The legacy of Florence Nightingale regarding the importance of total healing environments for patients has had a momentous influence on the development of the fundamental values of healthy work environments. In January, 2005 the American Association of Critical Care Nurses released their standards for Establishing and Sustaining Healthy Work Environments; A Journey to Excellence. These essential standards include skilled communication, true collaboration, staffing, meaningful recognition, and authentic leadership. These standards have since been adopted by numerous professional nursing organizations and strategically integrated into their work. In 2006, Shirey described healthy work environments as “supportive of the whole human being,” “patient-focused,” and “joyful workplaces.” As Nightingale’s beliefs contributed to the healing of patients, research has demonstrated that a healthy work environment leads to both improved patient outcomes and increased nursing satisfaction. In contrast unhealthy work environments have been linked with medical errors, ineffective delivery of care, conflict, and stress among health professionals.
The articles in this topic elaborate on the essential elements of and strategies to create healthy work environments. Readers have a unique opportunity to learn, at the strategic planning level, both tactics for implementation of healthy work environments and effective mechanisms for evaluation. The articles describe competencies for nursing leadership development, strategies to enhance autonomy and control over practice, a model for becoming a skilled communicator, insight into the cognitive work of nursing, strategies to address abusive behavior and tools to evaluate the academic work environment.
Sherman and Pross address the significant role of nurse leaders in building and sustaining healthy work environments in Growing Future Nurse Leaders to Build and Sustain Healthy Work Environments at the Unit Level. They introduce a competency model for nursing leadership development, namely the “Nurse Manager Collaborative Learning Domain Framework,” which includes three domains: The Leader Within: Creating the Leader in Yourself; The Art of Leadership: Leading People; and The Science of Leadership: Managing the Business. They note that personal mastery is a critical component for leadership success and that outstanding leaders value the importance of emotional intelligence in leadership. Although the authors define leadership as both an art and a science, they note it is the art of leadership that requires us to think about leadership in terms of meaningful relationships, especially with the nurturing of future leaders. In addition, they address the importance of secession planning to assure that emerging leaders are successful in continuing the very important work of improving the environment for both nurses and patients.
In Strategies for Enhancing Autonomy and Control Over Nursing Practice, Weston discusses the value of autonomy and control over practice in promoting a healthy work environment and offers strategies to enhance these elements in the work environment. She describes strategies for enhancing autonomy, including setting clear expectations for utilizing nursing knowledge and developing expertise in making independent and sound clinical judgments. In achieving control over practice, Weston stresses the importance of influencing decisions that impact the nature, scope, and context of their practice. She cites the importance of formal structures that allow nurses to participate in organizational decisions and the need for power to make decisions. In essence, the visionary nurse leader supports the engagement, inclusion, and ownership of nurses over their clinical practice thus setting the context for high levels of these elements within an organization.
Kupperschmidt, Kientz, Ward, and Reinholzin, in A Healthy Work Environment: It Begins with You, discuss the individual nurse’s responsibility for becoming a skilled communicator in order to develop meaningful relationships that contribute to healthy work environments. The authors offer their Five-Factor Model for Becoming a Skilled Communicator. The factors, namely awareness of self-deception, reflection, authenticity, mindfulness, and candidness, will help nurses engage in a level of private introspection regarding their manner of communication. The authors stress the importance of all nurses being willing to focus their attention on themselves and what they as individuals can and must do to effect healthy work environments. The authors remind us that the bottom line is that a healthy work environment begins with us all.
Ebright provides new insight about the need to understand the cognitive work of nursing and the complex environments in which RNs provide care. In The Complex Work of RNs: Implications for Healthy Work Environments, she describes new understanding about the complex cognitive work of nursing called ‘”stacking” - the invisible, cognitive work of continuous organizing, re-prioritizing, and decision-making for the management of work flow and care delivery. She further describes the value of viewing healthcare delivery through the lenses of Complexity Science, an interdisciplinary field of inquiry focused on how complex adaptive systems, such as nurses and patients, evolve, interact, and maintain order. Research findings on the actual work of RNs in healthcare settings have important implications for supporting the new RN, focusing on the direct care function, designing and implementing technology, and “designing-out” system barriers to care. The author notes that further focus and research are needed on the current complexity of direct care.
In Combating Disruptive Behaviors: Strategies to Promote a Healthy Work Environment, Longo provides an overview of the nature of disruptive behaviors and the strategies members of the healthcare team can use to formally address such behaviors. Acknowledging the effect of disruptive behaviors on patient safety and the well being of healthcare workers, the Joint Commission recently instituted a leadership standard mandating that facilities seeking accreditation institute policies to address disruptive behaviors. Longo recommends that organizations take a zero-tolerance stance towards disruptive behaviors and that sound policies and processes be in place to address such behaviors. Education to develop skills to confront disruptive behaviors is key, and all healthcare members have a responsibility to acquire these skills. The author cautions that disruptive behaviors, if gone unchecked, can become ingrained into the culture of the organization. She notes that the presence of disruptive behaviors threatens collaboration among healthcare providers and has been linked to adverse events. It is the responsibility of all members of the team to develop self-awareness about their own behaviors and to become adept at skilled communication so as to prevent disruptive behaviors.
Brady, in her article, Healthy Nursing Academic Work Environment, addresses the importance of a healthy work environment in nursing academia and its impact on the recruitment and retention of faculty. The National League for nursing has published the Healthful Work Environment Tool Kit© designed to be used by those in nursing education to evaluate the academic environment in terms of the nine areas identified as critical to a healthy work environment: salaries, benefits, workload, collegial environment, role preparation and professional development, scholarship, institutional support, marketing and recognition, and leadership. The author notes that the one component of a healthy work environment with which faculty struggle is that of the lower salaries. She states that although competitive salaries are fundamental to the recognition of faculty contributions and accomplishments, in this challenging economic environment, other satisfiers may need to be in place.
The articles in this topic propose that creating a healthy work environment is both an individual and collective responsibility. While there are individual and organizational factors to consider, it is the nursing leadership who must acknowledge the necessity and value of maintaining a healthy work environment. They must embrace it, authentically live it, and engage others in the journey. In this challenging economic time, educational opportunities for leaders to develop skills necessary to establish the elements of healthy work environments may be compromised; yet cultures of innovation and learning need to be formed. The Joint Commission’s mandate to manage disruptive behavior sets the stage for healthcare organizations being held accountable for other aspects of a healthy work environment. Organizations of the future will have no choice but to take a strategic approach to create and sustain healthy work environments to ensure patient safety, nurse recruitment and retention, and organizational financial viability- all of which are linked into the practice environment.
The journal editors invite you to share your response to this OJIN topic addressing Healthy Work Environments either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.
Jeanette Ives Erickson, RN, MS, FAAN
© 2010 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2010
American Association of Critical-Care Nurses. (2005). AACN standards for establishing and sustaining healthy work environments: A journey to excellence. Aliso Viejo, CA: Author.
Shirey, M. R. (2006). Authentic leaders creating healthy work environments for nursing practice. American Journal of Critical Care, 15, 256-267.