Hospital nursing organizational factors, nursing care left undone, and nurse burnout as predictors of patient safety: A structural equation modeling analysis

Xu Liu, Jing Zheng, Ke Liu, Judith Gedney Baggs, Jiali Liu, Yan Wu, Liming You

Research output: Contribution to journalArticlepeer-review

131 Scopus citations


Background: Promotion of patient safety is among the most important goals and challenges of healthcare systems worldwide in countries including China. Donabedian's Structure-Process-Outcome model implies that patient safety is affected by hospital nursing organizational factors and nursing care process. However, studies are imperative for a clear understanding about the mechanisms by which patient safety is affected to guide practice. Objective: The objective of this study was to explore the impact of hospital nursing work environment, workload, nursing care left undone, and nurse burnout on patient safety. Design: This was a cross-sectional study conducted in 23 hospitals in Guangdong province, China in 2014. Data from nurses (n = 1542) responsible for direct care on 111 randomly sampled medical and surgical units were analyzed. Methods: Work environment was measured by the Practice Environment Scale of Nursing Work Index. Workload was measured by day shift unit patient-nurse ratio and non-professional tasks conducted by nurses. Nursing care left undone was measured by 12 items addressing necessary nursing activities. Nurse burnout was measured by the emotional exhaustion subscale of the Maslach Burnout Inventory-Human Services Survey. Patient safety was measured by three items indicating nurses’ perception of overall patient safety and nine items addressing patient adverse events. Structural equation modeling was used to examine a hypothesized model that supposed work environment and workload have both direct and indirect effects on patient safety through nursing care left undone and nurse burnout. Results: The findings generally supported the hypothesized model. Better work environment was associated with better patient safety both directly and indirectly. Lower workload primarily indirectly related to better patient safety. Nursing care left undone and nurse burnout were mediators negatively associated with patient safety. Conclusions: Improving work environment, increasing nurse staffing levels, and providing sufficient support for nurses to spend more time on direct patient care would be beneficial to patient safety improvement.

Original languageEnglish (US)
Pages (from-to)82-89
Number of pages8
JournalInternational Journal of Nursing Studies
StatePublished - Oct 2018


  • Burnout
  • China
  • Patient safety
  • Structural equation modeling
  • Work environment
  • Workload

ASJC Scopus subject areas

  • General Nursing


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