Better Work Environment for Nurses, Better CDI Control Linked in New Study


Hospitals with the highest work-environment scores were less likely to have above-average Clostridioides difficile infection (CDI) rates.

Health care organizations have tried a wide range of strategies to reduce the risk of hospital-acquired Clostridioides difficile infection (CDI), but a new report suggests they need to consider another factor: their employees’ work environment.

A new study in Medical Care found hospitals whose nurses were most satisfied with their work environments had lower CDI infection rates. The investigators said the findings suggest factors like collegial relationships between physicians and nurses and the involvement of nurses in organizational governance ultimately translate into greater success at preventing CDI.

They explained that along with colleagues, nurses represent the largest number of health care professionals in hospitals, and their regular interactions with patients and physicians give them a unique role in patient care.

“It is nurses who implement the bundle of practices to prevent and control the spread of hospital-onset CDI, which includes prompt and appropriate diagnostic testing of unformed stool, prompt initiations of contact precautions among patients with CDI, exceptional hand hygiene, and the potential to influence best environmental disinfection or antibiotic stewardship,” they wrote.

Yet, all of that work—and the precautions related to it—can be challenging and time consuming for nurses. Thus, the authors wondered whether the ability of an organization to make nurses feel supported might affect their performance in terms of CDI control.

“It is hypothesized that a supportive clinical work environment would reduce these barriers and facilitate consistent adherence to best practices in infection prevention,” they said.

To test their hypothesis, they used data from a 2016 survey of registered nurses in California, Florida, New Jersey, and Pennsylvania. There were questions about the nurses themselves and about their work environments. The responses were used to score hospitals on 4 subscales: managerial support, nurse participation in hospital governance, physician-nurse relations, and adequate staffing.

The investigators then merged that information with 2016 CMS data related to hospital-onset cases of CDI. Finally, they used the American Hospital Association’s annual survey to integrate hospital characteristics into their analysis. Their analysis included 15,982 nurses from 353 general acute care hospitals.

Within that data set, 188 hospitals (53%) had standardized CDI ratios (SIRs) above the national average. However, the likelihood of a particular hospital having a lower-than-average SIR was associated with the work-environment scores given by nurses. Specifically, hospitals in the highest-scoring quartiles of each of the 4 work-environment subscales had lower odds of having an SIR above the national average. The odds ratios of highest-quartile hospitals having above-average SIRs ranged from 0.35 to 0.45 vs hospitals in the lowest quartile of each work-environment subscale. This suggests work environments may play an important role in helping to prevent CDI transmission, the authors said.

They noted that CDI prevention practices are “continually evolving, multifactorial, and complex.

“Investing in the work environment may help hospitals to prioritize these interventions and disseminate related information, as supportive work environments enable nurses to identify opportunities for improvement in daily cleaning or encourage colleagues to be diligent about hand hygiene,” they wrote.

The investigators conceded that improving a work environment can come with its own challenges and costs but that the benefits of improving a work environment will also improve patient outcomes.

“Because a significant share of hospitals has deficient work environments that continue to hamper infection prevention, a promising strategy to lower hospital-onset CDI and other infections is a serious and sustained commitment by the hospital industry and its leaders to significantly improve hospital nurse work environments,” they concluded.


Jung OS, Aiken LH, Sloane DM, et al. Nurse work environment and hospital-onset Clostridioides difficile infection. Med Care. 2023;61(6):360-365. doi:10.1097/MLR.0000000000001854

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