1. Healthy Work Environments for Nurses: An Evidence-Based Toolkit
Alissa Samoya DNP, RN, CPN, CNE
Vanderbilt University School of Nursing
Greenville Technical College
Introduction
Significance
Pilot Study
Figure 1. Sample of content provided in toolkit.
Hyperlinks are activated in online version.
Many would argue that the state of healthcare in the United States is largely dependent on the availability of nurses to care for the patients in need. However, the nursing profession continues to struggle in its ability to overcome the nursing shortage that resulted from a culmination of an increasingly aging population, the economic recession, implementation of healthcare reform, decreased availability of qualified entry-level nurses with a shortage of nursing faculty, and lack of experienced nursing staff as a result of burnout and dissatisfaction. All nursing leaders, administrators, legislators, and patient populations must recognize the inherent risks that accompany a shortage of nurses and work to enhance the environmental factors that could make a positive impact.
The RN shortage could increase to 29% of the entire nursing population by the year 2020, which will negatively affect operational costs as organizations resort to paying premium dollars for overtime and increasing salary dollars to maintain competitiveness in the market.2
Research has shown that hospitals possessing the components of a HWE report increased job satisfaction, employee retention, enhanced recruitment efforts, and improved patient outcomes. 3
Researchers have found evidence linking HWEs for nurses, and desired patient outcomes such as decreased mortality, improved patient safety, decreased length of stay, and increased patient satisfaction in all patient populations.3
To determine the toolkit’s applicability for nursing leaders nation-wide, it was evaluated and piloted by a nursing leader in a Magnet-designated hospital. The health of the work environment was assessed at two points in time during the 90-day period. The two sets of data were compared to national benchmarks and descriptive statistics were calculated for each standard (See Table 1). In addition, a questionnaire, constructed using the REDCap secure data capture system developed by Vanderbilt University, was sent to the nurse leader at the target hospital to obtain the leader’s feedback regarding the usefulness, clarity, and applicability of the tool, and to gain feedback related to potential areas in need of improvement (See Table 2).
Background
Table 1. Data Analysis for Individual Standards
There is a wide breadth of research, dating back to the 1980’s, that supports the idea that leadership practices and organizational structures have an impact on nurses’ perceptions of a healthy work environment (HWE). In fact, the American Association of Critical-Care Nurses (AACN) and the American Nurses Credentialing Center (ANCC) have advocated for HWEs by identifying the essential standards, elements, and structures required for such an environment to exist. However, these efforts alone do not ensure that practice changes can or will actually occur. In order to make lasting and successful changes to the work environment, nursing leaders need readily available and easy to use resources to guide their efforts to ensure evidence-based changes are executed appropriately and efficiently. This toolkit addresses that need with evidence-based links between theory, research, and leadership practice and serves as a guide to translate knowledge into meaningful application in any practice setting.
Theoretical Framework
The Path-Goal Theory, which focuses on a leader’s ability to influence empowerment, motivation, and satisfaction of employees, so that each will become productive contributors to the unit and/or organization, was used for the theoretical framework. 4
Dissemination
Conceptual Framework
Samoya, A. (In press). Healthy Work Environments: An Evidence-Based Toolkit for Nurses. Nursing2015 Critical Care.
Samoya, A. (June 11, 2015). New healthy work environment toolkit. Web-based publication. American Association of Critical-Care Nurses Critical Care eNewsline (digital). Aliso Viejo, CA.
Samoya, A. (May 28, 2015). HWE toolkit. Interactive Web-based publication. American Association of Critical-Care Nurses. Accessible at   
The AACN’s six essential standards of a HWE1, which align with the IOM’s core competencies for health professionals, were developed to identify systemic behaviors that contribute to safe conditions and augment organizations’ and professionals’ abilities to achieve excellence.
Table 2. Leader Questionnaire Results.
Likert scale ratings included “Needs Improvement”, “Average”, “Good”, and “Very Good”.
AACN Standard
Applicability Rating
Usefulness Rating
Clarity Rating
Skilled Communication
Very Good
True Collaboration
Good
Effective Decision Making
Appropriate Staffing
Meaningful Recognition
Authentic Leadership
AACN’s Six Essential Standards of a HWE
Skilled Communication
True Collaboration
Effective Decision Making
Appropriate Staffing
Meaningful Recognition
Authentic Leadership
Objective
The toolkit was developed to provide evidence-based information in a quick-reference format to individuals or groups involved in planning, coordinating, or facilitating practice change implementation as they strive to translate the knowledge of HWEs into meaningful applications in their respective practice settings.
Results
The Time 2 score of 3.31 was higher than the Time 1 score and higher than the national benchmark of While this change in score indicates an improvement, no relationship to the use of the toolkit can be inferred since it had not been fully implemented. Also, since the Time 1 and Time 2 groups were not equivalent, their scores cannot be compared. Comparisons for both HWE results can be made to national benchmarks, however. Overall, the leader agreed that the resources provided in the toolkit augmented her ability to create a healthier work environment.
References
Methodology
1. American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence. Am J Crit Care. 2005;14(3):
2. Ritter, D. The relationship between healthy work environments and retention of nurses in a hospital setting. J Nurs Manag. 2011;19:
3. Kramer M, Schmalenberg C, & Maguire P. Nine structures and leadership practices essential for a magnetic (healthy) work environment. Nurs Admin Q. 2010;34(1): 4-17.
4. House RJ. Path-Goal Theory of leadership: lessons, legacy, and a reformulated theory. Leadersh Q. 1996;7(3):
The toolkit’s design included an independent review of the current literature, synthesis of the findings, and subsequent development of an evidence-based summary of the existing literature in the format of a toolkit for formal and informal nursing leaders (See Figure 1 for sample). As a result, the project created an evidence based link between theory, research, and leadership practice in one central location.