Starting Now: Implementing the Healthy Work Environment Standards Is More Important Than Ever

Bedside nurse turnover in the United States is 22.5%, representing a national challenge that has been attributed to poor work environments. Poor work environments result in decreased nurse satisfaction and retention as well as poor patient outcomes. Healthy work environments have the opposite effects. To evaluate the impact of implementation of the American Association of Critical-Care Nurses (AACN) healthy work environment framework in an intensive care unit on work environment scores, turnover, and tenure during a 6-year period. A prospective, longitudinal design was used to evaluate implementation of the healthy work environment framework in an intensive care unit in a large academic medical facility. Interventions for each of the 6 healthy work environment standards were carried out. The AACN Healthy Work Environment Assessment Tool was used to measure each standard in 2017, 2019, 2021, and 2023. No statistically significant differences were found between cohorts. The score for each healthy work environment standard and the overall score increased significantly from 2017 to 2023. Nurse turnover increased during the COVID-19 pandemic but restabilized within 2 years. Findings from this study suggest that targeted interventions addressing the healthy work environment standards are associated with improved staff satisfaction and reduced turnover. Furthermore, the findings highlight the value of the healthy work environment framework in improving nurse retention.

Introduction: The increasing emphasis on creating healthy work environments is driven by their impact on both nurse and patient outcomes. Previous evidence has established a link between supportive nursing leadership and work environments, but demographic characteristics have not been adequately explored. This study aims to investigate whether demographic variations among nurses influence their perceptions of supervisory support and work environment. Methods: Secondary data analysis of a cross-sectional quantitative survey was utilized to recruit registered nurses employed in a government-owned and corporate-controlled (GOCC) tertiary hospital in the Philippines from September 2022 and October 2022. The primary data were collected through a demographic questionnaire, the validated Supervisory Support Scale tool, and the American Association of Critical-Care Nurses’ Healthy Work Environment Assessment Tool. Inferential analyses were employed to examine differences between study variables. Data processing was performed using Microsoft Excel 2022 and the R program, with a significance level set at 0.05. Results: The original dataset with a sample of 519 registered nurses was predominantly composed of non-married female nurses with bachelor’s degrees and varying clinical experiences. The secondary data analysis revealed no significant differences in work environment and supervisory support perceptions in relation to nurses’ demographic characteristics. Conclusions: This study provides critical insights into the Philippine nursing workforce literature by demonstrating that nurses’ demographic variations alone do not significantly influence their supervisory support and work environment perceptions. These results suggest that shifting the focus to broader factors beyond demographic variations among nurses may play a more critical role in shaping nurses’ work environment and supervisory support perceptions. Future research should explore the potential intersection of systemic factors such as leadership competencies, psychological safety, and workplace policies in shaping the nursing workforce dynamics.

The American Association of Critical-Care Nurses (AACN) Healthy Work Environment Assessment Tool was developed as a simple screening tool to assess the characteristics of a healthy work environment (HWE) in critical care environments. The purposes of these 2 qualitative research studies are to explore the nurse leaders' and direct care nurses' perceptions of the meaning of a HWE, to describe the nurse leaders' and direct care nurses' perceptions of a HWE, and to define the characteristics of a HWE in acute care settings. Exploratory descriptive designs using focus groups and guided questions with tape-recorded interviews were used to define the characteristics of an HWE. The 6 original themes from AACN HWE standards and 2 new themes emerged as a result of the nurse leaders and direct care nurses defining the characteristics of a HWE, which included appropriate staffing, authentic leadership, effective decision making, meaningful recognition, skilled communication, true collaboration genuine teamwork, and physical and psychological safety. The qualitative statements from these 2 studies will be used in future studies to describe and develop HWE scales for nurse leaders and direct care nurses and to assess the psychometric properties of these new tools.

Nurse staffing increasingly has become a topic of research studies. Data currently exist on the relationship between adverse events and nurse staffing.1,2 Data also exist on the relationship between fatigue and patient outcomes.3 Knowing the right number of nurses to have and how to optimally manage their schedules is a goal that all hospitals would like to achieve. The American Association of Critical-Care Nurses (AACN) has listed Appropriate Staffing as an essential standard for a healthy work environment (HWE).4 AACN states that “Staffing must ensure the effective match between patient needs and nurse competency.”4(p28) Many critical elements of this standard relate to the structures and processes necessary for staffing that matches the needs of patients with nurses’ competencies, which ultimately leads to an HWE.Appropriate staffing is necessary to keep patients safe. Numerous staffing bills have been introduced at the state level. Some have passed and become law, such as the Staffing Ratio Assembly Bill 394 in California. Opinions are mixed about whether this bill improved care by identifying a fixed ratio, but an improvement was observed in the overall skill mix, with an increase in the number of registered nurses hired to meet the ratios. Aiken et al2 presented a relationship between higher skill mix in registered nurses and better patient outcomes. Donaldson et al5 found that after reviewing nursing outcome data before and after implementing the ratios in California, a significant difference was not found in the prevalence of hospital-acquired pressure ulcers, restraint use, or reduction of falls at the unit level in medical-surgical units.So, what is the right mix for staffing? Is there a magic number? As mentioned previously, staffing must ensure an effective match between the needs of the patient and the competency of the nurse. To achieve this match, the nursing care delivery model in the hospital needs to address these issues; a method must be in place to determine staffing and patient acuity. The remainder of this article discusses some examples of structures and processes that some hospitals have implemented for determining staffing and acuity based on the AACN Synergy Model for Patient Care.6Many hospitals are searching for an acuity system that will give them the number of nurses needed for staffing on the basis of patient acuity, and that would help the charge nurses and managers know when to decrease staffing as a patient’s acuity becomes lower and the staffing needs are decreased. Acuity programs have improved over the past 10 years, and a few systems are available to help hospitals effectively manage their staffing needs and overall labor management, while also decreasing costs. Cerner Clarvia (Cerner Corporation, Kansas City, Missouri) is an acuity program that can electronically determine patient acuity by pulling data from the electronic health record and determining a nursing acuity score based on identified nursing outcomes. It is an acuity-based system used to move patients to the desired outcomes needed for discharge. As a patient’s condition improves, the number of nursing hours needed for patient care decreases. This system also has a scheduling component that is fully integrated, which assists in matching nursing scheduling needs with patient acuity. When linked electronically with a competency system, it can propose nursing assignments by matching nurse competencies to the needs of the patients. Nursing acuity and staffing systems are moving away from the traditional nursing task-based staffing to effectively match the patient’s needs with the nurse’s competencies, as deemed essential by the Appropriate Staffing standard. The Cerner Clarvia staffing and acuity system is one example that is consistent with the critical elements of the HWE Appropriate Staffing standard. We have come a long way from paper-and-pencil acuity tools that were in place years ago.The AACN Synergy Model was developed on the principle that patient characteristics drive patient acuities. Table 1 lists the 8 patient characteristics of the Synergy Model, and Table 2 lists the 8 nurse characteristics of the Synergy Model. The goal of this model is to match the nurse’s competencies with the patient’s needs/characteristics, resulting in synergy.6 This model was based on the work by Curley7 and created by the AACN Certification Corporation. Curley was the first to publish research on “patient-nurse synergy.” This model has been incorporated at various hospitals for staffing and as a model for professional nursing. Baylor Healthcare in Dallas, Texas, is a hospital that has incorporated the Synergy Model into patient care and has it as the foundation for the Baylor Healthcare System Professional Nursing Practice Model. John Dixon has lectured on this topic at several national conferences, including the AACN National Teaching Institute (NTI). As Dixon said in his 2008 presentation at the American Nurses Credentialing Center Magnet conference, “Professional nursing practice occurs in a healthy work environment where patient needs are assessed and matched to nursing competencies. This synergy results in Safe Passage for patients.”8With the changes occurring in health care and the increasing emphasis on wellness, a strong focus of hospital care is to move the patient through the care continuum as quickly as possible. Structures and processes are needed to achieve ideal patient outcomes. Appropriate staffing continues to be an essential standard to provide the best care while optimally using appropriate resources. Resources are available on the AACN Web site if you are interested in learning more; these resources include journal articles, posters presented at AACN conferences, and statements about what others have done to implement these standards in their work environment.

The COVID-19 pandemic exacerbated staffing challenges in intensive care units, with increased burnout and moral distress cited as major problems. A healthy work environment is critical to nurses' success and wellbeing. During the pandemic, a survey by the American Association of Critical-Care Nurses revealed decreased composite scores in each of the 6 critical elements of a healthy work environment. Hospital units that improved even 1 critical element reported higher job satisfaction. The use of telehealth tools by expert nurses expanded care delivery during the pandemic by improving response to acutely and critically ill patients while supporting hospital-based nurses. All of the critical elements of a healthy work environment are relevant to the tele-critical care nurse's role and challenges. This article describes how tele-critical care nurses were affected by the pandemic and how healthy work environment strategies promoted successful nurse and patient outcomes.

Changing the Work Environment in ICUs to Achieve Patient-Focused Care: The Time Has Come

Transition to Practice: Onboarding Components for Establishing and Sustaining Healthy Work Environments.

“In Our Unit” highlights unique practices, innovations, research, or resourceful solutions to commonly encountered problems in critical care areas and settings where critically ill patients are cared for. If you have an idea for an upcoming “In Our Unit,” send it to Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 362-2049; e-mail, ccn@aacn.org. The atmosphere of the units has begun to change ... from one of “why bother” to “we can do it!” Over the past year, I have become acquainted with the American Association of Critical-Care Nurses’ Standards for Establishing and Sustaining Healthy Work Environments (www.aacn.org/hwe) as our manager and staff strive to make our critical care units better places to work. I am a staff nurse and can already see the changes taking place in unit morale and staff retention. Our hospital has 2 critical care units that are separate from one another but share the same manager, educator, and clinical nurse specialist. One unit is a 15-bed intensive care unit (ICU) with medical-surgical-neurological patients. The other unit is an 18-bed adult critical care (ACC) unit—it was originally a progressive care unit but now the staff have been educated and trained to care for ICU patients. Staffing the 2 units requires a number of nurses and, consequently, we have many different personalities and skill levels providing nursing care for patients, in 2 distinct, high-stress environments. The ICU primarily deals with higher acuity patients and the ACC unit deals with more patient demands because a significant number of the ACC patients do not receive mechanical ventilation nor do they require the same level of care. Patient turnover is high, especially in the ACC unit, and the acuity is high enough on the ICU that frequently nurses on both units are not able to take lunch breaks. Adding to the complex, stressful environment is the reality that the 2 units will be merged into 1 unit within the next 5 years upon the completion of a new building at our suburban campus. In our shared governance committee, nurses, physicians, and other health care professionals can discuss problems and celebrations. The physicians, for the most part, have high regard for the nurses and vice versa. However, we needed to do more to ensure a healthy work environment for our staff. Our manager noticed that morale was low and that there was poor communication among employees and low satisfaction among the staff, particularly nurses. In order to help solve this problem, and to ease the transition to one combined unit, she suggested and helped us implement several strategies to make our work environment healthier.

Background A healthy work environment has tremendous benefits on organizational performance, health service delivery, health worker performance and patient outcome. In 2009, International Council of Nurses (ICN) undertook a global survey which sought for nurses’ opinion on the nursing profession and their work environment in 11 countries, excluding Nigeria. Little is known about how Nigerian nurses, particularly nurses in Cross River state perceive their work environment. This study explores registered nurses’ perceptions and experiences with selected features of a positive practice environment, as a basis for developing an intervention strategy for improving nurses’ workenvironment in Calabar, Cross River state.Methods This study was a descriptive survey by design. Perceptions of features of positive practice environment were explored among Registered Nurses in full time employment at tertiary and secondary health facilities in Calabar using a modified 51-item standard structured questionnaire originally developed by Pfizer to measure Nurses expectations and needs in a 2009 ICN Quadrennial Study. The questionnaire was adapted with the permission of Pfizer. Data werecomputer analyzed using SPSS for Windows version 15. Interrelationships between variables were tested using Chi- Square analysis.Results The mean (SD) age of the respondents was 37.4 ± 8.3 years while respondents’ mean (SD) working experience was 15.8 ± 8.7 years. The respondents were predominantly female 149(90.3%) while 109 (66.1%) were married. The level of education indicated that most 110(66.7%) had diploma in Nursing, 43(26.1%) had first degree, and 12(7.3%) had post-graduate qualification. Most 86(52.1%) of the nurses had heard just a little some about positive practice environment (PPE), 30(18.2%) had heard nothing at all while only 49(29.7%) were quite knowledgeable. The features of PPE rated highly by the participants were clear and comprehensive description of their job responsibility 75(45.5%) and an environment of team work and collegiality 71(43.0%). Similarly, in their practice experience, the very positive feature in their work environment was an environment of open communication, teamwork and collegiality 60(36.4); clear and comprehensive description of their job responsibility 53(32.1%). Most favorable aspect of nursing identified by the nurses was helping patients/patient contact 75 (45.5%) while the most unfavourable aspect of nursing identified were risk of contracting infections 61(37.0%). Although 96(58.2%) of the participants opined that nursing is better today than 5 years ago, only 50(30.3%) were very satisfied with nursing while 103(61.8%) of the nurses expressed the desire to remain in the nursing profession in the next 5 years.Discussion The findings have established the need for making information on PPE widely available to practicing Registered Nurses in Calabar. Employers of nurses should take urgent steps to improve health and safety policies and procedures at the work place to create a more positive practice environment for nurses to perform their duties and improve patient outcome. More efforts are required by the professional association to negotiate better pay packages, benefits and incentives for nurses in order to guarantee nurses wellbeing and retention in the profession.KEYWORDS: Positive Practice Environment, HealthCare, Registered Nurses, Satisfaction, Nigeria

Background: Dealing with the complex psychological aspects of patient care required a good leader to maintain healthy work environments. Even early in a nursing career, the call for leadership was an essential aspect to enhance the outcomes related to both nurses and patients, especially in the challenging field of mental health nursing. It is known that a supportive work environment is important for nurses working in mental healthcare settings.Purpose: The purpose of this study was to explore the role of nurse leaders in maintaining healthy work environments for nurses working in a mental health hospital in Taif, Saudi Arabia.Methods: This study used a descriptive-qualitative design. Data were collected from nurse leaders at the Mental Health Hospital in Taif City, Saudi Arabia. Nonprobability, purposive sampling was applied to collect data. Data were collected through semistructured interviews. NVivo was used as a software management system to analyze the data.Results: Nine nurse leaders participated in this study. Thematic analysis was applied to determine the categories of narrative analysis. Based on the participants' interviews, the findings were categorized into two main themes and six subthemes which are Facilitators to Maintain Healthy Work Environments: Ways to Maintain Healthy Work Environments, Building Teamwork, The Required Leadership Skills in Mental Health Hospitals, Entertainment; and Barriers to Keep the Environments Healthy: Mental Health Nurses' Traits, and Burnout.Conclusion: Nurse leaders have an important role in maintaining a healthy work environment for mental health nurses, decreasing stress and workload, and improving nurses' outcomes. Nurse leaders also have to pay attention to their staff's mental health if they are in leadership positions in mental healthcare hospitals.

The main aim of this study was to determine the perceptions of clinical nurses and nurse leaders about authentic nurse leadership, work environment, pandemic impact, well-being and intent to leave their position and profession during the second year of the pandemic. This research team studied the variables pre-pandemic and in year one of the pandemic. As the pandemic continued, subsequent reports of workforce instability, deteriorating work environment and vulnerable well-being called for an understanding of the current state to inform needed actions by leadership. This study is a cross-sectional, descriptive, correlational analysis using national survey data from 1795 US clinical nurses and nurse leaders in the fall of 2021. Pandemic impact was high, authentic nurse leadership was present, healthy work environment was not present and nurse well-being was at-risk and negatively correlated to both healthy work environment and authentic nurse leadership. Within our sample, 61.8% of nurses had no intention to leave their positions, and 82.5% had no intention to leave the profession. Compared with clinical nurses, nurse managers had significantly higher scores on all instruments. The findings of this study support leadership as positively related to a healthy work environment. Authentic nurse leadership, a healthy work environment and nurse well-being are all critical components of efforts to stabilize the nursing workforce as we recover and rebuild post-pandemic. This is a call to action for leadership that will serve the goals of retaining nurses, rebuilding work environments and improving well-being.

Background This systematic review set out to examine the impact, if any, of nursing workload and staffing on creating and maintaining healthy work environments. For the purposes of this review, the term 'healthy work environment' was defined as '. . . a practice setting that maximizes the health and well-being of nurses, quality patient outcomes and organizational performance'. This definition identifies nurse, patient and organisational outcomes as indicators of the establishment and maintenance of a healthy work environment. Objectives The review sought to determine the impact of: • Patient characteristics, nurse characteristics, system characteristics and system processes on workload, scheduling and concepts of productivity and utilisation • Workload, scheduling and concepts of productivity and utilisation on the quality of outcomes for clients, nurses and the system/organisation Search strategy The search strategy sought to find both published and unpublished studies and papers written in the English language. A three-step search strategy approach was used. An initial limited search of MEDLINE and CINAHL databases was undertaken to identify optimal search terms followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second extensive search using all identified keywords and index terms was then undertaken. The third step consisted of a search of the reference lists of all identified reports and articles for additional studies. Selection criteria Types of studies: This review considered research papers that addressed the appropriateness and effectiveness of workload and staffing concepts in fostering a healthy work environment in healthcare. The types of papers to be considered included: meta-analysis, randomised controlled trials, quasi-randomised controlled trials, cohort studies, case-control studies, descriptive studies and correlational studies. The review considered all participants involved or affected by workload and staffing concepts within the nursing workforce in a healthcare environment, including staff and patients. System and policy issues were also considered. Types of interventions: All workload and staffing strategies that impact on the work environment, patient and nurse outcomes were considered in this review. Types of outcome measures: Outcomes of interest were categorised into four groups: nursing staff outcomes, patient outcomes, organisational outcomes and system outcomes. Data collection and analysis Following assessment of methodological quality, data were extracted using data extraction tools based on the work of the Cochrane Collaboration and the Centre for Reviews and Dissemination. Statistical pooling was not possible and findings were presented in narrative form. Results Of the 2162 papers identified in the search, 171 were selected for full paper retrieval and assessed independently by two reviewers for methodological quality. A total of 40 papers were included in the review: one systematic review; one cohort study; and 38 correlational descriptive studies. Results were summarised in narrative form. The evidence suggests strong correlations between patient characteristics and work environments; and workload and staffing and the quality of outcomes for clients, nurses and the system/organisation. This gave rise to a number of recommendations for practice and for further research, such as: • A greater proportion of regulated staffing (i.e. registered nurses, enrolled nurses, practical or vocational nurses) is associated with improved outcomes related to the Functional Independence Measure score, the Short Form Health Survey (SF-36) vitality score, patient satisfaction with nursing care, patient adverse events (including atelectasis, decubitus ulcers, falls, pneumonia, postsurgical and treatment infection and urinary tract infections) • An increase in the number of registered nurse hours available is associated with improved patient outcomes in relation to falls, pneumonia, pressure ulcers, urinary tract infection, length of stay and postoperative infection rates.

Introduction. Oil and gas refinery industry often face unique challenges in creating a healthy and productive work environment. This difference gender composition in an industry dominated by male workers provides its own dynamics in interpersonal relationships in the workplace. Work stress and bullying have potential to create an unhealthy work environment and harm an individual's psychological well-being. The aim of this research is to determine relationship between work stress and bullying, work stress and gender, and relationship between bullying and gender in oil and gas refinery industry Methods. This study used correlative analysis with sample of 218 workers. Instrument used is PSS-10 questionnaire (work stress) and the relationship dimension in HSE MS-IT (bullying) Results. Statistical test show there is a relationship between work stress and bullying (p value=0.0001), there is no relationship between gender and work stress (p value= 0.287), there is a relationship between gender and bullying (p value= 0.001). Discussion. Our findings show workers who report being bullied are more likely to experience work stress. Gender differences do not influence a person to experience work stress, this suggests other factors beyond gender may be more dominant in influencing work stress. Male workers more often report experiences of bullying, these findings highlight the importance of understanding gender dynamics in the context of workplace bullying. Conclusion. It is important to overcome bullying in the workplace, so work stress decreases and a healthy work environment is created. Anti-bullying policies, training for management and employees, and psychosocial support can be necessary solutions.

Work in high-voltage (HV) facilities is high-risk and falls into the category of jobs with special working conditions. In order to preserve the life and health of employees who service HV facilities, it is necessary to ensure the highest level of protection. In Elektroprivreda Crne Gore AD Nikšić, by fully implementing legal regulations and an integrated management system (IMS), within which the international standard ISO 45001:2018 - Management systems for health protection and safety at work was implemented, an integrated solution is provided that provides employees with a safe, healthy and sustainable working environment. The principle based on risk management has been adopted, with a focus on identifying and reducing risks, through continuous improvement, which has made a major qualitative shift in corporate governance, which is the basis for maintaining a safe and healthy working environment. In order to minimize risks in HV facilities, by organizing work through general, organizational and technical protection measures, procedures and rules are prescribed that must be consistently implemented and respected. Therefore, all categories of work performed in HV facilities: work in a de-energized state, work near voltage and work under voltage must be accompanied by work documents, without which work cannot begin. The culture of safety and health at work is precisely based on the daily respect of the rules and responsibilities of all of us, which is also a commitment to a common goal, which is a safe and healthy working environment.

This study examined the effect of registered nurse (RN) staffing level, work environment, and education on adverse events experienced by residents in nursing homes. A cross-sectional study was conducted with 216 RNs working in nursing homes who were selected using random stratified sampling by location and bed size. Self-reported questionnaires regarding staffing level, work environment, education level, adverse events, and nurse characteristics were administered. Data from the National Health Insurance Service were used to describe nursing home characteristics. Both multiple and multinomial logistic regressions were used to control for the characteristics of nurses and nursing homes, and investigate the effects of nursing staffing level (number of older adults assigned to a nurse), work environment (Practice Environment Scale of the Nursing Working Index), and level of nursing education on the adverse events experienced by residents. An increase of one resident per RN was significantly associated with a higher incidence of pressure ulcers (OR= 1.019, 95% CI=1.004-1.035). Poor work environment increased the incidence of adverse events such as pressure ulcers (OR= 3.732, 95% CI=1.155-12.056) and sepsis (OR=3.871, 95%CI=1.086-13.800). Compared to RNs with a baccalaureate or higher, RNs with diplomas reported increased incidence rates of pressure ulcers (OR=2.772, 95%CI= 1.173-6.549). RN staffing, work environment, and education level affect the incidence of pressure ulcers, and the work environment affects the incidence of sepsis among residents in nursing homes. Policy-wise, improving the level of nurse staffing, nursing work environment, and nursing education will improve health outcomes of residents.