The state of healthcare in the United States is largely dependent on the availability of nurses to care for patients in need. The nursing profession continues struggling to overcome the nursing shortage that resulted from a culmination of an aging population, the economic recession, implementation of healthcare reform, decreased availability of qualified entry-level nurses with a shortage of nursing faculty, and a lack of experienced nurses resulting from burnout and dissatisfaction. Nurse leaders, administrators, and legislators must recognize the inherent risks that accompany a shortage of nurses and work to enhance the environmental factors that could make a positive impact.
Research links a healthy work environment (HWE) to improved patient outcomes, nurse satisfaction, and employee retention.1 The American Association of Critical-Care Nurses' (AACN) Standards for Establishing and Sustaining HWEs provides a clear-cut, evidence-based guide to help nurse leaders create an HWE by implementing six essential standards. This article describes the development of an evidence-based, best-practice toolkit that supports nurse leaders in incorporating the AACN's six essential standards of an HWE into current practice settings.1
The RN shortage could increase to 29% of the entire nursing population by the year 2020. A shortage of this magnitude will negatively influence operational costs as organizations resort to paying for overtime and increasing salaries to maintain competitiveness.2 Evidence links HWEs for nurses with decreased mortality, improved patient safety, decreased length of stay, and increased patient satisfaction.3 A study by Stimpfel, Rosen, and McHugh provided new insight into how nursing influences quality with its report that the overall quality of patient care is optimized when nurses work in a positive environment.4 This is especially significant as improvements to healthcare quality and value-based purchasing have primarily focused on the impact of physician-driven services. This study demonstrates that professional nursing care is an important factor that affects patient outcomes, and it's the duty of all hospital leaders to implement new models of care that create HWEs to meet the needs of physicians, nurses, and patients.5
Leaders are often given the daunting responsibility of ensuring their organizations are functioning in the most efficient way, increasing productivity and maximizing profitability. In healthcare, this responsibility is more complex due to the dynamic and ever-changing nature of the work environment. Nurse leaders have a responsibility to demonstrate positive management qualities and styles conducive to creating an HWE. Research asserts that authentic and transformational leadership qualities and clear communication styles are essential to the creation of an HWE for nurses.3,5 In addition, nurse managers are a fundamental link to promoting change and ensuring positive work environments exist, which enhances staff retention.2
To assist the process, the AACN encourages leaders to use six evidence-based standards as a guide to monitor their organization's work environment.1 When coupled with the results of unit and self-assessments, the six standards provide leaders with valuable information regarding the current status of their work environments and areas in need of change.
Advanced practice nurses (APNs) are leaders of the nursing workforce. As such, they must demonstrate leadership styles that promote a positive organizational culture, a HWE, employee satisfaction, retention, enhanced recruitment, and quality patient care. These professionals should use their organizations' expertise of best-practice standards and experience to guide a collaborative review of the literature to develop and implement evidence-based, standardized models for HWEs. Such an approach would yield positive results for nurses and patients. By demonstrating effective leadership styles, the APN serves as a leader, patient advocate, nurse advocate, and facilitator for consistent, evidence-based, quality patient care.
The six standards
The AACN's six essential standards for a HWE are:
- skilled communication
- true collaboration
- effective decision making
- appropriate staffing
- meaningful recognition
- authentic leadership.1
Using these standards as a guide for an evidence-based toolkit enhanced its clarity and usefulness, and ensured that it would be a comprehensive resource guiding nurse leaders' efforts to create or maintain HWEs. While the AACN's standards provided the conceptual framework, the theoretical perspective used to guide this toolkit's development was the Path-Goal Theory.6
The Path-Goal Theory focuses on a leader's ability to influence empowerment, motivation, and satisfaction of employees so each will become productive contributors to the unit and the organization. The basis of the theory, much like the basis of the AACN standards, is that a leader has the ability to adjust his or her style to influence employees and the team's ability to reach a goal.6 Applying these theoretical principles to the process of implementing the AACN standards allows the leader to understand his or her role in creating and sustaining a HWE.
The evidence-based toolkit
The toolkit's design included an independent review of current literature, synthesis of findings, and subsequent development of an evidence-based summary of existing literature in the format of a toolkit for formal and informal nurse leaders. As a result, the project created an evidence-based link between theory, research, and leadership practice in one central location.
The toolkit was formatted similarly to the Registered Nurses' Association of Ontario's best practice guidelines, and begins with an introduction to the concept of a HWE, along with a review of evidence related to the benefits of creating such an environment.7 Because the first step in the process is for the leader to conduct an assessment of the current work environment, a table with evidence-based assessment tools is provided from which the leader can choose. Although use of the AACN HWE Assessment Tool is encouraged, other reliable and validated tools are offered.8 The findings of an individualized assessment provide the leader with a baseline for measuring the health of the work environment, and assist the leader in identifying which of the six essential standards is in need of improvement. Once the area in need of improvement is identified, the leader consults the toolkit for further guidance.
The toolkit is divided into sections corresponding to the AACN's six essential standards.1 Each section provides the AACN's definition for that standard, a review of literature related to that standard, and a table with evidence-based tools for assessing and/or implementing strategies to improve that aspect of the work environment. The toolkit is meant to provide guidance to individuals or groups involved in planning, coordinating, or facilitating practice change by assimilating evidence-based information in a quick-reference format. The entire toolkit is in the HWE Resources section of the AACN's website at www.aacn.org/hwe. However, selecting tools and implementing changes are roles of the nursing leader, as he or she is equipped to utilize the best strategies for each unique environment.
To determine the toolkit's applicability for nursing leaders nationwide, it was evaluated and applied by a nursing leader in a Magnet®-designated hospital. The health of the work environment was assessed at two points in time during a 90-day period. The two sets of data were compared to national benchmarks, and descriptive statistics were calculated for each standard. In addition, the nurse leader at the target hospital received a questionnaire, constructed using the Research Electronic Data Capture secure data capture system, developed by Vanderbilt University. The leader provided feedback regarding usefulness, clarity, and applicability of the tool, and potential areas in need of improvement.
The AACN's web-based HWE Assessment Tool, whose psychometric properties have resulted in Chronbach's alpha of at least .80, was used to survey the perceptions of the current work environment in critical care units of a target hospital.8 Employees accessed the survey with a unique link, ensuring anonymity of data input, and baseline data gathered from the survey were interpreted based on the AACN's published guidelines. Using data from the Time 1 assessment of staff's perceptions of the health of the work environment, nurse leaders identified the area most in need of change by selecting the standard with the lowest aggregate score. (See AACN HWE web-assessment tool.)
For this pilot study, the standard of meaningful recognition was the only standard that fell below the national benchmark in the Time 1 assessment. (See Data analysis for individual standards.) Therefore, information within the toolkit was used to devise a plan to guide change processes related to meaningful recognition in this work environment. The leader's action plan was developed over a 90-day period. (See Leader's action plan.)
Staff was asked to reassess their work environment 3 months after the first assessment, using the same web-based tool, and Time 2 data were analyzed and compared again with national benchmarks. The Time 2 score of 3.31 for meaningful recognition was higher than the Time 1 score and higher than the national benchmark of 3.23. While this change in score indicated an improvement, no relationship to the use of the toolkit could be inferred because it hadn't been fully implemented. Also, because the Time 1 and Time 2 groups weren't equivalent, their scores couldn't be compared. However, comparisons for both HWE results could be made to national benchmarks.
The director of critical care and intermediate care reviewed the toolkit in its entirety and rated its contents via a Likert scale. Scores for applicability, usefulness, and clarity were ranked as “Good” or “Very good,” which were interpreted as positive responses. The leader reported that she would be “Very likely” to use the toolkit to guide improvement efforts and to suggest this toolkit as a resource for other nurse leaders focusing on creating HWEs. No suggestions were provided to strengthen the toolkit's ease of use, applicability, clarity, or resources regarding skilled communication. Overall, the leader agreed that the resources provided in the toolkit augmented her ability to create a healthier work environment. (See Leader questionnaire results.)
Strengths and limitations
Ensuring that the contents and resources in the toolkit were based on current available evidence and published standards lends credibility to its appropriateness to practice. Furthermore, providing direct access to evidence-based tools via active hyperlinks enhances the toolkit's ability to augment the leader's efforts to implement successful changes. This toolkit provides consolidated access to the body of knowledge related to HWEs and supports the AACN's efforts to establish a culture of HWEs across the nation.
The most prominent limitation of this project is that it was piloted at one Magnet-designated hospital with a small target population. Magnet hospitals have a culture that encompasses many of the standards required for HWEs to exist. Therefore, the ability to generalize the information to all hospitals is limited. Obtaining feedback from a broader sample of leaders would enhance the generalizability of the toolkit in other settings. Furthermore, a convenience sample was used that also limits generalizability. Although the invitations for each survey (Time 1 and Time 2) were sent to all nurses on the same unit, there was no way to determine if the same nurses responded to each survey, particularly because some staff left and others were hired between the two assessment periods.
Impact on nursing practice and patient care
The potential impact of any project related to creating and maintaining an HWE can be enormous because the work environment has a direct impact on employee satisfaction and retention, as well as the quality of care and patient outcomes. A 2013 survey revealed that the national average for clinical RN turnover was 13.1%, with subsequent costs to organizations of $3.74 million to $4.98 million per hospital.9 Although it's difficult to quantify the exact costs related to nurse turnover, reports from the past 20 years show the cost per nurse ranged from $10,098 to $88,000, while total annual costs ranged from $550,000 to $8.5 million, which shows that $4.98 million is likely a conservative estimate.10 Improved patient outcomes, which have been attributed to staff retention, can also translate into cost savings for the organization under the regulations of health reform. These findings, along with the estimate that each additional increase in percentage point of turnover costs each organization an additional $331,800, show that implementing strategies to increase nurse retention is imperative to the viability of all healthcare organizations.9
HWEs have an impact on mortality, complication rates, failure to rescue rates, medication error interception, healthcare-associated infections, and Hospital Consumer Assessment of Healthcare Providers and Systems scores. In fact, researchers reported that decreasing the nurse workload by one patient per nurse lowered mortality by 9% in hospitals with the best work environments, 4% in hospitals with average work environments, and virtually no effect in hospitals with poor work environments. Similarly, for every 10% of nurses who reported job dissatisfaction, the percentage of patients who would definitely recommend the hospital decreased by approximately 2%.11
Despite these links, evaluations of critical care work environments in 2006, 2008, and 2013 found that frontline nurse managers, directors, and administrators reported that the AACN standards were either fully implemented or on their way to being implemented in 28.8% of work units and in 22.2% of organizations.11 Unfortunately, the mean ratings didn't improve dramatically between 2008 and 2013. In fact, the mean rating for most standards declined. The most significant change between 2008 and 2013 was a decline in the effective decision making item that values nurses as partners in policy making, directing and evaluating clinical care, and leading organizational operations.11 Based on these findings, it's evident that HWEs are far from being the norm, but rather continue to be the exception.
A fundamental premise of the AACN's standards is that they will only lead to excellence when adopted by every individual at every level of an organization.11 Providing a toolkit with contents and resources based on current available evidence and published standards lends credibility to this toolkit's application to practice in all settings. Furthermore, providing direct access to evidence-based tools via active hyperlinks enhances its ability to augment the leader's efforts to implement successful changes. This toolkit provides consolidated access to the body of knowledge related to HWEs and supports the AACN's efforts to establish a culture of HWEs across the nation, augmenting nurse leaders' potential for achieving excellence, by providing step-by-step, evidence-based guidance and support that has been unavailable up to this time.
1. American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence. Am J Crit Care
2. Ritter D. The relationship between healthy work environments and retention of nurses in a hospital setting. J Nurs Manag
3. Kramer M, Schmalenberg C, Maguire P. Nine structures and leadership practices essential for a magnetic (healthy) work environment. Nurs Adm Q
4. Stimpfel AW, Rosen JE, McHugh MD. Understanding the role of the professional practice environment on quality of care in Magnet and non-Magnet hospitals. J Nurs Adm
5. Cummings GG, MacGregor T, Davey M, et al. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Int J Nurs Stud
6. House RJ. Path-Goal Theory of leadership: lessons, legacy, and a reformulated theory. Leadersh Q
7. Registered Nurses' Association of Ontario. Healthy work place environment guidelines. http://rnao.ca/bpg/guidelines/hwe-guidelines
8. American Association of Critical-Care Nurses. AACN's free new healthy work environment assessment tool. 2015. www.aacn.org/WD/HWE/Content/hwehome.content?menu=hwe
10. Li Y, Jones CB. A literature review of nursing turnover costs. J Nurs Manag
11. Ulrich BT, Lavandero R, Woods D, Early S. Critical care nurse work environments 2013: a status report. Crit Care Nurs