Creating and Sustaining a Healthy Work Environment Guidelines and Issues In Nursing

The Creating and Sustaining a Healthy Work Environment Guidelines and Issues In Nursing. Issues like understaffing, inadequate funding, and high-stress levels can negatively impact a healthy work environment.

How Creating and Sustaining a Healthy Work Environment Guidelines and Issues In Nursing

Creating and sustaining a healthy work environment in nursing is crucial for both nurses’ well-being and patient care. It involves fostering open communication, promoting teamwork, ensuring adequate staffing, supporting professional development, and enhancing workplace safety. Key elements include skilled communication, true collaboration, effective decision-making, meaningful recognition, and authentic leadership.

Creating and Sustaining a Healthy Work Environment

The health-care work environment can impact nurses’ overall outlook as well as their own safety and the ability to provide safe and quality nursing care to patients. Unhealthy work environments create stress among nurses and can contribute to adverse events. Work environments that are unhealthy also typically lack civility, respect, and courtesy; in turn, ineffective interpersonal relationships and workplace violence are often tolerated in such climates.

In contrast, a healthy work environment leads to work satisfaction, increased retention, effective organizational performance, and improved patient outcomes (Sherman & Pross, 2010). In addition, healthy work environments support meaningful work, joy in the workplace, and safer patient care delivery (Lucian Leape Institute, 2013). A healthy work environment also enhances nurse recruitment and retention and helps sustain an organization’s financial viability.

Nurse leaders and managers are responsible and accountable for creating and sustaining a safe and supportive work environment for their staff and patients. However, they face extraordinary challenges in creating a healthy work environment because of the increasing demand for and decreasing supply of registered nurses, reimbursement declines, and constrained resources (Schwarz & Bolton, 2012).

To create and sustain a healthy work environment effectively, nurse leaders and man agers “must be skilled communicators, team builders, agents for positive change, committed to service, results oriented, and role models for collaborative practice” (American Association of Critical-Care Nurses, 2014, p. 19).

Guidelines For Building A Healthy Work Environment

Over the years, nursing organizations have worked to identify elements and competencies for a healthy work environment. A healthy work environment “is one that is safe, empowering, and satisfying not merely the absence of real and perceived physical or emotional threats to health but a place of physical, mental, and social well-being, sup porting optimal health and safety” (American Nurses Association [ANA], 2016a).

A healthy work environment supports excellent nursing care, creates a culture of physiological and psychological safety, and gives nurses the satisfaction of knowing that they are valued and their work is meaningful.

The ANA has developed numerous initiatives, position statements, and brochures focusing what is part of a healthy work environment (e.g., safe patient handling and mobility [SPHM] and healthy working hours) and what is not (e.g., bullying, workplace violence, and nurse fatigue). In 2001, the ANA developed the Nurses’ Bill of Rights to help nurses to improve their work environment and ensure their ability to provide safe, quality patient care (Wiseman, 2001).

According to the document, nurses have the right to practice nursing in adherence to professional standards and ethical practice, advocate freely for them selves and their patients, and practice in a safe work environment (ANA, 2016b). Although the Bill of Rights is a statement of professional rights and not a legal document, it can assist nurse leaders and managers in the development of organizational policy and in advocating for healthy work environments for staff.

In 2002, the American Association of Colleges of Nursing (AACN) identified eight hallmarks of a work environment that foster professional nursing practice. The AACN’s (2016) hallmarks represent “characteristics of the practice setting that best support professional nursing practice and allow baccalaureate and higher degree nurses to practice to their full potential.” Intended to apply to all professional practice settings and all types of professional nursing practice, the hallmarks are as follows (2016):

Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability.
Recognize the contributions of nurses’ expertise on clinical care quality and patient outcomes.
Promote executive level nursing leadership.
Empower nurses’ participation in clinical decision making and organization of clinical care systems.
Maintain clinical advancement programs based on education, certification, and advanced preparation.
Demonstrate professional development support for nurses.
Create collaborative relationships among members of the health-care team.
Use technological advances in clinical care and information systems.

Nurse leaders and managers in all practice settings can find these hallmarks useful. These elements are key in creating and sustaining a work environment that recognizes professional nurses for their knowledge and skills as well as ensuring retention of nurses (AACN, 2016).

In 2005, the American Association of Critical-Care Nurses developed Standards for Establishing and Sustaining Healthy Work Environments to promote the creation of healthy work environments that support excellence in patient care wherever nurses practice. The organization identified six essential standards for establishing and sustaining a healthy work environment (American Association of Critical-Care Nurses, 2016, p. 10):

Skilled communication: Nurses must be as 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: Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement.

These standards provide an “evidence-based framework for organizations to create work environments that encourage nurses and their colleagues in every health-care profession to practice to their utmost potential, ensuring optimal patient outcomes and professional fulfillment” (p. 1). These standards also are interdependent , and implementing them requires a commitment throughout the organization.

In fact, all nurses have an ethical obligation to establish and sustain work environments conducive to providing safe, quality nursing care (ANA, 2015a). Nurses must promote a work environment that demands “respectful inter actions among colleagues, mutual peer support, and open identification of difficult issues” (ANA, 2015a, p. 24). Further, nurses should actively participate in establishing, maintaining, and improving health-care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession.

The American Organization of Nurse Executives (AONE) met with the Emergency Nurses Association in 2014 to develop a set of guiding principles for reducing violence in the workplace. What resulted was a set of guidelines for nurse leaders and managers to use to decrease and control workplace violence in the hospital setting. The AONE Guiding Principles: Mitigating Violence in the Workplace (2014) offers eight principles to reduce lateral and patient and family violence systematically in the workplace (para. 3):

That violence can and does happen anywhere is recognized.
Healthy work environments promote positive patient outcomes.
All aspects of violence (patient, family and lateral) must be addressed.
A multidisciplinary team, including patients and families, is required to address workplace violence.
Everyone in the organization is accountable for upholding foundational behavior standards, regardless of position or discipline.
When members of the health-care team identify an issue that contributes to violence in the workplace, they have an obligation to address it.
Intention, commitment, and collaboration of nurses with other health-care professionals at all levels are needed to create a culture shift. 8. Addressing workplace violence may increase the effectiveness of nursing practice and patient care.

Safety Issues In A Health-Care Environment

An essential element of a healthy work environment is workplace safety, defined by the Lucian Leape Institute (2013) as “a workplace free from risks of both physical and psychological harm” (p. 1). Yet, compared with other occupations, health-care workers have a high number of work-related injuries and illnesses (The Joint Commission [TJC], 2012). The prevalence of physiological injuries among health-care professionals is much higher than in other industries, and psychological harm such as emotional abuse, bullying, and disrespectful treatment is also common (Lucian Leape Institute, 2013).

In 2011, an ANA survey completed by 4,614 registered nurses regarding health and safety issues found that major safety concerns of nurses are disabling musculoskeletal injuries and the acute and chronic effects of stress and overwork (L. C. Williams & Associates Research Group, 2011). Although patient safety programs are prevalent throughout health-care systems, focus on nurse safety is not readily apparent: “Workforce safety in healthcare organizations tends to be considered and managed in silos often unconnected to the work of patient safety” (Lucian Leape Institute, 2013, p. 11).

However, patient safety and nurse safety are linked. A systems approach that involves integration of workforce safety efforts with patient safety initiatives fosters a healthy work environment. If conditions exist in a health-care work environment that compromise the physiological and psychological health of nurses, patient safety is jeopardized.

Nurse leaders and managers are responsible for ensuring a safe work environment and addressing related problems, the most common being improper patient handling and mobility, nurse fatigue, and workplace violence. In fact, accrediting agencies and the Magnet recognition program include standards that address these issues because they impact patient safety and nurse outcomes.

Safe Patient Handling and Mobility

Registered nurses risk musculoskeletal disorders (MSDs) on a daily basis through activities such as standing for extended periods of time and moving equipment. In the 2011 ANA survey, 62% of nurses reported that developing an MSD was a top concern, 56% indicated that they had experienced musculoskeletal pain that was made worse by their job, and 80% of the nurses surveyed who had pain from MSDs continued working despite experiencing frequent pain (ANA, 2013).

The most common tasks that can lead to MSDs include lifting, transferring, and repositioning patients (ANA, 2013). In the daily handling and movement of patients, nurses jeopardize their own physical health and the physical health and well-being of their patients (Ogg, 2011). Nursing experts contend “there’s no such thing as safe lifting” when nurses use their bodies as lifting mechanisms (Fitzpatrick, 2014, p. 1).

Further, they contend that “old school teachings about body mechanics have been proven invalid,” and nurses as well as nurse leaders and managers must change the techniques used to move, transfer, and reposition patients. There are significant clinical consequences of improper and/or awkward patient handling and mobility techniques that can negatively impact the quality of care, patient safety, and patient comfort. The two principle methods for lifting and moving patients are the two-person lift and the hook-and-toss methods (TJC, 2012).

Use of proper body mechanics and training in lifting techniques have been the sole methods in the United States used to prevent or minimize injuries related to moving patients, yet these methods alone continuously fail to reduce injuries during the delivery of patient care (Krill, Raven, & Staffileno, 2012), and they are still prevalent in nursing care today (ANA, 2013; TJC, 2012). Use of body mechanics is simply insufficient to protect nurses from the extremely heavy weight, uncomfortable positioning, and repetition associated with manual patient handling.

Commonly, manual lifting results in micro injuries to the spine that may not be noticeable to the nurse immediately but, when cumulative, can result in a debilitating injury (ANA, 2013). Many barriers to eliminating the risk of harm exist. Nurses cite specifically the lack of a “no-lift” policy, the lack of adequate lifting equipment, and inadequate space on patient care units as major barriers to the development safe patient handling measures.

Lack of equipment, decreased staffing levels, and the architecture of the environment are the three main modifiable attributes to improving the environment of care and increasing the safety of patient handling and mobility (Krill, Staffileno, & Raven, 2012). Furthermore, nurses frequently do not report their injuries, most commonly because nurses believe that they would be letting their patients down, they con sider injuries to be part of the profession (e.g., many nurses believe that back pain is expected), and they think that making a report would be pointless (Callison & Nussbaum, 2012).

To effect change and to ensure safer patient handling and mobility, nurse leaders and managers must implement Safe Patient Handling and Mobility (SPHM) programs and establish policies to prevent nurses and patient injuries across the care continuum. They must also gain the knowledge, skills, and attitudes to best create an environment that focuses on minimizing risk of harm to the workforce and patients alike.

A helpful resource for managers and leaders is the set of inter-professional national standards for SPHM developed by the ANA (2013). The SPHM standards outline the roles of nurse leaders and managers as well as staff and encompass the following (ANA, 2013):

A culture of safety
A formal and sustainable SPHM program throughout the organization
An ergonomic-specific approach
Inclusion of SPHM technology
An effective system of education, training, and maintaining competence
Patient-centered assessments and plans of care adapted to meet individual patient needs
Reasonable accommodations and post injury return to work for staff members who have been injured
A comprehensive evaluation system to evaluate SPHM program status

The ANA supports the adoption of “no-lift” policies and the elimination of manual handling nationwide (ANA, 2008). However, the Occupational Safety and Health Administration (OSHA) cannot enforce such policies; rather, it can only require employers to evaluate work environment safety. Currently, 11 states (California, Illinois, Maryland, Minnesota, Missouri, New Jersey, New York, Ohio, Rhode Island, Texas, and Washington) have enacted safe patient handling laws.

Additionally, Hawaii has a resolution in place calling for support of safe handling and mobility policies. Of these states, 10 require a comprehensive program in health-care facilities, including an established policy, guidelines for securing appropriate equipment and training, collection of data, and evaluation (ANA, 2016c). In December 2015, legislation on SPHM was introduced in the House of Representatives (H.R. 4266) and the Senate (S. 2408).

The implementation of SPHM programs involving the use of patient handling equipment and devices, education, ergonomic assessment protocols, no-lift policies, and patient lift teams has facilitated the reduction in incidences of workplace injuries. These programs are believed to improve the quality of care for patients, reduce work-related health-care costs, and improve the safety of patients (Krill, Staffileno, & Raven, 2012). Further, they can increase worker satisfaction and increase health-care savings as a result of reductions in worker’s compensation, patient falls and pressure ulcers, and employee turnover (ANA, 2013).

Nurse Fatigue

Occupations such as nursing that have extended shifts of more than 12.5 hours, rotating shifts, and higher workloads are associated with worker fatigue and sleep deprivation, both of which can lead to injuries, accidents, and performance errors (TJC, 2012). Nurse fatigue is the “impaired function resulting from physical labor or mental exertion” (ANA, 2014, p. 8). Fatigue can be one of three types: physiological, or reduced physical capacity; objective, or reduced productivity; and subjective, a weary or unmotivated feeling (ANA, 2014).

Findings from a landmark study (Rogers, Hwang, Scott, Aiken, & Dindes, 2004) indicated that the number of errors and near misses registered nurses make are directly related to the number of hours worked. In addition, nurses who work more than 12.5 hours in 24 hours are three times more likely to make errors than are nurses who work less than 12.5 hours. The Institute of Medicine (Page, 2004) found that prolonged work hours resulted in negative worker performance, including slow reaction times, lapses of attention to detail, errors of omission, and compromised problem-solving.

In light of this evidence, the Institute of Medicine recommended that “state regulatory bodies should prohibit nursing staff from providing patient care in any combination of scheduled shifts, mandatory overtime, or voluntary overtime in excess of 12 hours in any given 24-hour period and in excess of 60 hours per 7-day period” (Page, 2004, p. 236). Another common situation that contributes to nurse fatigue and that can jeopardize patient safety is the lack of rest breaks during working hours. Nurses are notorious for not taking meal breaks or rest breaks during a shift.

If and when a nurse takes a break, he or she will often not completely relinquish patient care responsibilities (TJC, 2012). Although this practice is not safe for patients or nurses, rest breaks are not mandated by federal regulations, and fewer than 25 states currently have legislation enforcing workers’ legal rights to breaks (Witkoski & Dickson, 2010). Even though evidence supports recommendations that nurses take uninterrupted breaks, self-care is often sacrificed for patient care.

Unfortunately, this is the current cultural attitude, and it puts both patient safety and nurse safety at risk. There is a well-documented relationship between nurse fatigue and nurse errors that can compromise patient care and safety (ANA, 2014; Bae & Fabry, 2014; Rogers et al., 2004; Witkoski & Dickson, 2010). It is critical to safety and quality care that nurses carefully consider their level of fatigue when accepting a patient assignment that extends beyond the regularly scheduled workday or work week (ANA, 2006).

In fact, nurses have an ethical obligation to practice in a manner that maintains patient and personal safety (ANA, 2014). As a patient advocate, nurses must be “alert to and take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the healthcare team or the healthcare system or any action on the part of others that places the rights or best interests of the patient in jeopardy” (ANA, 2015a, p. 12).

Working when fatigued can place the nurse’s safety, as well as the patient’s, in jeopardy. Fatigue can result in irritability, reduced motivation, inability to stay focused, diminished reaction time (TJC, 2012), increased risk for errors, decreased memory, increased risk-taking behavior, impaired mood, and ineffective communication skills. It can also negatively impact the health and well-being of nurses (ANA, 2014).

In December 2011, TJC issued a Sentinel Event Alert linking health-care worker fatigue and adverse events to high levels of worker fatigue, reduced productivity, compromised patient safety, and increased risk of personal safety and well-being (TJC, 2011, para. 1). Nurses at all levels are obligated to seek balance between their personal and professional lives; fatigue can negatively impact both. Nurses have a responsibility to arrive at work well rested, alert, and prepared to deliver safe, quality nursing care (ANA, 2015a, 2015b).

In addition, nurse leaders and managers have an ethical responsibility to foster this balance among their staff members. Nurses and nurse leaders and managers have a joint responsibility in reducing the risk of fatigue and sleepiness in the workplace. Nurses at all levels should adopt evidence-based fatigue countermeasures and personal strategies to reduce the risk of fatigue (ANA, 2014, p. 4).

Some examples include sleeping the recommended 7 to 9 hours within a 24-hour period, taking brief rest periods before work shifts, improving overall health, adopting stress management strategies, taking scheduled meal and rest breaks when working, and taking naps in accordance with organizational policies (ANA, 2014, p. 4). Nurse leaders and managers are responsible for creating and sustaining a healthy work environment that promotes healthy work schedules. The ANA (2014) offers the following evidence-based strategies that nurse leaders and managers can use to prevent nurse fatigue (pp. 6–7):

Limiting shifts nurses work to no more than 12 hours in 24 hours and no more than 40 hours per week
Conducting regular audits to ensure that safe schedule policies are followed
Ensuring that nurses are able to take scheduled meal and rest breaks
Establishing policies to allow nurses to take naps during long shifts
Supporting nurses’ decisions to decline working extra shifts or overtime without penalizing them

Nurse leaders and managers must be change agents to develop policies that support evidence-based recommendations for dealing with nurse fatigue. They must monitor overtime to ensure that staff members are not working fatigued, develop flexible work schedules, and implement work schedules with minimal rotation of shifts (TJC, 2012).

Nurse leaders and managers are “responsible for establishing a culture of safety; a healthy work environment; and for implementing evidenced based policies, procedures, and strategies that promote health work schedules and that improve alertness” (ANA, 2014, p.5).

Workplace Violence

The health-care industry has a long history of tolerating disrespectful behaviors that erode confidence and self-esteem. Many of these behaviors fall under the umbrella of workplace violence and create a culture of fear, diminish staff morale, impact patient safety and job satisfaction, and drain joy and meaning from work (Lucian Leape Institute, 2013).

Further, workplace violence in health-care settings results in disrupted work relationships, miscommunication, and an unhealthy work environment, and it is linked to negative patient and nurse outcomes. A review of the literature suggests that workplace violence is a global problem and is not unique to any one specific nursing specialty (Hockley, 2014).

The United States is believed to have more workplace violence than any other industrialized nation in the world, and the incidence of violence is higher for health-care workers than for those in other occupations (Nelson, 2014). The World Health Organization, the International Council of Nurses, and Public Services International identified workplace violence as an important universal public health issue (Child & Mentes, 2010; Magnavita & Heponiemi, 2011).

A meta-analysis of research studies con ducted in 38 countries revealed that approximately 30% of nurses worldwide are physically assaulted and injured, and approximately 60% of nurses have experienced nonphysical violence (Spector, Zhou, & Che, 2014). The National Institute for Occupational Safety and Health (NIOSH) uses the following classifications for workplace violence (NIOSH, 2013):

Type 1: The perpetrator has criminal intent and no legitimate relationship with the organization or its employees.
Type 2: The perpetrator is the customer or client, patient, family member, or visitor and has a relationship with the organization and becomes violent while receiving services. This type of workplace violence is very common in health care.
Type 3: The perpetrator is another coworker or commits worker-on-worker violence. This type of workplace violence includes incivility and bullying and is very common in health care.
Type 4: The perpetrator has a relationship with a worker but no relationship with the organization. This type of workplace violence involves personal relationships (e.g., an employee is followed to work by his or her spouse with the intent to threaten or harm the employee).

Nonphysical workplace violence includes emotional abuse, intimidation, put downs, harassment, humiliation, and humor at the expense of a colleague (Lucian Leape Institute, 2013). Bullying and incivility are two examples of the most prevalent nonphysical workplace violence. Bullying is defined as “repeated, unwanted actions intended to humiliate, offend, and cause distress in recipients” (ANA, 2015a, p. 3). Bullying harms, undermines, and degrades others and includes hostile remarks, verbal attacks, threats, taunts, intimidation, withholding of support (ANA, 2015a; McNamara, 2012; Rocker, 2012).

Incivility is defined as “disrespect, rudeness, and general disdain for others” (Rocker, 2012, p. 2) that often results in psychological and physiological distress for those involved (Griffin & Clark, 2014). Incivility can also include gossiping, spreading rumors about others, and refusing to assist a coworker. It typically constitutes a continuum of disruptive behavior , with non-verbal behavior (eye rolling) on one end of the spectrum and physical violence and tragedy on the other (Clark, Barbosa-Leiker, Gill, & Nguyen, 2015).

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