Averting the Perfect Storm: Creating a Healthy Work Environment

A healthy work environment is one in which people are valued and priority is given to the multiple aspects of the workplace that affect employees’ ability to function well in order to accomplish the goals of the organization.¹ Since its early days, nursing has been a profession of service in a high-stress, ever-changing healthcare environment, often without appropriate thanks, reward, recognition, or appreciation. The psychological implication of these phenomena has garnered the interest of researchers over the past two decades. Concern about a high-stress work environment amidst a global nursing shortage leading to nurse burnout and increasing turnover in the workplace has seeded studies exploring psychological demands, social support, work complexity, inadequate staffing, workload imbalance, job strain, and decision latitude among nurses.^2-7

Nurse burnout is a consequence of an unrelenting stressful work environment, which leads to job dissatisfaction and subsequent turnover.⁴ When nurses do not feel empowered, work under strained staffing conditions, and lack management and organizational support, the workplace can become weakened, resulting in patient-safety risks.8 Im proved work place health and safety increases productivity and patient safety.⁹

In the past decade, the phrase “healthy work environment” has gained prominence to describe a workplace with minimal psychological distress, and embraces, among other

elements, staff empowerment and shared decision-making. The Association of Critical-Care Nurses (ACCN)’s Healthy Work Environment Initiative is a multiyear effort to engage professional nurses and health care organizations to recognize the importance of collaborative teamwork and meaningful recognition to improve the working environment for nurses.¹⁰

Both The Joint Commission and the Institute of Medicine have identified elements of a healthy work environment for nurses and are advising healthcare organizations to be aware of the impact of unhealthy work environments on increased healthcare costs, increased job dissatisfaction, nurse turnover, and patient safety concerns.^11,12 A report by Isgur documented a turnover rate of 27.1% among new graduate nurses within their first year of employment,¹³ and the cost of registered nurse turnover

continues to rise. A survey by the Maryland Hospital Association revealed that, in 2000, the estimated cost to fill a vacant nurse position was between $30,000 and $50,000.¹⁴ Total turnover cost can be staggering, not just in the cost to find a nurse replacement, but also in staff morale and retention. Given the current economic climate, unhealthy work environments will be even more costly to the bottom-line finances of healthcare organizations.

Oncology nurses face life-and-death scenarios daily in the care of their patients. High-stress levels are inherent in the specialty. Patient care also encompasses the care of families who are involved and concerned about their loved ones. Today’s healthcare climate of shrinking resources of both personnel and supplies, coupled with a strained work force with more demand than supply of nurses and other healthcare providers, is a formula for the perfect storm of an unhealthy work environment.

Nurses are all too familiar with the nursing workforce trends of the past decade, including supply and demand, aging of nurses, compensation, and higher acuity of patients. Even with the lack of supply of nurses to meet current demands, especially in specialties like oncology, several elements are within the control of nurse leaders to support and inspire a healthy work environment.

Elements of an unhealthy work environment

Today’s healthcare environment is fraught with challenges such as unfilled staffing vacancies, staff dissatisfaction, hostile/volatile work environment, recruitment, and retention as well as issues surrounding patient safety resulting from inadequate staffing, stress, and caregiver fatigue. Work environments that lack trust, collaboration, and teamwork are at risk. Organizations that fail to recognize unhealthy work environments will have a revolving door of nursing staff as a result of staff distress, dissatisfaction, and burnout.

Aspects of an unhealthy work environment start with relationships between employees. Inherent in any relationship are attributes of trust, integrity, open and honest communication, transparency, and intention. A lack of any one of these attributes can derail the workplace and lead to an atmosphere that unintentionally fosters workplace aggression, violence, and discord. A healthy work environment is integral to averting the perfect storm. The organization’s reputation as a good or bad place to work will affect its recruitment efforts.

Transforming the workplace environment

The first step in creating a healthy work environment is to recognize and understand the signs of an unhealthy work environment. Often underreported, some forms of workplace violence do not involve physical violence. In a survey by Hader, types of workplace violence included intimidation, angry outbursts, hypersensitivity to criticism, and harassment.¹⁵ The players involved, including healthcare staff, nurses, physicians, patients, and visitors, were categorized as either victims or perpetrators. Intimidating, aggressive, and disruptive behavior in the workplace can undermine a culture of safety. Nurses should take an introspective look at their behaviors and identify where they may be the victim or perpetrator in any given situation.

Transforming the work environment will require transforming the organization’s culture, which will require commitments from every level of organizational leadership. Nursing leadership can implement key strategies to create positive workplace initiatives, including improving staffing levels and initiating programs centered on employee health and well-being, dignity, and respect. These programs will need to address psychosocial health, shared decision-making, and empowerment.^16-18 The organization must adopt a zero-tolerance policy of unhealthy behaviors by employees, physicians, patients, and visitors. In addition, the organization must adopt a fair and just culture that supports a no-blame and punitive-free reporting system. Some organizations have instituted anonymous tip lines for employees to report behavioral infractions related to unhealthy work behavior. According to the ACCN, fostering a healthy work environment requires a fundamental commitment to three basic assertions: (1) a link to patient safety, (2) a formal program, and (3) a program driven by leadership.¹⁹

Professional organizations’ healthy work initiatives

Table 1 outlines the elements of workplace health necessary for staff satisfaction, improved communication, collaboration, shared decision-making, retention, and patient safety, as identified by nursing organizations and governmental agencies. Organizations that have achieved Magnet designation are more likely to exhibit the elements of a healthy work environment. Several common themes are threaded throughout the different organizational descriptions of healthy work environment elements. The “14 forces of magnetism” identified in the American Nurses Credentialing Center (ANCC) Magnet model fall into five key areas that represent the fundamental components of a healthy work environment, including transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovations, and improvement; and empirical quality outcomes (Table 2).

Optimal clinical practice environment

According to a study by Beal and colleagues, the key characteristics of an optimal practice environment include: (1) valuing scholarly practice, (2) seamless support for nurses at every level of the organization, (3) support for professional development needs of clinical nurses, and (4) nurses’ respect for and appreciation of their value and worth.²⁰ Based on the forces of magnetism identified by the ANCC, nurse managers should focus on three primary priority forces: organizational structure, management style, and interdisciplinary relationships.²¹

First, the organizational infrastructure must embrace transforming the culture to value the worth and contributions of nurses as professionals. This promotes transparency and shared decision-making, while fostering empowerment of voice and action. Second, the style of management must embrace shared decision-making in aspects of organizational governance that impact nursing practice to facilitate positive patient outcomes. Third, the organization must create the ideal environment by promoting interdepartmental and interdisciplinary teamwork among all healthcare providers to achieve desired patient outcomes. An environment in which individual and professional value and worth, as well as respect for what each discipline brings to the whole, is also part of what makes for the optimal clinical practice workplace.

Creating a healthy work environment

Inherent in creating a healthy work environment is establishing and nurturing trust, one of the most powerful forms of motivation and inspiration in the workplace.²² Organizations without positive employee and leadership relationships and trust are at risk for dysfunctional, toxic, and punishing systems and unhappy employees. Organizations with healthy trust relationships have complete open, transparent, and effortless communication between employees and leadership, resulting in a team of professionals working together with true joy, characterized by caring and love.²²

Opportunities exist for managers to avoid the storm of an unhealthy work environment and transform a culture that embodies shared decision-making, trust, and positive communication. Creating a healthy work environment is not something that can be accomplished by one person. It requires the committed efforts of nursing leadership and staff, organizational support, and physician engagement, but it is created one person at a time. Within the zone of empowerment, ask yourself and your staff what you can do to empower your voice and connect in the workplace. Begin by understanding the administrative structure related to policy development, budget structure (operations, capital, and salary), and how staffing decisions are made for both professional and unlicensed assistive personnel. Form a shared decision-making model to engage front-line staff in all aspects of decisions that inform professional practice. Create a professional

nursing environment that fosters open transparent communication, autonomy, accountability, respect, dignity, and professional development. Develop strategies to offer meaningful recognition of nursing staff for top-level performance. There will be a significant return on investment to the organization with cost savings, increase in staff satisfaction, high retention rates, patient satisfaction and safety, and improved overall quality of patient care and a reputation of being an employer of choice.

References

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