A 2003 report from the Institute of Medicine concluded that improvements in nurses' work environments were needed to reduce patient harm. The report made eight key recommendations for achieving this goal, and evidence has suggested that progress has been made. Researchers seeking to determine the extent to which hospital work environments have improved used surveys of nurses and patients at 535 hospitals in four states at two points in time between 2005 and 2016 to measure changes in work environments and quality and safety measures.

They found that in 2015 and 2016, 60% of nurses rated the quality of care in their hospital as less than excellent. Nearly 30% gave their hospital an unfavorable grade on patient safety and infection prevention, 81% rated their work environment as less than excellent, and 69% were less than very satisfied with their job. A total of 32% of patients gave their hospital an unfavorable rating, and 30% wouldn't recommend it to others. Between 2005 and 2016, only 21% of hospitals showed greater than 10% improvements in clinical work environment scores, whereas 7% had worse scores. In hospitals in which the work environment improved, nurses and patients reported favorable changes in care quality and safety.

Among the limitations of the study was that it relied on subjective rather than objective measurements of quality of care and patient safety. The authors note that complete adherence to evidence-based safety recommendations is difficult in poor work environments, suggesting that certain organizational interventions, such as Magnet recognition, could be used to improve work environments. They also note the potential benefits of altering health policy-by having the Centers for Medicare and Medicaid Services require public reporting of nurse staffing levels, for example-and of promoting a blame-free culture in which nurses feel free to report errors.

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