Sustaining healthy work environments

FigureThomas Paine, an English American writer, and author of Common Sense, a pamphlet that influenced the American Revolution, once wrote, "A long habit of not thinking a thing wrong gives it a superficial appearance of being right."1 Influencing the health of our work environments begins by recognizing that the status quo of these environments isn't optimal and seeking out opportunities for change within ourselves, our units, and our organizations. As evidence-based clinicians, the next step in the journey is embracing and acting on the evidence to create dynamic, healthy practice environments. The American Association of Critical-Care Nurses (AACN) initially launched the Standards for Establishing and Sustaining Healthy Work Environments in 2005, yet there are ongoing challenges in translating these standards into practice.2 Historically, a variety of barriers impeded the translation of evidence into practice, including a lack of authority, time, and resources.3,4 However, rethinking translation of best evidence into practice is needed to achieve success in the adoption of the Healthy Work Environment (HWE) standards (Skilled Communication, True Collaboration, Effective Decision-Making, Appropriate Staffing, Meaningful Recognition, Authentic Leadership). We can begin with individual commitments. Yes, creating a supportive environment requires a collective effort, but individual commitment to align personal actions to best evidence begins with us. Moving best practice into daily actions requires persistence of intent and often revisiting daily operating routines. The HWE standards are synergistic, but elements of them can be operationalized and contagious based on the principles of role modeling, especially as a nurse leader.5,6 Acknowledging perceived barriers that can stifle effective translation of evidence into daily practice is the first step for success and overcoming hurdles. Table 1 provides examples of using the six HWE standards as part of a shared governance process. Table 1: - AACN's HWE standards within a shared governance framework The following scenario provides examples of using the six HWE standards in a shared governance process. Scenario: A unit Shared Governance Committee was asked to rethink self-scheduling to accommodate staff members' changing needs, including family leave and new team members, while avoiding the use of overtime and agency staff. Standard Shared governance action(s) Skilled Communication Developing a concise message that objectively addresses the desire to retain self-scheduling decisions at the unit staff level True Collaboration Using staff huddles, idea boards, and meetings to generate possible ideas to design a new and innovative self-scheduling process Effective Decision Making Knowing the organizational goals for avoiding overtime and agency use but acknowledging that the staff were empowered to be creative with staffing matrix and scheduling guidelines to cover the unit and meet minimum safe staffing guidelines Appropriate Staffing Empowering staff to develop a system to match patient needs with nurse competencies by designing a new self-scheduling process Meaningful Recognition Developing a "kudos" column on the self-scheduling board for innovative shift coverages. Creating a "high five" announcement at daily huddles to thank team members for a job well done. Posting positive affirmation messages at the time clock to encourage staff to start and end their shift with positive energy. Authentic Leadership Acknowledging the leadership within each team member and ideas they bring to the new process for developing a more patient/nurse-centric, self-scheduling model Skilled communication Effective communication is based on principles of active listening, willingness to share information, openly discussing errors in a blame-free manner, role modeling asking for help, and creating a psychologically safe space.7-9 Listening with the intent to understand and asking nonjudgmental questions that seek to clarify creates a two-way dialogue for clearer communication among nurse leaders, staff, colleagues, patients, and patients' families. A recent integrative review focused on best practice recommendations for HWEs found that effective communication was central.9 The researchers identified that clear communication builds team cohesion, enhances patient safety and satisfaction, and fosters diversity of thought. Effective communication is often a learned skill that requires personal commitment and is developed through creating nonjudgmental environments and actively seeking feedback. Becoming an effective communicator takes both time and reflective effort. Role modeling, providing feedback, and supporting each other in developing communication skills also address adverse climates of incivility and bullying.10 Clear communication isn't devoid of conflict but consistently aims to be factual, open to other opinions, and honest.9 A personal commitment to become better with communication skills begins the evidence-translation journey toward healthier work environments. True collaboration and effective decision-making Well-functioning teams in healthcare require more than effective communication skills. A collaborative mindset that builds on individual and collective strengths is essential.11,12 Individual actions that build collegial relationships demonstrate support, caring, respect, and collective focus on a common goal, the provision of safe, high-quality patient care.13-15 Research by Mabona and colleagues found that HWEs can't function without effective teams, and effective teams require collaboration.9 Ensuring that individual voices are heard within a team is crucial to successful collaboration and subsequent decisions. The standard of effective decision-making can be fostered by ensuring nurses are present and engaged in care decisions though both interprofessional and nurse leader rounds.16,17 In healthcare's highly demanding environments, engaging nurses in decisions about patient care, unit culture, and organizational initiatives is essential, both to the quality of those decisions and as recognition of nurses' valuable and unique perspective. A systematic review found that including nurses in decisions fostered improved patient outcomes, engagement, and professional accountability.18 Although this study explored characteristics of Magnet®-recognized hospitals, the emphasis on the principle of nurse engagement in decisions was evident; better outcomes are obtained when nurses are included in decisions that affect care and work environments. In a blog post, one nurse leader outlined strategies to encourage involvement of frontline nurses in innovative decisions to drive excellence and build stronger teams.19 This nurse leader describes creating a space to speak freely and actively engage in decisions, thus generating new ways to improve practice and increase autonomy and accountability. Appropriate staffing Appropriate staffing is often perceived as a challenge and an opportunity. However, evidence continues to mount in support of a shared governance approach to staffing decisions.20,21 As the individuals most impacted by these decisions, including nurses is central to patient safety, unit effectiveness, and quality of care. A systematic review of 27 longitudinal studies on nurse staffing and patient outcomes affirms the causal link between staffing and patient outcomes, such as reduced mortality, hospital-acquired infections, and unplanned critical care unit admissions.21 With the influx of nurses both new to the unit and new to practice, a critical element in appropriate staffing is nurses' competence to care for diverse patient populations and dynamic needs. Emerging science is supporting the need for better staffing that addresses increased patient acuity, staffing levels, and skill mix. A systematic review using an economic model found that improved nurse staffing that addresses skill mix improves outcomes and reduces net costs, although more robust studies are needed.22 True collaboration, effective decision-making, and appropriate staffing are an effective bundle in the synergistic equation of building and sustaining HWEs. Breaking these three standards down to individual actions implies understanding that each person's engagement in a team impacts the overall success of the team. Decisions need to be made based on as much current data as possible, and data to inform decisions require asking questions to understand and formulate the best choices. Data for decisions obtained from nurses provide insights and understanding regarding possible barriers that need to be overcome. And putting staffing decisions, as much as possible, in the capable hands of those most impacted (frontline nurses) supports shared governance principles and improves high-quality and cost-effective outcomes.20,22 Meaningful recognition Evidence continues to suggest that the most meaningful recognition comes from peers, patients, and families.23 Rethinking meaningful recognition can be as simple as offering a colleague a break after a tough exchange or event such as an unexpected resuscitation or patient death. An integrative review associated implementing a "pause" after an unexpected patient event (an intervention that takes only moments) with reduced clinician burnout and unresolved grief, increased self-reported resilience and retention, and improved patient outcomes.24 Similarly, thoughtful recognition expressed in a handwritten note from colleagues or nurse leaders can communicate value for the recipient.25 Posting positive affirmations for a shift well done and a restful day off at the time clock or entrance to the unit can foster a sense of caring for the individual. A Cochrane review couldn't determine the best interventions to support resilience and mental health for clinicians. However, this mixed-methods systematic review did conclude that the best interventions are those that are adapted for local needs, involve effective communication of gratitude both formally and socially, and support the team in fostering a positive, safe, environment.26 Genuine acknowledgment of each other and the contributions we make is the essential element.25,27,28 A meaningful thank-you by peers and nurse leaders during huddles can model meaningful recognition and serve as a significant step toward establishing and sustaining HWEs. Authentic leadership A Harvard Business School blog articulated the benefits of authentic leadership, including better relationships, higher levels of trust, improved productivity, and more positive work environments.29 The key characteristics of an authentic leader are making a personal commitment to better oneself; inspiring others to be the best they can be; and being trustworthy, truthful, mission-driven, and self-aware.9,30 Authentic leaders may hold formal and informal roles within the healthcare system and are essential in achieving HWEs. A systematic review of 21 studies analyzed elements that influence authentic leadership styles and associated outcomes. The researchers found that there was improvement in employee satisfaction, health and wellness, performance, environment, and patient outcomes when authentic leadership was present within a work environment.30 Becoming an authentic leader requires being self-aware; leaning into one's own experiences, values, and strengths; and seeking feedback to continually grow.30 Within the context of creating and sustaining HWEs, each of us can own our individual responsibilities to lean into ourselves and grow our authentic leadership skills. The collective outcome would be more positivity within the daily functions of healthcare, physically and psychosocially. Leadership doesn't require a formal position or title; anyone who influences others can be a leader.31 Power of one Building evidence-informed HWEs requires a commitment from all team members. The six AACN HWE standards are synergistic. However, individual development of the standards may occur at a different pace for members of the team. The "secret sauce" is persistence in a desire to overcome perceived barriers to evidence-based translation. Through persistence and a desire to change our environments, singular effort grows into collective effort, which then blossoms into a new way of being, or sustained HWEs.