Measuring a Healthy Work Environment in Acute Care Hospital Settings

Healthy work environments (HWEs) have been described as policies, procedures, and processes developed to assist nurses at all levels to meet the organizational goals and achieve personal satisfaction in the work environment. The American Association of Critical-Care Nurses (AACN, 2005) developed the standards of a HWE to improve the health of the work environment for critical care nurses. The standards included appropriate staffing, authentic leadership, effective decision-making, meaningful recognition, skilled communication, and true collaboration. The AACN also developed a Healthy Work Environment Assessment Tool (HWEAT) for critical care nurses to assess the health of the work environment in acute care settings.  Through the adaptation and modification of the AACN HWEAT (2015), the HWE standards were relabeled as characteristics of a HWE with genuine teamwork and physical and psychological safety being added.  After further research, two tools were developed from the adaptation and modification of the AACN HWEAT to measure the health of the work environment in acute care hospital settings. These tools were entitled Healthy Work Environment Scale for Direct Care Nurses (HWES for DCNs) and Healthy Work Environment Scale for Nurse Leaders (HWES for NLs).  The purposes of these studies were to adapt and modify the AACN HWEAT to develop tools to measure a HWE for direct care nurses and nurse leaders; to assess the validity and reliability of these tools; and to describe the direct care nurses’ and nurse leaders’ perceptions of a HWE using a non-experimental descriptive design.  As a result of these studies, the Healthy Work Environment Scale for Direct Care Nurses (HWES for DCNs) and the Healthy Work Environment Scale for Nurse Leaders (HWES for NLS) were developed.

The sample for the HWES for DCNs consisted of 986 direct care nurses.  Principal component analysis of the HWES for DCNs version 3 revealed 39 items with five components identified.  Authentic leadership and meaningful recognition loaded on component one.  Effective decision-making and skilled communication loaded on component two.  Genuine teamwork loaded on component three.  Appropriate staffing loaded on component four.  Physical and psychological safety loaded on component five.  The characteristic of true collaboration loaded on all five components.  Direct care nurses perceived health of the work environment mean scores ranged from 2.79 (standard deviation 0.59) to 3.51 (standard deviation 0.43). Strong internal consistency of HWES for DCNs was found with a Cronbach alpha of .957.

The sample of the HWES for NLs in formal positions consisted of 314 nurse leaders ranging from nurse managers to chief nursing officers.  Principal component analysis of the HWES for NLs version 3 revealed 40 items with four components identified.   The HWE characteristics of authentic leadership, effective decision-making, genuine teamwork, and true collaboration loaded on component one.  The HWE characteristic of meaningful recognition loaded on component two.  The HWE characteristic of appropriate staffing loaded on component three.  The HWE characteristic of skilled communication loaded on component four.  Physical and psychological safety loaded on all four components.  Nurse leaders perceived health of the work environment mean scores ranged from 2.96 (standard deviation 0.56) to 3.30 (standard deviation .51).  Strong internal consistency of the HWES for Nurse Leaders was found with a Cronbach alpha of .974.  Based on these research findings, the HWES for DCNs’ and the HWES for NLs’ instruments demonstrated strong psychometric properties to measure HWE in acute care hospital settings.

Direct care nurses and nurse leaders at all levels of acute care hospitals have the ability to develop, implement, and measure interventions for HWEs.  Interventions may range from strengthening communication between nurse peers and nurse to physician, developing team building exercises, developing new methods of recognition that are meaningful to individual nurses at all levels of the organization, developing new methods of collaboration with nurses having a voice to make decisions within the organization, establishing physical and psychological safety for patients, family members, significant others, and employees within an organization.  Interventions will need to be developed and individualized at the unit level to improve the overall health of the work environment with the intention to retain nurses in healthcare organizations.