AACN Advanced Critical Care Volume 27, Number 1, pp. 21-23 © 2016 AACN
Creating a Healthy
Workplace
Nancy Blake, RN, PhD, CCRN, NEA-BC Department Editor
Barriers to Implementing and Sustaining Healthy Work Environments Nancy Blake, RN, PhD, CCRN, NEA-BC
I
n speaking to people all over the country, I hear that they are struggling to implement healthy work environments. Although everyone wants to work in a healthy work environment, leaders still struggle to create one. Some of the most recent barriers that have been shared with me during the past year have been lack of leadership support, poor collaboration and communication, inadequate staffing, lack of accountability, and lack of meaningful recognition. Here I report the concerns I have heard and give some examples of what can be done to minimize these barriers. Leadership Support Leadership support is an important factor in improving the work environment. The leader must not only act as a role model, but must also hold others accountable for their behavior. Many nurse managers are promoted because of their clinical skills and have not been given appropriate education in the leadership and management aspects of the job. Addressing staff behavior, especially when it is inappropriate and hostile, is very difficult. Everyone needs to be held to the same standards, and holding people accountable for their behavior is a challenge. Most people do not intend to be obstructive, and often they are unaware that their behavior is inappropriate. When behavior challenges are brought to a staff member’s attention, he or she may become defensive. Leaders need to be coached in how to deal with difficult people so that they are prepared to address both the inappropriate behavior and the defensiveness that often occur when corrective discussions take place. These are always difficult conversations, but they are necessary. If the behavior continues despite ongoing mentoring, direct consequences are needed. More hospitals now provide leadership training for new managers to help give them the tools that they need to deal with difficult people. If all staff members agree to address their own behavior and gently remind coworkers when they are behaving in a manner that is not acceptable, bad behavior becomes much easier to address. Staff members accept feedback from their peers and even their friends much better than from their managers. The leaders have a responsibility to set the tone and teach the staff how to accept and receive feedback. It is especially important to address difficult behavior such as hostility, yelling, and condescending or defensive remarks when it happens and not wait until a staff member’s evaluation. Nancy Blake is Director, Critical Care Services, Children’s Hospital Los Angeles, 24719 Garland Dr, Valencia, CA 91355 ([email protected]). The author declares no conflicts of interest. DOI: http://dx.doi.org/10.4037/aacnacc2016553
21
Creating a Healthy Workplace
W W W .AACN ACCON LIN E .ORG
Collaboration Poor collaboration occurs when the team does not work together toward common goals. It is important for the interprofessional team to have a shared vision. Rounding together as a team to ensure that goals are shared with the patient and the patient’s family helps develop a sense of common purpose. This practice also improves satisfaction of patients and their families because they see the clinical team working together regarding the patient’s and family’s care. All staff members should know what the goal for the day is and what is being worked on to prepare for discharge. Many units are implementing rounds that include the full team with participation of patients and patients’ families. All questions are answered during rounds, and when the goals are put in writing and left at the bedside, all staff members can see what the team is working toward. The team cannot have collaboration if team members lack good communication. Whether the form of communication is structured (such as Situation, Background, Assessment, and Recommendation) or not is up to the individual unit or hospital, but open communication is important so that the entire team is aware of the plan for the patient, questions are answered as to why a certain therapy is chosen for the patient, and there is a chance for open dialogue. In addition, when communication is open, staff members have a chance to ask questions so they may learn.
so staffing needs are closely managed and typically no additional staff members are available when a unit has new admissions. Most hospitals manage their staffing on a shift-by-shift basis and when there are new admissions, staff members are redistributed to accommodate. Staggered shifts and oncall staff can help when units have multiple admissions in a shift. Accountability Holding staff members accountable is also important in maintaining a healthy work environment. When workers are not held accountable, apathy may develop. Managers who do not hold staff members accountable are, in essence, taking an action that everyone can see. In some cases, staff members exhibiting difficult behavior get by because managers are afraid to give them feedback. It is also important that there be joint accountability between members of the team and that not only physicians but nurses be held accountable for their behavior. When there is clear accountability for everyone, there are fewer problems because everyone understands their roles and expectations. Many units that are actively seeking to improve their work environment have staff and providers sign a commitment card stating that they will stop doing anything that interferes with a healthy work environment. The mere act of signing something helps hold people accountable. They also are more apt to accept feedback when they are not supporting a healthy work environment.
Staffing Inadequate staffing is a barrier that must be addressed not only at the unit level, but across the hospital. There has to be a way to determine the staffing needs for a patient. Staffing ratios do not take into account the acuity of the patient. There are times when the psychosocial needs of patients and their families take more time than expected, requiring the nurse to spend more time with them. Educational needs of the patient and family also must be taken into account. For example, at the point of discharge it may take a significant amount of time to train family members to do home care for a patient with complex needs. Unfortunately, many units do not take into account the individual needs of the patients and their families. Acuity systems can be implemented to take into account those individual needs. Labor is the biggest cost for hospitals,
Meaningful Recognition The one area that seems to be improving is meaningful recognition. Hospitals are implementing programs for employee of the month, national recognition programs, and the DAISY Award,1 increasing the number of people who are being recognized. In the past, organizations may have had an employee of the year award, but only 1 person was recognized annually. More institutions are recognizing those who have been nominated for awards, in addition to those who have been chosen. Recognizing nominees creates an experience that allows nurses to know that someone took the time and energy to recognize them for doing something good. Whereas many people say they are embarrassed and do not like being the center of attention, most people like the fact that someone noticed their good work. 22
Creating a Healthy Workplace
VOLU ME 27 • N U MB ER 1 • JANUARY-M ARCH 2016
Implementing these programs and recognizing people for their hard work or “going the extra mile” is a great thing. The DAISY Award program recognizes nurses, faculty, nurse leaders, and students for excellence and is currently in place in more than 1900 health care facilities in more than 14 countries.1 The American Association of Critical-Care Nurses’ Circle of Excellence Award is another national awards program that recognizes 25 nurses annually for excellence in an area of critical care nursing.2 These are a few of the many awards that are offered to recognize staff. Many nurses believe that recognition and recognition programs have improved and grown in the past 10 years.
and quality of care are improved when a team works well together and the environment is considered healthy.3 There is also a link to retention when the nurses feel that the leader is effective and competent.4 Under the best circumstances, health care is stressful and there are many difficult days, but the work is far more rewarding if the work environment is healthy, the team is collaborative, and excellent work is recognized. REFERENCES 1. The Daisy Foundation. http://daisyfoundation.org. Accessed November 16, 2015. 2. American Association of Critical-Care Nurses. Circle of Excellence Information. http://www.aacn.org/wd /memberships/content/circle-of-excellence.content? menu=Memberships. Accessed November 16, 2015. 3. Ulrich B, Lavandero R, Woods D, Early S. Critical care nurse work environment 2013: a status report. Crit Care Nurse. 2014;34(4):67-79. 4. Blake N, Leach LS, Robbins W, Pike N, Needleman J. Healthy work environments and staff nurse retention: the relationship between communication, collaboration and leadership in the pediatric intensive care unit. Nurs Adm Q. 2013;37(4):356-370.
Summary Whereas many barriers exist to creating and sustaining healthy work environments, it is important to move beyond those barriers and work diligently to improve nurses’ workplaces. Research indicates that patient safety
23
Creating a Healthy
Workplace
Nancy Blake, RN, PhD, CCRN, NEA-BC Department Editor
Barriers to Implementing and Sustaining Healthy Work Environments Nancy Blake, RN, PhD, CCRN, NEA-BC
I
n speaking to people all over the country, I hear that they are struggling to implement healthy work environments. Although everyone wants to work in a healthy work environment, leaders still struggle to create one. Some of the most recent barriers that have been shared with me during the past year have been lack of leadership support, poor collaboration and communication, inadequate staffing, lack of accountability, and lack of meaningful recognition. Here I report the concerns I have heard and give some examples of what can be done to minimize these barriers. Leadership Support Leadership support is an important factor in improving the work environment. The leader must not only act as a role model, but must also hold others accountable for their behavior. Many nurse managers are promoted because of their clinical skills and have not been given appropriate education in the leadership and management aspects of the job. Addressing staff behavior, especially when it is inappropriate and hostile, is very difficult. Everyone needs to be held to the same standards, and holding people accountable for their behavior is a challenge. Most people do not intend to be obstructive, and often they are unaware that their behavior is inappropriate. When behavior challenges are brought to a staff member’s attention, he or she may become defensive. Leaders need to be coached in how to deal with difficult people so that they are prepared to address both the inappropriate behavior and the defensiveness that often occur when corrective discussions take place. These are always difficult conversations, but they are necessary. If the behavior continues despite ongoing mentoring, direct consequences are needed. More hospitals now provide leadership training for new managers to help give them the tools that they need to deal with difficult people. If all staff members agree to address their own behavior and gently remind coworkers when they are behaving in a manner that is not acceptable, bad behavior becomes much easier to address. Staff members accept feedback from their peers and even their friends much better than from their managers. The leaders have a responsibility to set the tone and teach the staff how to accept and receive feedback. It is especially important to address difficult behavior such as hostility, yelling, and condescending or defensive remarks when it happens and not wait until a staff member’s evaluation. Nancy Blake is Director, Critical Care Services, Children’s Hospital Los Angeles, 24719 Garland Dr, Valencia, CA 91355 ([email protected]). The author declares no conflicts of interest. DOI: http://dx.doi.org/10.4037/aacnacc2016553
21
Creating a Healthy Workplace
W W W .AACN ACCON LIN E .ORG
Collaboration Poor collaboration occurs when the team does not work together toward common goals. It is important for the interprofessional team to have a shared vision. Rounding together as a team to ensure that goals are shared with the patient and the patient’s family helps develop a sense of common purpose. This practice also improves satisfaction of patients and their families because they see the clinical team working together regarding the patient’s and family’s care. All staff members should know what the goal for the day is and what is being worked on to prepare for discharge. Many units are implementing rounds that include the full team with participation of patients and patients’ families. All questions are answered during rounds, and when the goals are put in writing and left at the bedside, all staff members can see what the team is working toward. The team cannot have collaboration if team members lack good communication. Whether the form of communication is structured (such as Situation, Background, Assessment, and Recommendation) or not is up to the individual unit or hospital, but open communication is important so that the entire team is aware of the plan for the patient, questions are answered as to why a certain therapy is chosen for the patient, and there is a chance for open dialogue. In addition, when communication is open, staff members have a chance to ask questions so they may learn.
so staffing needs are closely managed and typically no additional staff members are available when a unit has new admissions. Most hospitals manage their staffing on a shift-by-shift basis and when there are new admissions, staff members are redistributed to accommodate. Staggered shifts and oncall staff can help when units have multiple admissions in a shift. Accountability Holding staff members accountable is also important in maintaining a healthy work environment. When workers are not held accountable, apathy may develop. Managers who do not hold staff members accountable are, in essence, taking an action that everyone can see. In some cases, staff members exhibiting difficult behavior get by because managers are afraid to give them feedback. It is also important that there be joint accountability between members of the team and that not only physicians but nurses be held accountable for their behavior. When there is clear accountability for everyone, there are fewer problems because everyone understands their roles and expectations. Many units that are actively seeking to improve their work environment have staff and providers sign a commitment card stating that they will stop doing anything that interferes with a healthy work environment. The mere act of signing something helps hold people accountable. They also are more apt to accept feedback when they are not supporting a healthy work environment.
Staffing Inadequate staffing is a barrier that must be addressed not only at the unit level, but across the hospital. There has to be a way to determine the staffing needs for a patient. Staffing ratios do not take into account the acuity of the patient. There are times when the psychosocial needs of patients and their families take more time than expected, requiring the nurse to spend more time with them. Educational needs of the patient and family also must be taken into account. For example, at the point of discharge it may take a significant amount of time to train family members to do home care for a patient with complex needs. Unfortunately, many units do not take into account the individual needs of the patients and their families. Acuity systems can be implemented to take into account those individual needs. Labor is the biggest cost for hospitals,
Meaningful Recognition The one area that seems to be improving is meaningful recognition. Hospitals are implementing programs for employee of the month, national recognition programs, and the DAISY Award,1 increasing the number of people who are being recognized. In the past, organizations may have had an employee of the year award, but only 1 person was recognized annually. More institutions are recognizing those who have been nominated for awards, in addition to those who have been chosen. Recognizing nominees creates an experience that allows nurses to know that someone took the time and energy to recognize them for doing something good. Whereas many people say they are embarrassed and do not like being the center of attention, most people like the fact that someone noticed their good work. 22
Creating a Healthy Workplace
VOLU ME 27 • N U MB ER 1 • JANUARY-M ARCH 2016
Implementing these programs and recognizing people for their hard work or “going the extra mile” is a great thing. The DAISY Award program recognizes nurses, faculty, nurse leaders, and students for excellence and is currently in place in more than 1900 health care facilities in more than 14 countries.1 The American Association of Critical-Care Nurses’ Circle of Excellence Award is another national awards program that recognizes 25 nurses annually for excellence in an area of critical care nursing.2 These are a few of the many awards that are offered to recognize staff. Many nurses believe that recognition and recognition programs have improved and grown in the past 10 years.
and quality of care are improved when a team works well together and the environment is considered healthy.3 There is also a link to retention when the nurses feel that the leader is effective and competent.4 Under the best circumstances, health care is stressful and there are many difficult days, but the work is far more rewarding if the work environment is healthy, the team is collaborative, and excellent work is recognized. REFERENCES 1. The Daisy Foundation. http://daisyfoundation.org. Accessed November 16, 2015. 2. American Association of Critical-Care Nurses. Circle of Excellence Information. http://www.aacn.org/wd /memberships/content/circle-of-excellence.content? menu=Memberships. Accessed November 16, 2015. 3. Ulrich B, Lavandero R, Woods D, Early S. Critical care nurse work environment 2013: a status report. Crit Care Nurse. 2014;34(4):67-79. 4. Blake N, Leach LS, Robbins W, Pike N, Needleman J. Healthy work environments and staff nurse retention: the relationship between communication, collaboration and leadership in the pediatric intensive care unit. Nurs Adm Q. 2013;37(4):356-370.
Summary Whereas many barriers exist to creating and sustaining healthy work environments, it is important to move beyond those barriers and work diligently to improve nurses’ workplaces. Research indicates that patient safety
23
