Date of Award

May 2016

Degree Type


Degree Name

Doctor of Philosophy



First Advisor

Karen H. Morin

Committee Members

Christine R. Kovach, Leigh E. Wallace, Susan Houston


Hospitals, Leadership, Nurses, Online Survey, Patient Safety, Quantitative


Background: An aging population and retiring workforce might affect United States health delivery care and could threaten the quality of care in hospitals. Nurses, as the largest profession in healthcare, can buffer these effects if supported in a safe nurse work environment. The purpose of this dissertation was to understand how peer-to-peer registered nurse workplace incivility as a mediator, and collective efficacy as a moderator, influence relationships among hospital structures (i.e. nurse manager leadership and staffing) and hospital outcomes (i.e. missed nursing care and patient safety cultures).

Methods: Donabedian’s (1980) structure-process-outcomes conceptual framework was the theoretical basis for this study. A cross-sectional, correlational design was employed that involved path analysis to investigate a conditional process model. Six instruments were administered online: 1) the Hospital Survey on Patient Safety; 2) the Acute Care Missed Nursing Care Subscale; 3) the Workplace Incivility Scale (WIS); 4) the Collective Efficacy Beliefs Scale; 5) the Practice Environment subscale of the Nursing Work Index; and 6) a demographic information form. In all, surveys comprised 117 items.

Findings: The total sample (N) was 212. There were small to moderate inverse relationships between: 1.) nurse manager leadership and coworker incivility (r = -.38, N = 212, p <0.01), 2.) staffing and coworker incivility (r = -.28, N = 212, p < 0.01), and 3.) coworker incivility and patient safety culture (r = -.19, n = 212, p < 0.01). There was a moderate positive relationship between nurse manager leadership and patient safety culture (r = .36, n = 212, p < 0.01). There was a moderate relationship between staffing and patient safety culture (r = .30, n = 212, p < 0.01). There was a small inverse correlation between the level of staffing and missed nursing care (r = -.15, n = 212, p < .05). The relationship between missed nursing care and the structure and process variables was not influenced by the mediator variable, coworker incivility. Missed nursing care was not significant as an outcome variable with or without coworker incivility as a mediator. Patient safety culture was not significant as an outcome variable with coworker incivility as a mediator or with collective efficacy as a moderator. Inspection of hierarchical regression indicated that nurse manager leadership, staffing, and coworker incivility predicted 15% of the variance for patient safety culture, with nurse manager leadership explaining most of the variance.

Implications: Results support the important role nurse manager leadership can play in relation to patient safety outcomes at hospital patient care units. Collective efficacy among registered nurse peers and hospital staff should be further studied through research to better understand its direct effect on improving patient safety cultures.

Limitations: Results may be limited to Magnet hospitals. Response rate was low (7.8%) with a potential for sample bias.

Recommendations: Further instrumental development of the Missed Nursing Care Survey is needed. More advanced methodological approaches to studying missed nursing care may improve the validity for measuring this phenomenon.