Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)

Graduate Group


First Advisor

Matthew D. McHugh


Background: Registered nurse (RN) turnover is a significant problem in nursing homes and has been consistently linked to poor patient outcomes in this setting. Extensive evidence from hospitals has shown that work environment is an important predictor of patient care quality and nurse factors leading to turnover such as job dissatisfaction and burnout, but very little research has explored these same relationships in nursing homes.

Objectives: To study the empirical relationships between work environment and patient and nurse outcomes in nursing homes.

Design: Cross-sectional secondary data analysis linking 2015 RN4CAST four state nurse survey data; LTCfocus, a publically available data set from Brown University; and Nursing Home Compare from the Centers for Medicare and Medicaid Services (CMS).

Population Studied: The nursing home sample consisted of 245 CMS-certified nursing homes in California, Florida, New Jersey, and Pennsylvania. The nurse sample consisted of 692 RNs employed in those facilities.

Results: Patient outcomes: Compared to nursing homes with poor work environments, facilities with good work environments had a 3.04 higher odds of receiving an overall star rating of 4 or 5 stars versus 1 or 2 stars, 1.8% fewer high risk residents with pressure ulcers, and 0.15 fewer hospitalizations per resident year; facilities with average work environments had 2.23% fewer long-stay residents on antipsychotics. The relationships between good and poor environments for antipsychotics and 30 day readmissions were in the hypothesized direction but not statistically significant. Nurse outcomes: RNs working in nursing homes with good work environments were 89% less likely to report job dissatisfaction, 76% less likely to report intent to leave their jobs within one year, 87% less likely to experience burnout, and 73% less likely to report leaving necessary patient care undone compared to RNs working in facilities with poor work environments. RNs in good work environments were more likely to have been employed 3 years or more than RNs in poor environments, but the result was not statistically significant.

Conclusions: Nurse work environment is an important and tangible area to target for interventions to improve care quality and reduce staff turnover in nursing homes.

Included in

Nursing Commons