Healthy Work Environment: Standards for Practice Mary Duncan, Richardia Gibbs-hook, Dulcebelle Pearson, Stephanie Yohn Ferris State University December 6, 2011

Healthy Work Environment: Standards of Practice “What is it?” “Six standards for establishing and sustaining healthy work environments have been identified”  Skilled Communication  Nurses must be proficient in communication skills as they are in clinical skills.  True Collaboration  Nurses must be relentless in pursuing and fostering true collaboration.  Effective Decision Making  Nurses must be valued and committed partners in making policy, directing and evaluating clinical care and leading organizational operations.  Appropriate Staffing  Staffing must ensure the effective match between patient needs and nurse competencies.  Meaningful Recognition  Nurses must be recognized and must recognize others for the value each brings to the work of the organization.  Authentic Leadership  Nurses leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement.

Healthy Work Environment: Standards of Practice “ Who created the Healthy Work Environment Standards?”  In 2005 the American Association of Critical Care Nurses (AACN) published the six standards for developing and maintaining a healthy work environment known as HWE.  Established in 1969 in response to the need for continuing education for intensive care nurses.  Originally called American Association of Cardiovascular Nurses. The name was changed in 1971 to cover all nurses who care for the critically ill.  Provides members with education and resources to provide quality care to acute and critical care patients  The six standards are the AACN’s “highest advocacy priority.” (2011,12)

Healthy Work Environment: Standards of Practice “Why Were Healthy Work Environment Practice Standards Created?”  Evidence shows that unhealthy work environments contribute to dissatisfaction and frustration in the work setting for nurses.  Evidence also shows that unhealthy work environments contribute to more errors in patient care and puts patients at risk for unsafe care.  Healthy Work Environment Standards assure that nurses have a solid base from which to perform their jobs and ensure safe patient care and optimize patient outcomes.  Healthy work environments promote staff retention and recruitment which contribute to adequate staffing. Adequate staffing promotes satisfaction among nurses (Viejo, 2005).

Healthy Work Environment: Standards of Practice “Why Healthy Work Environment Standards Were Created?”  If a nurse is intimidated by a physician who is verbally abusive, she may not call the physician in an expeditious manner. This could result in delayed patient care.  If a nurse is forced to work mandatory overtime because of staffing shortages, she may be fatigued and not able to provide optimal, safe care to her patients.  If the patient to nurse ratio is not adequate based on patient acuity or sheer numbers on the floor this could lead to anger and frustration for the nurse. Again, an angry and frustrated nurse will not be able to provide optimal, safe care to her patients.  If nurses are not able to work in an environment that is healthy and safe for them, the environment will not be safe for their patients!

Healthy Work Environment: Standards of Practice “Why Healthy Work Environment Standards Were Created?”  The American Association of Critical-Care Nurses recognizes the link between the quality of work environments for nurses and the quality of care for patients (Viejo, 2005).  Contentious work environments breed frustration and hostility which creates a safety risk for nurses which translates into a safety risk for patients.  The standards are essential for elevating the quality of work environment for nurses and thus the quality of care and optimal outcomes for patients.

Healthy Work Environment: Standards of Practice “How long have HWE standards been around?”  American Association of Critical Care Nurses (AACN) dedicated to participate and encourage the creation of Healthy Work Environment (HWE) standards (Viejo, 2005).  Nursing Organizations Alliance (NAO) clearly defined the essential components of HWE standards (Viejo, 2005).  On January 26 in Washington, D.C. the AACN released the standards at a national briefing (Pinkerton, 2005).

Healthy Work Environment: Standards of Practice “How HWE Relates to Current Practice”  My current position is on a unit which was recently combined from two separate units. For a variety of reasons, the Progressive Care Unit and Observation Unit were combined utilizing staff from both units. Some nurses lost seniority, some lost full time status, and some moved from days to nights in order to remain employed. As a result there are multiple relationship issues. Below are some ways the unit embraces HWE Standards.  True Collaboration:  Once per month, a Unit Based Council identifies issues on the unit and seeks to find solutions. In addition, there is a monthly staff meeting where all employees are encouraged to share ideas and issues.  Authentic Leadership:  The Nurse Manager is very visible on our unit. She touches base with each employee on the unit every morning and seeks to identify potential issues. She has much experience as well as her MSN. She is approachable and fair. Richardia Gibbs-Hook

The lack of a healthy work environment is evident in the Long Term Care setting.  Appropriate Staffing  The federal government regulations state “Nursing homes must employ adequate staff to provide services for each resident. Additionally, there must be adequate staff on duty during each shift to provide these services.” (U.S. government). It is common in nursing homes to have a rehabilitation unit as well as a long term care unit in the same facility. All patients are counted in the census when determining staff. This results in the acute care nurse having 10 patients whereas the long term care nurse ratio is one nurse to 27 patients and one certified nursing assistant to nine patients. The same nurse is responsible for upwards of 60 narcotic cards stored snugly in the narcotic drawer. Mary Duncan Healthy Work Environment: Standards of Practice “How HWE Relates to Current Practice”

 Meaningful Recognition  The long term care setting can no longer be considered a home for the aged. It is imperative that it be known that long term care nurses are working with patients experiencing chronic and acute disease, psychiatric conditions, hospice, ESRD and dialysis, burns, respiratory conditions, wound care and non healing wounds to name a few. These patients deserve quality care.  True Collaboration  As times change and computer documentation becomes necessary more paperwork is added to the nurses responsibility without an increase of staff. The inconsistencies go unnoticed.  Authentic Leadership  It is unrealistic for those supervisors in charge to expect nurses to stay mistake and medication error free under these circumstances. HWE is an ideal in my current practice that is wished for but not as yet attained. Mary Duncan Healthy Work Environment: Standards of Practice “How HWE Relates to Current Practice”

In the Medical-Surgical Floor that I work in, I have observed the following examples for HWE practice standards:  Skilled Communication  The SBAR method is used in all forms of communication: from shift change, to doctor-nurse reporting, to communicating with other members of the health care team.  True Collaboration and Effective Decision Making  Shared governance is practiced where nurses are dedicated to providing an accountability-based nursing practice for our patients, families, peers, physicians and other disciplines and the community at large while fostering an atmosphere of patient partnership and interdisciplinary collaboration. ~Dulcebelle Pearson Healthy Work Environment: Standards of Practice “How HWE Relates to Current Practice”

 Appropriate Staffing:  Acuity based staffing instead of relying on “headcount” is what the Unit is trying to implement. Ideally, one nurse per 3-4 patient is the number that the unit manager is hoping for at all times and barring extenuating circumstances, they average that ratio for the most part.  Meaningful Recognition:  There is a vertical progression to an RN’s career path that rewards excellence not just by an increase in pay and public recognition but by a measurable set of algorithms. A nurse follows a career path that moves from “competent nurse”, “accomplished nurse” to “expert nurse” and these stages have 4 steps built into them. Apart from that, there are separate recognition criteria that acknowledges excellent work performance but also how an employee/nurse exemplifies the facility’s core values. ~Dulcebelle Pearson Healthy Work Environment: Standards of Practice “How HWE Relates to Current Practice”

My current role as a nurse manager in a skilled nursing facility has opened many doors of opportunity to put into place the standards and make a difference. I have not always been successful but the following are examples of the standards and how I have applied them without knowing what they were.  Skilled communication:  We have implemented an SBAR tool that we use for all communication with physician, EMS and report when sending a resident to a procedure, or the ER.  True Collaboration:  We had a change in physician services. Nurses were afraid to call the physician due to communication barriers. We all sat down with our concerns and through collaboration came up with a plan to ensure the best patient outcomes and working relationships. Stephanie Yohn Healthy Work Environment: Standards of Practice “How HWE Relates to Current Practice”

 Effective decision making:  A nurse came to me and said “we are given an enormous amount of responsibility, life and death decisions but we don’t have the autonomy to make the simplest of decisions”. Discussion ensued on the unit with the nurses. Simply empowering them has made the difference.  Appropriate Staffing:  This is a difficult area. The current staffing model is based on the total census. This is not working anymore and we need to change to acuity based as the face of long term care is a dynamic environment that can no longer support the residents who only require basic care. We are working on an acuity based staffing model due to the need for appropriate staffing as we have seen an increase in staff burn-out.  Meaningful Recognition:  We are using Studer’s “Hardwiring for Excellence” this is recognition within the organization. I received a note from a nurse the other day that said she had just worked a double and on her way home contemplated continuing employment as she was so overwhelmed. She said that she is still with us because the simple thank you card that was sent as an appreciation for all the extra time she had been putting in was what she needed to keep going.  Authentic Leadership:  As a nurse leader I am always available to the staff. They know my schedule and know that they can always interrupt any meeting. When there are call-ins I am the first one to jump in and cover the floor or when I simply see them “drowning” pitch in and get the job done. I advocate for them daily and let them know. When we have a great day we celebrate!!! Stephanie Yohn Healthy Work Environment: Standards of Practice “How HWE Relates to Current Practice”

References American association of critical-care (2011,para 12) Retrieved from Nurses Code of federal regulations (42, 3) U.S. Government printing office via GPO access (October, 2002 CITE: 42CFR483.10) Retrieved from Pinkerton, S.(2005). AACN standards for establishing and sustaining healthy work environments. Nursing Economics,23(3)138. Retrieved from Academic OneFile Shirey, M. R. (2006). Authentic leaders creating healthy work environments for nursing practice. American Journal of Critical Care, 15(3), Retrieved from Studer, Q. (2004) Hardwiring Excellence: Purpose, Worthwhile Work, Making a Difference Gulf Breeze Florida: Firestarter Publishing Viejo, A. (2005) AACN Standards for Establishing and Sustaining Healthy Work Environments. American Association of Critical-Care Nurses Retrieved from