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The CNO's role in a healthy work environment

Burns, Helene M., DNP, RN, NEA-BC; Gonzalez, Judith F. Zedreck, DNP, RN, MPM, NEA-BC; Hoffmann, Rosemary L., PhD, RN, CNL; Fulginiti, Susan, DNP, RN-BC, NE-BC

doi: 10.1097/01.NUMA.0000546200.94337.06

Read about this project that assessed CNOs' understanding of a healthy work environment (HWE) and provided a toolkit with suggestions to nurture and engage in HWE initiatives.

Helene M. Burns is the vice president and chief nurse executive at Jefferson Health New Jersey in Voorhees, N.J. At the University of Pittsburgh (Pa.) School of Nursing, Judith F. Zedreck Gonzalez is a professor and the health systems executive leadership DNP program coordinator and Rosemary L. Hoffmann is an associate professor and the MSN program director. Susan Fulginiti is the manager of clinical excellence at Jefferson Health-New Jersey in Stratford, N.J.

The authors have disclosed no financial relationships related to this article.



In hospital nursing, a healthy work environment (HWE) is defined as a safe, empowering, and satisfying environment that supports optimal health and safety. In an HWE, healthcare team members have good working relationships, clinical nurses are involved in decision-making, and the organization listens and responds to patient care issues identified by clinical nurses.1 When these attributes aren't present, the environment is unhealthy.

The CNO's role is to provide leadership in the development and fostering of an HWE for clinical nurses, setting the stage to sustain an HWE. To accomplish this task, the CNO must commit to the principle of using evidence-based practice to lead change through collaboration and partnership with nurse leaders, clinical nurses, and all disciplines.2

This project, based on the American Association of Critical-Care Nurses' (AACN) HWE model, assessed CNOs' understanding of an HWE and provided a toolkit with suggestions to nurture and engage in HWE initiatives. Specific aims of the project included surveying CNOs in New Jersey (preassessment), assessing their understanding of and priorities for an HWE, providing a CNO toolkit, and surveying CNOs in New Jersey (postassessment) to determine the toolkit's value.

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When hospitalized, every patient deserves high-quality nursing care that's grounded in competency, research, and best practices. Nurses have an obligation to deliver safe and efficient care while ensuring optimal patient outcomes. The American Nurses Association's Code of Ethics for Nurses states that nurses have an ethical responsibility to ensure patient safety and the health and wellness of nurses and other healthcare providers.3 As part of the healthcare team, nursing staff members perform with professionalism, accountability, transparency, involvement, efficiency, and effectiveness. When these attributes are in place, the nursing unit and the organization demonstrate a culture of safety.4

Clinical nurses are dissatisfied when there's a lack of advancement opportunities; a lack of educational opportunities; patient ratios and skill mix aren't adequate; cost-containment efforts affect patient care, including shorter length of stay and rapid patient throughput; relationships with physicians are problematic; the chief nurse isn't seen as visible and equal in authority to other hospital executives; and nursing management isn't seen as a partner.5

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The origin of an HWE for hospital-based nurses may have begun with the 1983 study “Magnet Hospitals: Attraction and Retention of Professional Nurses.”6 The early 1980s was plagued with hospital nursing shortages and many organizations' inability to attract and retain competent, experienced professional nurses. Certain hospitals across the country 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.

Two major components that emerged from nurse leaders and clinical nurses were the environment and the practice mode. The study's 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 these “magnet” hospitals, it was a combination of elements that created a positive practice environment.6 Today, we recognize this in the American Nurses Credentialing Center's (ANCC) Magnet Recognition Program.® The mission of the ANCC is “to promote excellence in nursing and healthcare globally through credentialing programs.”7 When the CNO looks to pursue a Magnet® journey for his or her organization, the Magnet standards align with HWE initiatives.

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Supporting literature

Using the Joanna Briggs Institute, Ovid, MEDLINE, and PubMed, many articles and published studies can be found linking nursing practice and an HWE.

Five systematic reviews of studies were found in the literature and evaluated. The first review recommended a multidisciplinary approach to improve outcomes and establish an HWE.8 The second review recommended that hospitals seeking to establish and maintain an HWE need to consider the role of nursing workload and nurse staffing.9 The third review concluded that a combination of leadership styles and characteristics was found to contribute to the development and sustainability of an HWE.10 The fourth review discovered nine pronounced factors considered important for an HWE: collaboration/teamwork; growth and development of the individual; recognition; employee involvement; a positive, accessible, and fair leader; autonomy and empowerment; appropriate staffing; skilled communication; and safe physical work.11 Finally, the last systematic review, published in 2014, suggested these strategies to create an HWE: an empowering work environment, a shared governance structure, autonomy, professional development, leadership support, adequate numbers and skill mix, and collegial relationships within the healthcare team.12

Seven independent qualitative studies were completed between 2011 and 2016. Of these studies, four concluded that nurse leaders, specifically nurse managers, play a vital role in ensuring an HWE.13-17 In the other three qualitative studies, the nurse-to-patient staffing ratios influenced the nurses' perceptions of an HWE.18,19

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Theoretical framework

The AACN made a commitment in 2001 to actively promote the creation of an HWE that would foster and support excellence in patient care in the acute and critical care hospital settings. The AACN initiated a study in 2004 that focused on caregiver interactions and their impact on patient well-being. Based on this work, the AACN commissioned a nine-person panel that developed six standards to establish and sustain an HWE.20 These six standards represent evidence-based and relationship-centered principles of professional performance, making up the AACN Synergy Model for Patient Care. (See AACN Synergy Model for Patient Care.) Each standard is considered essential and aligns with the core competencies for health professionals recommended by the National Academy of Medicine (formerly the Institute of Medicine).21

The AACN standards for establishing and sustaining an HWE include the following:22

  • 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. There must be an 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.
  • authentic leadership. Nurse leaders must fully embrace the imperative of an HWE, authentically live it, and engage others in its achievement.


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CNOs in New Jersey were asked to participate in this project. Permission for access to the CNO email list was requested from the Organization of Nurse Leaders, New Jersey. Participation provided an initial evaluation of CNOs' understanding of an HWE using the AACN Healthy Work Environment Assessment Tool.23 *

The assessment tool consists of 18 questions, with response definitions displayed using a Likert scale. The tool is a screening test to measure progress on achieving the AACN six essential standards of an HWE. A screening tool, not a diagnostic test, it provides an overall HWE score and scores for each of the standards.23

The assessment tool was chosen after review of the literature for reliability and validity of the instrument. A 2010 study examined the psychometric properties of the AACN Healthy Work Environment Assessment Tool, reviewed it for face validity, and administered it to two groups. Both samples were tested for reliability and showed internal consistency with identical factor structures and Cronbach's alpha scores of 0.80 or better. This study found that the instrument is a feasible, reliable, and valid method for assessing the work environment.24

The AACN Healthy Work Environment Assessment Tool survey was conducted in November 2017. Eighty-two surveys were distributed via email. Twenty-nine responses were obtained, for a 35% response rate. In addition to the 18 questions from the assessment tool, demographic questions were also asked. Demographics included gender, age, race/ethnicity, years of experience in nursing, years of experience in nursing leadership, current job title, years in current position, highest degree in nursing, highest degree in a field other than nursing, certification in a nursing specialty, hospital bed size, unionization, and Magnet recognition.

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Data analysis

The CNO group was comprised of primarily women and mostly in the age category of 50+. The majority had more than 30 years' nursing experience. The years of nursing leadership experience varied, but most were between 16 and 20 years. Note that “nursing leadership” wasn't defined for the survey. It's unclear if the respondents considered nursing leadership to include their experiences as nurse managers or nursing supervisors when answering this question. Of interest is that most respondents (62%) said they were in their current role for less than 5 years. Only two respondents had a long tenure—more than 15 years—in their current positions. Seventy-nine percent of the respondents had a master's or doctoral degree in nursing. Forty-one percent had a master's or doctoral degree in a field other than nursing. Another interesting response was that 86% of the group was certified in specialty practice. Degree and certification percentages demonstrate the value that both hold to the nurse executive group. Seventy-eight percent of respondents were at either Magnet hospitals or on the Magnet journey, demonstrating the value of Magnet recognition to nurse executives and healthcare organizations.

Using the AACN Synergy Model for Patient Care and the AACN team assessment results workbook, individual questions were grouped based on the six standards. For example, questions 1, 6, and 14 were correlated to skilled communication. Higher weighted standards had higher percentages of strongly agree.

The top aggregate scores for the CNOs were in the authentic leadership category. Relationships between nurse leaders (nurse managers, directors, advanced practice nurses, and so on) were most important, followed by the value of access and authority for nurse leaders to play a role in decision-making. Most of the CNOs said that it's important for nurse leaders to understand the requirements and dynamics at the point of care and use this knowledge in HWE initiatives.

The second highest aggregate scores for the CNOs were in the true collaboration category. The highest individual score was clinical nurse involvement with administrators, nurse managers, and physicians when making important decisions. When speaking with clinical nurses, administrators, nurse managers, and physicians, seek input and use it to make decisions. It isn't one-way communication or order giving. Finally, in this category, the CNOs stated that nurses can influence policies, procedures, and bureaucracy, but 17% of the CNOs were either neutral or disagreed that clinical nurses have an influential role in the organization.

The next aggregate scores for the CNOs were in the meaningful recognition category. Most important to the CNOs was a formal reward and recognition system in place to make nursing staff members feel valued. Also important to the CNOs were motivating opportunities for clinical nurse personal growth, development, and advancement. Leaders and coworkers need to speak up and let people know when someone does a good job. Of note, 14% of the CNOs were either neutral or disagreed with the question of speaking up when a job is done well.

After meaningful recognition, the next aggregate scores for the CNOs were in the effective decision-making category. For the CNOs, carefully considering the patient's and family's perspective when making important decisions was most important. The CNOs also responded that important decisions need to involve the right departments, professions, and groups, and use data-driven, logical decision-making processes at all levels of the organization.

After effective decision-making, the next aggregate scores for the CNOs were in the appropriate staffing category. Most important to the CNOs was that administrators and nurse managers work with nurses and other staff to ensure adequate staffing to maintain patient safety. Also important was that staffing is the right mix of nurses and other staff. Only 69% of the respondents stated that support staff members are provided at a level allowing nurses and other staff to spend their time on priorities of patient and family care.

The final aggregate scores for the CNOs were in the skilled communication category. Scoring highest was that everyone in the organization—from administrators to physicians and clinical staff—ensures their actions match their words. They “walk their talk.” Next, the CNOs valued frequent communication. When asked if there's a culture of zero-tolerance for disrespect and abuse, 41% of the respondents strongly agreed. Thirty-one percent of the respondents didn't agree or were neutral in their response that people are held accountable for disrespect regardless of their role or position.

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Authentic leadership was most important to the CNO respondents. To create and sustain an HWE, nurse executives must take leadership roles. Authentic leadership is pivotal and considered the “glue that holds together a healthy work environment.”25 True collaboration begins with the individual, not the organization; it's a process, not an event, that involves skilled communication, trust, knowledge, shared responsibility, and mutual respect to succeed.22 Effective decision-making is about nurses' involvement with medical staff and other healthcare workers in decisions that affect patient care. When clinical nurses are in an HWE, appropriate staffing is about providing an appropriate proportion of care hours. Evidence links nurse staffing and patient outcomes.26 Skilled communication is a two-way dialogue, with individuals thinking and deciding together to create a safe work environment.22

A toolkit with resources for HWE initiatives and the six domains of an HWE was designed and distributed to the CNOs in New Jersey. For example, to develop authentic leadership skills, the American Organization of Nurse Executives' website offers courses for early careerists, mid-level careerists, and nurse executives. Resources for true collaboration include Agency for Healthcare Research and Quality programs such as TeamSTEPPS. The DAISY Award for Extraordinary Nurses and the March of Dimes nursing program offer opportunities to provide meaningful recognition. Also included in the toolkit are programs recognizing organizational success, including the AACN Beacon Award for Excellence, ANCC Magnet Recognition Program, ANCC Pathway to Excellence® Program, and the Malcolm Baldrige National Quality Program.

A postassessment survey was completed in the first quarter of 2018 as an evaluation measure to determine the value of the toolkit. Ninety percent of the respondents were aware of the AACN HWE model, all respondents found the toolkit of value, and 60% used several resource examples. Toolkits like this one can become a reference for new and established CNOs in their leadership of HWE initiatives.

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Implications for practice

Nurse leaders and clinical nurses face challenges to develop and maintain an HWE. The AACN's HWE model provides a roadmap. It was no surprise to the authors that CNOs rated authentic leadership with the highest aggregate scores. Because the CNO's role is to provide leadership to help sustain an HWE, it's critical that he or she is engaged in organizational HWE initiatives. Resources are available, including educational offerings and programs to recognize organizational success, for the CNO to lead change toward an HWE.

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* The AACN Healthy Work Environment Assessment Tool was used without modification as requested, with acknowledgment to the original source: American Association of Critical-Care Nurses. Healthy Work Environment Assessment Tool. Aliso Viejo, CA: American Association of Critical-Care Nurses. @AACN. All rights reserved. Used and modified with permission.
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