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Improving work environments in health care: Test of a theoretical

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334 October–December  2009

Improving work environments in health

care: Test of a theoretical framework
Cheryl Rathert
Ghadir Ishqaidef
Douglas R. May

Background: In light of high levels of staff turnover and variability in the quality of health care, much attention is
currently being paid to the health care work environment and how it potentially relates to staff, patient, and
organizational outcomes. Although some attention has been paid to staffing variables, more attention must be
paid to improving the work environment for patient care.
Purposes: The purpose of this study was to empirically explore a theoretical model linking the work environment
in the health care setting and how it might relate to work engagement, organizational commitment, and
patient safety. This study also explored how the work environment influences staff psychological safety,
which has been show to influence several variables important in health care.
Methodology: Clinical care providers at a large metropolitan hospital were surveyed using a mail methodology.
The overall response rate was 42%. This study analyzed perceptions of staff who provided direct care to patients.
Findings: Using structural equation modeling, we found that different dimensions of the work environment
were related to different outcome variables. For example, a climate for continuous quality improvement was
positively related to organizational commitment and patient safety, and psychological safety partially mediated these
relationships. Patient-centered care was positively related to commitment but negatively related to engagement.
Practice Implications: Health care managers need to examine how organizational policies and practices are
translated into the work environment and how these influence practices on the front lines of care. It appears
that care provider perceptions of their work environments may be useful to consider for improvement efforts.

A
lthough hospitals’ primary objectives are to pro-
vide care for sick or injured patients, they are
also workplaces for many individuals. The In-
stitute of Medicine, among others, has argued that the
hospital work environment not only influences staff
variables such as satisfaction and turnover but also in-
fluences the ability to provide high-quality and safe care
to patients (Page, 2004). Although management schol-
ars have focused extensively on work contexts in non-
health care sectors, researchers are only recently turning
similar attention to health care workplaces. Some re-
search in health care has explored staffing ratios, use of
temporary staff, the number of hours worked, and how
these factors relate to patient outcomes (Aiken, Clarke,
& Sloane, 2002a; Aiken, Clarke, Sloane, Sochalski, &
Silber, 2002b). However, scant attention has been paid to

Key words: health care staff, psychological safety, work environment

Cheryl Rathert, PhD, is Assistant Professor, Health Services Management, Senior Scholar, Center for Health Ethics, School of Medicine,
University of Missouri, Columbia. E-mail: RathertC@health.missouri.edu.
Ghadir Ishqaidef, BA, is PhD Student, The School of Business, The University of Kansas, Lawrence. E-mail: Ghadir@ku.edu.
Douglas R. May, PhD, is Professor and Co-Director, International Center for Ethics in Business, The School of Business, The University of Kansas,
Lawrence. E-mail: drmay@ku.edu.
This article awarded Best Paper for the 2008 Annual Meeting of the Academy of Management, Health Care Management Division, August 8–3, 2008,
Anaheim, California. This research was funded by a University of Missouri, Columbia, Research Council grant, and the University of Missouri Center
for Health Care Quality provided additional support.
Health Care Manage Rev, 2009, 34(4), 334-343
Copyright A 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Improving Work Environments in Health Care
the health care work environment and how it may influ-
ence important individual and organizational outcomes.
This study empirically tested a theoretical framework that
proposes linkages between the health care work environ-
ment and important staff and patient variables (Rathert
& May, 2007a). Identifying such linkages can help pro-
vide organizations with specific tools to improve working
conditions for staff and in turn improve care for patients.
Three important dimensions have been proposed as
being necessary for an optimal health care work envi-
ronment, and these dimensions are proposed to influence
outcomes such as staff psychological safety, positive affect,
satisfaction, and organizational commitment (Rathert &
May, 2007a). In addition, these dimensions were proposed
to influence patient safety and satisfaction. This work
environment includes (a) support for patient-centered
care, (b) support for continuous quality improvement
(CQI), and (c) an ethical climate that is benevolent. The
purpose of this study was to empirically explore how these
dimensions relate to specific outcome variables. Outcomes
of interest in this study included organizational commit-
ment, job engagement, and patient safety. Psychologi-
cal safety is proposed to mediate relationships between
the work environment and outcomes as well. The con-
ceptual model tested in this study is depicted in Figure 1.
Foundations for Care
Work Environments and Caring
Nursing scholars argue that providing top-quality care to
patients requires more than simply performing specific
care protocols and tasks. For many in care work, caring is
a vocation or a calling, as opposed to a job. High-quality
care requires development of a somewhat intimate rela-
tionship with each patient and involves interpersonal dy-
namics between the care provider and patient, as well as
Figure 1
Conceptual framework linking the work environment to outcomes
CQI = continuous quality improvement
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
335
intrapersonal dynamics within the care provider (Brechin,
1998). This suggests that personal emotions and relation-
ships must be nurtured. When care providers develop close
relationships with patients, they are better able to tailor
treatment to each unique patient or avert an impending
crisis (Radwin, 1996; Wittemore, 2000). Indeed, such re-
lationships form the basis of patient-centered care, which
the Institute of Medicine asserted as one of its six ob-
jectives for improving the quality of care (Berwick, 2002).
Such care improves patient satisfaction (Cleary, 1998)
and clinical outcomes (Fremont et al., 2001).
Along with the need to provide better patient care,
intrapersonal dynamics must be considered for the sake
of care providers. When care providers are involved in
processes that lead to poor outcomes or medical errors,
they tend to experience emotional distress. Increased
stress or distress impacts job and career perceptions, can
lead to physical health problems, and can impact the
care of subsequent patients (Firth-Cozens & Greenhalgh,
1997; Waterman et al., 2007; Wu, 2000). Physicians have
acknowledged that job-related stress results in medical
errors that cause harm and even death to patients (Firth-
Cozens, 2003). Thus, it is imperative to begin identify-
ing specific work environment attributes that influence
the ability of providers to deliver the best care to
patients. In this study, the work environment is con-
ceptualized as the social atmosphere that gives rise to
management practices and interactions among staff, as
opposed to the physical and structural context.
Important Outcomes in Health Care
Staff Engagement and Organizational
Commitment
Given that staffing and turnover are and will continue
to be a challenge for hospitals (Aiken et al., 2002a,
336 Health Care Management REVIEW
2002b; Page, 2004), we argue that organizations should
focus on engaging staff in their work and on character-
istics that should facilitate organizational commitment.
Organizational commitment has been shown to be a
better predictor of turnover than is job satisfaction
(Gees, Manojlovich, & Warner, 2008). Commitment is
a dynamic, iterative process and develops when indi-
viduals accept the organization’s goals and values and
are motivated to contribute to and maintain a good
relationship with the organization (Shwu-Ru, 2008).
Accordingly, commitment may facilitate high-quality
care even in the face of staffing shortages.
Work engagement should be a desired outcome for
health care organizations given that many care providers
seek caring as a vocation. Engagement relates to enthu-
siasm for and immersion in one’s work and the extent to
which that work meets the worker’s needs (May, Gilson,
& Harter, 2004; Vinje & Mittlemark, 2007). Impor-
tantly, engagement appears to be related to burnout in
that as engagement decreases, burnout tends to increase
(Maslach & Leiter, 2008; Saks, 2006). Thus, engage-
ment seems to be a particularly important variable to
cultivate among health care providers.
Psychological Safety
The model of Rathert and May (2007a) proposes that
psychological safety is an important outcome of the
work environment and an antecedent to care provider
and patient variables. Psychological safety means that
providers are not afraid to speak up to improve work
processes or call attention to a potentially dangerous sit-
uation. Individuals who experience psychological safety
in their work roles tend to be more engaged (Kahn,
1990; May et al., 2004). Care providers who are engaged
in their work are likely to be more cognitively vigilant,
empathically connected to their patients, and observant
of processes that can be improved. We suggest that
psychological safety is an important variable that links
the work environment with care provider job engage-
ment and organizational commitment. When staff are
more engaged and committed, there should be improved
patient safety as well.
Antecedent Work Environment
Dimensions
Patient-Centered Care
Patients have defined quality as patient-centered care
(Cleary, 1998; Gerteis et al., 1993). Patient-centeredness
means that care is delivered in an individualized manner,
with consideration of the patients’ needs and preferences
at center, as opposed to being disease or physician cen-
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
October–December  2009
tered. Although most hospitals claim their missions and
values include patient-centered care, when policies and
practices are examined, patients are often far from central.
When the work environment is more patient centered,
care providers should be supported in developing relation-
ships with patients and thus be more engaged in their work.
Similarly, when they develop closer relationships with
patients, care providers are more likely to avert errors
(Rathert & May, 2007b; Wittemore, 2000). When care
providers are supported in these value-consistent ways, we
also might expect them to develop stronger bonds with the
organization overall (i.e., commitment).
Hypothesis 1: Patient-centered work environments
will be positively related to care providers’ or-
ganizational commitment, job engagement, and
patient safety.
Continuous Quality Improvement
Continuous quality improvement means that small in-
novative improvements are continually made to pro-
cesses and that these processes have a customer-driven
focus. In a study of organizational culture, Baker, Murray,
and Tasa (2002) found that successful hospitals had staff
who felt that they had influence over their work and
processes, were encouraged to focus primarily on pa-
tients, and had managers with specific styles conducive
to CQI. CQI environments emphasize participation,
teamwork, and staff empowerment. Empowerment in
the workplace is associated with meaning and satisfac-
tion (Spreitzer, 1995, 1996). Because CQI enables care
providers to study their work processes and empowers
them to improve their work, we should expect staff to be
more fully engaged. Positive emotional energy derived
from resulting high-quality collegial relationships likely
facilitates strong emotional bonds with the organization,
thus increasing commitment. Similarly, engaged staff
should focus their full cognitive attention on patients, so
patient safety is likely to increase as well.
Hypothesis 2: CQI will be positively related to care
providers’ organizational commitment, job engage-
ment, and patient safety.
Benevolent Ethical Climates
In contrast to other types of work, care work has been
said to be ‘‘morally defined’’ because the work involves
attending to sick and injured individuals (Austin,
Lemermyer, Goldberg, Bergum, & Johnson, 2005). Accord-
ingly, there is a need to understand how organizational
Improving Work Environments in Health Care
policies and procedures manifest in the work environ-
ment in terms of ethics. At the organization level, lead-
ers face the conflicting goals of maximizing the quality
of patient care while at the same time minimizing costs
(Mills & Spencer, 2005). Such dilemmas may result in
unintended or mixed messages about decision-making
priorities for frontline staff and may lead to moral
conflict at the bedside (Rathert & Fleming, 2006). Thus,
the ethical environment likely plays a key role in im-
portant outcomes.
Much of the research on organizational ethics has
stemmed from the seminal work of Victor and Cullen
(1988) that found that the social context and group
norms in organizations impact moral behavior above and
beyond individual ethics. They argued that the social
context is composed of different ethical climates. Ethical
climates are shared employee perceptions about the types
of behaviors expected in the organization or work group
(Cullen, Parboteeah, & Victor, 2003). Nine ethical cli-
mate types have been proposed and empirically supported
based on a theoretical matrix derived from three types of
ethical theory and three types of referent groups for
decision making (Martin & Cullen, 2006). Of interest in
this study was the climate type known as the caring or
benevolent type. Benevolent climates promote considera-
tion for the concerns of others, such as the work unit as a
group. In contrast, other climate types focus on indi-
viduals themselves, instrumental concerns of the organi-
zation, or even strict adherence to prescribed moral codes.
Given that care providers feel called upon to focus beyond
their immediate needs in the care of others (Vinje &
Mittlemark, 2007), the type of ethical climate in their
work environment should impact their engagement and
organizational commitment.
In benevolent climates, individuals would be ex-
pected to make decisions that benefit the patient’s well-
being, the care team, the work unit, or the community,
as opposed to themselves as individuals or the orga-
nization’s bottom line. Thus, care providers would likely
be encouraged and committed to the patient care goals
of the unit overall and be more likely to engage them-
selves more fully in their daily roles. Importantly, a
benevolent ethical environment in health care would be
less likely to be punitive as it suggests a more systems-
oriented approach as opposed to an individualistic one.
For example, as opposed to reprimanding staff when a
medical error occurs, unit leaders would offer support
and examine the systems and processes that led to the
error because the emphasis would be on the greater good
as opposed to punishing individuals. Nonpunitive work
environments are said to be essential for improving care
quality and patient safety (Kohn, Corrigan, & Donaldson,
2000). In such a benevolent work environment, staff
should feel more supported and thus more committed to
the organization overall.
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
337
Hypothesis 3: Benevolent ethical environments will
be positively related to care providers’ organizational
commitment, job engagement, and patient safety.
The Mediating Role of
Psychological Safety
Optimal working environments in health care should
benefit both patients and care providers because of
positive psychological states experienced by care pro-
viders in such an environment (Rathert & May, 2007a).
Of interest in this study was the mediating role of psy-
chological safety. Identifying antecedents to psycho-
logical safety is important because health care providers
who are more psychologically safe have been shown to
make more medical error interceptions (Edmondson,
1996) and learn new techniques more efficiently
(Edmondson, Bohmer, & Pisano, 2001), and employees
who are more psychologically safe also tend to be more
engaged in their work (May et al., 2004). Furthermore,
psychologically safe staff tend to engage in more quality
improvement efforts (Nembhard & Edmondson, 2006)
and less in workarounds (Halebesleben & Rathert,
2008). Thus, we expected care providers who feel more
psychologically safe to be more engaged in their work
and more committed overall to the organization because
of the support they feel. Because staff should be more
comfortable speaking up or correcting flawed care pro-
cesses, patient safety should be improved.
The theoretical framework tested in this study pro-
poses that the work environment can elicit psycholog-
ical safety in care providers (Rathert & May, 2007a). An
environment that supports patient-centered care should
help providers feel safe because they are supported in
engaging themselves fully in the work for which they
feel a calling. An environment that supports CQI prac-
tices should elicit psychological safety because providers
are empowered to study their work processes and are
expected to initiate improvements in patient care prac-
tices. A caring and benevolent ethical environment also
should support psychological safety because of its emphasis
on decisions that support patients, the unit, and the com-
munity, as opposed to encouraging defensive behaviors.
Thus, given that psychological safety should result from
the work environment and should be antecedent to posi-
tive outcomes, we hypothesized that psychological safety
would mediate relationships between the work environ-
ment and outcomes. Still, we acknowledge that work en-
vironments may operate through additional mechanisms
not explored here. Thus, we proposed the following:
Hypothesis 4: Psychological safety will partially
mediate the relationship between the work envi-
ronment and care providers’ organizational com-
mitment and job engagement and patient safety.
338 Health Care Management REVIEW
Method
Participants and Procedure
Data were collected using a cross-sectional field study
methodology. All clinical care providers who worked in
medical units of a large metropolitan acute care hospital
in the Northwest were invited to participate in this
study. Questionnaire packets were mailed to eligible
participants by the hospital. Packets included a ques-
tionnaire, cover letter, and postage paid return envelope
addressed to the first author. A second reminder mailing
was made to participants 3 weeks later. This yielded a
response rate of 42%, with 306 surveys returned. Most
respondents were nurses (79%), but staff from several
other clinical professions responded as well. Respon-
dents were eliminated from the analysis if they indicated
that they did not provide direct care to patients. Thus,
our final sample size was 252 respondents, 87% of whom
were nurses, 7% were allied health professionals, and 6%
were health care support personnel. Available respon-
dent characteristics are depicted in Table 1.
Work Environment Measures
Patient-Centered Care. Patient-centered care was
measured using a 12-item scale, developed for this study,
based on content patients identified regarding what is
important to them for patient-centered care (Cleary,
1998; Gerteis et al., 1993). Respondents answered ques-
tions such as, ‘‘If patients have anxieties or fears about
their condition or treatment, is someone on your unit
able to discuss this with them?’’ ‘‘Are you able to respond
to call buttons as quickly as you think you should?’’
(Cronbach’s  = .81).
Continuous Quality Improvement. This dimension
was measured using three subscales, based on dimensions
identified for the Quality in Action survey by Baker
Table 1
Survey respondents’ characteristics
Length of time worked
Years at this hospital
<1 12
1–5 39
6–10 16
11–15 11
16–20 10
21 or more 11
Note. Values are in percentages. Percentages may not equal 100% due to rounding.
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
October–December  2009
et al. (2002). The first subscale, Quality Improvement
Leadership, used 5 items that asked respondent percep-
tions’ of unit managers’ behaviors related to elements of
a CQI culture. An important element of successful CQI
is that leaders solicit feedback on work processes from
staff who are empowered to continually study their
work. An example item is, ‘‘If I have an idea for im-
proving the way we do our work, managers in my work
unit listen to it’’ ( = .87). A second subscale used was
Patient Focus. This measure used 5 items that asked
respondents the extent to which patients are treated
well and their needs are valued and considered a priority
for the organization, such as, ‘‘In this unit, we are
actively doing things to improve the quality of patient
care’’ ( = .82). We also included a 6-item measure of
Empowerment (Spreitzer, 1995, 1996) as the third sub-
scale. Participants responded to items such as, ‘‘I have
significant autonomy in determining how I do my job,’’
and ‘‘I have a great deal of control over what happens in
my unit’’ ( =.86).
Ethical Climate. We used a 9-item scale adapted from
Cullen et al. (2003). Example items included, ‘‘People in
this work unit are actively concerned about the patient’s
and public’s interest,’’ and ‘‘The effect of decisions on
the patient and the public are of primary concern in this
work unit’’ ( = .86). Responses that were more positive
indicated higher levels of benevolence in the respon-
dents’ work unit.
Outcome Measures. Psychological Safety. A 7-item
scale was adapted from Edmondson (1996). Example
items were, ‘‘If you make a mistake on this work unit, it is
often held against you,’’ and ‘‘Members of this work unit
are able to bring up problems and tough issues’’ ( = .63).
Organizational Commitment. A 7-item scale was used
to measure organizational commitment (Mowday, Steers,
& Porter, 1970). Example items included, ‘‘I talk up this
organization to my friends as a great organization to
Length of time worked Length of time worked
in current unit in current specialty
16 6
49 37
16 19
10 8
5 8
6 22
Improving Work Environments in Health Care 339

work for,’’ and ‘‘This organization inspires the very best
in me in the way of job performance’’ ( = .86).
Engagement. We used 9 items from May et al. (2004).
Because internal consistency was low in our study (.57),
we used structural equation modeling (SEM) lambda
loadings to identify items that provided the best fit with
the different models tested, which resulted in elimina-
tion of 5 items. The final scale was composed of items
such as, ‘‘Performing my job is so absorbing that I forget
about everything else,’’ and ‘‘I exert a lot of energy when
I do my job.’’ Consistent with the theory in this area, we
chose to retain 4 items as one scale. Confirmatory factor
analysis (CFA), which we used to test the model, can
yield valid unbiased estimates of relations between con-
structs even when internal consistency is low (Little,
Lindenberger, & Nesselroade, 1999).
Overall Patient Safety Perceptions. Four items were
adapted from the Agency for Healthcare Research and
Quality Patient Safety Culture Survey (Sorra & Nieva,
2004) to measure overall patient safety. The scale was
then reduced to 3 items after CFA. The 3 items used in
the analysis were, ‘‘Our procedures and systems are good
at preventing errors from happening,’’ ‘‘We have patient
safety problems in this unit,’’ and ‘‘It is just by chance
that more serious mistakes don’t happen around here’’
(=.63).
All items were adapted to include a 4-point response
scale that asked respondents to indicate the frequency
with which specific behaviors, interactions, and practi-
ces tended to occur in their work units, on a scale where
1 = never, 2 = sometimes, 3 = usually, and 4 = always.
Analysis. We used SEM as the analytical tool to examine
our hypotheses. We chose SEM for a number of reasons.
First, it allows researchers to directly test how well their
measures reflect the intended constructs through CFA,
which is more rigorous and more parsimonious than are
the traditional techniques of exploratory factor analysis.
Second, SEM techniques enable us to specify and test
complex models with prediction paths. Third, we can
simultaneously assess the quality of the measurements
and examine predictive relationships among the con-
structs (Kelloway, 1998).
In all of our models, we set the variance of the latent
constructs (Psi matrices) equal to 1.0, following the unit
variance identification technique to assign scales to the
factors (Kline, 1998). In addition, no indicator was al-
lowed to load on more than one factor; therefore, our
measurement models were unidimensional. Moreover,
exogenous latent constructs were allowed to covary, as
well as endogenous constructs. Finally, we used the maxi-
mum likelihood method in estimating covariance matri-
ces for all models.
We tested the following: (a) the measurement model
that specifies the relations between manifest indicators
(i.e., measurement or scale items) and latent constructs
(e.g., CQI), (b) the structural model (latent regression)
that specifies relations between the latent variables and
outcomes (psychological safety included as an outcome),
and (c) latent regression analysis between the work
environment variables and outcome variables (psycho-
logical safety included as mediator). The SEM approach
to mediation analysis uses similar logic to the approach
of Baron and Kenny (1986) (Frazier, Tix, & Barron,
2004). Five models were tested to find the best solution.
Specific details of the analysis and results are available
on request from the first author. Descriptive statistics,
reliability coefficients, and intercorrelations are depicted
in Table 2.
Results
Our initial analysis tested the validity of our decision to
include the three CQI subscales as one higher order

Table 2

Means, standard deviations, and Pearson correlations among study variables

Variables M  1 2 3 4 5 6 7 8 9

1. Patient focus 2.70 .60 (.82)

2. Quality improvement leadership 2.65 .69 .63 (.87)
3. Empowerment 2.66 .57 .45 .41 (.86)
4. Patient-centered care 2.60 .37 .52 .53 .42 (.81)
5. Benevolent ethical climate 2.97 .47 .64 .50 .38 .54 (.86)
6. Psychological safety 2.98 .43 .37 .54 .32 .28 .44 (.63)
7. Commitment 2.90 .63 .55 .53 .45 .57 .43 .32 (.86)
8. Overall patient safety 2.94 .55 .43 .51 .29 .39 .44 .39 .40 (.63)
9. Engagement 2.99 .44 .08 .12 .03 .21 .02 .09 .08 .14 (.57)
Note. Two-tailed pairwise correlations. n = 252. Cronbach’s alpha values are between parentheses. Correlations in bold are significant
at p < .01.

Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
340 Health Care Management REVIEW
construct. Quality improvement leadership, patient focus,
and empowerment’s statistically significant factor load-
ings ( p < .001) onto CQI were .52, .50, and .31, respec-
tively, so further analysis treated this as a unified variable.
Because we were interested in the degree to which
the work environment predicted our outcomes, we ex-
amined different regression models. First, we considered
the beta weights of the work environment variables
when predicting psychological safety, commitment, en-
gagement, and patient safety. This model showed good
fit to the data (root mean square error of approximation
[RMSEA] = .062, nonnormed fit index [NNFI] = .922,
comparative fit index [CFI] = .928). Our latent regres-
sion analysis demonstrated the following: (a) Patient-
centered care was significantly and positively related to
October–December  2009
was evidence of mediation effect, we looked at the path
coefficients, direct effects, and indirect effects. If we
were to find significant indirect effects, then we would
have evidence of full (in the occasion that direct paths
were not significant) or partial mediation (in the occa-
sion when direct paths were significant). Analysis found
partial support for Hypothesis 4 in that psychological
safety partially mediated relationships between two work
environment dimensions (patient-centered care and CQI)
and commitment but not engagement or patient safety.
Model 2 found psychological safety as a significant
partial mediator with good model fit (RMSEA = .066,
NNRI = .928, CFI = .933).
A full model that included all constructs of interest
was analyzed. Direct path relationships remained sig-
commitment ( = 0.45, z = 2.7) and negatively related to nificant. However, no evidence of mediation effect was
engagement ( = 0.61, z = 2.74) and psychological found in the full model. Model 5 had good model fit
safety ( = .67, z = 1.93). Thus, we found partial (RMSEA = .062, NNFI = .922, CFI = .928). Ultimately,
support for Hypothesis 1. (b) CQI was significantly and we found partial support for the theoretical model. The
positively related to psychological safety ( = 2.13, z = final model is depicted in Figure 2, and path coefficients
3.61), commitment ( = 1.19, z = 4.13), and patient and fit statistics are presented in Table 3.
safety ( = 1.04, z = 4.19). Thus, results show partial
support for Hypothesis 2 as CQI did not significantly Discussion
predict engagement. (c) Furthermore, ethical climate
was significantly and positively related to engagement The purpose of this study was to empirically test a
( = 0.49, z = 2.22) but negatively related to commit- theoretical framework that specifies relationships be-
ment ( = 0.42, z = 2.11). Thus, we found partial
support for Hypothesis 3.
We then tested our fourth hypothesis in which we
predicted that psychological safety would partially medi-
ate the relationship between work environment dimen-
sions and outcomes. We first considered each outcome
separately (thus, three models) and then included all
outcomes together in a final model. To decide if there
tween the health care work environment and variables
such as care provider’s organizational commitment and
job engagement and patient outcomes, such as patient
safety. This framework is one step toward teasing apart
predictive elements of the acute care work environment.
We found some support for our hypothesized relation-
ships. It is notable that the work environment dimen-
sions differentially predicted the outcomes. First, care

Figu re 2

Path model depicting work environment prediction of outcomes via psychological safety.
CQI = continuous quality improvement

Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Improving Work Environments in Health Care 341

Table 3

Unstandardized path coefficients and fit statistics for five models

Path Model 1 Model 2 Model 3 Model 4 Model 5

a 1.19*** 2.74*** _ _ 2.12*

b 2.13*** 2.41*** 2.2*** 2.21*** 2.11***
c 0.195 _ _ _ 0.05
d 1.04*** _ _ 0.84* 0.82*
e 0.67* 0.84** 0.69* 0.69* 0.66*
f 0.45** _ _ _ 0.22
g 0.61** _ 0.69** _ 0.69*
h 0.42* 0.51* _ _ 0.45*
i 0.49* _ 0.51* _ 0.49*
j 0.54** _ _ 0.4
k _ 0.09 _ 0.11
l _ _ 0.07 0.08
TE of CQI 1.45*** 0.21 0.99*** Commitment = 1.28***
Engagement = 0.19
Safety = 0.99***
IE of CQI 1.29* 0.21 0.15 Commitment = 0.84
Engagement = 0.24
Safety = 0.18
TE of patient-centered care 0.45* 0.62** 0.05 Commitment = 0.48**
Engagement = 0.62**
Safety = 0.06
IE of patient-centered care 0.45* 0.067 0.05 Commitment = 0.27
Engagement = 0.08
Safety = 0.06
TE of ethical climate _ 0.51* _ Commitment = 0.45*
Engagement = 0.49*
Safety = 0.03
IE of ethical climate _ _ _ _
RMSEA 0.062 0.066 0.062 0.069 0.062
NNFI 0.922 0.928 0.927 0.93 0.922
CFI 0.928 0.933 0.933 0.936 0.928
Note. Model 1: direct effects of the WE constructs on psychological safety, commitment, engagement, and patient safety. Model 2: effects
of WE on commitment, with psychological safety as mediator. Model 3: effects of WE on engagement, with psychological safety as
mediator. Model 4: effects of WE on patient safety, with psychological safety as mediator. Model 5: effects of WE on commitment,
engagement, and patient safety, with psychological safety as mediator (full model). TE = total effect; IE = indirect effect; RMSEA = root
mean square error of approximation; NNFI = nonnormed fit index; CFI = comparative fit index; WE = work environment.
* p < .05. **p < .01. ***p < .001.

providers who reported that their work units were more
patient centered were more committed to the organi-
zation but less engaged in their work. Second, care
providers who reported greater CQI environments re-
ported greater psychological safety, organizational com-
mitment, and patient safety but were not significantly
more engaged in their jobs. Third, care providers who
felt that the ethical environment on their units was
more benevolent tended to be more engaged in their
jobs but were less likely to be committed to the orga-
nization overall.
Work environment dimensions differentially predicting
outcomes is consistent with previous research in this area.
A meta-analysis of organizational climate studies found
that specific environments were predictive of specific
outcomes (Carr, Schmidt, Ford, & DeShon, 2003).
Similarly, in a study of nurses, Vinje and Mittelmark
(2007) found that engagement was positive in some
contexts but related to burnout in others. This suggests
that there may be an optimal constellation of dimensions
depending on the types of work units and outcomes of
interest. For example, the ethical environment may be
more highly related to outcomes in critical care units
where care providers regularly face end-of-life decision
making. In contrast, CQI environments may be more im-
portant in units that deal primarily with diagnostics, and
patient-centered care may be most important in surgical
step-down units where otherwise healthy patients are

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342 Health Care Management REVIEW
recovering from surgery. Although our study’s results are
enlightening, further research is needed to tease apart
specific outcomes and their antecedent work environments.
Limitations
Although all our hypotheses were partially supported,
our study is not without limitations. First, our study was
a cross-sectional survey design, so we cannot infer cau-
sation from our results. Second, some of our measures
had low reliability based on conventions of classical
testing theory. Yet, as noted earlier, CFA can yield valid
unbiased estimates of relations between constructs even
when internal consistency is low. Our 4-point never–
always scale resulted in somewhat low variability and
‘‘ceiling effects’’ in responding. For example, for some
items, 80%–90% of respondents indicated one of the
two most positive responses. Low variability in responses
could have attenuated some relationships. Finally, our
study obtained data from staff at one hospital. Future
research will need to examine whether the findings here
are generalizable to other health care settings.
Future research also should explore work environ-
ments and outcome variables at the unit or organization
levels of analysis. The sample size of this study did not
allow us to examine the variables at a group level. Re-
search that includes additional organization-level data
in the model as dependent variables should be explored
as well, as should longitudinal research that could pro-
vide richer causal inferences.
Implications for Practice
Health care leaders and unit managers are recognizing
that the work environment impacts important variables
for care providers and their patients. Research such as
this study brings us closer to understanding ways in
which work environments can be improved. Adopting a
CQI approach, in which leaders empower frontline
clinical providers to assist in development of important
care processes, should increase not only quality of
patient care and work quality but patient safety as well.
Managers need to pay attention to how organizational
policies and practices are perceived among frontline
care providers. For example, if organizational missions
and objectives emphasize patient-centered care, leaders
will need to be sure staff do not perceive that the
organization’s most important focus is the ‘‘bottom line.’’
Similarly, managers cannot simply tinker around with
CQI processes as the environment needs to support such
processes or they will not be implemented successfully
(Shortell et al., 1998). Although improving the work
environment may come with costs, inhospitable work
environments come with tangible costs as well: Esti-
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
October–December  2009
mated costs for replacing clinicians range between
$10,000 and $145,000 per person, depending on the
type of care provider, and turnover averages approxi-
mately 20% (Barney, 2002). Thus, focusing resources on
improving the work environment may be a long-term
good investment.
In conclusion, our study provided some evidence that
the work environment can be an important predictor of
care providers’ commitment and engagement and patients’
well-being in terms of patient safety. In addition, we found
that psychological safety partially mediated the work
environment–outcome relationship. Finally, this study
suggests that the work environment can be managed to
support all persons, care providers as well as patients.
Acknowledgments
The authors would like to offer special thanks to
Kimberly Rogers for her assistance with the project. We
also wish to thank Bill Kreutzweiser, Liz Buller, Susan
Wannamaker, and the survey participants at Vancouver
Coastal Health.
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