Chapter 21. Creating a Safe and High-Quality Health 

Care Environment 

Patricia W. Stone, Ronda Hughes, Maureen Dailey 

Background 

Maintaining a safe environment reflects a level of compassion and vigilance for patient 

welfare that is as important as any other aspect of competent health care. The way to improve 

safety is to learn about causes of error and use this knowledge to design systems of care to “... 

make errors less common and less harmful when they do occur”1 (p.78). As a result, researchers, 

policymakers, and providers have intensified their efforts to understand and change 

organizational conditions, components, and processes of health care systems as they relate to 

patient safety. 

Health care is the second-fastest growing sector of the U.S. economy, and nursing is the 

largest occupation within the industry, with more than 2.4 million jobs and the highest projected 

growth.2 As noted in recent reports by the International Council of Nursing and the Institute of 

Medicine, one of the reasons for the current and future shortages of nurses relates to the work 

environment.3, 4 Improving the environment in which nurses work may attract new students to 

nursing as well as engage current professionals in developing innovative models of care delivery 

that will help retain and nurture future generations of nurses. Most important, improving the 

work environment may also improve the quality and safety of patient care. 

High turnover has been recognized as a problem in many service industries, including health 

care.5 In U.S. hospitals, nursing turnover has been reported to range from 15 percent to 36 

percent per year.6 These turnover rates are much higher than those for other health care 

professionals, which are estimated to average 2.3 percent per year.7

 Past estimates of the cost to 

replace one medical-surgical registered nurse (RN) range between $30,000 and $50,000; and 

replacement costs for critical care nurses are closer to $65,000.8

 More recently, Jones9 estimated 

the total turnover costs of one hospital-based RN to range from $62,000 to $67,000 depending on 

the service line. While these cost estimates rely on nurse manager reports of decreased 

productivity, clearly there are avoidable organizational monetary and human costs related to high 

turnover of desirable employees. Using multiple databases in an academic medical center, other 

analysts found the low-end estimate for the cost of employee turnover accounted for greater than 

5 percent of the annual operating budget.10 Clearly, understanding organizational aspects that 

promote a stable workforce is important. 

Besides the obvious harm to patients, preventable adverse health care events related to 

patient safety have major financial consequences for the patient, the provider, the insurer, and 

often the family and/or caregivers. Using Agency for Healthcare Research and Quality (AHRQ) 

patient safety indicators, researchers estimated the excess length of stay for postoperative sepsis 

to be approximately 11 days at a cost of almost $60,000 per patient.11 While in some instances 

there is extra payment made by insurers to hospitals for these adverse events, it has been 

estimated to be considerably less than the total cost of the resources used.12 Furthermore, with 

increased discussions about pay-for-performance and mandatory reporting of certain adverse 

patient safety events, providers may have increased financial as well as other incentives to 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

improve patient safety.13 Therefore, understanding organizational aspects that promote patient 

safety is also very important. 

Throughout the body of patient safety and occupational health literature, authors refer to 

concepts of organizational climate and culture as well as safety climate and culture. Culture 

broadly relates to the norms, values, beliefs, and assumptions shared by members of an 

organization or a distinctive subculture within an organization.14, 15 Organizational culture is 

typically thought of as evolving over the course of time and difficult to change. Organizational 

climate refers to members’ shared perceptions of organizational features like decisionmaking, 

leadership, and norms about work, including opportunities for advancement and collaboration.16 

Organizational climate has been likened to a weather pattern.17 For example, Clarke18 pointed out 

that organizational climate refers to an atmosphere, which is a moveable set of perceptions 

related to working and practice conditions, many of which can be directly influenced by 

managers and organizational leaders. There are other microclimates; for example, safety climate 

is the current landscape of employees’ perceptions and attitudes about safety, such as state of 

current safety initiatives and safety behaviors.19 

Additionally, a number of safety climate scales have been developed in the fields of 

occupational health and patient safety. In occupational health, attributes of a safe climate in 

hospitals have been found to include senior management support for safety programs, absences 

of hindrances to safe work practices, availability of personal protective equipment, minimal 

conflict, cleanliness of work site, good communication, and safety-related feedback.20 A positive 

safety climate has been significantly correlated to reduced risk of work injury and exposure.20 In 

patient safety, attributes of a safe hospital environment have been identified as a positive work 

environment, supportive supervisor/manager, improved interdisciplinary communications, and 

increased safety event reporting.21 Obviously these microclimates overlap. Additionally, they 

should be synergistic and correlate with the overall organizational climate. Indeed, a positive 

organizational climate is most likely an essential antecedent to the development of a strong 

safety climate. 

As part of AHRQ’s The Effect of Health Care Working Conditions on the Quality of Care 

research portfolio (RFA HS-01-005), a team of interdisciplinary scholars developed a model 

depicting aspects of organizational climate and their relationship to worker and patient 

outcomes.22 These investigators tested the model in various settings (i.e., ambulatory care, home 

health, long-term care, Veterans Health Administration facilities, and acute care hospitals) and 

identified important organizational structures (leadership and infrastructure) and processes 

(supervision, work design, group behavior, and quality/safety emphasis). Using this model as the 

organizing framework, this chapter reviews the evidence examining the impact of organizational 

climate on patient and employee outcomes. It is important to note that we are focusing on the 

broad concept of organizational climate. Another chapter in this volume focuses specifically on 

safety culture and climate. Based on the evidence on organizational climate and the relationships 

with patient outcomes, job satisfaction, and turnover, we have developed a new conceptual 

model of organizational attributes and outcomes. 

Research Evidence 

Overall 14 studies were reviewed. In four of the published studies, the researchers focused 

only on patient outcomes,23–26 with one of the teams reporting the results related to worker 

turnover and job satisfaction in other publications.27, 28 Two of the research teams published 

2 
Patient Safety and the Health Care Environment

results related to patient outcomes and worker outcomes in single manuscripts.29, 30 The majority 

of the manuscripts reviewed focused on worker outcomes. In the following section, the studies 

focusing on organizational climate and patient outcomes are synthesized, followed by a synthesis 

of the evidence linking organizational climate with turnover and job satisfaction. 

Organizational Climate and Patient Outcomes 

Table 1 describes the primary research (six studies) found investigating organizational 

climate and patient safety outcomes. The attributes of organizational climate measured varied. 

Some researchers focused on quality,23 measures of morale, and consensus of 

depersonalization,24, 29 while others used a composite organizational climate measure, which 

focused on nurses’ perceptions of the work environment.25 The patient outcomes were also 

varied and specific to the setting. For example, in one study the measure of patient safety was 

nurse-reported medication errors;24 another research team measured self-report service quality.29

All other research teams used some form of existing administrative data to measure patient safety 

outcomes, with one team using clinical and laboratory data elements collected for participation in 

the Centers for Disease Control and Prevention’s National Healthcare Safety Network.25 The 

National Safety Network hospitals collect standardized nosocomial infection data. The settings 

studied also varied across projects and were primary care sites, rural hospitals, outpatient social 

services, specialized hospital settings (e.g., emergency departments and intensive care units) and 

the Veterans Health Administration. All studies used cross-sectional designs with the exception 

of one group reporting on the evaluation of a quality-improvement project.23 Despite these 

varying measurement issues, settings and populations, and research designs, positive 

organizational climates were generally found to improve patient safety. 

Organizational Climate, Turnover, and Job Satisfaction 

Table 2 provides the results of the current evidence found examining the relationships among 

organizational climate and worker outcomes (i.e., turnover and job satisfaction). Ten studies 

were found, half of which included both job satisfaction and turnover. Again, the organizational 

climate attributes varied from morale to composite measures of organizational climate.28, 30 The 

study populations were mainly nurses (60 percent), but outpatient caseworkers and mental health 

providers were also studied. Most studies (80 percent) were conducted in the United States, but 

nurses employed in Australia,31 Begium,32 and Hong Kong33 were also studied. The majority of 

the studies were cross-sectional, with only one pre-post test intervention study.34 All of the 

researchers reported that positive organizational climates were related to increased worker 

satisfaction. The results related to turnover were not quite as strong, and researchers in one study 

found that job satisfaction mediated the effect of organizational climate on turnover.35

Evidence-Based Practice Implications 

Overall, there is an emerging evidence base pointing to the need for positive organizational 

climate. For the most part, the research findings were consistent; patient and employee outcomes 

were affected by organizational climate. However, the strength of the relationship between 

organizational climate and job satisfaction was stronger than the relationship between 

organizational climate and turnover. Furthermore, the evidence base regarding organizational 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

climate and patient safety outcomes was scant, with only six studies found, and only three of 

those studies focused on patients in acute care settings. Despite these limitations, the consistency 

of the findings point to the importance of organizational climate on patient and employee 

outcomes. 

Based on this review and our previous work,22 we developed the conceptual model displayed 

in Figure 1. The structural characteristics of the setting may serve as enabling factors for 

outcomes. These first and foremost include senior leadership. Other important enabling factors 

are related to the infrastructure (such as technology available) and communication systems. We 

call these enabling factors structural characteristics because they are not easily changed. These 

enabling factors influence the settings’ microclimates, which may be grouped into three main 

foci: employee/staff, patient, and organizational. It is important to understand these 

microclimates are not conceptualized as mutually exclusive or independent. We believe these 

microclimates interact with each other and are synergistic. For example, a setting that focuses on 

occupational safety may also focus on evidence-based, patient-centered care; additionally, 

collaboration and communication among providers and patients may be important shared 

components of each microclimate. The microclimates influence the actions of the staff, patient, 

and often the family and/or caregivers, which in turn have an impact on the outcomes. Again, the 

outcomes are conceptualized at three different levels: the employee, the patient, and the 

organization. The list of specific outcomes under each category is representative of the category, 

but it is not exhaustive. For more complete lists of patient safety outcomes, the reader should 

refer to AHRQ’s Patient Safety Indicators and the National Quality Forum’s consensus standards 

for nursing-sensitive care.36, 37 

Based on the literature reviewed and the conceptual model developed, there are a number of 

practice recommendations at all levels of nursing (e.g., nursing leaders, nurse managers, staff 

nurses, and educators). The existence of a relationship between a positive organizational climate 

and both worker and patient outcomes means that facilities need to be aware of the importance of 

assessing and periodically reassessing the climate within their organization. There are published 

reviews of instruments used to assess organizational climate.38 Additionally, data regarding the 

climate should be correlated with outcomes along all three of the foci (employee, patient, and 

organizational).39 The recommended frequency of conducting these analyses is not clear, but 

such assessment and reassessment should be part of a continuous quality-improvement process, 

and it seems reasonable that employee surveys should be conducted at least annually. Nurse 

educators need to develop and evaluate safety and leadership curriculum.40, 41 Additionally, as we 

rapidly increase the information technology available in health care, we must ensure that this 

infrastructure promotes patient safety, increases efficiency, and contributes to nursing 

knowledge.42 

Nursing leaders and managers need to be cognizant of the job satisfaction of all employees 

on an ongoing basis, specifically as low satisfaction can be linked to burnout, intention to leave, 

and even higher rates of job turnover or loss to the nursing profession (i.e., early retirement or 

transfer to another career). With the high costs of nursing turnover, efforts to increase job 

retention levels are likely to be financially beneficial.9, 10 

Despite the scant evidence linking organizational climate—broadly defined—and patient 

safety, the evidence supporting the significant relationship between a climate of safety—a 

specific component of organizational climate—and patient safety is growing, given increased 

utilization of safety climate surveys. (This is discussed further in the next chapter.) It is likely 

then that development and utilization of readily available tools to assess organizational climate 

4 
Patient Safety and the Health Care Environment

will expand the evidence base and provide key information to leaders and managers to improve 

job satisfaction, interdisciplinary teamwork, and retention, ultimately improving the quality of 

health care delivery. Indeed, the usefulness of this information would likely be considerably 

improved if it were linked with ongoing patient-safety monitoring and quality-improvement 

activities within the organization. Organizational climate is more malleable and open to change 

than the more-entrenched aspects of culture. Thus, data-driven leaders can be proactive by 

assessing both worker perceptions and outcomes to ensure safety processes are adhered to more 

consistently (i.e., less violations or work-arounds); this should improve all outcomes. For staff 

and future staff, nurses’ job satisfaction is key to not only providing quality care, but to having 

lower levels of occupational stress and higher levels of occupational safety, both of which are 

discussed in other chapters within this book. 

Research Implications 

This review identified a number of gaps in the research evidence. First and foremost, as 

interventions are developed to improve the organizational climate, rigorous research and 

evaluation studies need to be conducted. It is important to note, however, that this type of 

research will not often lend itself to randomized controlled trials. Other epidemiological designs 

that control for confounding variables and ensure comparability between groups will most likely 

be needed. Second, future research aimed at understanding the impact of human capital variables 

(i.e., stability of the workforce, education, etc.) on patient outcomes and system efficiencies is 

warranted. Furthermore, consistency in measurement tools would help advance the field and 

assure that study results are more consistent and comparable. 

Lastly, more cost analyses need to be conducted to make the business case for improving the 

organizational climate in nurses’ work environment and improving patient, employee, and 

organizational outcomes. The model provided presents various aspects of organizational climate 

that may be measured in different research projects, across a research portfolio, and in various 

settings. It is doubtful that any one study would include all aspects presented in this model. 

Rather, the researcher may use this model to select the organizational aspects and outcomes most 

appropriate to their research aims. 

Organizational climate is one of the overarching aspects found in the work environment. 

However, it is not the only aspect related to patient safety and worker satisfaction and turnover. 

Other environmental aspects include actual workload, such as nurse-to-patient ratios in acute and 

long-term care and caseloads in outpatient settings; scheduled work hours (e.g., shift length, 

nights versus days); mandatory overtime; information systems for decision support to prevent 

errors of commission and omission; and human factor engineering solutions. The impact of these 

other aspects of the work environment is discussed elsewhere in this volume. 

There are both strengths and limitations to this review. In our search for evidence we 

attempted to be comprehensive. However, we may have missed some studies. Additionally, only 

primary studies published in English after the year 2000 were audited. 

Conclusion 

Gradually, evidence is accumulating that links work environments to behavior, attitudes, and 

motivations among clinicians. These behaviors and orientations can, in turn, affect quality 

processes and outcomes. A growing number of studies in health care show that members of 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

organizations are more satisfied when they work in climates that have more supportive and 

empowering leadership and organizational arrangements, along with more positive group 

environments (often reflecting elements of group support and collaboration). Moreover, although 

the research base is not as strong, there is emerging evidence that these same organizational 

attributes impact employee turnover and, most important, patient safety. Improving the 

organizational climate is likely to improve patient safety and decrease overall health care costs. 

However, future research studying specific interventions and their cost effectiveness is needed. 

Search Strategy 

A systematic review of the literature was conducted focusing on relationships among 

organizational climate and three outcomes: patient safety, nurse turnover, and job satisfaction. 

Medline and AHRQ’s Patient Safety Network (PSNET: www.psnet.ahrq.gov) searches were 

conducted using the key word “organizational climate,” then cross-referenced with “patient 

safety” and “patient outcomes,” “satisfaction,” as well as “turnover” and “intention to leave.” 

More than 200 titles were examined. Abstracts were examined by two nurse researchers if the 

article was published in 2000 or after, written in English, and pertained to health care 

organizations. Manuscripts were obtained and reviewed if they were primary reports of research 

findings. Editorials were excluded. Reference lists were also reviewed for key articles. 

Publications that presented primary research findings and had sample sizes of greater than 30 

respondents were organized into two tables presenting evidence on the relationships between 

organizational climate and (1) patient outcomes, and (2) worker satisfaction and retention of 

workers. Each study was audited for the following elements: the organizational climate attributes 

studied, the design type, the outcome measures (patient or worker), study setting and population, 

study intervention, and key findings. All studies were reviewed by two authors. Following the 

guidelines put forth by AHRQ, the study design types were categorized using the “type of 

evidence” criteria. 

Author Affiliations 

Patricia W. Stone, Ph.D., M.P.H., R.N., assistant professor, Columbia University School of 

Nursing; e-mail: ps2024@columbia.edu. 

Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Agency for 

Healthcare Research and Quality; e-mail: ronda.hughes@ahrq.hhs.gov. 

Maureen Ann Dailey, R.N., M.S., doctoral student, Columbia University School of Nursing; 

e-mail: mad2147@columbia.edu. 

 

6 
Patient Safety and the Health Care Environment

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Evidence Table 1. Organizational Climate and Patient Outcomes 

Source Organizational 

Climate Attributes 

Design Type 

Patient Safety Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(

Cretin 200123 Importance of improving quality of 

care, current status in quality improvement, climate for guideline implementation, attitude toward practice guidelines, and motivation for guideline implementation 

Quality improvement projects/ research 

Primary care followup, physical therapy or chiropractic care, specialist care 

U.S. Army Medical Department: 4 facilities in the Great Plains Region served as demonstration sites, and there were 5 comparison facilities. 31,273 new lowback pain patients 

Integrated model guideline implementation system: Evidence-based practice guidelines, education/training, toolkit, and interdisciplinary team approach 

Significant dowpercentage of physical thera(10.7%–7.2%) as compared No discernablcare referrals visits at the decompared to c

Fogarty & McKeon 200624

Workplace morale, supervisor leadership, participative decisionmaking, role clarity, professional interaction, appraisal and recognition, professional growth, goal congruence, workplace distress, and excessive work demands 

Crosssectional study 

Medication error index 

11 rural hospitals in Australia 176 nurses 

Not applicable Self-report me

correlated to corganizationa

0.01). Howevemediated by hpsychological distressed emlikely to report 

Glisson & James 200229

Employee consensus of depersonalization, emotional exhaustion, and role conflict 

Crosssectional study 

Service quality measured by perceptions of case managers 

33 child welfare and juvenile case management teams in 30 counties (4 urban and 26 rural) in 1 southeastern State in the U.S. 

Not applicable Case manage

constructive cservice quality 

organizationasignificantly re

9
10

Source Organizational Climate Attributes Design Type Patient Safety Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(Stone 200725 Composite measure of organizational climate Cross- sectional study Central line bloodstream infections (CLBI), ventilator- associated pneumonia (VAP), catheter- associated urinary tract infections (CAUTI), 30-day mortality and decubiti (pressure ulcers) 51 adult intensive care units in 31 U.S. hospitals 15,902 patients 1,095 nurses Not applicable Results were 

Organizationasignificantly poand significanCAUTI (

P < 0

Warren 200730 Organizational climate as 

measured by 4 metafactors: employee focus, support, professional demands, and pay satisfaction 

Crosssectional study 

1. Management of 2 chronic diseases (diabetes and chronic obstructive pulmonary disease [COPD]) 2. Prevention Index (PI): Summary of prevention care delivery (vaccination, tobacco prevention, disease, and risk factors screening) 3. Surgical outcomes using the National Surgical Quality Improvement Program (NSQIP) measures postsurgical morbidity and mortality 

74,662 employees from the U.S. Veterans Health Administration 

Not applicable Positive assoc

employee focuand preventio
11

Source Organizational 

Climate Attributes 

Design Type 

Patient Safety Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(

Wright 200343

Fairness and equity, role ambiguity, role overload, role conflict, workgroup cooperation and facilitation, growth and advancement, job satisfaction, emotional exhaustion, personal accomplishment, and depersonalization 

Crosssectional study 

Frequency of staff members’ clinical work with patients with psychiatric problems 

1 general hospital emergency department (ED) in a U.S. urban Midwest location 131 ED staff (medial, nursing, and psychiatric workers) 

Not applicable Workgroup co

is positively as

frequency of cpatients. 
 Evidence Table 2. Organizational Climate and Worker Outcomes 

Source Organizational Climate Attributes Design Type Worker Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(sAarons & Sawitzky 200635 Demoralizing climate 8 Job satisfaction, 1-year turnover 322 pediatric, adolescent, and family mental health providers in 49 public sector programs in California Not applicable The effect of o

satisfaction anpartially mediaclimate in strucWorker attitudeturnover 1 yea

Albion 200344 Workplace morale, supervisor leadership, participative decisionmaking, role clarity, professional interaction, appraisal and recognition, professional growth, goal congruence, workplace distress, and excessive work demands 4 Job satisfaction, intention to leave 1,097 regional Health Service District employees in Australia Not applicable Nurses reporte

climates on all interaction (

P < 

significantly lowadministrators, operational stahospital reportesatisfaction an(P < 0.05). 

DunhamTaylor 200045

Transactional leadership, laissezfaire leadership 4 

Staff satisfaction 396 nurse 

executives and 1,115 staff who report to them 

Not applicable Staff satisfactio

correlated with leadership (r = satisfaction deleader as being 0.37, 

P < 0.000

laissez-faire le< 0.0001). 

Glisson 200634 Depersonalization, emotional 

exhaustion, role conflict, and role overload 

6 Turnover 235 caseworkers 

and 26 case management teams that provide child welfare and juvenile justice services 

Availability, responsiveness, and continuity (ARC) intervention 

In hierarchical was found that reduced turnovorganizational 

12
13

Source Organizational 

Climate Attributes 

Design Type 

Worker Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s

Glisson & James 200229

Employee consensus of depersonalization, emotional exhaustion, and role conflict 

4 

Job satisfaction, 1 year turnover 

33 child welfare and juvenile case management teams in 30 counties (4 urban and 26 rural)in 1 southeastern State in the U.S. 

Not applicable Case manager

constructive cuturnover rates 

climate was noturnover. Orgasignificantly posatisfaction. 

Siu 200233 Organization, 

immediate upper level, coworkers, involvement, flexibility, work environment, and well-being 

4 

Job satisfaction Two separate 

samples of Hong Kong nurses sample 1: 144 nurses sample 2: 114 nurses 

Not applicable Findings were 

samples. In sasignificantly coIn sample 2, wpredictor of job 

Stone 200627

Professional practice, staffing/resource adequacy, nurse management, nursing process, nurse/physician collaboration, nurse competence, and positive scheduling climate 

4 

Intention to leave 2,323 registered 

nurses from 66 hospitals and 110 critical care units 

Not applicable Organizational 

an independenintention to leaconditions wernurse compete0.05). 

Stone 200728 Composite measure 4 Intention to leave 837 nurses employed in 39 

adult critical care units from 23 hospitals 

Organizational determinant of wages did not therefore, it waincreased pay organizational to reduce nurs
14

Sourc

e Organizational Climate Attributes Design Type Worker Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(s

Stordeur 200632 Meaning of work, relationships with nursing management, relationships with team, relationships with doctors, relationships with administration, quality of leadership, social support from superior, social support from colleagues, days dedicated for professional development, satisfaction with handover shifts 4 Intention to leave, job satisfaction 2,065 registered nurses in 12 Belgian hospitals Hospitals with high and low turnover were compared Relationships w

work ability; antime, handover were also bette

< 0.001). Job scommitment whospitals, wherlower (P < 0.00

Warren 200730 Organizational climate as 

measured by 4 metafactors: employee focus, support, professional demands, and pay satisfaction 

4 

Intention to leave, job satisfaction 

74,662 employees from the Veterans Health Administration 

Not applicable Employee focu

associated with support was neturnover intent
Patient Safety and the Health Care Environment

Figure 1. Conceptual Model of Organizational Attributes and Outcomes 

Enabling Factors: Leadership, 

Technologies, Communication, Financial Resources

Employee/Staff Actions

(e.g., hand washing, 

providing evidence-based care, etc.)

Patient

- Patient-centered care

- Evidence-based care

Employee/

Staff

- Workflow & workload

- Collaboration

- Occupational Safety

Organizational

- Efficiency

- Effectiveness

- Quality improvement

Structural Characteristics Structural Characteristics

Patient Actions

(e.g., adherence, collaboration)

Patient

-Falls

- Health care 

acquired infections

Employee/

Staff

-Job satisfaction

- Stress

- Occupational health

Organizational

-Cost of care

- Staffing shortages

- Reputation

Outcomes Outcomes

Microclimates

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