The Institute of Medicine ‘s landmark report (2004), Keeping patients safe: Transforming the work environment of nurses recommended that research should examine the relationship between nurse staffing levels and quality care while simultaneously considering organizational variables such as work environment. A Healthy Work Environment (HWE) enables the nurses and other workers to function fully within their abilities to provide for safe and quality patient care and support optimal health and safety for both patients and nurses (Aiken et al, 2013). A HWE is defined as an environment that enable nurses to function fully within their abilities. Researchers have found that HWEs are associated with lower mortality and mortality from complications (Aiken et al, 2011; Blake et al, 2013). There is a direct relationship between nurse staffing levels, work environment, and the delivery of safe and reliable care (Needleman et al, 2015; Sanders et al, 2013). Although nurse staffing is recognized in the literature as a component of a HWE, focusing solely on staffing ignores the contribution of a HWE to quality care. The purpose of this qualitative study was to understand perceptions of clinical nurses, and nurse leaders of a HWE. Gaining further understanding from the perspective of nurses, can be used to inform both hospital and healthcare policy implications.
Methods:
In this qualitative study, ten separate focus groups were conducted over an 8 week period with clinical nurses (n = 46) and nurse leaders (n = 43) from five pilot acute care hospitals in New Jersey. A clinical nurse was defined as a professional nurse who spends the majority of his or her time providing direct patient care. A nurse leader was defined as a registered nurse with 24-hour/ 7-day accountability for the supervision of all clinical nurses and other healthcare providers who deliver nursing care in an inpatient or outpatient area. A semi-structured interview guide was developed based upon the American Association of Critical Care Nurses (AACN) Standards for Establishing a Healthy Work Environment (2016) (HWE) which includes (1) skilled communication; (2) True collaboration; (3) Appropriate Staffing; (4) Meaningful Recognition; (5) Effective Decision Making; (6) Authentic Leadership. All focus groups were audio-recorded and transcribed verbatim and checked for accuracy. Data were uploaded into NVivo Pro (2017) for analysis. Thematic content analysis was used to analyze the focus group data
Results:
The overarching theme of a HWE for clinical nurses and nurse leaders was having sufficient resources at their hands to provide quality care in the correct way. Clinical nurses described first-hand accounts of experiencing, living, and working in a HWE whereas leaders spoke about concrete components of what makes up a HWE. The HWE sub-theme for clinical nurses was teamwork described as a symphony with staff working together to provide the best care. Although the sub-theme for nurse leaders was also teamwork, nurse leaders viewed this theme with communication not only with nursing but with all providers. Common themes shared by both clinical nurses and nurse leaders were identified for four of the six AACN HWE standards (1) Skilled Communication- Good communication leads to good outcomes: (2) True collaboration: Setting matters with varying levels of collaboration dependent on the type of unit: (3) Appropriate staffing: Patient acuity and complexity matters: (4) Meaningful recognition: One size doesn’t fit all. For the remaining two themes, effective decision making and authentic leadership, no common themes were identified. Overall, clinical nurses minimized their role in effective decision making and did not self-recognize that they engaged in effective decision making and they did not self-identify themselves as a leader. On the contrary, when queried about authentic leadership, clinical nurses spoke about their nurse managers.
Global Implications for Nurse Leaders: To advance hospital safety and quality and improve patient outcomes, organizational interventions should be directed toward improving the work environment. This environment should be supportive of nurses’ work, including adequate staffing, managerial support for nurses, and good relationships among nurses and physicians. Nurse leaders must engage clinical nurses about the importance and key elements of a HWE. As respected and trusted healthcare professionals, nurse leaders are positioned to drive transformative healthcare policy initiatives.