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Claudia Schmalenberg is a research associate and consultant at Health Science Research Associates in Apache Junction, Arizona.
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.
To learn more about healthy work environments, read "Authentic Leaders Creating Healthy Work Environments for Nursing Practice" by Maria Shirey in the
American Journal of Critical Care, 2006;15(3):256–267.
Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit http://ccn.aacnjournals.org and click "Respond to This Article" in either the full-text or PDF view of the article.
This research was funded in part by a grant from AACN.
Corresponding author: Marlene Kramer, RN, PhD,PO Box 7667, Tahoe City, CA 96145 (e-mail: mcairzona{at}juno.com).
Professional organizations such as the American Association of Critical-Care Nurses (AACN), Joint Commission for Accreditation of Hospitals, Institute of Medicine, American Nurses’ Credentialing Center, American Organization of Nurse Executives, American Association of Colleges of Nursing, and Nursing Organizations Alliance have identified and established criteria for healthy, professional, magnetic, excellent, effective, and rewarding work environments.1–9 No matter what adjective is used to modify environment, common to all the organizations’ lists of environmental attributes is that the criteria focus on structures, policies, systems, and programs that reflect the perspective and domain of nurses in leadership roles and in executive practice.
In this article, we consistently use "healthy" as defined in the AACN Standards for Establishing and Sustaining Healthy Work Environments4 and in our original construction of the Nursing Work Index.10 Healthy means productive, able to give quality care, satisfying, and able to meet personal needs.
The perspective of clinical nurses at the front line as to what constitutes a healthy work environment is essential if interventions to improve practice environments in hospitals are to be implemented. Only staff nurses can confirm whether strategies designed to improve the health of the work environment are effective. Nurses in executive positions may implement well-planned structures, policies, and systems; they may implement superb shared governance council structures, but unless these implementations are confirmed as functional by staff nurses, desired patient and nurse outcomes will not result.11 Staff nurses are the nursing professions’ most frequent and intimate interface with patients and patients’ families and are the source of the public’s valuation of nursing as the most respected and ethical profession for the eighth consecutive year.12 Staff nurses are the structurally empowered gatekeepers. By what they choose to observe and transmit, these nurses control physicians’ access to information about patients. As guardians of patients’ safety, staff nurses are vital in ongoing surveillance, rescuing patients from potential harm. And because of the reduction in the number of hours worked by residents, these nurses figure prominently in the increased numbers of seamless transfers of patients from one healthcare professional to another. Before desired outcome goals can be achieved, the components of a healthy work environment from the perspective of staff nurses must be identified, and a tool to measure the components must be developed. Only then can the baseline attributes of a healthy work environment be established and the effectiveness of strategic interventions to improve the health of work environments be measured.
Identification and Measurement
Identification of Healthy Work Environments From the Perspective of Staff Nurses
In 2001, staff nurses in 14 magnet hospitals identified 8 of 37 of the original characteristics of magnet hospitals as the essential attributes of a healthy work environment13 (Table 1
). We labeled these 8 attributes the Essentials of Magnetism. Nurses in both magnet and comparison hospitals have repeatedly confirmed the validity of these 8 essentials of a healthy work environment.14–19 They were also confirmed recently by staff nurses in 13 home health agencies in 9 states.20
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through 5. When the elements in these models are compared with the Essentials of Magnetism identified by staff nurses (Table 1
), several facts become apparent. The attributes of a healthy work environment identified by staff nurses in acute care hospitals differ from those cited by professional organizations and nurse executives. The only attribute of more or less full congruence is leadership. However, all of the professional organizations and the chief nurse executives focus on the dynamics and quality of leadership; staff nurses are interested in a specific leadership function: support from their nurse manager. Two other attributes show partial alignment: education and interdisciplinary relationships. But here again, elements in the lists generated by professional organizations and those in the list generated by staff nurses differ. The American Nurses’ Credentialing Center (Table 2), the American Organization of Nurse Executives (Table 5), and the chief nurse executives (Table 3) emphasize providing educational programs and opportunities. The American Nurses’ Credentialing Center standards of a productive work environment specify both support and access to educational programs. Staff nurses’ primary concern is support in the form of time off the unit and competent staff to take care of their patients so nurses can take advantage of the educational opportunities offered. In interdisciplinary and nurse-physician relationships, again compared with nurse leaders and professional organizations, staff nurses are interested not just in the presence of collaborative working relationships, but in the specific attributes of such a relationship, that is, one based on mutual trust, power, and respect between parties.14,15
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At the end of the day, I feel good, I feel like I’ve made a difference.
My patient looks better and his condition indicates that I’ve done a good job. Being able to give quality patient care is everything! If I can figure out the right blend of antinausea drugs so that my patients have 1, 2, or 3 more quality days of life, that’s a gift from me to them, and in turn, knowing that I have improved their quality of life affirms my reason for being, my existence as a nurse. I feel fulfilled. If others appreciate, value, and respect my efforts, so much the better, but giving quality patient care is the key to my identity and satisfaction as a professional nurse.
Measuring Healthy Work Environments
Nurse executives implement structures, best management practices, and systems designed to enable caregiving work processes and relationships that produce desired patient outcomes. Staff nurses use work processes, relationships, and interventions to achieve quality patient care. Processes, relationships, and nurse-patient interventions are the domain of staff nurses. Achieving goals and outcomes are the responsibility of all. For almost 4 decades, this structure-process-outcome model21 has guided the evaluation of healthcare systems and the quality of patient care. Structure is having the "right things in place"; processes are "doing things right" so that outcomes, "having the right things happen," will occur. All 3 components—structures, processes, and outcomes—are necessary for quality care. This quality care model is linear and unidirectional; quality patient outcomes are achieved when structures enable processes that produce outcomes. None of the components is optional; all are causally linked.
A classic study22 of all intensive care units in 13 hospitals nationwide by an interdisciplinary team of physicians and nurses illustrates the principles of the structure-process-outcome model. Intensive care units have unique structures—physical layout, number of physicians and the frequency of their visits to the unit, nurse-patient ratio, technology available—that differ from the structures of other units. Knaus et al22 studied the impact of structures on work processes and relationships and on outcomes and found that positive patient outcomes (decreased acuity-adjusted mortality) were due, not to structures alone, but to the process of nurse-physician collaboration enabled by the structures. Only in those intensive care units where structures led to improved nurse-physician collaboration did a significant decrease in patient mortality occur. Once again, confirmation of nurses at the front line is what determines the viability and effectiveness of work systems designed to improve patients’ outcomes.
A healthy work environment is the totality of all factors that influence satisfaction and performance of the job. The least common denominator of the environment for staff nurses in hospitals is the clinical unit or clinic; therefore data collected from individual nurses must be aggregated to the unit level. With most environmental measurement tools, a structural approach is used to measure the degree of or the presence/absence of desired attributes. The construct (an organized group of concepts) being measured is often not theory based and is not conceptually defined.23 Items are a sampling of aspects of the concept of interest. For example, these 2 items, "nurses need more autonomy in their daily practice" and "nurses have a good deal of control over their own work," from a tool24 commonly used to measure aspects of the work environment, give the respondent no indication which of the 34 different definitions of autonomy found in the literature25 should be used in responding to the item. Because the environmental attributes identified by staff nurses are work relationships and processes, appropriate tools must be based on theory and the practitioner’s definition of the construct. Items must reflect the components or steps in the work process and must be weighted if some steps are deemed by practitioners to be more important than others.
The Essentials of Magnetism (EOM) instrument26–28 was designed with items that measure the steps or components of each of the 8 work processes identified by staff nurses as essential to a healthy unit work environment. Separated into 8 sub-scales, the 58 items are based on grounded theories29 generated through observations of and individual interviews with almost 1000 nurses, three-fourths of whom were staff nurses working in 35 magnet hospitals.14–19,25,30 Almost 500 additional staff nurses in other magnet and comparison hospitals participated in the development of the tool by validating the content of the items, providing clarification and definition of ambiguous constructs, establishing appropriate weighting for the items, and establishing test-retest reliability.
Since its initial construction in 2002, a few items have been added or deleted on the basis of additional input from staff nurses. For example, evidence-based practice as a foundation for competent performance and autonomous decision making was not mentioned in the interviews with staff nurses in 2001,13 so items were not included on those EOM subscales. Since then, much has changed with respect to the importance and usefulness of evidence-based practice, so in the latest revision, items to measure awareness and participation in such practice were added as components of the clinical competence and clinical autonomy subscales.
Of all of the models generated by the previously mentioned professional organizations, commissions, or chief nurse executives, the AACN model (Table 4) is the one most closely aligned with the environmental features identified by staff nurses (Table 1) and measured by using the EOM tool. Although the description and explanations of the AACN standards contain some structural elements, in the main they represent evidence-based and relationship-centered principles of professional performance.31 The Essentials of Magnetism focus on work processes and relationships through which staff nurses achieve patient and organizational goals. Both the Essentials of Magnetism (Table 1) and the AACN standards (Table 4) emphasize that it is the aggregate, not any single process or relationship, that produces a healthy work environment. Descriptions and conceptual analysis of the 6 standards4 and the 8 essentials32–35 indicate that all of the 8 processes identified as essential by staff nurses are included in the descriptions and explanations of the AACN standards. Magnet hospital staff nurses define one of the essentials, clinical autonomy, as "the freedom to act on what you know in the best interest of the patient; to make independent decisions in the nursing sphere of practice and interdependent decisions in those spheres of practice where nursing overlaps with medicine and other disciplines."25 The AACN model for a healthy work environment is the only one of the environmental models that cites the importance of acknowledging the unique and overlapping spheres of practice and the relationship between this concept and collaboration with physicians and other professional disciplines.4(p190) For these reasons, the EOM tool can be a useful instrument to provide a baseline reading on the health of work environments in terms of the AACN standards.
Implementation
Baseline Confirmation
| IMPROVED QUALITY OF CARE FOR PATIENTS AND INCREASED JOB SATISFACTION FOR NURSES CAN BE ACHIEVED. Improving the work environment requires identifying organizational structures and best practices that work, that enable the work processes staff nurses say they need to achieve quality patient care. Who better to identify the systems, structures, and practices that work than the experts—staff nurses and other professionals working in clinical units in hospitals confirmed to have healthy work environments?
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The EOM measures the health of staff nurses’ unit work environment. This statement means that input from individual nurses is aggregated to obtain a unit score for each of the essential attributes and a total environmental score. The unit score is accurate and reliable only to the extent that it truly represents the nurses on the unit and their perceptions of their work environment. For a baseline unit reading, the literature36 recommends that a 50% sample of all staff nurses be obtained so that individual data can be validly and reliably aggregated to the unit level. In our research and in the work environment confirmation studies we have conducted for many hospitals, we have found that although a 50% sample is most desirable and representative, a 35% sample will work if care is taken to obtain survey input from nurses on all shifts and from nurses with educational and experience backgrounds proportionate to those of the unit population.37 When less than a 50% sample is obtained, it is advisable to check correlation between nurses in the sample and all the nurses in the unit on those variables related to the construct being measured. If the correlation is good, then one can feel more comfortable in accepting the scores as representative of the unit. Many hospitals have shown that it is possible to achieve more than a 50% sample when staff nurses are thoroughly briefed on the purpose and reason for establishing a baseline reading of the health of the work environment, understand the concept of adequate representation, are briefed on how they will receive a report of the baseline and what is going to be done with the results, and, particularly, when the entire work environment confirmation process is coordinated by unit champions or by staff and other nurses on research or evidence-based practice councils. If representative unit data have been obtained, confirmation of the health of the hospital work environment can be obtained by aggregating unit scores to the hospital level.
Assessing the Effectiveness of Interventions
Following the baseline assessment of the unit work environment, the effectiveness of interventions designed to improve the environment can be ascertained. Analysis of item scores for each subscale of the EOM is useful in identifying strengths and in providing direction for changes needed to improve the work environment for staff nurses and the outcomes of care. In assessing the impact of strategic changes or interventions, none of the 8 attributes is optional in a healthy unit work environment; all 8 are needed, because they are highly intercorrelated.26,27 For example, clinical competence is the baseline for independent decision making; autonomous practice is the major source of the trust, power, and respect essential to both collegial and collaborative nurse-physician relationships.14–16 All 8 attributes must be measured at baseline and after interventions.
The following examples illustrate how staff nurses’ confirmation has been useful in empirically determining whether strategic interventions improved the unit work environment. A nurse researcher in a 6-hospital system who was particularly interested in nurse manager support used the EOM to evaluate clinical units in these hospitals before and after instituting a leadership course for nurse managers. A doctoral student interested in control of nursing practice used the EOM to survey all units in a hospital before and after setting up a shared decision-making council on some units. In Burke’s case study,38 "When Bad Things Happen to Good Organizations," a thrice-designated magnet hospital that had "run onto hard times" used the hospital’s scores on the EOM to better align organizational goals with nurses’ concerns. At the 2006 10th National Magnet Conference, Hughes-Rease39 used the Essentials of Magnetism as the core of a conceptual framework designed to assist hospitals to "magnetize" their organization’s culture. In a recent article on lessons learned when Magnet designation is not received, Miller and Anderson40 describe challenges made to the organization by the Magnet appraisers, including advocating for specific changes in the practice environment, many of which were items on the EOM. In a recently completed study, Church41 used the EOM to measure the differences in the work environments of 2 magnet- and 2 nonmagnet-designated hospitals in the same corporate system.
Summary
The overall goal of every hospital or healthcare organization is to systematically develop and reinforce organizational strategies, structures, and processes that improve the organization’s effectiveness, particularly in achieving quality patient care and employee job satisfaction. Openness and advocating for needed change are everyone’s responsibility.
Administrators need the input and confirmation from staff nurses about what is working and what is not, what changes need to be made, and what structures need to be reinforced. When staff nurses understand the necessity of unit representation for measuring the health of the unit work environment and how the results of work environment surveys are to be used, they are often more willing to participate.
What Comes Next?
Establishing baseline confirmation of the health of the work environment by staff nurses is a necessary first step toward achieving the next objective of improving nurses’ work environment so that the goals of improved quality of care for patients and increased job satisfaction for nurses and retention of nurses can be achieved. Improving the work environment requires identifying organizational structures and best practices that work, that enable the work processes staff nurses say they need to achieve quality patient care. Who better to identify the systems, structures, and practices that work than the experts—staff nurses and other professionals working in clinical units in hospitals confirmed to have healthy work environments?
In the next article in this series, we identify and describe clinical units in which staff nurses report the healthiest work environments and answer questions such as these:
Which units report the most job satisfaction?
Do staff nurses consistently rate quality of patient care higher in some units than in others?
Is there a difference in the quality of patient care reported by experienced nurses in contrast to less experienced nurses?
The answers to these questions will be based on the EOM scores of 3000 staff nurses working in 8 magnet hospitals.18,19,30 These 8 hospitals were selected from the 76 magnet hospitals so far tested because they had the highest or second highest EOM scores by region of the United States. Staff nurses in these confirmed healthy work environments exert a pivotal leadership role by assisting their counterparts and the nurse leaders in other hospitals in the quest for improvement of staff nurses’ work environment to achieve high-quality outcomes for patients and nurses.
PRIME POINTS
Acknowledgments
The leaders and on-site investigators at each of the study sites contributed immeasurably to this study of evidence-based management practice. We express our gratitude and appreciation to Bernie Cullen, RN, MSN, CWON, CNAA, BC, vice president, acute and postacute services, and Janice Kishner, RN, MSN, MBA, chief nursing officer/chief operating officer, at East Jefferson General Hospital, New Orleans Louisiana; Karen Cox, RN, PhD,executive vice president and co-chief operating officer, Cheri Hunt, RN, MHA, chief nursing officer, and Susan Teasley, RN, advanced clinical research coordinator, at Children’s Mercy Hospitals and Clinics, Kansas City, Missouri; Sue Hanauer, RN, MSN, chief nursing officer, and Barbara Brewer, RN, PhD, director of professional practice, at John C. Lincoln Hospital, Phoenix, Arizona; Mary Krugman, RN, PhD, director of professional resources, and Colleen J. Goode, RN, PhD, vice president, patient services, and chief nursing officer, at University of Colorado Hospital, Denver; Mary Waldo, RN, PhD, CNS-BC, CNS, outcome studies and nursing research, and Gladys Campbell, RN, MSN, assistant administrator, nursing and patient care, at Providence-St. Vincent’s Hospital, Portland, Oregon; Linda Chmielewski, RN, MS, CNAA, BC, vice president, hospital operations/chief nursing officer, and Roxanne Wilson, RN, MSN, care center director, internal medicine/professional development, at St. Cloud Hospital, St. Cloud, Minnesota; Diana Meeks-Sjostrom, RN, MSN, PhD, CS, FNP-C, ONC, director of nursing research, and Vickie Moore, RN, MSN, CHE, CNAA, BC, senior vice president of operations, at St. Joseph’s Hospital of Atlanta, Atlanta, Georgia; and Cynthia Padula, RN, PhD, research coordinator, and Rebecca Burke, RN, MSN, CNAA, vice president, patient care services, chief nursing officer, at the Miriam Hospital, Providence, Rhode Island. Without the generous contribution of managers, directors, physicians, hospital leaders, representatives from other disciplines, and, above all, the spirited, enthusiastic participation and willingness to share of the clinical nurses at the front line, this study could not have been done.
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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