Evidence-based Synthesis Program 

The Effect of Working 

Conditions on Patient Care: 

A Systematic Review 

Department of Veterans Affairs 

Health Services Research & Development Service 

January 2012 

Prepared for: 

Department of Veterans Affairs 

Veterans Health Administration 

Health Services Research & Development Service 

Washington, DC 20420 

Prepared by: 

Evidence-based Synthesis Program (ESP) Center 

Minneapolis VA Medical Center 

Minneapolis, MN 

Timothy J. Wilt, MD, MPH, Director 

Investigators: 

Principal Investigator: 

Kandice A. Kapinos, PhD 

Research Associates: 

Patrick Fitzgerald, MPH 

Nancy Greer, PhD 

Indulis Rutks, BS 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

PREFACE 

Health Services Research & Development Service’s (HSR&D’s) Evidence-based Synthesis 

Program (ESP) was established to provide timely and accurate syntheses of targeted healthcare 

topics of particular importance to Veterans Affairs (VA) managers and policymakers, as they 

work to improve the health and healthcare of Veterans. The ESP disseminates these reports 

throughout VA. 

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help: 

• develop clinical policies informed by evidence, 

• guide the implementation of effective services to improve patient 

outcomes and to support VA clinical practice guidelines and 

performance measures, and 

• set the direction for future research to address gaps in clinical 

knowledge. 

In 2009, the ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system. 

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov. 

Recommended citation: Kapinos KA, Fitzgerald P, Greer N, Rutks I, Wilt TJ. The Effect of 

Working Conditions on Patient Care: A Systematic Review. VA-ESP Project #09-009; 2012. 

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at the Minneapolis VA Medical Center, Minneapolis, MN funded 

by the Department of Veterans Affairs, Veterans Health Administration, Office of 

Research and Development, Health Services Research and Development. The findings 

and conclusions in this document are those of the author(s) who are responsible for 

its contents; the findings and conclusions do not necessarily represent the views of 

the Department of Veterans Affairs or the United States government. Therefore, no 

statement in this article should be construed as an official position of the Department 

of Veterans Affairs. No investigators have any affiliations or financial involvement (e.g., 

employment, consultancies, honoraria, stock ownership or options, expert testimony, 

grants or patents received or pending, or royalties) that conflict with material presented 

in the report. 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

EXECUTIVE SUMMARY 

BACKGROUND 

A large body of evidence shows clear linkages between workplace conditions and employee 

satisfaction and stress in a wide variety of organizational and industry settings. In the healthcare 

industry, increasing interest in understanding these linkages stems from the idea that healthcare 

providers’ working environments also affect important patient outcomes, including safety, quality 

of care and satisfication. Additionally, meeting objectives of the current healthcare reform to 

increase healthcare quality by increasing the availability of primary care providers and making 

care safer, more efficient, effective and patient-centered hinges on the ability to deal with the 

documented shortage of primary care providers in the US and at the same time improve patient 

outcomes. The purpose of this report was to systematically review the evidence on the role of 

primary care providers’ workplace conditions in influencing patient outcomes. We focused on 

patient satisfaction, safety, and quality of care for patient outcomes (note that there may be some 

overlap in how these patient outcomes are measured). We excluded articles that focused on one 

specific disease or patient population. The focus on primary care providers’ work environment 

will provide evidence on increasing healthcare quality. Results from this review may inform 

policymakers as they endeavor to implement aspects of the healthcare reform related to 

increasing the supply of primary care providers and improving patient outcomes. 

The key questions were: 

Key Question #1. How are human resources (HR) practices, such as skill levels, training, 

workload, hours worked, autonomy, and electronic medical records/systems, associated with 

patient outcomes? 

a. quality of care (access and effectiveness) 

b. safety (medication errors) 

c. patient satisfaction (with provider, with clinic/practice) 

Key Question #2. How are other working conditions, such as organizational culture or physical 

environment, associated with patient outcomes? 

a. quality of care (access and effectiveness) 

b. safety (medication errors) 

c. patient satisfaction (with provider, with clinic/practice) 

Key Question #3. In studies that report provider outcomes, how are working conditions 

associated with provider outcomes (e.g., job satisfaction, productivity, pay)? 

METHODS 

We conducted searches for each of the workplace conditions (i.e., human resource practices 

[separate searches for staffing and workflow], organizational culture, and physical environment) 

in MEDLINE and PsycINFO using standard search terms. We also searched both MEDLINE 

and PsycINFO for studies of team-based approaches to care. We included randomized controlled 

trials (RCTs), systematic reviews, and prospective studies published in English from 2000 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

to September 2011. Our search focused on primary care physicians, nurse practitioners, and 

physician assistants as providers and adult patients. For provider outcomes, we searched 

MEDLINE and the Cochrane Effective Practice and Organization of Care (EPOC) Group Web 

site for recent systematic reviews or meta-analyses. We excluded articles that focused on one 

disease or patient population (e.g., diabetes or depression), lacked data analysis, or focused on 

the effect of credentials or skills (i.e., MD [physician] vs. PA [physician assistant] or NP [nurse 

practitioner]) on quality of care or patient safety. We excluded the latter studies as there is 

already a body of evidence suggesting that increased skills improve clinical effectiveness (see 

Agency for Healthcare Research and Quality [AHRQ] report 2003). All searches were limited to 

articles pertaining to human subjects and published in the English language. Additional citations 

were identified from reference lists of related articles. 

Titles, abstracts, and articles were reviewed by researchers trained in critical analysis of 

literature. We attempted to pool data if appropriate. Other data were summarized narratively. 

Study characteristics, patient characteristics, and outcomes were extracted by a trained research 

associate under the supervision of the Principal Investigator. We assessed risk of bias in 

individual studies according to established criteria for randomized controlled trials and based 

on population, outcomes, measurement, and confounding for non-randomized trials. Strength of 

evidence was determined for primary outcomes. 

DATA SYNTHESIS 

We constructed evidence tables for study characteristics and for outcomes, organized by working 

condition. We analyzed studies to compare their characteristics, methods, and findings. Findings 

from VA or active service populations were identified and highlighted. 

PEER REVIEW 

A draft version of this report was reviewed by members of our technical expert panel, as well as 

clinical leadership. Reviewer comments were addressed and our responses were incorporated in 

the final report (Appendix C). 

RESULTS 

The Effect of Human Resources Practices (Key Question #1) 

For Key Question #1, we screened 1008 abstracts and 95 full text articles related to staffing and 

1,581 abstracts and 94 full text articles related to workflow. We included 14 references from the 

staffing search and 9 references from the workflow search. Four additional references were added 

from our hand search of reference lists for a total of 27 references. Among these studies, three 

were randomized controlled trials, seven were longitudinal (cohort or pre-post with repeated 

cross-sections) studies and 17 were cross-sectional. 

Nine out of eleven of the studies we examined that focused on patient quality of care as an 

outcome specifically measured clinical effectiveness, thus there is insufficient evidence on 

the role of provider workplace conditions on access as a quality of care measure. The most 

frequently studied HR practice for quality of care was workload and while three of the studies 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

suggested that an increase in workload results in lower quality of care, one study also found 

a positive effect and one found no effect. The other HR practices studied were evaluated less 

frequently, but there was more consistency in the results across studies: more training (2 studies), 

shorter hours (2 studies), and computerized systems (3 studies) lead to better quality. Only one 

study we reviewed examined provider autonomy or flexibility and found mixed effects on quality 

of care scores; this is insufficient evidence for the role of autonomy. Overall, these results are 

suggestive but make it difficult to make strong conclusions about the role of HR practices on 

patient quality of care. 

We identified four studies in our review that explicitly examined the role of workplace conditions 

on patient safety in the primary care setting. While these were relatively well designed studies, 

more studies are needed. Because only two studies examined workload, one examined autonomy, 

one examined teams, and one examined computerized systems, there is insufficient evidence to 

answer our key question about how HR practices influence patient safety. 

We identified 17 unique studies that investigated how HR practices influence patient satisfaction 

with either the provider or the clinic. We found mixed evidence on the role of provider skills 

(MD vs. NP/PA) on patient satisfaction; two studies found no effect and two studies found a 

negative effect of skills. We found mostly no effect of provider workload on patient satisfaction 

(3 studies), with the exception of one Norwegian study reporting that a longer listsize resulted in 

greater patient satisfaction. All four of the studies that examined provider training and all three 

that examined provider work hours found that they had no effect on patient satisfaction. Thus, 

there was suggestive evidence that training and work hours do not effect patient satisfaction, 

but again because of the lack of well-designed studies, we cannot make strong conclusions 

about these findings. Similarly, we conclude that there is inconsistent evidence on the role of 

skills and workload. We identified no studies that looked at how electronic medical records or 

computerized systems affect patient satisfaction. 

The Effect of Organizational Culture and Physical Environment (Key Question #2) 

For Key Question #2, we screened 541 abstracts and 44 full text references from our search 

for studies related to organizational culture. We included 2 references from our organizational 

culture literature search, 1 reference from our team-based care literature search, and 6 references 

that were identified by hand searching. Our physical environment search yielded 49 abstracts to 

review. From the 49 abstracts, we reviewed 3 full text articles; none met inclusion criteria. We 

included 2 references identified by hand searching. 

Our findings on the effect of organizational culture are similar to findings of earlier reviews. 

The diversity of study methodologies used and constructs of organizational culture studied and 

the lack of consistent and validated outcome measures limit the ability to draw conclusions. 

Two studies (one randomized controlled trial and one pre/post study) found a positive effect of 

provider teams on patient quality of care, though one found no effect (case control study). Two 

studies that examined the effect of implementing patient centered medical homes (PCMH) found 

positive effects on quality of care. A cross-sectional study also found that organizations with an 

organizational culture that emphasized the importance of information sharing had high quality of 

care. 

Although there has been research on the effect of physical environment (notably lighting, color, 

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The Effect of Working Conditions 

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auditory stimuli, and temperature) on workplace performance, much of that work has been done 

in industrial settings and what has been done in healthcare has largely focused on hospitals rather 

than the primary care setting. 

Provider Outcomes (Key Question #3) 

For Key Question #3, we included provider outcomes from studies identified in the literature 

searches for Key Questions #1 and #2. We also included systematic reviews pertaining to 

provider outcomes in primary care. 

The relationships between workplace conditions, provider outcomes, and patient outcomes 

are complex and dynamic in such a way that not only are the effects felt at many levels 

(provider, patient, healthcare system), but also they create a cycle of reinforcing behaviors 

and outcomes. There are several potential policy interventions at the various levels that might 

positively influence provider well-being. In this study, we focused on studies that shed light 

on possible workplace interventions (as opposed to provider self-care or higher-order system 

level interventions) that could ultimately impact patient outcomes. Such changes to workplace 

conditions will likely also influence provider outcomes. However, we presented these results 

as only suggestive, but consistent with other literature, that has established evidence on the 

intermediate link between workplace conditions and provider outcomes. 

Strength of Evidence 

We evaluated the strength of evidence for the workplace conditions and patient outcomes for 

which we had at least three studies. Strength of evidence overall was low for patient satisfaction 

and provider skills, workload and hours; and for quality of care and provider workload and 

electronic medical records. Most of the evidence was rated high or moderate on risk of bias 

due to the lack of many well-designed RCTs or observational studies that address potential 

biases. There was also inconsistent measurement of both the workplace condition constructs 

and the patient outcome constructs, which made comparisons across studies difficult. There was 

insufficient evidence for patient safety and all workplace conditions, quality of care and training 

and hours, and patient satisfaction and electronic medical records (EMRs). Additionally, there 

was insufficient evidence on provider autonomy and all patient outcomes. 

CONCLUSIONS 

Overall, the studies we reviewed suggest that in primary care settings 

•		 a lighter provider workload/shorter work hours, more provider training, and 

computerized systems result in higher patient quality of care 

•		 provider training and work hours have no effect on patient satisfaction. 

We found mixed evidence on the effect of provider skill levels and workload on patient 

satisfaction. We identified very few studies in our review that explicitly examined the role 

of workplace conditions on patient safety or the role of the physical environment on patient 

outcomes in the primary care setting, thus more studies are needed. Several workplace conditions 

have been insufficiently studied and thus there is no evidence on how these practices matter in 

ambulatory care settings: the effect of computerized systems, provider autonomy and teams on 

patient satisfaction; the effect of autonomy on quality of care. 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

The available literature provides low strength or insufficient evidence for varied components of 

organizational culture including PCMH, team-based care, care environment, and clinic values 

and their effect on outcomes highlighted in our key questions. Such evidence does not permit 

conclusions with regard to quality of care, patient safety, and patient satisfaction. 

We found two studies that focused on the effect of physical environment in primary care clinics. 

No study attempted to isolate any one component of the physical environment. Reported 

outcomes included self-report of satisfaction (worker and provider/staff) with no objective 

measures of patient safety or quality of care or provider performance. 

Consistent with more thorough systematic reviews of the literature examining how workplace 

conditions affect providers’ stress, job satisfaction, etc., among the studies in our review that also 

examined provider outcomes, we found that greater workloads and less control over work tasks 

resulted in greater provider stress, burnout, and less job satisfaction. One study we examined 

found that electronic medical records did not result in greater provider stress. 

FUTURE RESEARCH 

There is little research that investigates the effects of working conditions on patient safety, which 

we measure specifically as medication errors, in the primary care setting. More generally, more 

well-designed studies are needed to replicate the few that have been conducted. For example, 

all ten of the studies we reviewed that investigated the role of workload were cross-sectional 

studies. While undertaking randomized controlled trials may be impractical, well-designed 

cohort studies or other pre-post designs will allow for more convincing evidence on the causal 

effect of the workplace conditions. Additionally, there is a need for research that looks rigorously 

at the interdependent role of human resource practices (such as hours worked, provider 

autonomy, and electronic medical records), organizational culture, and physical environment 

in explaining patient outcomes in primary care settings. For example, implementation of teambased work is often accompanied by other changes in the workplace, such as the use of electronic 

medical records/computerized systems or changes in organizational culture to foster teamwork. 

Therefore, any changes in patient outcomes from such an implementation could be the result 

of the teamwork, but could also be attributable to the changes in the organizational culture 

or computerized systems, etc. Current studies do not adequately try to isolate these effects. 

Finally, the development of or more consistent use of construct valid measures of both working 

conditions and patient or provider outcomes in the primary care settings is needed to make 

comparisons across studies easier. 

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