A healthy work environment (HWE) is critical to ensuring safe, competent, and compassionate nursing care. Empirical inquiries validate that a healthy nursing work environment contributes to greater patient safety and quality, decreased nurse burnout, absenteeism and turnover, and greater patient and staff satisfaction.1-8 Despite this evidence, unhealthy work environments continue to plague healthcare institutions and impede the delivery of safe, effective, timely nursing care. Many macrolevel and microlevel contextual factors contribute to this reality. A shrinking nursing workforce and greater healthcare fiscal constraints have led to inadequate staffing levels or inappropriate skill ratios, forcing many nurses to work harder and for longer hours.9 Additionally, the very nature of nursing as a care-taking profession can be emotionally, physically, and spiritually demanding, leading to high rates of burnout and compassion fatigue.10 And finally, real or perceived professional and organizational hierarchical cultures that promote ineffective communication patterns, diminish nurses’ feelings of empowerment, lead to nursing role confusion, and create unequal power relations can also be a barrier to a HWE and safe patient care.5,11
Appreciating the considerable effect the nursing work environment can have on patient safety, the American Association of Critical Care Nurses (AACN) assembled an expert panel of nurses working in the critical care environment to review and synthesize relevant HWE research and evidence. In 2005, the AACN working group published the AACN Standards for Establishing and Sustaining Healthy Work Environments.12 As a result of their work, 6 standards were identified that are deemed integral to developing and sustaining a HWE. These standards are (1) skilled communication, (2) true collaboration, (3) effective decision making, (4) appropriate staffing, (5) meaningful recognition, and (6) authentic leadership. An explanation of each standard is included in the Table. These standards were recognized as fundamental elements of a HWE because, when considered “optional” in the nursing work environment, effective, sustainable, quality-based outcomes all but disappeared.12
The purpose of this article was to describe how nursing staff and leadership from a large, level I US military trauma center developed a HWE working group and used the 6 AACN evidence-based standards to facilitate and guide group discussion and problem solving to restore a healthier nursing work environment in a 20-bed IMCU. The AACN standards served as a guide to identifying and developing staff and leadership initiatives to foster a HWE with the ultimate goal of improving patient care and safety. The process was accomplished using the Iowa Model of Evidence-Based Practice to Promote Quality Care.13 By using this model, the group was able to consider the most relevant evidence, within the context of the nurses’ own clinical, management, and leadership experience; the cultural nuances of the military healthcare system; and the personal preferences and values of the IMCU nursing staff.
Ten years of war and government economic reform that has targeted rising military healthcare costs has led Military Health System leaders to closely examine the quality and cost of providing healthcare to its beneficiaries. The Army Medical Department is the largest of the 3 US military medical departments within the Military Health System. It provides care to nearly 4 million active-duty service members, retirees, and their eligible family members at 8 Army medical centers, 27 smaller community hospitals, and numerous clinics in the United States, Europe, Korea, and Japan.5 Results from a study conducted by Patrician et al5 of 955 military and civilian nurses working in 23 US-based Army hospitals demonstrated similarities between military and civilian healthcare facilities with regard to the nursing work environment and its effect on quality patient care. They found that, in military hospitals, unfavorable nursing practice environments had a significant relationship with nurses’ reported job dissatisfaction, emotional exhaustion, intent to leave, and perceptions of fair to poor quality of care.
In an effort to standardize the provision of quality, evidence-based, compassionate nursing care across Army Medical Department healthcare facilities, the US Army Nurse Corp began systematic implementation of the Patient Caring Touch System (PCTS) across the Army healthcare organization.14 Modeled after the Essentials of Magnetism, the PCTS is based on 5 essential elements: patient advocacy, enhanced care team communication, clinical capability building, evidence-based practices (EBPs), and HWEs. As part of PCTS implementation, Unit Practice Councils (UPCs) were organized to diffuse innovation and evidence at the bedside.
Brooke Army Medical Center (BAMC), a 450-bed level I trauma military treatment facility, was one of the first hospitals to implement this new system of care. At the same time, BAMC was also undergoing a significant physical and cultural transformation. In 2008, a $724 million construction and renovation project was started to integrate Wilford Hall Medical Center (WHMC) at Lackland Air Force Base and BAMC. Both BAMC and WHMC were renamed: BAMC became San Antonio Military Medical Center (SAMMC), and WHMC became Wilford Hall Ambulatory Surgical Center (WHASC). Ongoing construction and renovation led to the reorganization and relocation of several BAMC/SAMMC inpatient units and the consolidation of services at WHASC. In 2011, WHASC officially closed its inpatient services and trauma center. Also Air Force military and civilian medical personnel were reassigned to SAMMC. The integration of two distinct military and hospital cultures was underway.
IDENTIFY PROBLEM- AND/OR KNOWLEDGE-FOCUSED TRIGGERS
The Intermediate Care Unit (IMCU) Practice Council attempted to initiate several unit-based EBP projects to address nursing-relevant clinical issues identified by IMCU staff nurses. Their efforts were met with resistance and negativity from nursing staff when trying to implement changes in clinical practice. In response, the UPC chair took her concerns and her interest in examining the IMCU nursing work environment forward to the facility-level nurse practice council. In response, it was proposed that a facility-level EBP working group would be established to evaluate the evidence and implement successful leadership strategies to improve the IMCU nursing work environment.
FORM A TEAM
Key nursing stakeholders from the hospital, section, and unit levels; members of the IMCU Practice Council; IMCU nursing staff members; the nursing Performance Improvement coordinator; and the staff resiliency provider were all invited to participate in the working group. The team was led by a doctorally prepared nurse scientist from the Center for Nursing Science & Clinical Inquiry who was trained in implementation of EBP. This process was facilitated using the Iowa Model of Evidence-Based Practice to Promote Quality Care.13
The agreed-upon purpose of this working group was to facilitate and guide group discussion and problem solving among unit- and senior-level nursing leaders to restore a healthier nursing work environment in the IMCU with the goal of improving patient safety and quality care. The following EBP PICOT question was proposed: Based on the AACN Standards for Establishing and Sustaining Healthy Work Environments12; nurses’ own clinical, management, and leadership expertise; and the personal preferences and values of the IMCU nursing staff, what evidence-based leadership initiatives can be instituted in the IMCU to create a sustainable, healthier nursing work environment?
A multifaceted approach was taken, not only to validate the hypothesis that the IMCU had an unhealthy work environment, but also to collect baseline data from which to track progress on the unit. Intermediate Care Unit staff members agreed to participate in a confidential unit survey that assessed unit morale and stressors. In addition, the hospital nursing performance improvement coordinator queried the unit’s monthly reported performance improvement metrics for the prior 6 months. The hospital staff resilience provider also scheduled a unit sensing session with staff members to allow venting of frustrations and to problem solve proposed solutions from the IMCU staff perspective. Hospital nursing administrators were asked to collate unit-level staffing and patient turnover data. As a result of these efforts, several problem- and knowledge-focused triggers were identified that substantiated the presence of an unhealthy nursing work environment and its effect on quality patient care. These included poor staff morale, absenteeism, lack of staff knowledge regarding the function of the UPC, a high number of falls on the unit, and poor performance on performance improvement metrics.
A 10-item, Likert-scale questionnaire was developed by members of the working group to measure staff attitudes toward unit morale, unit stressors, and staff behaviors in response to the work environment. Two additional open-ended questions were included to identify sources of unit conflict and processes that could be targeted for intervention. This questionnaire was reviewed by unit leaders and by a PhD-prepared nurse scientist with experience in survey development to establish content and face validity. Among respondents who answered the anonymously administered computerized survey, 59% (n = 27) of staff members rated staff morale on 3 East as “poor,” and 15% rated it as “fair.” Ninety-six percent felt that the stressors on the unit directly affected staff morale in the IMCU, and 93% of the staff surveyed reported a belief that these stressors directly affected patient outcomes. Staff members identified several stressors on the unit that they believed contributed to poor staff morale: scheduling, poor communication between leadership and staff nurses, staff negativity and poor communication, inappropriate patient admissions, inappropriate staff-to-patient ratios because of inexperienced charge nurses, high patient admission/discharge ratios, and lack of trust in leaders because of frequent turnovers. More than one-third of staff members (38%) reported witnessing a reportable event that was not documented in a Patient Safety Report over the last year. Forty-five percent of staff members were dissatisfied or very dissatisfied with their schedules, and 79% felt that IMCU staff was not recognized for their hard work and contributions to the unit. The staff resiliency provider concurred that similar issues were brought forth during the staff sensing session. In addition, the resiliency provider noted that a few of the staff members were perpetuating the issues by feeding into a lot of the negativity. She witnessed poor interpersonal communication and mounting frustration among staff members during the problem-solving phase of the session.
The clinical nurse officer in charge (head nurse) and section supervisor added that there was not a medical director assigned to provide medical oversight for admission criteria and advocacy for staff issues with physician providers. Because of base realignment and closure–related hospital construction, the unit had been physically relocated 2 times within a 6-month period and had experienced a high rate of staff and leadership turnover over a 5-year period. In addition to staffing short falls that required the use of float and on-call nursing staff, there were frequent call-ins by IMCU staff nurses, and some nurses from other floors refused to float to the IMCU because of the poor staff morale and heavy workload. Additionally, a formal delineated scope of services for the unit had never been written. Consequently, there were often inappropriate patients admitted to the unit, resulting in high patient workload acuities with daily patient turnover rates that routinely exceeded 100%. It was further noted that this particular unit had a long-standing history of poor morale, high acuity, and staff and leader turnover. Furthermore, a recent sentinel event and subsequent root-cause analysis led leadership to question the competency of some of the staff nurses or whether burnout and compassion fatigue were contributing factors.
The hospital nursing performance improvement coordinator reviewed IMCU nursing sensitive indicators from the prior 6 months. These included pain management documentation and reassessment, falls risk, medication reconciliation, electronic medical records documentation, and restraints. Pain management, falls risk, and medication reconciliation were below benchmark levels for the IMCU. The top adverse events identified for the unit through patient safety reports were falls and medication errors. Based on the baseline data collected, restoring a HWE on the IMCU was identified as an organizational priority to improve nursing sensitive outcomes and staff morale.
ASSEMBLE, CRITIQUE, AND SYNTHESIZE RESEARCH FOR USE IN PRACTICE
By using the already assembled, critiqued, and synthesized AACN guideline, the working group was able to brainstorm solutions in the context of the evidence-based standards, the clinical and administrative expertise of the working group members, and the opinions and values of IMCU staff members within the context of the military nursing work environment. This allowed for the development of evidence-based, quick-win, and long-term solutions that promoted a healthier work environment within the IMCU. The following changes were implemented over a 6-month period. Problem-focused solutions were developed in response to the unit stressors identified by IMCU nursing staff that contributed to poor staff morale and an unhealthy work environment. The identified evidence-based leadership strategies were framed within the AACN’s 6 standards for creating and sustaining a HWE.
PILOT THE CHANGE
According to the AACN standard, skilled communication, nurses must not only be proficient in their delivery of nursing care, they must also be proficient communicators.12 The IMCU staff members reported that there was poor peer-to-peer communication as well as poor communication between nursing leaders and staff nurses. To address this, several strategies were used. First, multiple forms of overlapping communication were instituted. A dedicated IMCU share drive was instituted on the hospital intranet that contained all relevant unit operating policies and procedures and staff updates. A written communication book and hard-copy unit policies and procedures were placed in the staff report room in case computer access was unavailable. Additionally, the IMCU began a monthly newsletter and bulletin board to highlight ongoing EBP projects and keep staff up to date on clinical practice changes. To improve peer-to-peer communication, all nursing and physician staff attended TeamSTEPPS training. TeamSTEPPS is an evidence-based teamwork system developed by the Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality. It is designed to improve communication and teamwork skills among healthcare professionals. In addition to this training, the staff resiliency provider conducted bimonthly staff sensing session to encourage staff to vent frustrations and proactively solve problems.
In order to create and sustain a HWE, nurses need to actively pursue and foster collaboration and cooperation among members of the healthcare team.12 In the spirit of true collaboration, a physician medical director was assigned oversight of the IMCU to serve as the physician point of contact for multidisciplinary problem solving. In addition, a clinical nurse specialist (CNS) was assigned to oversee the IMCUs within the hospital. This allowed for greater multidisciplinary collaboration among staff nurses, nurse administrators, and physicians regarding nursing issues specific to this clinical area. The unit charge nurse, CNS, and head nurse participated in monthly “cross-talk” meetings with the physicians of the medicine department to share unit and staff strengths and suggest areas for improvement. The medical director, in conjunction with the IMCU unit- and section-level nursing leadership, created a written IMCU Scope of Services that outlined appropriate admission and discharge criteria for patients on this unit. The IMCU CNS was critical to implementing evidence at the bedside by mentoring staff through the EBP process. She trained nursing staff to ensure nursing skill competency, mentored the UPC as they rolled out new projects, educated nursing staff on changes in clinical practice and new procedures and equipment, and served as a subject matter expert for nursing staff to consult regarding patient-related clinical issues. Also, the general surgery and cardiothoracic surgeons took an active role in simulation training for the IMCU skill-building course organized by the CNS. Because all staff nurses assigned to the IMCU were required to attend this skill-building course, it helped build collaborative working relationships between the physician and nursing staff.
Effective Decision Making
Healthy work environments are also rooted in ownership, which comes from effective decision making.12 After experiencing repeated unit- and hospital-level transitions including staff and leader turnover, physical relocation of the unit, blending of 2 distinct military cultures, and initiation of a new system of care, the IMCU nurses no longer felt like valued, committed partners in the patient care. One method of restoring nurses’ feelings of ownership and empowerment in the decision making process was through the establishment of the UPCs. There was an aggressive campaign to educate the staff that the purpose of the UPCs was to engage them in clinical change initiatives and give them a voice in how nursing care is provided in the IMCU. In addition, the unit head nurse reinforced his open door policy, encouraging nurses to actively identify unit and process problems and strategize effective solutions to those problems. Because staff members also reported the inexperience of charge nurses when making staffing assignments as a stressor that contributed to an unhealthy work environment, several novice nurses were sent to a charge nurse course, and a Charge Nurse Committee was established, where more-experienced staff nurses were encouraged to mentor the more-junior nurses on making patient assignments while functioning in the charge nurse role. Additionally, the AACN synergy model was implemented as a patient care model and taught to the nursing staff to help them make better decisions in patient assignments. Meeting patient needs with nurse characteristics was optimized in the IMCU.
In an era of fiscal constraints and an impending nursing shortage, appropriate staffing remains a necessary standard for maintaining a HWE. Staffing shortages contribute to nursing burnout and poor patient outcomes.12 In an effort to address staffing issues, the goal was to improve the nursing work environment, and staff call-ins and turnover would decrease. A Charge Nurse Committee was also formed. This was composed of the most experienced staff nurses and staff preceptors on the unit. It was charged with developing a mentoring and preceptor program for new nurses on the unit. Better trained nurses would be more effective at managing complex patients and assigning the right mix of patients to a nurse when functioning in the charge nurse role. Additionally, nurse staffing huddles were initiated at the beginning of every shift to improve staff communication and teamwork. In an effort to decrease the rapid patient turnover in the unit, the medical director also began to hold admitting physicians accountable for admitting only patients who needed step-down care, rather than admitting patients based on falsely held beliefs that their patients would not be as closely monitored in the general medical surgical nursing units. Lastly, a self-scheduling initiative was begun so staff had greater flexibility and ownership in determining their work schedules.
Every nurse has a desire to be recognized for his/her hard work and commitment to his/her patients.12 In an effort to improve recognition, a morale committee was organized. A gold star award program was initiated whereby excellence in patient care could be highlighted at any time, by any staff member. A kudos/thank-you board is posted on the unit where a staff member can write a thank-you or kudos comment to a staff member and post it on the board for all staff to view. This has become very popular with staff, and senior nursing leaders and physicians have also contributed positive comments about staff performance. Staff nurse achievements and compliments from patients and physician staff were routinely recognized at staff meetings and through the UPC newsletter. A staff nurse picture board and awards were displayed at the entrance to the unit so staff accomplishments could be observed by patients, family members, physicians, nurse peers, and visitors to the unit.
As this EBP project unfolded, it became the ultimate test of authentic leadership. At first, IMCU staff members appeared reticent to believe this was just not another whim of the current nursing administration. The nursing leadership had to be willing to listen and make changes that were sustainable for the long term. For some staff nurses, there was a lack of understanding as to why certain problems could not be solved through immediate implementation of their recommendations. For instance, self-scheduling could not be immediately instituted without labor union review and approval, which required time and reconsideration of the initial plan for roll-out. Open and honest communication and explanations for institutional and budgetary constraints were necessary at times. Listening and allowing the nursing staff to have ownership in the problem-solving process were necessary to demonstrate attributes of authentic leadership. A civilian assistant head nurse was hired to provide consistent leadership in times when military head nurses were rotated to new duty locations or deployed overseas. This diminished some of the turbulence that occurred every time staff nurses had to adjust to a new military head nurse. A 3-day staff development off-site staff meeting was also conducted. The topics focused on nursing skill building, team building, and resilience training. The leadership conducted a problem-solving session where staff was encouraged to state concerns and to brainstorm solutions to unit and patient care issues. These staff days were tremendously successful, as noted in staff evaluation surveys, at improving staff attitudes, morale, and communication. Additionally, senior nurse leaders became attuned to assessing the talents of incoming military nurse leaders and matching the unit characteristics and needs with incoming military head nurses’ strengths, attributes, and capabilities.
Preliminary analysis at 6 months after the first team meeting and 3 months after implementation of many of the proposed leadership initiatives showed positive trends in the outcome metrics. The IMCU demonstrated a decrease in staff absenteeism by 48.5% over the first 3-month period of implementation when compared with the 3 months prior to implementation of the leadership initiatives. Six written patient compliments had been submitted to the IMCU head nurse about the excellent nursing care provided by the nursing staff. One patient noted, “All staff on 3 East appear to be content, and it shows with their caring attitudes.” In the 6 months preceding implementation, there had been no written compliments submitted by patients. A follow-up sensing session of staff members also reflected more positive feedback and open communication among IMCU staff members. The following observations were provided by the nursing staff: “I have seen evidence that some physicians are advocating for appropriate admissions.” “I see a lot more teamwork and the staff is more patient focused.” And “The head nurse’s communication has helped with staffing; more advocating for staff.”
The staff also provided negative feedback during the staff sensing session that provided areas for initiative improvement and future direction. The staff was concerned that although the unit scope of services had been drafted, and they were beginning to implement the admission and discharge criteria, it remained unsigned by the medical director assigned to the unit. The staff felt that by not having the signed document, they would not have the traction they needed to advocate for the unit when physician staff tried to admit patients to the IMCU that did not fall within the specified scope of services. Some staff nurses were also upset that the self-scheduling initiative had still not been instituted. This provided an opportunity for staff education on the process of labor union negotiations and the status of the self-scheduling initiative. What remained most evident during the staff reassessment was that IMCU nursing staff continued to verbalize an ongoing lack of trust in senior leaders to make changes necessary to create a healthier work environment. The staff resilience provider provided active listening and directed problem solving in response to concerns.
With regard to patient outcomes and quality care, patient falls on the unit had decreased by 75%, and the number of patient safety reports filed by staff members decreased by 20%. Additionally, the unit’s monthly reported performance improvement metrics that had previously fallen below benchmark levels (pain management, falls risk, and medication reconciliation) had all improved from baseline; falls risk had exceeded benchmark criteria.
In the early stages of implementation, there have been several lessons learned from this EBP project that focused on using evidence-based leadership initiatives to create a healthier nursing work environment in a military medical center, IMCU. First, organizational change takes time, so plan on doubling projected time estimates when working across disciplines to create change. Additionally, organizational trust among staff members is easy to lose and takes time and consistency to regain. Making sure to negotiate reasonable, attainable goals up front; following through with those leadership initiatives; and open communication of success, barriers to success, and what the leadership plans to do about those delays have been key to winning back that trust one staff member at a time. And finally, having a unit champion such as the CNS who is available to the staff on a daily basis and can quickly advocate for staff with physicians and leadership provided a solid foundation for implementing organization and unit-level changes.
Using the 6 AACN Standards for Establishing and Sustaining Healthy Work Environments, (1) skilled communication, (2) true collaboration, (3) effective decision making, (4) appropriate staffing, (5) meaningful recognition, and (6) authentic leadership, military and civilian nurse administrators, staff nurses, resilience providers, and CNSs were able to create a healthier nursing work environment in this IMCU. Brainstorming leadership initiatives that were achievable, reasonable, and agreeable to IMCU nursing staff, stakeholders, and members of the EBP working group provided a solid platform for moving forward. Follow-through was critical to attaining staff trust in the organization and the nursing leaders. Early preliminary evaluation of this EBP project has revealed positive changes in the work environment. To date, these leadership initiatives have had a positive effect on staff nurse absenteeism, patient and staff satisfaction, and nursing quality indicators.
The authors would like to acknowledge the following members of the IMCU UPC: CPT Leigh Traylor, BSN, RN; Sheila Gomez, ADN, RN; SGT Fernando Garcia, LVN; Amanda Cardey, LVN; Jeannette Luna, BSN, RN; and Debra Garza, CNA.