The origin of a healthy work environment for hospital-based nurses may have begun with an original study in 1983 by McClure, Poulin, Sovie and Wandelt titled “Magnet Hospital: Attraction and Retention of Professional Nurses”. The early 1980s was faced with hospital nursing shortages and an inability to attract and retain competent, experienced professional nurses for many health care organizations. The Governing Council of the American Academy of Nursing appointed a Task Force on Nursing Practice in Hospitals in 1981. The task force was charged to examine characteristics of systems impeding and/or facilitating professional nursing practice in hospitals. Certain hospitals across the country had succeeded in creating nursing practice organizations that served as “magnets” for professional nurses. These organizations attracted and retained well-qualified nurses and were consistently able to provide high-quality care. The task force recommended a study from a national sample of what would be referred to as magnet hospitals. Two major components that emerged from nurse leaders and clinical nurses were the environment and the practice mode. Respondents focused on the factors of autonomy, primary nursing, mentoring, professional recognition, respect, and the ability to practice nursing as it should be practiced. In the defined magnet hospitals, it was a combination of elements that creates a positive practice environment (McClure, Poulin, Sovie, & Wandelt, 1983).
Using the Joanna Briggs Institute, Ovid MEDLINE, PubMed, many articles and published studies can be found linking nursing practice and a healthy work environment. Five systematic reviews of studies were found in the literature and evaluated. The first review recommended a multi-disciplinary approach to improve outcomes and establish a HWE (Pearson, et al, 2006). The second review recommended that hospitals seeking to establish and maintain a HWE need to consider the role of nursing workload and nurse staffing (Pearson, et al., 2006). The third review concluded that combination of leadership styles and characteristics was found to contribute to the development and sustainability of a HWE (Pearson, et al, 2007). The fourth review discovered nine pronounced factors considered important for a HWE: collaboration/teamwork; growth and development of the individual; recognition; employee involvement; positive, accessible and fair leader; autonomy and empowerment; appropriate staffing; skilled communication; and safe physical work (Twigg & McCullough, 2014). Finally, the last systematic review, published in 2014, suggested these strategies: empowering work environment, shared governance structure, autonomy, professional development, leadership support, adequate numbers and skill mix and collegial relationships within the healthcare team to create a HWE (Lindberg & Vingard, 2012).
Seven independent qualitative studies were completed between 2011 and 2016. Four studies concluded that nurse leaders, specifically nurse managers, play a vital role in ensuring a HWE (Smokler, Lewis, & Malecha, 2011; Hartung & Miller, 2013; Blake, Searle, Leach, Robbins, Pike, & Needleman, 2013; Manning, 2016). In three studies, the nurse-to-patient staffing ratios influenced the nurses’ perceptions of a HWE (Kutney-Lee, Wu, Sloane, & Aiken, 2013; Needleman et al., 2011; Van den Heede et al., 2013).
The American Association of Critical-Care Nurse (AACN) made a commitment in 2001 to actively promote the creation of a healthy work environment that would foster and support excellence in patient care in the acute and critical care hospital settings. AACN initiated a study in 2004 with VitalSmarts, a leadership training organization, that focused on caregiver interactions and its impact on patient well-being. Based on this work, AACN commissioned a nine-person panel developed six standards to establish and sustain a HWE. According to AACN, six standards represent evidence-based and relationship-centered principles of professional performance. Each standard is considered essential and align with the core competencies for health professionals recommended by the Institute of Medicine. The model defined by AACN, became known as “The AACN Synergy Model for Patient Care™”. The AACN standards for establishing and sustaining healthy work environments include the following (American Association of Critical-Care Nurses, 2016): Skilled Communication: nurses must be as proficient in communication skills as they are in clinical skills; True Collaboration: nurses must be relentless in pursuing and fostering true collaboration; Effective Decision Making: nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations; Appropriate Staffing: staffing must ensure the effective match between patient needs and nurse competencies; Meaningful Recognition: nurses must be recognized and must recognize others for the value each brings to the work of the organization; and Authentic Leadership: nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement.
This project was a nursing practice model’s view of nursing from an organizational level. It was based on the AACNs Model for a Healthy Work Environment (HWE). In 2017, Chief Nurses in New Jersey were asked to participate in this project. A survey was sent to the Chief Nurses via email. Using the AACN Healthy Work Environment Assessment Tool, a sample of Chief Nurses in New Jersey was surveyed. The survey received a 35% response rate.
Using the AACN Synergy Model for Patient Care™ six standards priorities for CNEs were identified. The top aggregate scores for CNOs was authentic leadership. In this category, relationships between nurse leaders (nurse managers, directors, advanced practice nurses, etc.) is most important followed by the value of access and authority for nurse leaders to play a role in decision making. Most CNEs said that it is important for nurse leaders to understand the requirements and dynamics at the point of care and to use this knowledge in HWE initiatives. The second highest aggregate scores for CNEs was true collaboration. The highest individual score was clinical nurse involvement with administrators, nurse managers, and physicians when making important decisions. For meaningful recognition, most important to the CNEs was that there is a formal reward and recognition system in place to make nursing staff feel valued. Also important to CNEs is that there are motivating opportunities for clinical nurse personal growth, development and advancement. For effective decision making, carefully considering the patient’s and family’s perspective when making important decisions was most important in this category. CNEs also responded that important decisions need to involve the right departments, professions and groups. With appropriate staffing, most important to CNEs is that administrators and nurse managers work with nurses and other staff to make sure that there is enough staff to maintain patient safety. Also important is that staffing is the right mix of nurse and other staff. Finally, in skilled communication scoring highest was that everyone in the organization - from administrators to physicians and clinical staff – make sure that their actions match their words. If you are going to “talk the talk”, you’ve got to “walk the walk”. Next the CNEs valued frequent communication. When asked if there is a culture of zero-tolerance for disrespect and abuse, 41% of respondents strongly agreed. 31% of respondents did not agree, or were neutral in their response, that people are held accountable for disrespect regardless of the person’s role or position.
A toolkit was developed and disseminated to support nurse leaders in healthy work environment initiatives. A post-assessment survey was completed to determine if the toolkit provided value.
Chief Nurses have an influential role in development and maintenance of a HWE. The toolkit can be utilized as a reference for new and established Chief Nurse in their leadership for HWE initiatives.