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Working Environment of Nurses


The working environment of a nurse has a direct impact on the quality of service a patient will receive. Following the introduction of the Patient Protection and Affordable Care Act (ACA), healthcare structures have been transformed to meet quality standards expected by the patient, thus influencing the working conditions at the facility. Facilities have introduced laws on improving the quality of services offered to the patients while simultaneously reducing the running cost.

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Most practicing nurses find the current environment hostile and it affects their decision-making process. In a case study, James Wu instructs a nurse not to reveal information about his medical history even to family members. Nurses are professionally required to uphold the patient privacy policy. Ethical dilemmas can be reduced if hospital administrations create an enabling practicing environment by hiring more skilled nurses to reduce work burden, eliminating cost-effective policies, and nurturing career development among the nurses.

Capstone Paper

The working environment of a nurse affects the quality of service a patient will receive. The practice environment is influenced by the work scheme, facility organization and administration, the workload and the labor force participation rate, and the culture in the place of work. Patient attitude secondarily affects the working environment of a nurse. Following the introduction of the Patient Protection and Affordable Care Act (ACA), healthcare structures have been transformed to meet quality standards expected by the patient, thus influencing the working conditions at the facility. These changes influence the decision-making process of nurses, hence affecting the service quality offered to the patients. To reduce working costs, for instance, hospital administrations have reduced the number of nurses employed, raising the workload for those who retain their jobs. On the contrary, ACA gives the patient a right to demand quality services irrespective of the prevailing conditions. Patients put their trust in nurses, thus administrators need to form an environment that will promote information confidentiality and patient privacy.

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Case Study

In any hospital setting, nurses are expected to provide patient care and ensure comfortability and satisfaction are achieved throughout hospitalization. Below is a case study of a patient who could be a victim of negligence due to the nurse's work environment.

Patient Details


IPNO: 653533/18

AGE: 45


SEX: Male

RELIGION: Christian

Anthropometric Measurements




Table 1

  • Biochemical Assessment

















Patient History

The patient, James Wu, was diagnosed with pulmonary tuberculosis, hypertension, and diabetes in 2015. During the second admission, in 2018, the patient had been diagnosed with the same complication since he stopped medication from December 2017 to the time of entry. He has a wife and two children, one in secondary school and the other at the primary level. Medicare supports his hospital bills. The patient lacks appetite and looks dehydrated as evidenced by sunken eyes and a BMI of 17.2kg/m2.

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Dilemma Description

The patient was hospitalized at the Massachusetts General Hospital on 15th June 2018. During the first three days, he was administered insulin which functions to lower glucose levels in the body. As a result, the patient showed improvement in blood pressure, pulse rate, and oxygen rate. Due to the positive progress, the medical doctors at the facility prescribed a lower dose of insulin for the patient - from 1.0 U/kg/day to 0.5 U/kg/day, together with a prescription of premixed aspart/lispro. The purpose of insulin therapy for the patient was to reduce calorie levels, prevent tuberculous pancreatitis, and prevent the prevalence of hepatic diseases among other opportunistic disorders that may arise.

Two weeks after the change of drug prescription, the patient showed good progress meaning that he would soon be discharged. He was to be taking tuberculosis medication from home but regularly coming to the hospital for check-ups. When the patient was nearing the scheduled discharge date, the family members gathered and demanded an explanation for the onset of diabetes. However, the nurse was under the instructions of the patient not to tell the relatives that at a certain point he had stopped taking the given dose.

Literature Review

The primary purpose of this capstone project was to determine the relationship between nurses’ working environment and the quality of services they offer to the patients. To identify literature on this topic, various sources were used. The resources include Google search, Cumulative Index for Nursing and Allied Health Literature (CINAHL), National Center for Biotechnology Information (NCBI), the United State National Library (USNL), and PubMed. Keywords used during the literature search were working environment, treatment service quality, patient expectation, patient satisfaction, and ethical practice.

In 2010, Roche and Duffield researched various mental-surgical units with the purpose to identify the different working conditions and their impact on nursing practice. The research included 102 mental-surgical units across 24 healthcare facilities in 2 Australian states. The projected number of participants was 3,348 people (Roche & Duffield, 2010). The study specifically used the Practice Environment Scale of the Nursing Work Index (PES-NWI) instrument to assess the quality of nurses’ working environment in the selected accredited healthcare facilities.

According to the study done by Roche and Duffield (2010), the majority of the nurses in the mental-surgical units work in a positive environment. They reported that they shift from one department to another, a factor that boosts their self-esteem as they feel valued and needed. In another parameter used in the study, it was found that the nurses were more involved in the administrative affairs of the facility they were working at. Additionally, the nurses were found to be directly affected by policy implementation. They also reported needing more access to senior managerial, and administrative positions and opportunities to advance their career. The involvement of nurses in facility decision-making will encourage job efficiency and satisfaction for both the nurse and patient. Therefore, the participation of nurses in decision-making processes and the provision of career advancement opportunities can improve the general services offered by nurses to patients in mental care facilities.

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Another research which was looking at the perception of nurses of their working environment and its influence on patient satisfaction was conducted in Western New York facilities. Boev (2012) researched four adult Intensive Care Units (ICUs) targeting the views of the patients and nurses, and after that comparing the two variables. Boev’s study lasted for five years and reached a total of 671 nurses and 1532 patients (or family members). The study found that patients reported ultimate satisfaction when the nurses had a positive perception of their working environment (Boev, 2012). Likewise, the patients reported poor services when the nurses viewed the working environment as negative.

Additionally, the research found that nursing leadership had a direct impact on the quality of services the nurses are likely to offer (Boev, 2012). Also, when the nurses are few, the quality of the services provided to the adult patient population in ICUs was described to be impoverished by the patients. Nurses described this scenario to cause fatigue due to the imbalanced workload to workforce ratio.

Shaffer and Tuttas (2008) conducted research purposing to establish a relationship between nurse efficiency and patient satisfaction with hospital compensation. In this particular investigation, patients and nurses were issued with HCAHPS. HCAHPS is made up of 27 questions where patients are required to answer 18 of the 27. The 18 items focus on the patient’s perspective of the quality of service being offered. Nurses, on the other hand, are required to answer six of the 27 questions. The analysis reveals that quality care service is linked to the attitude and behavior of the nurse towards the patient. Therefore, hospitals and caregiving facilities should educate nurses on the importance of using HCAHPS to understand how a patient views a specific nurse (Shaffer & Tuttas, 2008). This study corresponds to the one done by Aiken et al. (2012) across 12 countries in the United States and the United Kingdom.

Additionally, the research suggests more workforces should be availed in such facilities to have a balanced nurse-to-patient ratio, which will consequently lower the work burden among the nurses and increase the personalization of services. To reduce the onset of infections among patients, the study further suggests that hospital administrations should equip nurses with the materials necessary to educate patients on the same (Shaffer & Tuttas, 2008). Such implementation would improve the quality of services offered by nurses, hence strengthening the relationship between the patient and nurse.

Investigations about health services and patient satisfaction have also been done outside the United States. In the Netherlands, for instance, a study was done (1) to explore the aspects of the working environment that affected the service superiority based on the views of the nurses; (2) to learn how the mentioned factors relate to the eight elements of magnetism; and (3) to identify how the aspects contribute to the level of customer satisfaction (Kieft et al., 2014). The subjects were asked questions both digitally and manually. Among the environmental factors that they responded to be a positive quality, contributors include adequate staffing, an interdisciplinary collaboration among the staff, and good nursing leadership. Among the factors that contributed to negative work quality among the Dutch nurses were found to be conservative policies, clarity, and responsibility objectives. Together, these factors make healthcare facilities hire small and less skilled staff to minimize costs. The report also established that when nurses work in an environment with high pressure on service efficiency and economic policies, then patients tend to be less satisfied. On the other hand, patients reported positive remarks in an environment where nurses actively engaged in the major decision-making processes and are nurtured in their careers. In conclusion, Kieft et al. (2014) explain that there is a link between the influence of hospital policies on the working environment and the level of patient satisfaction.

Structural empowerment affects the productivity of workers in a working place (Hauck et al., 2011). The research specifically issued questionnaires to 257 nurses across five tertiary hospitals in the eastern part of the upper United States. However, only 98 participants responded. The study found out that nurses who perceived themselves as empowered in their workplace had no plans of looking for job opportunities elsewhere. Similarly, nurses considered themselves empowered when they have access to career development opportunities, access to information, and direct support from the administration of the facility they are working at. The study authenticates Kanter’s theory of structural empowerment. According to the theory, work inspiration is typically achieved when workers have resources, support, and information at their disposal (Hauck et al., 2011). Hauck et al. (2011) conclude that for patients to be service-satisfied, healthcare management should first work towards the empowerment of the nurses.

Below is a description of a case that illustrates the relationship between nurse empowerment and patient satisfaction. Sherry Albert is a practicing nurse with over 35 years of experience. From an early age, she watched her father care for the elderly. According to her father, people aged above 65 usually live lonely, a factor that pushes them to substance abuse. Her father would invite them every day to have dinner with them. When she graduated from high school, Sherry Albert secured a job with Red Cross where she was paid $3.20 per hour. Her role was to provide personal care to senior adults. She later joined college to do a diploma in nursing (Sherry Albert, 2017). Today, Sherry Albert is the nurse in charge of a 56-bed hospital, and she not only provides services to patients but also supervises other workmates. She says that her role is not to delegate rules but to ensure the needs of the nurse are met. A nurse who has an input in the decisions of the facility works better than one who is denied the chance to be part of the decisions made. She also devotes herself to counseling youths and family spouses (Sherry Albert, 2017). Due to her efficiency in nursing leadership, Albert has been appointed as a member of the National Seniors Council where, together with the other members, she advises the government on matters about health. Nurse empowerment, therefore, is influenced by the reigning leaders (Breau & R? aume, 2014). Good leadership leads to good services among the rest of the workers.

Another study was conducted in four states-Pennsylvania, California, Florida, and New Jersey. The goal was to establish the relationship between the hospital environment and the level of patient approval. A total of 430 hospitals and 20,984 nurses were reached. After that, the researchers classified the responses as better, poor, or mixed. The nurses with a lot of workloads viewed their environments as poor (5.3 patients against 4.6 patients). For a situation to be considered better, the patient had to be willing to recommend another person to the same facility. The study further indicates that when one patient reduced the nurse workload, the environment changed from poor to better. The investigation concludes by recommending healthcare administrations focus on improving the working environment if they are to attain patient satisfaction (Kutney-Lee et al., 2013). Emphasis should be on increasing job satisfaction, decreasing workload, and supporting nurses in career development agenda.

Ethical versus Practical Dilemma

In the case study described above, the nurse finds himself between the patient and the relatives. From a moral view, patients’ relatives have the right to know the cause, progression, and treatment of the disease their loved one is suffering from. However, from the ethical perspective, a nurse serves to care for the patient and, therefore, if he instructs that specific information should not be revealed, so it should be.

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The description confirms that the case study is an example of an ethical dilemma. Generally, ethical dilemmas occur when a person finds difficulties in making decisions on the grounds of social norms. Nurses are regarded as the first people a patient can trust. They are told information sometimes beyond the sphere of their practice. While other parties, such as the relatives for this case, may demand to know the truth about the disease or any information related to it, nurses should always be genuine in the information they give. However, if a patient of sound mind is against the issuance of information to anyone, including relatives, then the nurse must abide by that command. In some cases, such information can only be revealed to legal parties such as police officers, personal lawyers, or any other person mentioned in a legal paper written by the patient.

Practical dilemmas refer to situations where a decision made has an impact on the general public or another person apart from the first person in question. In this case study, the decision whether to reveal the medical information of the patient has no consequences to the family members and thus falls under the ethical bracket.

Data and Ethical Principles

The American Nurses Association (ANA) has set aside a set of regulations under the Center for Ethics and Human Rights to guide nurses when making decisions during their daily work (Long, 2012). The nurse’s decision not to give the family members information about the patient was based on standards of the federal Health Insurance Portability and Accountability Acts (HIPAA) of 2002 which became applicable in April 2005. According to HIPAA, nurses and other healthcare providers should maintain the confidentiality of the patient from any form of media and unauthorized personnel (Long, 2012). HIPAA sets rules for healthcare workers.

The HIPAA security rule has however been violated several times since the time it became practical to the present day. One particular instance was during the death of Michael Jackson, a famous pop musician who allegedly died from insomnia. According to an article written by CNN, Cherilyn Lee later appeared before a court hearing as a witness in the Michael Jackson case (Duke, 2013). Another instance, where HIPAA security law was violated, was after the death of Farrah Fawcett when nurses were condemned for leaking information about the cause of his death (Alsonfi et al., 2009). Therefore, when making ethical decisions, nurses should consider the law irrespective of the influence of external sources.


The categorical imperative, also known as the Duty-based approach, provides a way to formulate a decision on ethical grounds. The method is linked to Immanuel Kant (1724-1804) and stresses the personal will and intention when faced with a dilemma about issuing information about a patient (Spence Laschinger et al., 2010; Arnold, 2014). According to the philosopher, an ethical resolution should be based on telling the truth despite the consequences that might occur (Spence Laschinger et al., 2010; Arnold, 2014). Although the method has been criticized as religious (since it was previously widely used by church leaders such as Saint Augustine of Hippo (354-430)), it provides a framework where workers can stick to the moral path rather than the legal obligations.

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Another strategy that can be used in the case study is the Rights Approach which has its roots in the Stoics of Ancient Greece and Rome. According to this approach, ethical decisions should be based on dignity (Spence Laschinger et al., 2010; Arnold, 2014). This strategy, therefore, protects one side of all the factors in question. For this case study, this approach favors the dignity of the patient.

  • Implement Strategies

Implementation was based on the above strategies. First, the relatives were made to understand the law of confidentiality. It was vital for them to comprehend why their request had been rejected, to prevent a radical reaction. In an attempt to preserve the dignity of the patient, an explanation about personal health was made. The federal health law stipulates that everyone “owns” their health, thus the patient had the right to decide who may know his whereabouts or who may not (Solove & Schwartz, 2014). Nurses are expected to comply with this law in every decision they make.

  • Evaluation

The relatives of the patient initially received the information with shock. According to them, they had the right to know every piece of information about their hospitalized loved ones. However, after explaining to them that patients had the right to privacy, even from their family members, they unwillingly stopped being aggressive on the matter and resolved to ask the patient in person once he is discharged.

  • Legal Consideration

Patient’s rights are put in place mainly to safeguard the human pride of the patient after he recovers. In circumstances, where he does not improve, society should maintain respect for the deceased and not in any way should medical practitioners, especially nurses, reveal the medical or general life history of the patient to any form of media. At Massachusetts Hospital, there is an imbalance between the number of patients to that of nurses which can therefore easily lead to the breach of the right to the privacy policy (due to huge workload) and exposure of some information to unauthorized parties - due to stress from overworking. There is legal recuperation for such occurrences.

When any medical practitioner breaches a patient's right to information privacy, a cause of action may be taken against the provider for malpractice or any related form of tort. It should, however, be noted that if there was consent from the patient, that case is not regarded as a breach of the law. Besides taking the case to a lawsuit, legal action can be taken against the nurse by the hospital administration. Once the patient learns that his confidentiality has been violated, he is allowed to forward the evidence to the head administrator or the Quality control department of the hospital (Solove & Schwartz, 2014). The nurse in the subject may either be fired or face another form of disciplinary action depending on the magnitude of the case.

In the case study described above, the nurse faced with the dilemma could have easily given out the information to take away the dilemma burden. However, after reviewing the consequences of such a move, the nurse decided to hold the data until he gets approval from the patient. The nurse never revealed the information as it would have been a violation of the patient’s privacy. Likewise, the relatives could have asked the patient directly at any convenient moment since he was now in a stable condition.

Policy Implementation

The process of making ethical decisions may seem easy but can be complicated, especially when dealing with the right to privacy. Sometimes, the person seeking the information is of high influence such as media reporters or close relatives of the patient. Nurses, therefore, need to design ways that will enable them to abide by the rule of law.

The advancement in technology renders information easily conveyable among different people. Hospital management should introduce laws that prohibit nurses from using their phones. With constant personal contacts, such as through calls, text messages, and social media platforms, it becomes easy for them to communicate with a stranger and leak some information, either about the patient they are caring for or anything about the facility. Phones should hence be kept away during working hours. The law should also clearly state that phone communication should only be between inter or intra-professionals in the hospital departments.

The legislature has a role to play in ensuring that patient confidentiality is upheld. According to the current HIPAA law, a patient has a right to receive written information about his diagnosis and treatment options given to him. However, the code should be specific that such information should be provided electronically and discarded once used. By issuing the information digitally and deleting it afterward, third parties will not be able to view it or retrieve it thus sustaining patient privacy.

Patient information is typically used by researchers to investigate the prevalence, epidemiology, treatment, and post-recovery progression of patients. Such provision of information is a loophole in breaching the medical details of patients. A law that prohibits the use of people’s medical history should be made to tighten the privacy act. If researchers are to use that information, they should first seek the consent of the patient or have a permit from the court of law.


James Wu was diagnosed with diabetes and tuberculosis. Many patients want their relatives to know everything about the disease given that both diabetes and tuberculosis are chronic diseases and need tender care both at the hospital and at home. Wu, however, decided not to let the family members know how he came to be rediagnosed with the same diseases he had been treated for about two years ago. It was the nurse’s duty to maintain the privacy of the patient, through pressure from family members was unbearable. The environment a nurse is working in impacts the decisions he makes. In a hospital, where there is a lot of workload and stringent quality rules, the service provided tends to go down. However, every nurse should abide by the privacy obligation of the Nightingale Pledge. Nurses should be able to bear work pressure and ensure that every client is satisfied with the services provided.

Hospital administrators have a mandate to ensure that the practicing environment in the healthcare center is conducive. According to the research done by Kutney-Lee et al. (2013), the number of patients per nurse has a direct influence on the quality of services offered. Similarly, it has been proven by several types of research that when the administration tightens nursing rules on the variety of services to be provided, the reverse happens. Hospital management should, therefore, create an enabling practicing environment by hiring more skilled nurses to reduce the work burden, eliminating cost-effective policies, and nurturing career development among nurses.