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AACN’s Healthy Work Environment Standards and an Empowering Nurse Advancement System

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To learn more about healthy work environments, read "AACN standards for establishing and sustaining healthy work environments: a journey to excellence" in the American Journal of Critical Care, 2005;14:187-197. Available at www.ajcconline.org.

This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:

1. Identify the standards for establishing and sustaining a healthy work environment
   
2. Describe the advantages of a clinical nurse advancement system
   
3. Discuss how the nurses at Rochester General Hospital infuse AACN’s healthy work environment standards into their Clinical Nurse Advancement System
   

Corresponding author: Zara R. Brenner, Rochester General Hospital, 1425,Portland Ave., Rochester, NY 14621 (e-mail: Zara.Brenner{at}rochestergeneral.org).

The American Association of Critical-Care Nurses (AACN) has a substantial history of advocating for positive work environments in which "acute and critical care nurses can make their optimal contribution."¹ Globally, the International Council of Nurses has launched a campaign to promote positive practice environments, recognizing their impact on employees’ well-being, productivity, retention, and outcomes.² Toward this essential end, AACN developed and published Standards for Establishing and Sustaining Healthy Work Environments.³ This document affirms that healthy work environments support and foster excellence in patient care and are imperative to ensure patient safety, enhance staff recruitment and retention, and maintain an organization’s financial viability. It also recognizes the inextricable links among the quality of a nurse’s work environment, excellent nursing practice, and patient care outcomes. AACN’s 6 standards for establishing and sustaining a healthy work environment are described in Table 1. Effective and sustainable outcomes do not emerge when any standard is considered optional; thus all 6 standards must be implemented to create a healthy work environment.³

A successful nurse advancement system can endorse and facilitate all 6 AACN healthy work environment standards. It creates a milieu that empowers nurses,

to establish, maintain, and improve healthcare environments and employment conditions conducive to providing quality care consistent with the values of the profession, and to maintain compassionate and caring relationships.³

	The Clinical Nurse Advancement System at Rochester General Hospital

Top The Clinical Nurse Advancement... Skilled Communication and CNAS True Collaboration and CNAS Effective Decision Making and... Appropriate Staffing and CNAS Meaningful Recognition and CNAS Authentic Leadership and CNAS Summary PRIME POINTS References

 
The Clinical Nurse Advancement System (CNAS) at Rochester General Hospital (RGH), Rochester, New York, has been in continuous existence since 1982. The CNAS committee, composed primarily of staff nurse representatives from each unit, is responsible for developing job descriptions for nurses and governs the advancement process. The CNAS process holds nurses accountable to a standard that is applicable to all clinical practice settings. The CNAS is a system based on activity points in which nurses begin at the clinician I level with advancement opportunities up to the clinician VI level, as described by Brenner et al.⁵ Criteria are in place at all levels regarding education, years of professional experience, and certification. All nurses at RGH have some mandatory role responsibilities, and nurses do not earn activity points for those responsibilities. Nurses are encouraged to advance and earn activity points for their clinical competencies and expertise in delivering excellent patient care, as well as their contributions to the institution and to the nursing profession. Table 2 details the activities included in our CNAS. Thirty-two percent of nurses at RGH have chosen to advance by the CNAS.

	Skilled Communication and CNAS

Top The Clinical Nurse Advancement... Skilled Communication and CNAS True Collaboration and CNAS Effective Decision Making and... Appropriate Staffing and CNAS Meaningful Recognition and CNAS Authentic Leadership and CNAS Summary PRIME POINTS References

 
According to Maxfield,⁶ hospitals are knowledge organizations and communication is the lifeblood of such organizations. As such, the development and maintenance of a healthy work environment requires skilled communication. AACN defines skilled communication as a "two-way dialogue in which people think and decide together."³ Furthermore, the AACN standard³ states that, "Nurses must be as proficient in communication skills as they are in clinical skills." Organizations that readily acknowledge the necessary amalgamation of skilled communication and clinical skills create a catalyst that promotes a healthy work environment.

A successful nurse advancement system rewards the maturation of vital communication skills. At our hospital, the CNAS sponsors nursing grand rounds, which are presented monthly at 2 different times throughout the day by staff nurses to a hospitalwide audience in a state-of-the-art teaching auditorium. These rounds provide an opportunity for staff nurse presenters to acquire and hone public presentation skills while the attendees learn new content (see Table 2, activity 27). In addition, attendees of nursing grand rounds serve to generate further discussion regarding the topic presented; they are provided with a sticker that reads "I attended nursing grand rounds today." The CNAS committee has noted a dramatic increase in the number of attendees at the afternoon session of nursing grand rounds directly related to the conversations that occur as a result of someone noticing the grand rounds sticker. Staff nurses and attendees continue to look forward to nursing grand rounds as a way to enhance their communication skills and share the amazing work they do each day.

The CNAS encourages and rewards enhanced communication skills among nurses on a broader scope. As clinicians publish articles, review textbooks, and present at regional and national conferences, these activities promote nursing as an art and science and further develop communication skills (see Table 2, activities 19, 36). These accomplishments are acknowledged at multidisciplinary functions by nursing, medical, and administrative leaders, as well as the chief executive officer of our organization. The public acknowledgment of these nursing successes generates further discussion about the expertise of our advanced CNAS clinicians, thereby promoting discussion about future nursing research, publication, and presentation opportunities.

In addition to facilitating opportunities that embrace skilled communication, a flourishing nurse advancement system also recognizes, along with the AACN standard, that "skilled communication includes the use of appropriate communication technology."³ CNAS satisfaction surveys indicated that many nurses desired a change from a paper application process to an electronic one. In response, the CNAS worked with the information technology department to develop and implement an electronic application process. A dedicated Web site was created on the organization’s intranet to facilitate the advancement process by including all forms necessary to complete advancement. The incorporation of communication technology has improved access and streamlined the application process, as well as encouraged nurses to learn about and use available technology.

	True Collaboration and CNAS

Top The Clinical Nurse Advancement... Skilled Communication and CNAS True Collaboration and CNAS Effective Decision Making and... Appropriate Staffing and CNAS Meaningful Recognition and CNAS Authentic Leadership and CNAS Summary PRIME POINTS References

 
True collaboration is an unconditional component in fostering the culture of a healthy work environment in a health care organization. The absence of true collaboration often leads to a health care team that is disenfranchised, fragmented, and has members who are unable to work together as partners. True collaboration must be visible throughout all levels of the health care organization from nurse with patient and family, nurse with nurse, nurse with physician, and nurse with leaders and managers. AACN standards state that in an environment of true collaboration,

Every team member contributes to the achievement of common goals by giving power and respect to each person’s voice, integrating individual differences, resolving competing interests, and safeguarding the essential contribution each must make in order to achieve optimal outcomes.³

The CNAS committee collaborates with multiple disciplines throughout the hospital to achieve common goals. This collaboration is exemplified through the CNAS partnership with senior level leadership. The chief nursing officer appoints the CNAS chairperson and is an active member of the committee. In return, the CNAS chairperson attends senior leadership meetings to communicate new developments, problems, and issues that may arise. The CNAS chairperson assumes the role as advocate for nurses within the organization.

True collaboration is also visible in nurse-to-nurse partnerships that exist within the organization. The CNAS strongly encourages and recognizes nurses as resources. Our advanced practice nurses developed and implemented an early nursing intervention team, which has been described previously.⁷ This rapid response team is unique in that it is entirely nurse led. The team’s nurse, usually the critical care unit charge nurse, is consulted by the staff nurse for patients with critical needs who may require a higher level of care and quick transfer to the ICU. The staff nurse and critical care nurse collaborate on a daily basis, both contributing to the common goal of patient safety and optimal outcomes. The nurses initiate a proactive collaboration to assess significant changes in the patient, which facilitates the transfer of a critically ill patient from the general care area to a critical care unit as needed. The increased nurse-to-nurse collaboration resulting from the early nursing intervention team has reduced the number of cardiopulmonary codes in the general care areas.⁷

CNAS clinicians are empowered to be true collaborators and decision makers for policy change. Two CNAS clinicians worked with a physician, a nurse practitioner, and a pharmacist to change our hospital’s strategy for delirium prevention and treatment. Previously, delirium management activities were implemented by physician’s order only. The newly developed protocol is implemented on the basis of a nurse’s or a physician’s assessment. Nurses have welcomed the increased autonomy and mutual collaboration resulting from this initiative (see Table 2, activities 10, 33, 36, 39). Furthermore, physicians have duly hailed the true collaboration that this protocol fosters.

	Effective Decision Making and CNAS

Top The Clinical Nurse Advancement... Skilled Communication and CNAS True Collaboration and CNAS Effective Decision Making and... Appropriate Staffing and CNAS Meaningful Recognition and CNAS Authentic Leadership and CNAS Summary PRIME POINTS References

 
Nurses affect patients’ outcomes by their direct actions and their influence over the actions of others.⁸ The standard of effective decision making demands an environment where,

nurses are valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.³

A requirement for all nurses advancing by the CNAS is committee membership. The committee structure at RGH uses the principles of shared governance. By embracing shared governance, nurses on the CNAS committee are involved with decision making regarding positive patient outcomes and nurse satisfaction and retention. In addition, advanced CNAS staff nurses are leaders and members of interdisciplinary committees such as pharmacy, quality improvement, ethics, anticoagulation, and infection control.

Nurses facilitate and contribute to best practices within their committee structures and within their work-place. Nurse participation in committees has increased exponentially, coinciding with the inclusion of committee participation as mandatory for CNAS advancement. In response, the CNAS Web site was expanded to offer a listing of hospitalwide committees in which nurses are valued participants.

Another example of the CNAS facilitating effective decision making is through its support of national patient safety goals and organizational service standards and guiding principles. The CNAS rewards nurses for specific behaviors that support these values (see Table 2, activities 10, 11). Thus, CNAS clinicians are active participants in the hospital’s achievement of multiple national award designations, including magnet nursing status, Joint Commission Accredited Stroke Care Unit, Nurses Improving Care of Health System Elders, and consistent listing as a Solucient Top 100 Heart Hospital. These accomplishments are a result of effective decision making by the interdisciplinary teams involved.

	Appropriate Staffing and CNAS

Top The Clinical Nurse Advancement... Skilled Communication and CNAS True Collaboration and CNAS Effective Decision Making and... Appropriate Staffing and CNAS Meaningful Recognition and CNAS Authentic Leadership and CNAS Summary PRIME POINTS References

 
Appropriate staffing is a key factor in healthy work environments and positive outcomes for patients.^9,10 Moreover, AACN and the American Nurses Association recognize that appropriate staffing is more than the nurse-to-patient ratio; it also includes skill mix.¹¹ The AACN healthy work environment standards state that, "staffing must ensure the effective match between patient needs and nurse competencies."³

A nurse advancement system is a means to achieving an appropriate staffing mix by rewarding nurses who remain at the bedside, providing patient care, as they progress from novice to expert. Nurses are further supported and rewarded for enhancing their clinical skill sets (see Table 2, activity 5). A nurse advancement system recognizes the health care organization’s responsibility to assist nurses in acquiring educational, professional, and skill development. Nurses desire professional growth, and the CNAS facilitates the opportunity to do so.

The CNAS also recognizes that nurses must possess appropriate education, knowledge, and skills to provide care for various populations of patients. To facilitate nurses who possess the skill set required to care for multiple patient populations, nurses who successfully cross-train to work in different units acquire CNAS activity points (see Table 2, activity 13).

Certified nurses bring expertise to the bedside, promoting beneficial outcomes for patients.¹² The CNAS committee’s endorsement of certification places it in the distinct position as an agent of retention and recruitment at our hospital (see Table 2, activity 1). Nurses receive financial support for certification, as well as advancement to a higher clinician level; this higher level also carries an additional financial reward. Thirty percent of RGH nurses are currently certified. Consequently, patients receive expert care by nurses certified in their subspecialties. This empowerment of nurses to elevate their level of nursing knowledge and skills creates an atmosphere that embraces appropriate staffing.

	Meaningful Recognition and CNAS

Top The Clinical Nurse Advancement... Skilled Communication and CNAS True Collaboration and CNAS Effective Decision Making and... Appropriate Staffing and CNAS Meaningful Recognition and CNAS Authentic Leadership and CNAS Summary PRIME POINTS References

 
It is a common human trait to seek validation of one’s contributions in all aspects of life, particularly from the organization for which one works. It is essential that the organization generate a sense of appreciation and acknowledgement as

3 out of 4 members and constituents of the American Association of Critical-Care Nurses rank recognition for their contributions as a central element of a healthy work environment.¹²

The AACN standards affirm, "Nurses must be recognized and recognize others for the value each brings to the work of the organization."³ Meaningful recognition is the foundation upon which nurse advancement systems are built.

The CNAS at RGH is the epitome of meaningful recognition. A formal nurse advancement process ensures that meaningful recognition is intertwined with the health care organization’s infrastructure. At our institution, such recognition includes the following:

• Public acknowledgement of advancement through a new title with advanced clinician status (clinician levels II-VI)
  
• An identification badge inscribed with clinician level
  
• An advancement ceremony open to all nurses, their invitees, and top hospital management whereby each nurse is individually recognized for his or her accomplishments
  
• A free uniform jacket with CNAS logo (see Figure)
  
• A significant salary increase with each level of advancement
  
• Publication of clinicians’ advancement in a systemwide newsletter
  

View larger version (70K): [in this window] [in a new window]   Figure Logo for the Clinical Nurse Achievement System.

	Authentic Leadership and CNAS

Top The Clinical Nurse Advancement... Skilled Communication and CNAS True Collaboration and CNAS Effective Decision Making and... Appropriate Staffing and CNAS Meaningful Recognition and CNAS Authentic Leadership and CNAS Summary PRIME POINTS References

 
Authentic leadership and a successful nurse advancement system coexist in a mutually beneficial relationship. Engaging others in authentic leadership is essential to the journey toward excellence as described by AACN. A healthy work environment results from a process of psychological engagement of employees by authentic leaders.¹⁴

A clinical advancement system designed, implemented, and maintained by nurses is supported by with authentic leadership. It exemplifies critical elements of AACN’s healthy work environment standards such as,

nurse leaders lead the design of systems necessary to effectively implement and sustain standards for healthy work environments and . . . the healthcare organization facilitate[s] the efforts of nurse leaders.³

The AACN healthy work environment standards state that authentic leadership includes, "providing the necessary time and financial and human resources" and ensuring that nurse leaders are positioned so that their role can include "participation in key decision-making forums, access to essential information, and the authority to make necessary decisions."³ Our CNAS is designed and administered by a committee of nurses. The committee chair receives 0.2 full-time equivalents for this role and has a standing meeting agenda with the chief nursing officer. The entire committee meets monthly; furthermore, subcommittees meet frequently and share progress at monthly meetings. During an annual all-day workshop, process changes to the system are designed. Committee members are paid for their attendance at all meetings. In addition, a dedicated administrative assistant is assigned to the committee to facilitate the processing of applications and the committee’s work.

Authentic leadership is integral to each individual nurse’s advancement process, as well. A group of 3 nurses are selected to work with the candidate:

• CNAS sponsor: this advanced CNAS staff nurse from the candidate’s unit, selected by the manager, becomes the candidate’s mentor for the process
  
• CNAS resource nurse: this nurse is a member of the CNAS committee who serves to ensure the accuracy and integrity of the advancement process
  
• The candidate’s nurse manager
  

This triad is held responsible for reviewing the candidate’s completed activity points packet to determine if the criteria have been met and for awarding advancement as appropriate. Thus, nursing leaders at various clinical and administrative levels participate in key decision making and have the authority to make the decision about the candidate’s advancement.

Our clinical advancement system links with authentic leadership as described in the AACN standards.

The leadership contribution to creating and sustaining a healthy work environment is a criterion in each nurse leader’s performance appraisal.³

As described in Table 2, leadership is 1 of the 4 dimensions measured and validated by the CNAS process. Nurse leaders at RGH earn access to and are rewarded for participation in decision-making forums within the institution.

	Summary

Top The Clinical Nurse Advancement... Skilled Communication and CNAS True Collaboration and CNAS Effective Decision Making and... Appropriate Staffing and CNAS Meaningful Recognition and CNAS Authentic Leadership and CNAS Summary PRIME POINTS References

 
An empowering clinical nurse advancement system can facilitate institutional behaviors that embrace all of AACN’s healthy work environment standards and thus serve as a building block for developing a flourishing health care environment. The results generate positive outcomes that are evident to health care professionals, patients, patients’ families, and health care organizations. Patients benefit from highly satisfied employees who work in a culture of caring and excellence.

	PRIME POINTS

Top The Clinical Nurse Advancement... Skilled Communication and CNAS True Collaboration and CNAS Effective Decision Making and... Appropriate Staffing and CNAS Meaningful Recognition and CNAS Authentic Leadership and CNAS Summary PRIME POINTS References

 

• Nurse advancement systems provide a process for recognizing nurses who move from novice to expert in providing or influencing patient care.
  
• These systems have expanded opportunities for professional nurses and health care organizations in regard to recruitment, retention, clinical excellence, leadership development, and professional recognition.
  
• A successful nurse advancement system can endorse and facilitate all 6 AACN healthy work environment standards.
  

	References

Top The Clinical Nurse Advancement... Skilled Communication and CNAS True Collaboration and CNAS Effective Decision Making and... Appropriate Staffing and CNAS Meaningful Recognition and CNAS Authentic Leadership and CNAS Summary PRIME POINTS References

 

1. American Association for Critical-Care Nurses. Key statements, beliefs and philosophies behind the American Association of Critical-Care Nurses (AACN). http://www.aacn.org/WD/Memberships/Content/mission_vision_values_ethics.pcms?m-enu=Membership. Accessed July 30, 2009.
2. Oulton JA. The workplace is the issue—isn’t it obvious? Int Nurs Rev. 2006;53(2):91.[CrossRef][Medline]
3. American Association for Critical-Care Nurses. Standards for Establishing and Sustaining Healthy Work Environments. http://www.aacn.org/aacn/WD/HWE/Docs/HWEStandards.pdf. Accessed July 30, 2009.
4. Drenkard K, Swartwout E. Effectiveness of a clinical ladder program. J Nurs Adm. 2005; 35(11):502–506.[CrossRef][Medline]
5. Brenner Z, Dambaugh L, Hill E, Roberts C, Vollers D. Redesigning a Clinical Nurse Advancement System. Nurs Manage. 2008; 39(10):28–35.[Medline]
6. Maxfield D. Creating healthy work environments: skilled communication. Chest Physician. 2007;2:16.
7. Daly ML, Powers J, Orto V, et al. Innovative Solutions: leading the way. Dimens Crit Care Nurs. 2007;26(1):15–20.[CrossRef][Medline]
8. George V, Burke L, Rodger B, et al. Developing staff nurse shared leadership behavior in professional nursing practice. Nurs Adm Q. 2002;26:44–59.
9. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–1993.[Abstract/Free Full Text]
10. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346(22):1715–1722.[Abstract/Free Full Text]
11. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Washington, DC: American Nurses Association; 2001.
12. American Association of Critical Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence. Am J Crit Care. 2005; 14:187–197.[Free Full Text]
13. Ulrich BT, Woods D, Hart KA, Lavendero R, Leggett J, Taylor D. Critical care nurses’ work environments: value of excellence in Beacon units and Magnet organizations. Crit Care Nurse. 2007;27:(3):68–77.[Free Full Text]
14. Shirey M. Authentic leaders creating healthy work environments for nursing practice. Am J Crit Care. 2006;15:256–268.[Abstract/Free Full Text]

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