Healthy Work Environments

Critical Care Nurse Work Environments 2013: A Status Report BETH T. ULRICH, EdD, RN RAMÓN LAVANDERO, RN, MA, MSN DANA WOODS, MBA SEAN EARLY, PhD

BACKGROUND The health of critical care nurse work environments has been shown to affect patient care outcomes as well as the job satisfaction and retention of registered nurses. The American Association of Critical-Care Nurses (AACN) Critical Care Nurse Work Environment Survey was first conducted in 2006 following the release of the AACN Standards for Establishing and Sustaining a Healthy Work Environment and was conducted again in 2008. This article reports the results of the third AACN Critical Care Nurse Work Environment Survey conducted in 2013. OBJECTIVE To evaluate the current state of critical care nurse work environments. METHODS A total of 8444 AACN members and constituents responded to an online survey. RESULTS The overall health of critical care nurses’ work environments has declined since 2008, as have nurses’ perceptions of the quality of care. Respondents rated their overall work environment and factors associated with healthy work environments including quality of patient care, staffing, communication and collaboration, respect, physical and mental safety, moral distress, nursing leadership, support for certification and continuing education, meaningful recognition, job satisfaction, and career plans. Although some factors improved, declines in any factors are a concern. CONCLUSIONS An increasing body of evidence has shown relationships between healthy nurse work environments and patient outcomes. The results of this 2013 survey identified areas in which the health of critical care nurse work environments needs attention and care, requiring the relentless true collaboration of everyone involved. (Critical Care Nurse. 2014;34[4]:64-79)

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he health of the environments in which registered nurses (RNs) work is critical to nurse job satisfaction and retention and to patient outcomes. In 2005, the American Association of Critical-Care Nurses (AACN) issued the AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence.1 Developed by an expert panel, these standards were based on published and experiential evidence from nurses and other health care experts throughout the United States. More than 50 content experts, representing a wide range of roles, acute and critical care settings, and geographic locations, reviewed the standards, critical elements, and explanatory text to establish face validity.1 ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014731

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The 6 essential standards—skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership—placed a spotlight on systemic behaviors often discounted despite mounting evidence that their absence affects safety, quality of care, and job satisfaction among health professionals. This landmark document underscored the association’s commitment, begun in 2001, to create healthy work environments and foster excellence in patient care. In 2003, AACN President Connie Barden challenged each nurse in AACN’s community of high acuity and critical care nurses to act boldly and personally commit to identifying the most pressing challenge in nurses’ immediate work environment, initiate discussions to find solutions to the challenge, and remain actively involved until the solutions took root.2

Impact of Healthy Work Environments Evidence of the impact of healthy work environments on nurses and patients continues to mount. Aiken et al,3 in a study of work environments in 9 countries, found that hospitals with poor work environments were associated with negative outcomes for nurses (burnout, job dissatisfaction) and patients (lower-quality care, not prepared for discharge). Another study by Aiken and colleagues,4 which included data from 655 hospitals and more than 39000 nurses, showed that the impact of better staffing was greater in hospitals with the best work environments. For example, the researchers reported that decreasing the nurse workload by 1 patient per nurse lowered mortality by 9% in hospitals with the best work environments and by 4% in hospitals with average work Authors Beth T. Ulrich is a Senior Partner at Innovative Health Resources, Houston, Texas, and a consultant on Healthy Work Environments for the American Association of Critical-Care Nurses in Aliso Viejo, California, and Editor of the Nephrology Nursing Journal. Ramón Lavandero is a Senior Director of the American Association of Critical-Care Nurses, and a Clinical Associate Professor at Yale University School of Nursing in New Haven, Connecticut. Dana Woods is the Chief Executive Officer of the American Association of Critical-Care Nurses. Sean Early is an Adjunct Assistant Professor at the University of Southern California in Los Angeles, California.

environments, but had virtually no effect in hospitals with poor work environments. Friese and colleagues,5 in a study of nurse practice environments and outcomes for surgical oncology patients, found that as the practice environment improved so did the 30-day mortality rates, complication rates, and failure to rescue rates. In a 2013 presentation, Aiken6 concluded the following: Good nurse staffing levels are necessary, but not sufficient, for excellent patient care outcomes. Indeed, the cost of improving nurse staffing in hospitals with poor work environments is not a good investment relative to improving the work environment. Medication errors are a major threat to patient safety, and RNs are the key to intercepting errors before they reach patients.7,8 Flynn et al9 studied the relationships between nurse practice environments and medication error interception in acute care hospitals. Better practice environments were positively and significantly associated with error interception. Kelly and colleagues10 investigated the relationship between critical care work environments and nurse-reported health care–associated infections (HAIs), using a sample of 3217 critical care nurses in 32 hospitals. There was a significant association between the health of the work environment and the occurrence of HAIs; in better work environments, nurse-reported HAIs were less likely to occur. These findings have major implications for patient safety and for decreasing the financial impact of errors. The quality of nurses’ work environments also has a significant relationship to all Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.11 McHugh et al12 found job satisfaction and nurse burnout had a statistically significant effect on patient satisfaction measured by 2 HCAHPS measures—hospital rating and willingness to recommend a hospital. For every 10% of nurses who reported dissatisfaction with their jobs, the percentage of patients who would definitely recommend the hospital decreased by about 2%, even after controlling for the effects of staffing and nurse work environment.

Corresponding Author: Beth T. Ulrich, EdD, RN, FACHE, FAAN, 3811 Abbeywood Drive, Pearland, TX 77584 (e-mail: [email protected]).

Critical Care Nurse Work Environment Studies

To purchase electronic or print reprints, contact the American Association of CriticalCare Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].

In our first Critical Care Nurse Work Environment Study, during the spring of 2006, we asked AACN

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members and constituents about a wide range of work environment issues.13 More than 4000 nurses responded to the online survey. The second Critical Care Nurse Work Environment Study was conducted in the fall of 2008; more than 5000 nurses responded to this survey.14 In this article, we compare the results of the current study, conducted in early 2013, with the results of the 2 previous studies.

Context It is important to consider the contexts in which these studies took place. In 2006, the United States continued to experience one of its most significant nursing shortages. Demand far exceeded supply. As a result of the nationwide recession that began in 2007, some RNs returned to the workforce while others increased their work hours. Hospital vacancy rates declined to the point that new graduate nurses in many job markets could not find work as RNs.15 Shortly after the 2008 survey was conducted, major changes were made in the federal reimbursement for health care that included nonpayment for “never” events, followed by similar changes from other payors and reimbursement penalties for preventable readmissions. By the time we conducted this third survey in 2013, there were signs of a general economic turnaround. Unemployment rates in the United States had decreased from peak recession levels. The stock market had recovered, and nurses’ retirement accounts were returning to levels that would allow retirement for those who had deferred it during the recession. At the same time, the Affordable Care Act initiated what could become sea change transitions in American health care. Hospitals experienced new uncertainty as they moved toward integrated care and reimbursement intended to reward the value of care rather than the quantity.

Methods Survey Instrument The AACN Critical Care Nurse Work Environment Survey instrument was developed in 2006 based on the AACN Standards for Establishing and Sustaining Healthy Work Environments1 and previous independent national research about nurses’ work environments.16 The AACN Critical Care Nurse Work Environment Survey has 3 parts: the Critical Elements of a Healthy Work Environment scale, a series of additional questions to explore work environment elements in more detail, and questions

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about participant and employing organization demographics. The 2006 survey was pilot tested with a national sample of RNs and no major changes were indicated.13 In 2008 and 2013, we modified the additional questions to probe results from the preceding surveys. For example, in 2008, a new open-ended question asked participants to describe the most meaningful recognition they had received. In 2013, we asked if the AACN healthy work environment standards had been implemented in the participants’ work units and employing organizations, and queried about which of the standards was the most challenging to meet in their work unit. The Critical Elements of a Healthy Work Environment scale is a 32-item survey based specifically on the AACN healthy work environment standards. The scale assesses the manifestation of the healthy work environment standards in a work unit and organization using Likerttype belief statements with 4-point response vectors17 of strongly disagree (1), disagree (2), agree (3), and strongly agree (4). A series of 62 questions then explores work environment elements in more detail, including questions about areas such as participant awareness of the AACN healthy work environment standards; perceptions of quality of patient care; frequency of verbal and/or physical abuse, sexual harassment, and discrimination; staffing and work that gets done; job and career satisfaction; and career plans. An additional 29 items collect demographic data about each participant and his or her employing organization. An open-ended question added in 2013, 8 years after the standards were released, invites suggestions for how to improve the healthy work environment standards. Cronbach , a measure of inter-item correlations that demonstrate how well a tool functions to target a specific underlying construct, was applied to the 32item Critical Elements of a Healthy Work Environment scale. Cronbach  for the scale is 0.97 based on a subsample size of 5875. In order to use complete-case data in the analysis, we excluded 2552 responses with at least 1 missing response. Inter-item correlations ranged from a low of 0.200 to a high of 0.906, with a mean inter-item correlation of 0.473. We further divided the scale into subscales that examine the employing organization as a whole and the work unit itself. Cronbach  for the organization subscale is 0.94 (n=6378) and 0.94 (n=6049) for the work unit subscale.

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The Critical Elements of a Healthy Work Environment scale is a traditional measurement scale that has remained constant across all 3 surveys. The other 2 sections of the AACN Critical Care Nurse Work Environment Survey are survey tools used to elicit participant opinions, report frequency of events of interest related to healthy work environments, and gather demographic information. Because of this distinction among its sections, standard measures of numerical reliability could not be applied to the entire survey.18 Data Collection All 3 surveys used a convenience sample of AACN members and other individuals in AACN’s database who linked to the online instrument from an invitation e-mail. Each survey included an incentive: participation in a drawing for a complimentary registration to attend the AACN National Teaching Institute & Critical Care Exposition. Completion of the survey implied consent. The 2013 survey was conducted from February 6, 2013, to March 2, 2013. Analysis Descriptive statistics (including frequencies, percentages, standard deviations, and means) were determined for all scalar variables. Frequencies, percentages, and modal values were calculated for categorical variables. Responses were cross-tabulated against demographic variables to determine which variables were significantly correlated (

Critical care nurse work environments 2013: a status report.

The health of critical care nurse work environments has been shown to affect patient care outcomes as well as the job satisfaction and retention of re...
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