Nursing surveillance has been identified as a core clinical process through which organizational conditions may influence patient safety; however, its explanatory role in the relationship between the nurse work environment and patient safety culture is not well established. This study examined whether nursing surveillance practices account for part of the association between the nurse work environment and patient safety culture in medical–surgical units. Cross‐sectional data were drawn from 1,597 medical–surgical nurses who participated in the RN4CAST‐Australia 2018 survey. The nurse work environment was measured using the Practice Environment Scale‐5, nursing surveillance using a validated 16‐item scale assessing the frequency of patient assessment practices for early detection of deterioration, and patient safety culture using a validated short form of the Hospital Survey on Patient Safety Culture. Structural equation modeling was used to estimate direct associations between the nurse work environment and patient safety culture and indirect associations via nursing surveillance. A more favorable work environment was directly associated with a more positive patient safety culture and more frequent surveillance practices. More frequent surveillance was also directly associated with a more favorable patient safety culture. In addition, the nurse work environment was indirectly associated with patient safety culture through increased surveillance. These findings suggest that nursing surveillance represents a specific, actionable mechanism linking work environment conditions to patient safety culture. Efforts to improve patient safety may therefore require both structural enhancements to the work environment and targeted strategies to strengthen proactive nursing surveillance.

To test whether missed nursing care and moral distress mediate the association between the nurse work environment and burnout among adult ICU nurses. This study used data from 4258 direct care nurses in adult ICUs from the 2024 Penn Nurses4All Study. Structural equation modeling with serial multiple mediation examined direct and indirect associations between the work environment and burnout through missed nursing care and moral distress, adjusting for nurse characteristics. Nurses averaged 14.1 years of experience (SD = 11.4); most were female (2429; 79.6%), worked full time (3456; 81.3%), and held a bachelor's degree or higher (2572; 79.2%). A more favorable work environment was significantly associated with lower burnout (total effect: standardized coefficient B = -0.67, p < 0.001). All indirect pathways were significant, including through missed nursing care (B = -0.11, p < 0.001), moral distress (B = -0.05, p < 0.001), and the sequential pathway via both mediators (B = -0.03, p < 0.001). The total indirect effect was significant (B = -0.19, p < 0.001), and the direct effect remained significant (B = -0.48, p < 0.001), indicating partial mediation. The association between the nurse work environment and ICU nurse burnout is partially explained through a sequential pathway from missed nursing care to moral distress. These findings empirically support a theorized erosion model in which structural deficiencies cascade through care omissions and moral injury to burnout. The remaining direct effect suggests additional unmeasured mechanisms also contribute. Interventions should target the organizational conditions that initiate this chain rather than focusing solely on individual-level resilience. Nurse leaders should prioritize work environment improvements as upstream strategies to prevent the cascade toward burnout. Reducing missed care through structural investment may attenuate the moral distress that follows from repeated ethical compromise. Unit-level strategies such as structured debriefing and ethics consultation may further interrupt the pathway.

Background: While the nursing profession has advocated for workforce diversity, limited research has examined how institutional inclusion efforts are associated with the experiences of nurse practitioners (NPs), particularly in hospital settings. Purpose: To examine whether institutional inclusion efforts were associated with NPs’ strong recommendation of their hospital and whether this relationship was explained by NPs’ assessments of organizational climate. Methods: This cross-sectional study analyzed 2023 data from 742 NPs across 412 U.S. hospitals, drawing on the Penn Nurses4All Survey, the Healthcare Equality Index (HEI), and the American Hospital Association Annual Survey. The independent variable was employment in an HEI-participating hospital, and the dependent variable was NPs’ strong recommendation of their hospital to family and friends. Mediating variables included NPs’ assessments of organizational climate. Mediation analysis using weighting estimators was conducted to adjust for confounding and evaluate the extent to which organizational climate explained the relationship between HEI participation status and hospital recommendation. Results: NPs in HEI-participating hospitals were 15% more likely to strongly recommend their hospital (95% CI: .07–.22). Significant indirect associations were observed and accounted for the total association through overall organizational climate (26.6%), professional visibility (26.6%), and NP–administration relations (20%), respectively. Practice Implications: Hospital participation in the HEI is associated with stronger hospital recommendations among NPs, partly through more favorable assessments of organizational climate. As health care systems work to improve work environments and job outcomes for a diverse workforce, cultivating a climate of inclusion through meaningful, everyday practices will be essential.

Background: The Pathway to Excellence (Pathway) program recognizes healthcare organizations that support positive nurse work environments, yet the impact of Pathway designation and engagement in the Pathway journey before designation on outcomes remain understudied. Purpose: To examine nurse job outcomes, nurses' assessments of the work environment, and patient satisfaction in Pathway-designated hospitals and hospitals pursuing Pathway designation. Methods: This cross-sectional study integrated data from the 2021 RN4CAST Study, the American Hospital Association Annual Survey, and Hospital Consumer Assessment of Healthcare Providers and Systems. The sample included 5,497 nurses across 360 hospitals in New York and Illinois, including Pathway, prospective Pathway, and non-Pathway hospitals. Outcomes included nurse job outcomes, work environment assessments, and patient satisfaction. Multilevel modeling was used to compare nurse outcomes, and multiple linear regression models were used to compare patient satisfaction across two contrasts: (1) Pathway versus non-Pathway hospitals and (2) prospective Pathway versus non-Pathway hospitals. Results: Compared with nurses in non-Pathway hospitals, nurses in Pathway hospitals reported lower burnout, lower job dissatisfaction, more favorable work environment assessments, and higher patient recommendation scores. Nurses in prospective Pathway hospitals reported lower job dissatisfaction and more favorable work environments. Conclusion: Engagement in the Pathway journey was associated with more favorable nurse outcomes. Pathway designation was further associated with higher patient satisfaction. Implications: Investments in supportive nurse work environments represent a transformative organizational process with potential benefits for both nurse well-being and patient experience.