their units, but were only somewhat satisfied with the quality of geriatric care. They perceived the general work environment as favorable, but perceived the geriatric-specific work environment less favorably.
Five of the six subscales measuring the general work environment were perceived as favorable, while none of the geriatric-specific subscales were perceived as favorable. Nurses only somewhat agreed that institutional values regarding older adults contributed to quality of geriatric care, while the subscales for capacity for collaboration and geriatric resource availability were perceived as somewhat interfering with the delivery of quality geriatric care. These finding are important as they support previous research (Kim et al., 2009) indicating that there are differences between the general work environment and the geriatric-specific work environment that contribute to nurse-perceived quality of care. Nurse-perceived quality of care has been associated with actual patient outcomes (McHugh & Stimpfel, 2012) for non-geriatric-specific outcomes in urban settings. Future research should look at the association of geriatric-specific work environment factors and geriatric-specific patient outcomes in rural hospitals.
The concordant findings of the integrated results provide strong evidence of the need to strengthen RN relationships and address staffing and staff utilization challenges as a potential means to improve the quality of geriatric care in rural hospitals. The discordant findings are important, but the reasons for these findings are unclear. Further research is needed to understand and strengthen how technology can improve efficiency and quality without compromising the art of nursing with our older adult patients. It is also important to have more granular analyses of nurse–physician relationships to ensure that all patients receive quality care at all times regardless of interpersonal dynamics.
Strong, collegial RN relationships were identified as an important aspect of the work environment among nurses working in rural hospitals. Nurses in this study told stories of how collegial relationships have a positive influence on unit morale, as well as patient care. Their narratives uncovered a broad range of work environment processes important to the delivery of quality geriatric care including extramural activities, availability of help when needed, continuity of patient care, and teamwork and camaraderie. Strengthening those relationships may be one way to optimize the work environment to improve the quality of geriatric care.
Much of the literature related to relationships and quality of care has been focused on nurse–physician relationships, while the importance of formal and informal relationships among nurses has not been as widely explored. When the nurses’ qualitative data were explored in conjunction with the scales that measured workgroup cohesion, satisfaction, and organizational commitment, the benefits of a cohesive work unit became clear; collegial relationships appear to contribute to high levels of job satisfaction, organizational commitment, and better quality of care for older adults. Among nurses in general, workgroup cohesion has been associated with patient satisfaction and symptom management, as well as overall quality care (Chang, Hughes, & Mark, 2006; Djukic et al., 2011). Our findings add to this literature by demonstrating that strong, collegial relationships are important to the delivery of quality geriatric care in rural hospitals.
Similarly, the strong concordance between the qualitative data related to staffing inadequacies and the two quantitative subscales from the PES-NWI and the GCES measuring staffing and resource availability demonstrated the importance of staff utilization and skill mix (e.g., nurse aides) in relation to the quality of geriatric care. Participant’s stories consistently related staffing and poor use of nurse aides as diminishing the quality of geriatric care. Therefore, staff utilization and specifically the right skill mix (i.e., RNs, nursing aides) are needed to provide quality geriatric care. The findings suggest that it may be worthwhile for hospital administrators to explore work environment redesigns that emphasize skill mix and utilization of nurse aides to optimize the quality of geriatric care.
RN staffing has been associated with the quality of care in hospitals, such as lower mortality rates, hospital-acquired pneumonia, unplanned extubation, and lower risk of failure to rescue (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Although such outcomes are important measures of quality, other measures of quality, especially those for hospitalized older adults, may be more sensitive to nurse aide staffing than RN staffing. Kalisch (2006) found that RNs and nurse aides reported ambulation, repositioning, assistance with eating, bathing and hygiene needs, emotional support, patient education, and discharge planning as the most missed care occurring in two hospitals. The primary reason for this was lack of staff due to inadequate nurse to patient ratios, and too few nurse aides (Kalisch, 2006, 2009; Kalisch, Friese, Choi, & Rochman, 2011). The nurses in this study described similar missed care opportunities, such as the inability to get patients out of bed for morning care and assistance with ambulation to the bathroom. Participants also discussed how having a nurse aide allowed them to focus on tasks “only an RN could do.” Other studies have shown that RNs’ perceptions of nurse aides are positive, because having a nurse aide facilitates RNs being able to focus on their responsibilities (Standing & Anthony, 2008).
Redesigning and improving rural hospital work environments are critical for improving the quality of care for hospitalized older adults. Over the past two decades, the importance of the work environment for quality of care and patient outcomes has been well established. Unfortunately, few studies have focused specifically on older adults—the highest consumers of health care services (Hall, DeFrances, Williams, Golosinskiy, & Schwartzman, 2010)—and little research has been done on the work environment of rural hospitals and how the work environment influences the quality of geriatric care in these settings.
Transforming the work environment of hospitals with a focus on the needs of hospitalized older adults has been shown to have a positive impact on the quality of care they receive (Boltz et al., 2008). The Nurses Improving Care for HealthSystem Elders (NICHE) program (Capezuti et al., 2012) is one approach hospitals have used to create systemic organizational change to improve the quality of geriatric care. The NICHE program focuses on transforming the work environment to support care of older adults through acute care for the elderly units (Landefeld, Palmer, Kresevic, Fortinsky, & Kowal, 1995), the use of geriatric resource nurses, and training of geriatric patient care associates (Capezuti et al., 2012).
This study provides evidence that strengthening nurse-to-nurse relationships and examining how nurse aides are utilized may be one approach rural hospitals can use to redesign care models and improve the quality of geriatric care. The NICHE program’s geriatric resource nurses and geriatric resource nurse aides may be an ideal approach to strengthen the quality of geriatric care in rural hospitals given the strong, collegial RN relationships and the recognized importance of the nurse aides in the care of hospitalized older adults.
This study was conducted in the northeast region of the United States. Findings, therefore, may not be applicable to all regions of the country. More research examining the work environment and quality of geriatric care in rural hospitals in other geographical locations (e.g., Appalachia, rural Colorado) is needed. The similarity in findings across all three hospitals provides credibility to the study, as do the demographic similarities between the nurses in this sample and national averages (U.S. Department of Health and Human Services, 2010). The study emphasized qualitative data focusing on nurse-perceived quality of care; however, information on actual patient outcomes may have provided additional value to the study findings.
Despite some limitations, this study has several strengths. To our knowledge, it is the first study to explore how the work environment influences perceived quality of geriatric care in rural hospitals. It is innovative in its use of a concurrent, embedded mixed-methods research design to identify how the work environment influences nurses’ perceptions of the quality of geriatric care in rural hospitals. Our findings suggest that rural hospital work environments may not be optimized to facilitate the delivery of quality geriatric care. Targeted interventions by hospital administrators aimed at strengthening nurse-to-nurse relationships and enhancing nurse aide staffing and utilization may improve the quality of care provided to older adults in rural hospitals.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the John A. Hartford Foundation Building Academic Geriatric Nursing Capacity (BAGNC) Scholars Program and New York University Upsilon Chapter of Sigma Theta Tau International.