Healthy Work Environments (HWEs) are important for the overall health of nurses, for successful nurse recruitment and retention, and for the quality and safety of patient care. Healthy work environments are healing, empowering environments that have been correlated with employee engagement and organizational commitment. These environments are characterized by a high level of trust between management and employees; by employees who treat each other in a respectful manner; by an organizational culture that supports skilled communication and collaboration; and by a climate in which employees feel emotionally and physically safe (Shirey, 2006). For the purposes of this article, a healthy work environment is conceptualized as a professional practice environment in which employees are skilled communicators and where face-to-face interactions are open, positive, and consistent with one’s professional and ethical mandates. Achieving HWEs is a nursing imperative (Cornett & O'Rourke, 2009; Stichler, 2009)

The conceptual framework of this article borrows from Parse’s Theory of Human Becoming (Parse, 1992). Parse sees professional nurses as being on a journey to becoming skilled communicators. On this journey, nurses interact with the environment and with people in the environment to co-create meaning between and among them. Nurses choose patterns of relating to each other and are responsible for the consequences of these choices. According to Parse, one of the goals of professional nurses is to truly be present with others as they interact together in-order-to enhance the quality of work life both for themselves and for others. Professional nurses have an ethical mandate to become skilled communicators to enhance their ability to interact respectfully with all team members and to attain and maintain healthy work environments.

The time has come for all nurses to focus upon their own responsibility for attaining and maintaining a healthy work environment. Much of the HWE literature to date has focused on nurses’ external environment, that is, actions that nurse leaders take to facilitate nurses’ ability to communicate with skill and respect (American Organization of Nurse Executives, 2003). However, many work environments remain unhealthy and nurses continue to leave their institutions and the profession. The time has come for all nurses to focus upon their own responsibility for attaining and maintaining a healthy work environment. We support the American Nurses Association (ANA) Code of Ethics (ANA, 2001) that states professional nurses have an ethical mandate to become skilled communicators. Embracing this mandate means that all nurses need to intently and purposefully look inward, focusing on what they must do rather than focusing upon what others must do to achieve desired HWEs. As Alspach (2009) noted, it is time for nurses to engage in a level of private introspection to become skilled communicators in order to develop meaningful relationships at work, relationships focused on positive staff and patient outcomes. Parse’s Theory of Human Becoming is used to conceptualize a Five-Factor Model for Becoming a Skilled Communicator. These five factors include becoming aware of self-deception, and becoming reflective, authentic, mindful, and candid.

Purposefully and intentionally practicing these behaviors depicted in the Figure will enable nurses to engage in private introspection and become skilled communicators. The factors are intimately intertwined. However, for clarity of presentation in this article, they will be discussed separately. The Figure depicts the Five-Factor Model for Becoming a Skilled Communicator and shows the relationships among the five factors and healthy work environments. The Table contains operational definitions of the five factors essential for becoming a skilled communicator.

Figure. Five-Factor Model for Becoming a Skilled Communicator

Key Communication - Healthy Work Environment Documents

As noted earlier, HWEs are essential for positive staff and patient outcomes. The negative outcomes of unhealthy work environments affect patient safety and nurses’ willingness to remain in the workplace. The publication, Silence Kills (Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005), focused public awareness on the negative outcomes resulting from nurses’ inability to communicate skillfully. This publication highlighted many situations in which nurses’ failure to communicate skillfully lead to patient care errors, and described how inappropriate team-member behavior was not confronted to the detriment of patient and staff well being. As a result of close public scrutiny into the healthcare work environment, as exemplified by the work of Maxfield and colleagues, efforts to identify factors essential for healthy work environments were intensified.

National nursing organizations, such as the ANA and the American Association of Critical-Care Nurses (AACN), have identified skilled communication as being an essential standard of practice. The ANA has identified an ethical imperative for professional nurses to assume personal accountability for their roles in their work environments. Provision 1 of the Code of Ethics asserts that “The nurse in all professional relationships practices with... respect” (ANA, 2001, p. 7) and Provision 6 reads that “The nurse participates in establishing, maintaining, and improving... conditions of employment... consistent with the values of the profession through individual and collective action” (ANA, p. 20). The American Organization of Nurse Executives (AONE) has identified skilled communication as a central competency for nurse manages (AONE, 2004), and executives (AONE, 2005)

Extensive reviews of the HWE literature have validated that skilled communication among nurses is essential if  organizations are to provide safe, high quality patient care and to retain nursing staff (Heath, Johanson, & Blake, 2004; Sticher, 2009). Alspach (2009) synthesized the HWE literature, including both the research and opinion-based literature. He noted that skilled communication at work is essential for relationship-centered communication with colleagues. Alspach asserted that it is time for professional nurses to acknowledge their individual accountability for HWEs and to engage in private introspection regarding their manner of communication.

Becoming Skilled Communicators

To become a skilled communicator one must attend to all five factors in the model at the same time. In preparing this article we debated in what order we should address these factors. We decided to begin with a brief exploration of becoming self-deceived in terms of believing that HWEs are someone else’s responsibility. This discussion lays the groundwork for exploring the need for becoming reflective, authentic, mindful, and candid.

Becoming Aware of Self-Deception

The classic short story, “The Emperor’s New Clothes,” focuses on the idea of self-deception (Anderson, March 2004). In this story the Emperor, concerned with surface appearance only, sought to dress himself in a new material that was fine, light, and invisible to those considered foolish and unworthy. The peasants, who did not want to appear foolish or unworthy, praised the Emperor’s clothes, even when they could not see them. Finally, it was a small child who pointed out that the Emperor had nothing on at all. As illustrated in this story, a classic definition of self-deception is a misconception that is favorable to the person who holds the misconception and fails to see that a problem exists.

Self-betrayal leads to self-deception. People betray themselves by acting contrary to what they believe or are told they should be doing. This betrayal becomes self-deception when they begin to believe that the contrary behavior is the way things should be. They begin to see the world in a way that justifies their self-betrayal (The Arbinger Institute, 2002). Over time, their view of reality becomes distorted and they may be unable to focus on their responsibility for the consequences of their behaviors.

In nursing education...[s]tudents may think that they are good communicators if they can transfer an idea or thought to another person, or...stand up in front of a group and speak, something they have been doing since they were children. In nursing education, self-deception can be seen as nursing students consider the concept of communication. Students may think that they are good communicators if they can transfer an idea or thought to another person, a learned behavior since early childhood, or if they can stand up in front of a group and speak. Often they have learned some components of communication prior to their formal nursing course work and do not ‘hear’ when faculty try to enlarge their concept of communication. Therefore, they never grasp the importance of listening as a key component of communication. Additionally students often do not place a high priority on communication skills compared, for example, to clinical skills. They are deceived into believing that they can “wing it” when it comes to communicating. This is just one example of self-deception learned early that continues as students move into the nurse role, negatively impacting their communications within the work environment.

Carroll (2007) noted four specific strategies that can be used to overcome self-deception, such as the deception that a HWE ‘is not my responsibility.’ The first strategy is for each nurse to fully appreciate the work of nursing and the environment in which that work takes place. Secondly, nurses, as professionals, must be willing to assume responsibility to make initial efforts at attaining and maintaining HWEs, even when they feel that the responsibility should be shared or that someone else should make the initial effort. An individual or small group of nurses that begins to demonstrate skilled communication may encourage others to assume their professional responsibility for communication in a way that strengthens a work environment. Thirdly, nurses need to drop their defenses and protective mechanisms, to become more open and trusting, thus facilitating communication. Lastly, nurses must be willing to acknowledge and change past routines and behaviors that have hindered skilled communication. As nurses achieve a heightened awareness of self-deception, and move toward becoming skilled communicators, they should view themselves as accountable for their work environment.  

In today’s complex, continuously changing, healthcare environment, it is essential that all nurses, regardless of formal position or practice setting, become aware of  self-deception regarding responsibility for a HWE. Because becoming reflective facilitates an awareness of self-deception, this important aspect of skilled communication is discussed next.

Becoming Reflective

John Dewey (1933) defined being reflective as an active, persistent, and careful consideration of any belief or supposed form of knowledge in light of the grounds that support this knowledge. Becoming reflective is the process of stepping back from an experience to ponder, carefully and persistently, its meaning to the self and of creating new meaning, drawing upon past and/or current events that serve as a guide for future behavior. An integral aspect of becoming reflective is self-questioning, that is, questioning for the purpose of understanding situations so that they become increasingly clear and coherent (Daudelin, 1996; Parse, 1992).

Reflection-in-action means the nurse develops the ability during interpersonal actions to recognize a problem and to act to make the situation better. Becoming reflective can be differentiated as reflection-in-action and reflection-on-action. Reflection-in-action means the nurse develops the ability during interpersonal actions to recognize a problem and to act to make the situation better. Conversely, reflection-on-action is being reflective after the encounter. The act of reflecting-on-action reviews an interaction after it has been completed to explore the reasons why those involved may have responded as they did (Smith, 2001).

Vinje and Mittelmark (2008) found that becoming reflective was a necessary building block for meaningful work and HWEs. In their study nurses increasingly raised awareness of and discussed values, ethical issues, and the meaning of the work as they became more reflective. These authors recommended that healthcare organizations provide education to enhance nurses’ ability to become reflective. From this vantage point, the authors asserted that becoming reflective was more likely to become part of the culture of the organization if there was a clear expectation for and support of staff in becoming reflective.

Roberts and Stark (2008) found that becoming reflective was central to the development of professional behavior in medical students. To both identify the presence of, and to promote becoming reflective, they surveyed over 1,200 medical students. Students were asked (a) if they took time to reflect on their thoughts, (b) if they took time to examine their feelings, (c) if they were interested in analyzing their behavior, and (d) if they were often puzzled by the way they acted. The researchers found that acknowledging and reflecting upon their thoughts and behaviors was important for these medical students both for becoming reflective and for strengthening other professional behaviors. Although not specifically mentioned, it can be inferred from this study that some level of authenticity, i.e., a willingness to acknowledge one’s purpose, is a key ingredient of becoming reflective. Thus, becoming authentic is discussed next as an important factor in becoming a skilled communicator.

Becoming Authentic

Connected relationships in which one senses that one is not isolated from others are fostered as nurses share their personal nursing experiences with co-workers. A common synonym used for ‘being authentic’ is ‘being real or genuine.’  Becoming authentic requires deliberate knowledge and skill acquisition. Shirey (2006) adapted George's (2003) model of authentic leadership to nursing leadership. Becoming authentic is depicted as a journey comprised of self-discovery and reflection. Although Shirey’s discussion centered on becoming an authentic leader, the discussion can be applied to all professional nurses. Shirley has explained that nurses’ openness to becoming authentic and to acknowledging their strengths and weaknesses fosters an urgency to assume responsibility for HWE’s. She explained that understanding one’s purpose, holding and practicing professional values, practicing with heart, establishing enduring relationships, and practicing self-discipline are essential aspects of becoming authentic.

According to Shirey (2006), nurses who are becoming authentic understand and embrace their responsibility to treat each person with respect. They role model this professional behavior in all of their interactions. Practicing with heart requires forming relationships that are meaningful and bringing about connectedness with others. Connected relationships in which one senses that one is not isolated from others are fostered as nurses share their personal nursing experiences with co-workers. Nurses on the journey to becoming authentic, be they leaders, educators, or clinicians, are skilled at connecting with others to create HWEs. They can be role models for novice nurses in this regard. Becoming authentic includes a willingness to solicit, receive, and act upon feedback. Paying attention to feedback fosters nurses’ willingness and ability to see themselves as others see them, thereby setting the stage for meaningful behavioral changes. Becoming authentic then implies that nurses are becoming skilled communicators who communicate with respect and honesty and assume responsibility for their own work environment. On their journey to becoming authentic, nurses are potentially becoming mindful as described below.

Becoming Mindful

Being mindful means that between the stimulus and response, a nurse can choose to respond positively or react negatively. Becoming mindful means that one has a heightened awareness of and alertness to both one’s own and the others' verbal and nonverbal communication (Webster's New World College Dictionary, 2004). For example, a staff nurse is mindful that she has a patient issue she must discuss with the charge nurse, even though the charge nurse is perceived as threatening. Being mindful also involves becoming present-centered, acknowledging, and accepting each thought and feeling as it is experienced (Weick & Sutcliffe, 2006). The staff nurse might acknowledge feeling anxious because of past negative interactions with the charge nurse. Becoming mindful has been positively correlated with the ability to pay attention to the current experience (the staff nurse focuses on her current feelings and her responsibility for positive outcomes) and negatively correlated with dwelling on past negative experiences. Being mindful means that between the stimulus and response, a nurse can choose to respond positively or react negatively. The nurse who is becoming mindful remains with the current experience without a spill-over of bad feelings from prior interactions (Narayanan & Moynihan, 2006).

A simple technique for becoming mindful involves deliberately paying attention to an interaction in a nonjudgmental way while focusing upon one’s breathing (Ucok, 2006). Consider, for example, what could happen when the staff nurse referenced above approaches the charge nurse to ask a question, who sharply responds, “Don’t you see that I have too much work to do with being the charge nurse?” Before the staff nurse responds, she remembers that she can choose how she responds; i.e., she can respond either positively or negatively. Recalling this, she takes a deep breath in and out and purposefully focuses on the present, trying not to judge the charge nurse, although the charge nurse tends to respond in a negative manner when approached for assistance. The staff nurse can choose not to respond negatively to the charge nurse's sharp comment (stimulus), and choose rather to approach her privately later (response). When she approaches the charge nurse later, she can share how the earlier response affected her, stressing that it is each professional nurse’s responsibility to communicate in such a way as to enhance and support a HWE, and requesting that the charge nurse communicate with her more appropriately in the future. In this example, the staff nurse's skilled communication is not only an example of becoming mindful but also of becoming candid. Becoming candid may not seem to fit with personal introspection. However, candidness is essential for becoming a skilled communicator as discussed in the following paragraphs.

Becoming Candid

Unfortunately, in today’s turbulent work environments, nurses may be fearful of becoming candid. An intentional positive regard for self and others is an essential part of becoming candid which includes speaking with frankness, free from bias, and with a willingness to risk speaking and hearing the truth (Webster's New World College Dictionary, 2004). Unfortunately, in today’s turbulent work environments, nurses may be fearful of becoming candid. These fears may include fear of job retribution (risk losing influence and support from team members), fear of social retribution (risk damaging social networks at work), and/or fear that becoming candid could cause team members to perceive them negatively and, in turn, respond to them negatively (Bolton, 2006).

Kupperschmidt (2008) addressed becoming candid in presenting her model of carefronting. In this model, nurses, as members of a profession purportedly based on caring, must care enough to candidly carefront inappropriate behavior and communication in a caring manner in order to stop negative behavior and attain and maintain a HWE.

This article has focused on the individual nurse’s accountability for a HWE. However, Pipe’s (2009) assertion, namely that becoming candid can only happen in environments where nurses feel there is sufficient trust, must be acknowledged. Nurse Leaders can foster environments in which nurses are becoming candid by role modeling candid and frank conversations, being willing to listen, and affirming and valuing staff who may disagree with the Nurse Leader. Each professional nurse, whether educator, clinician, or leader, has an ethical obligation to become a skilled communicator which includes becoming candid when others’ actions are inconsistent with efforts to attain and maintain HWEs.

Summary

No effort has been made in this article to address the role of managers in decreasing workplace conflicts. Rather, this article has focused on the importance of all nurses being willing to focus their attention on themselves, considering what they individually can and must do to effect HWEs. Nurses must recognize that a HWE, one in which they feel emotionally safe, begins with them. The factors depicted in the Five-Factor Model for Becoming a Skilled Communicator (Figure) and the accompanying discussion have provided a guide for all nurses to use in assuming their individual responsibility for their work environments.

Becoming aware of self-deception is an important key to becoming a skilled communicator. With intentional focus and practice, nurses can enhance their awareness of being self-deceived and overcome this deception. Nurses are also encouraged to become reflective, that is, to step back from an experience to ponder the experience and to use it as a guide for their future behavior. Becoming authentic is also necessary for HWEs. Nurses who are becoming authentic will “practice with their hearts” and form relationships that enhance connectedness with others. Nurses who are becoming authentic, be they leaders, educators, or clinicians, are skilled at connecting with others to create HWEs. Developing the capacity to acknowledge and accept experiences and feelings and focusing on the here-and-now of the situation are essential to becoming mindful, another important behavior. Finally becoming candid, that is, speaking with frankness, is also important. Carefronting is suggested as a strategy to assist nurses to overcome fears related to becoming candid. As nurses purposefully implement the strategies described in this article, they will become skilled communicators. The bottom line is that a healthy work environment begins with each individual nurse, i.e., it begins with you!

Authors

Betty Kupperschmidt, EdD, RN, NEA, BC
E-mail: Betty-Kupperschmidt@ouhsc.edu

Dr. Kupperschmidt began her nursing career in 1962 as a diploma-prepared nurse. She is currently an Associate Professor, University of Oklahoma (OU) College of Nursing, teaching administrative clinical and theory courses. She states she knew her clinical roles as staff nurse, Night Supervisor/ER Nurse, and Clinical Director and Educator included bringing order out of chaos (before chaos and healthy work environments (HWEs) were in vogue). Over the span of 47 years, she has facilitated HWEs in clinical and educational settings and, most recently, published and presented numerous times focusing on using carefronting, the ANA Code of Ethics, and generational differences to foster HWEs.

Emma Kientz, MS, BS, CNS, CNE
E-mail: emma-kientz@ouhsc.edu

Emma Kientz completed her MS degree at the University of Oklahoma with a CNS focus. She has been a faculty member at the OU College of Nursing, Tulsa campus, since 2002. Emma is uniquely qualified to speak to healthy work environments as she creates HWEs for faculty and students while directing the Traditional Programs and arranging and supervising collaborative learning opportunities for nursing students in a weekly interprofessional clinic providing care to a wide array of clients. These rich professional experiences have afforded her opportunities to present, often with her students, at state, national, and international conferences

Jackye Ward, MSHRM, RN, CNAA-BC
E-mail: rjward@flash.net

Jackye Ward is Vice-President of Patient Care Services and Chief Nursing Officer at Valley View Regional Hospital (VVRH), a 168-bed acute care hospital located in rural Oklahoma. She received her BSN and her MS degree in Human Resources Administration from East Central University, and her MS from the University of Oklahoma. Jackye’s passion for creating a HWE in a rural setting with scarce resources was recognized when VVRH was selected in 2006 as one of the 50 hospitals (only one of two in Oklahoma) to participate in the American Organization of Nurse Executives/Robert Wood Johnson Foundation Transformation of Care at the Bedside dissemination project. Recognizing the value of and using the five factors for becoming a skilled communicator, Jackye has grown a nursing leadership team that enjoys a 98.2 percent RN retention rate. She has also served as President of the Oklahoma Board of Nursing.

Becky Reinholz, MS, RN
E-mail: bjreinholz@saintfrancis.com

During her graduate studies at the University of Oklahoma, Becky had the unique opportunity to combine the theory of transition with the HWE literature to facilitate a successful move from an “old but comfortable” Pediatric ICU to an ICU in a brand new facility. She continued her interest in HWEs by using evidence-based literature to recruit and retain a highly functioning team. Becky then used this knowledge and experience as a springboard to develop an agency-wide Charge Nurse Development Program focused on attaining and maintaining a HWE.

© 2010 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2010