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Ramón Lavandero is the director of development and strategic alliances for the American Association of Critical-Care Nurses. He is an adjunct associate professor at Indiana University School of Nursing, Indianapolis, Ind, where he serves on the school’s external board of advisors.
Karen Hart is a senior vice president in the Health Care Division of Bernard Hodes Group, a recruitment communications company.
Dana Woods is the director of marketing and strategy integration for the American Association of Critical-Care Nurses. She is the AACN staff lead for healthy work environments.
John Leggett is executive vice president for marketing, interactive, events, and research at Nursing Spectrum.
Diane Taylor is research manager for Bernard Hodes Group.
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
Corresponding author: Beth T. Ulrich, RN, EdD, CHE, 3811 Abbeywood Dr, Pearland, TX 77584 (e-mail: BUlrich{at}NursingSpectrum.com).
Recognizing that a healthy work environment is the base for recruiting and retaining nurses and ultimately for providing optimal care for patients, the American Association of Critical-Care Nurses (AACN) began a major effort in 2001 to actively promote and support healthy work environments.6 At the 2003 AACN National Teaching Institute and Critical Care Exposition, in the Act Boldly Campaign, AACN called on critical care nurses to actively commit to addressing workplace issues in the nurses’ organizations.7 That same year, AACN conducted a national survey, part of which solicited more details on healthy and unhealthy work environments.8 AACN position papers were developed on prevention of violence in the workplace and on zero tolerance for abusive behaviors.9,10 In 2004, AACN completed the landmark National Critical Care Survey, the first survey to provide data on critical care units and the environments in which critical care nurses work.11 Before this study, little information specific to critical care environments was available.
In January 2005, AACN published national standards for establishing and sustaining healthy work environments.12 Specifically, the standards address skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership in the work environment.
The standards complement and support the American Nurses Association Code of Ethics for Nurses,13 the Institute of Medicine recommendations,5,14,15 the elements of a healthy work environment as determined by the Nursing Organizations Alliance,16 the recommendations from the Joint Commission on Accreditation of Healthcare Organizations,17 and attributes of organizations receiving Magnet designation.18
In early 2006, a year after the standards were released, AACN, Nursing Spectrum (a communications company and division of Gannett Co), and Bernard Hodes Group (a world leader in integrated talent solutions and a division of Omnicom), conducted a national survey of critical care nurses to determine the status of critical care work environments. The nurses were also asked about their satisfaction with nursing as a career, their intent to stay in or leave their current positions, reasons for planning to stay or leave, and what might cause them to reconsider leaving. In this article, we present the major results of the survey.
Study Design and Sample
The online survey instrument contained questions based on the AACN healthy work environment standards and on previous research about RNs’ work environments. The questionnaire was pilot tested with a national sample of RNs, and no major changes were made as a result of the pilot data. Convenience sampling was used. Members and other constituents of AACN were invited via e-mail to participate in the study. The e-mail invitation contained an online link to the survey instrument. Respondents were offered an incentive to participate: the chance to win a complimentary registration to the AACN National Teaching Institute and Critical Care Exposition. The survey was conducted from April 18, 2006, to May 3, 2006. Frequencies, percentages, SDs, and means were determined for each question and were cross-tabulated against demographic variables. Because a convenience sample of RNs associated with AACN was used, the generalizability of the findings is limited.
A total of 4346 RNs from every state and the District of Columbia responded to the survey. Of these, 4034 reported currently working as an RN. The responses of RNs who were not currently working as RNs were not included in the data analysis. Table 1
gives the demographic information.
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Healthy Work Environment Standards: Overview
More than 50% of the respondents indicated that they were aware of the AACN standards for healthy work environments. Slightly less than 40% said that how well they established and sustained a healthy work environment plays a major (12.7%) or substantive part (27.1%) in their performance evaluations.
Questions about the status of work environments based on the AACN standards were asked for both organizations as a whole (macrosystems) and for the units on which the respondents worked (microsystems). In all instances in this survey, the respondents rated the health of their unit work environments higher than the health of their organizations (Table 2).
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), respondents were asked to rate the communication and collaboration in their work units among RNs and between RNs and physicians, frontline nurse managers, and administrators (Table 3). The highest levels of communication and collaboration were among RNs; the lowest levels, between RNs and administrators.
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).
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). Because the questions had only yes and no response options, a yes response could represent one occurrence or many. At least one instance of sexual harassment, regardless of the source, was reported by 18.2% of the respondents and discrimination by 26.6%. A large majority (64.6%) reported at least one instance of verbal abuse; 22.2% reported at least one instance of physical abuse.
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Nursing Leadership
Respondents were asked to rate the skills of their frontline managers and their chief nurse executives. In every instance, the skills of the managers were rated higher than the skills of the executives (see Figure).
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). More than 75% of the respondents worked for organizations that provided in-house continuing education, and 55.4% worked for organizations that provided paid time off for continuing education. Registration fees for continuing education were paid by 47.8% of the organizations. Specialty certification was less supported, although 47.9% of the respondents reported that initial examination fees were paid for or reimbursed, and 45.0% said that nurses who achieved certification were recognized.
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Quality and Outcomes of Patients’ Care
The majority of respondents rated the quality of care in their work units and organizations as excellent or good (Table 7). More than half indicated that the quality of care had increased in their organizations in the past year. When asked to describe the quality of the RNs in their work unit, 32.0% selected excellent, and 52.7% selected good. In reply to a question about having the right number of RN staff with the right knowledge and skills, an indication of the AACN standard for appropriate staffing, 6.1% of the respondents indicated that standard is met all the time; 43.0%, more than 75% of the time; 29.4%, 50% to 75% of the time; 16.8%, 25% to 49% of the time; and 4.9%, less than 25% of the time.
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). Other aspects of nursing care such as comforting, teaching, planning, and preparing for discharge are completed less often.
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). More than half (54.1%) would definitely advise a qualified individual to pursue a career in nursing, and another 34.0% probably would.
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Retention
In order to assess future retention, participants were asked to indicate whether they planned to leave their current nursing positions within the next 12 months or within the next 3 years. One in 5 (20.0%) indicated that they plan to leave their current position in the next 12 months; 28.6% plan to leave in the next 3 years. A little more than half (51.9%) indicated that they have no plans to leave their current position in the next 3 years.
Among those who said they plan to leave their current position, the most common reason for such planning was to take another position in clinical nursing (38.5%). Other reasons, in order, were returning to school to pursue additional nursing education (17.5%) and taking a different position in nonclinical nursing (17.0%). Only 5.3% of those planning to leave (2.6% of the total respondents) said that they were leaving their current position to pursue a job in another profession.
Respondents who reported plans to leave their current positions were asked how likely certain changes were to cause them to reconsider. Better leadership was the most frequently cited change; 44.0% of those who planned to leave said that better leadership would be very likely to cause them to reconsider leaving. Other changes that would make them reconsider leaving were higher salary and benefits, better staffing, more opportunities for professional development, more respect from both frontline management and administration, more meaningful recognition, and more opportunities to influence decisions about patients’ care.
Other Findings
In addition to the findings presented in this initial report, the data collected in the survey indicated significant differences according to the variables of age of the nurse, experience (most notably RNs with less than 5 years’ experience and those with more than 20 years’ experience), highest educational degree, and the Magnet status of the organizations in which the nurses worked. These differences are beyond the scope of this article and will be presented in detail in subsequent presentations and publications.
Discussion
This survey provides important information on the current health of work environments in critical care settings, RNs’ career and job satisfaction, RNs’ intent to stay in or leave current positions, and actions that would cause RNs to reconsider leaving. Organizations can use the findings as a blueprint to improve work environments and increase retention of critical care nurses.
Microsystems and Macrosystems
Healthcare systems are composed of organizations (macrosystems) and work units (microsystems). Microsystems, defined in healthcare as "a small group of people who work together on a regular basis to provide care to discrete sub-populations of patients,"19(p 474) have been identified as the key building blocks of macrosystems. Microsystems are the "moments of truth" of the macrosystem, the places at which the delivery of patients’ care either succeeds or fails.
In every instance throughout the survey, respondents rated the work environment higher in the microsystems than in the macrosystems. This finding needs to be investigated further. In contrast to the view that "the grass is always greener" elsewhere, RNs in the survey consistently thought that things were better in the units/microsystems where the nurses worked than in the rest of the organization/macrosystem. Perhaps the respondents have the best practices in their microsystems or they are less informed about what occurs outside their own microsystems. In either case, opportunities to share information and collaborate would be advantageous.
Communication and Collaboration
Communication and collaboration have a critical influence on both RNs’ satisfaction and patients’ outcomes. Beginning with the classic study published by Knaus et al in 1986,20 which first revealed the relationship between the degree of coordination in intensive care and the effectiveness of that care, many studies21–25 have indicated the relationship between collaboration and increased positive outcomes for both patients and RNs. In addition, in reports of the Joint Commission on Accreditation of Healthcare Organizations,26 inadequate communication is consistently cited as the most frequent root cause of sentinel events.
The results of the survey indicate that the highest level of communication and collaboration is among RNs and then between RNs and physicians. However, both areas have room for improvement. Communication and collaboration between RNs and frontline nurse managers and administration was rated lower. This finding supports the results of a previous AACN survey8 in which less than half of the AACN members ranked their relationships with managers and administrators as positive. Our respondents also indicated room for improvement in the communication and collaboration skills of frontline nurse managers and chief nurse executives.
Respect
Mutual respect is a key component of effective, professional, collaborative relationships.27 Respect is related to job satisfaction and intent to leave.28,29 In this survey, the majority of RNs rated the respect from administration as fair (37.0%) or poor (24.3%), a matter of concern. Respect from physicians was rated the next lowest and should also be a concern. RNs who indicated plans to leave their current positions in the next 3 years also noted that more respect from frontline nurse managers and from administration would very likely make the RNs reconsider leaving. Nurses often talk about respect (and disrespect), yet little research specifically addresses how nurses define and what behaviors are associated with respect and disrespect.28 Additional inquiry into this topic is needed.
Physical and Mental Safety and Abuse
Sexual harassment, discrimination, and verbal and physical abuse should be zero tolerance issues, but the survey results (>9000 instances reported) clearly indicated that they are not. Almost 1 in 5 respondents reported experiencing sexual harassment and more than 1 in 4 reported experiencing discrimination in the preceding year while working as a nurse. In addition, the majority of the respondents reported experiencing verbal abuse, and more than 1 in 5 reported physical abuse. Much of the verbal abuse reported came from patients, patients’ families or significant others, and physicians; almost all of the physical abuse came from patients.
These data support previously reported research on physical and mental abuse in nursing work environments.30,31 Healthcare continues to lead other industries in the incidence of nonfatal injuries and assaults. In 2004, more than 284600 recordable nonfatal occupational injuries and illnesses occurred in hospitals, and another 124600 occurred in ambulatory healthcare settings.32 Of additional concern, these data most likely are conservative, because assaults and acts of violence often are not reported.33,34
Creating safe work environments is the legal and moral responsibility of every organization. As indicated in the survey results, having policies in place does not equate with zero tolerance. Almost 20% of respondents did not know whether policies existed in their organizations.
Nursing Leadership
The American Organization of Nurse Executives has identified leadership development as a critical factor in creating excellent work environments.35 In addition, in a study of 29 high-performing clinical microsystems, Nelson et al19 found that leadership was a key factor in success.
In this survey, the respondents’ ratings of the skills of both frontline nurse managers and chief nurse executives underscore the need to make leadership development a priority. According to the American Organization of Nurse Executives, effective leadership development can only occur with a sustained organizational commitment to skills training in management and leadership, defined management career paths, and ongoing succession planning. Processes to evaluate and improve leadership effectiveness that include meaningful staff involvement, mutual learning, and follow-up are also required.35
Influence and Control Over Practice
Influence and control over their practice by RNs contributes to job satisfaction and improved patients’ care.36–38 As a result, in its 2003 report,5 the Institute of Medicine strongly recommended that direct care nursing staff be involved, engaged, and empowered in decisions about patients’ care and how that care is provided.
In this survey, almost 70% of the respondents strongly agreed or agreed that in their work units RNs are valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations. About three fourths of the respondents also strongly agreed or agreed with the statement that RNs have opportunities to influence decisions that affect the quality of patients’ care.
Shared governance is one method for involving staff. In this survey, more than 1 in 3 RNs (36.5%) reported working in organizations with a formal shared governance model in place. Another 10.96% reported that their organizations were implementing shared governance. These percentages are lower than the findings of the 2004 National Critical Care Survey,11 in which 55% of 300 units reported having formal shared governance programs.
Support for Professional Development
Continuing education is essential for maintaining competency and for individual professional growth. Continuing education and opportunities for professional development also are essential contributors to retention of nurses.39,40 More than three fourths of the respondents indicated that their organizations provided in-house continuing education, and about half of the organizations offered paid time off for such education and/or paid the registration fees.
Although most nurses say that they become certified for personal reasons,41 evidence exists that certification also benefits patients and healthcare organizations. In the largest international study42 of the certified nurse workforce, the benefits of achieving certification included improved quality care, patients’ satisfaction, and retention of staff. The study42 also indicated that certified nurses have increased confidence, competence, credibility, and control and that recently certified nurses (within 5 years of certification) may be quicker to recognize problems and intervene and less likely to commit errors than are nurses who are not certified. Programs such as the AACN Beacon Award for Critical Care Excellence and the Magnet Recognition Program require that a significant percentage of staff be certified because certification benefits patients, organizations, and nurses and should be supported more fully.41
Support for specialty certification in this survey was similar to that found in the 2004 National Critical Care Survey.11 Other than paying for the initial certification examination (47.9%) and recognizing nurses who achieve certification (45.0%), no other support was reported by more than 25% of the respondents. This lack of organizational support is unfortunate and shortsighted.
Recognition
Individuals who receive recognition and praise have increased productivity, engagement, and job satisfaction, but to be effective, recognition must be individualized, deserved, and specific.43 The respondents in our survey were clear that recognition from patients and patients’ families rated highest; next highest was recognition from other RNs. Recognition from frontline nurse managers, administrators/executives, and physicians was rated much lower.
The results of the survey suggest that having programs or processes that facilitate recognition of RNs by patients and patients’ families and by other RNs would be advantageous. An example is the highly successful Cameos of Caring nurse recognition program created by the University of Pittsburgh in 1998 and, since then, replicated at other institutions.44 Understanding how recognition from frontline nurse managers, administrators/executives, and physicians could be more meaningful would also be useful.
Quality and Outcomes of Patients’ Care
The survey findings about work that does and does not get done are the most striking when the quality of patients’ care and outcomes is considered. Similar to the results of Aiken et al,1 in this survey, giving medications, doing procedures, monitoring, and providing skin care and oral hygiene were most often completed. However, nursing activities that require critical thinking and synthesis, such as comforting patients, teaching patients and their families, developing and updating care plans, and preparing patients and their families for discharge were completed far less often.
It continues to appear that higher level nursing contributions are being sacrificed for lower level tasks. Patients’ participation in decision making, a key tenet of the AACN Synergy Model for Patient Care,45 is made considerably more difficult when nurses do not have sufficient time, as indicated in this survey, for talking with patients and teaching and preparing patients for discharge. Patient acuity indices used in critical care generally do not provide assessment of these higher level nursing activities.
Satisfaction With Nursing and With Current Position
National surveys of employees have repeatedly found that employees who have close relationships with the people they work with are more satisfied and more engaged in the work of their organizations than are employees without such relationships.46 The percentage of respondents in this survey who reported that they were very satisfied with being nurses is considerably higher than that found in previous studies. Satisfaction with their current position was consistent with that expressed by nurses in other recent surveys.47 The 4 principal factors that respondents indicated keep them working in their current organizations were the people they work with, salary and benefits, the patients they care for, and opportunities for professional development.
A key indicator of career satisfaction is the willingness to recommend your career to others. In this survey, more than half (54.1%) of the respondents definitely would recommend a nursing career, and another 34.0% probably would. This percentage is higher than that found by Buerhaus et al,47 perhaps because the respondents to this survey were critical care nurses.
Retention
Although nearly half (48.4%) of the respondents indicated that they planned to leave their current positions in the next 3 years, of note, only a small percentage planned to leave the nursing profession. Almost 75% of the RNs who expressed plans to leave their current positions said they would do so to take other clinical and nonclinical positions in nursing or to return to school to pursue additional nursing education. Organizational strategic initiatives that support such professional development and advancement can allow RNs to achieve these career plans while remaining in the organization.
The respondents who planned to leave their current positions also indicated actions by employers that would cause them to reconsider leaving; the highest rated action was better leadership. Organizations that ensure the competency of their nursing leaders have an advantage in retaining nurses.
Summary
AACN has taken a leading organizational role in explaining and promoting the fundamental need for healthy work environments, not only in critical care but across all of healthcare. This initial survey report provides information on the status of work environments 1 year after the publication of the association’s Standards for Establishing and Sustaining Healthy Work Environments. In the spirit of the AACN Act Boldly Campaign, the survey results indicate pressing challenges and offer a starting point for dialogs that can lead to solutions and a baseline for future measurement. The commitment of critical care nurses and nurse leaders to initiate these dialogs and to stay actively involved in the solutions until the solutions are working is essential to achieving healthy work environments.
Acknowledgments
This study was a joint effort of the American Association of Critical-Care Nurses, Nursing Spectrum, and Bernard Hodes Group, all of whom provided support for the project. We also thank Decision Critical for providing survey respondents with online access to Nursing Spectrum continuing education courses.
References
This article has been cited by other articles:
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  C. Schmalenberg and M. Kramer Clinical Units With the Healthiest Work Environments Crit. Care Nurse, June 1, 2008; 28(3): 65 - 77. [Full Text] [PDF]
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G. Alspach Lateral Hostility Between Critical Care Nurses: A Survey Report Crit. Care Nurse, April 1, 2008; 28(2): 13 - 19. [Full Text] [PDF]
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G. Alspach If I Am Ever Critically Ill, I Want __ To Be My Nurse Crit. Care Nurse, December 1, 2007; 27(6): 8 - 11. [Full Text] [PDF]
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 C. Schmalenberg and M. Kramer Types of Intensive Care Units With the Healthiest, Most Productive Work Environments Am. J. Crit. Care., September 1, 2007; 16(5): 458 - 468. [Abstract] [Full Text] [PDF]
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G. Alspach Critical Care Nurses as Coworkers: Are Our Interactions Nice or Nasty? Crit. Care Nurse, June 1, 2007; 27(3): 10 - 14. [Full Text] [PDF]
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B. T. Ulrich, D. Woods, K. A. Hart, R. Lavandero, J. Leggett, and D. Taylor Critical Care Nurses' Work Environments Value of Excellence in Beacon Units and Magnet Organizations Crit. Care Nurse, June 1, 2007; 27(3): 68 - 77. [Full Text] [PDF]
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