Leadership Agenda for Change Toward Healthy Work Environments in Acute and Critical Care

Strategies for building healthy work environmentsIn 2001, the American Association of Critical-Care Nurses (AACN) made a commitment to promote the creation of healthy work environments. The AACN followed through on this commitment with a landmark publication titled AACN Standards for Establishing and Sustaining Healthy Work Environments.1 Healthy work environments are known to contribute to excellent patient care.2,3 Organizations with such work environments have structures in place that enable processes such as team-work and collaboration to produce positive outcomes.3Although reports of the changing conditions in the health care work environment have been extensively documented in the general nursing literature,4–7 and changes in the work environment are linked to patient safety,8 limited formal studies before the AACN national critical care survey9,10 (hereafter referred to as the National Survey) have been undertaken to provide an empirical assessment of the health care work environment at the facility and unit level in critical care. As reported by Kirchhoff and Dahl,9 the National Survey offers the first glimpses of issues specific to acute and critical care units and the more than 500 000 nurses who work in these units.11 The aim of the National Survey was to provide important national averages to which hospitals can compare their institutions and critical care units. The significance of the National Survey is that it offers new insights into critical care units and nurses from the standpoint of unit-specific rather than aggregate data.Of note, although the data from the National Survey9 may provide early comparative data that were not previously available on critical care units, these data are not “benchmarks” because they do not constitute best demonstrated practices. Additional studies are needed to evaluate how these early data compare with performance standards and outcomes in Magnet facilities and units that have received the AACN Beacon Award, both designations recognized for excellence.2,3 The low facility response rate (18.2%) in this study of 120 (of 658 eligible) facilities and 300 (of 576 solicited) units should be considered. With Web-based surveys such as the National Survey, a 60% response rate is considered acceptable.12 Dillman,13 a pioneer in Internet survey methods, encourages closer to an 80% response rate while acknowledging that achieving such high response rates is difficult.Five percent of the responding hospitals in the National Survey9 had been designated as Magnet hospitals by the American Nurses Credentialing Center (no reference was made to AACN Beacon unit status). Nationally, only 3.6% (209 Magnet hospitals among 5759 hospitals in the United States) of all US hospitals are Magnet hospitals. This observation indicates that the hospitals in this study may overrepresent Magnet institutions and thus may not be fully representative of other facilities throughout the United States. At best, findings from the Magnet organizations may show more favorable outcomes than do those of other facilities. Thus, the snapshot of critical care units generated from the National Survey may be rosier than reality and points to the need for further work on behalf of critical care units and their respective nursing practice environments.The purpose of this article is to present a secondary analysis of the AACN National Survey published in the January 2006 issue of the American Journal of Critical Care9 and the 2004 National Critical Care Survey Findings Report10 to determine their implications for nursing administrators. The findings are then related to evidence and best-demonstrated practice where those practices exist. Finally, administrative strategies for change are recommended.Two nurses with advanced degrees and experience in critical care nursing, nursing administration practice, and research utilization conducted the secondary analysis. After independently examining the study findings, the reviewers came to agreement on themes that emerged from the findings. Four major themes were specifically relevant to nursing administration practice: leadership, practice environment, staffing, and professional advancement and recognition. Elements of the 4 themes were amenable to intervention. In the following sections, we discuss each of these vital themes. Table 1 provides a summary of the National Survey findings to support each of the identified themes. This table complements commentary for each theme within the following “Discussion” section.Nursing administration practice involves both leadership and management functions, although leadership and management are 2 separate and distinct concepts.14 Ideally, leadership and management expertise should exist simultaneously in the same person. Understanding the distinction between leadership and management is essential because both are needed to move organizations forward.For purposes of distinguishing between leadership and management, leadership involves “mobilizing the interest, energy, and commitment of all people at all levels of the organization.”15 Leadership addresses effectiveness (are we doing the right thing?) and focuses on what needs to be done and why. Leadership is transformational and places great emphasis on vision and innovation for the future. Importantly, leadership is about people and about relationships. Conversely, management is defined as “a process of coordinating actions and allocating resources to achieve organizational goals.”14 Management addresses efficiency (how can we do this better and faster?) and focuses on understanding processes with more of an emphasis on the status quo and bottom-line results. Management is more transactional and thus is driven by problems emerging in random order and requiring immediate operational actions.14In the National Survey, more attention was given to management structures (unit function and operations) than to leadership functions (influence and vision). Learning about the state of both leadership and management in critical care settings helps leaders create more positive environments for practice. Understanding the current leadership and management state of today’s practice settings also helps heed the warnings of prominent leaders who suggest organizations in the United States have for too long been over-managed and underled.15,16The unit governance structure is a distinct area mentioned in the National Survey that directly addresses both leadership and management functions. Although the results suggest that 55% of the units have shared governance, a collaborative management structure17 requiring the manager to serve as coach, mentor, and facilitator, the findings do not shed extensive light on the current leadership art and science practiced in today’s critical care work environment. Although the purpose of the National Survey was to provide a comprehensive view of hospitals and critical care units, it may have benefitted from a more detailed assessment of the state of current leadership in critical care. A separate study that uses staff nurse respondents to report on the conditions of the work environment and the perceived state of leadership within those environments would provide an even richer assessment to complement the National Survey. It is well known that staff nurses identify leaders’ empowering behaviors (inclusive of support) as important requirements of the desirable practice environment18 needed for nurse retention.19 Accordingly, addressing the extent to which authentic leadership, an essential element of the healthy work environment, is evident (or not) in today’s critical care practice settings is crucial for a fuller assessment of work environments. Because authentic leadership is an empowering leadership style and one that has been identified as “the glue” that holds together a healthy work environment,20 additional studies are needed to document the state of the leadership in today’s critical care units. Understanding the current state will help determine the necessary interventions required to bridge existing leadership and management gaps and propel movement toward the more desirable authentic leadership practices needed to promote healthy work environments.21The National Survey makes reference to critical care managers spending considerable time (number of hours per day are not specified) in the staffing function. This finding is consistent with the findings of qualitative studies that the amount of nurse manager time and energy taken with staffing the managers’ units is extraordinary.22 Although staffing is an important function, excessive time spent on this short-term aspect of the role precludes the manager’s ability to be visible and to build the necessary long-term relationships with staff that translate to engaged, committed, and retained employees for the future.The National Survey’s full findings report10 alludes to span of control. About three-fourths of the nurse managers surveyed reported having responsibility for 1 or 2 units; 1 in 5 nurse managers had responsibility for more than 2 units. On average, nurse managers had accountability for 71 staff members and 28 beds per unit. This nurse manager span of control appears to be higher than the 16 to 54 nurse manager direct reports noted in the most recent comparative study23 of acute care hospitals with 50 to more than 350 beds, respectively. The span of control figure in the National Survey is also far greater than the maximum 15 employees advocated by some experts.24 That the nurse manager’s plate may be too full is an understatement. Excessive managerial span of control is an important issue, particularly because recent research25 indicates an inverse relationship between nurse manager span of control and employee engagement. Research findings further suggest that “it is not humanly possible to consistently provide positive leadership to a very large number of staff while at the same time ensuring the effective and efficient operation of a large unit on a daily basis.”26(piv)The respondents to the National Survey were nurse managers whose demographics suggest a homogeneous group in terms of race/ ethnicity (82% white, 7% African American, 1% Hispanic), age (mean, 45 years), and sex (90% female). This profile mimics the national nursing demographics for the variables of race/ethnicity (88.4% white, 4.6% African American, 1.8% Hispanic), age (mean, 46.8 years), and sex (94.3% female) as reported in the national sample survey of US registered nurses.11 The demographic profile for both the National Survey and the national sample of US registered nurses, however, does not match the overall US demographic profile27 for the same variables (race/ethnicity, 75.1% white, 12.3% African American, 12.5% Hispanic; mean age, 35.3 years; sex, 50.9% female). This observation highlights the need to strengthen nursing leadership through further efforts to achieve workforce diversity in keeping with US and community demographic profiles.The findings of the National Survey suggest that the current nursing shortage and the increasing complexity of patient care have been felt in the critical care work environment. A total of 25% of nurse respondents perceived that staffing does not currently match patients’ needs to nurses’ skill level or mix. Lack of staffing, overwork, and stress have been reported8 and raise important implications for patient safety and considerations for adverse health outcomes in nurses.Despite reporting increases in acuity of critical care patients in the past 12 months, respondents to the National Survey indicated that no concurrent increases in budgeted positions for registered nurses (RNs) had occurred. This finding suggests that nurses are currently working harder and thus may be more at risk for physical and emotional exhaustion. Some evidence28–30 suggests that increasing acuity of patients combined with inadequate staffing (which is may to and among nurses, which in may with the nurse and patient was the by at of of in staff on their Although this practice may serve to an immediate staffing the hours by critical care nurses may not be considered. This National Survey finding is because of the known adverse of work hours for critical care nurses on nursing and patient reported of staff and by of the units in the National Survey also may have to do with both the current nursing shortage positions in 60% of units in the and the requirements control and of those critical care nurses at the for nurses with of experience were with for findings suggest that for nurses may be is evident among The for these nurses higher than for nurses a per of this does not with which has per a nurse for professional by early in a and low for nurses is an in the nursing to nurses’ patient care for nursing or from direct patient the is to and nurses, an analysis of may be necessary to identify for considerations and better of more mean staff rate reported in the National Survey was This figure with the national mean staff rate in critical care units of reported in the most recent comparative nurse within the care units, care units care units suggests that a desirable organizational is an important of to among nurses, and attention to organizational is most to nurse Because in organizational were not specifically further research to a between organizational and nurse may help to the in these for nurses working in all were the The mean time to however, were required for care units, for and for data about for these we can only that the greater in the positions may have to do with the of working in units, the more reported in the environment to be more and and the more desirable work hours of the practice nurses such as nurse and nurse do not to be in the critical care work the 300 units had no and had no nurse percent of critical care units had and of most were in were in care units and even in units nurse extensive evidence to suggest that contribute to nursing staff patient of and nursing of in hospitals in community does not With the evidence to support the of it is not to practice in critical care settings of the facilities in the National Survey were Magnet within the is consistent with national is not however, is that such a large of facilities were not into the and professional expertise that and Magnet In the of support from a of is an essential element required to Magnet the and within the required of that care organizations provide and for the utilization of particularly advanced practice of the high of in and in care into critical care units into as more to nurses in the role nurses report that the first to of professional practice are the most Although having a is not as an of nursing having such a practice in place is known to of new nurses and the nurses’ and to patient The need for the and of even more in the of that results from the number of of units staff and an increasing in nurses for percent of the units surveyed had shared governance The of shared governance structures with best-demonstrated practices that the control professional Although 55% of units having a shared governance structure may a great of note, of all facilities have some of shared for nurses, and shared governance is the most structure nurses in effective through of shared governance structures also a crucial of the AACN standards for healthy work The effectiveness of the shared governance a crucial to these to effective was not in the National of the National Survey that practices in the critical care work environment and thus performance efforts are evidence from the National Survey suggests that performance are needed for and 1 in 4 critical care units reported some of for care. the care by of unit. The of in care an important Although and on care in the evidence on which to best-demonstrated practices for care in critical care settings appears to be with an well recognized for expertise in help facilities to promote practices for care that have long been needed for critical care of the AACN collaborative findings with the and the Critical Care would be most the to a in the is also nursing time staffing of critical care nursing practice at the of and on in the by unit and Although critical care nurses have long the of in the limited and of an practice efforts to translate existing research into practice are are an important area for of patients and their with critical critical care nurses practice in the age, the finding that only of critical care units surveyed suggests that critical care units may be in the that more than of units not provide data a of or does it a in management or in how to those critical care nurse managers about the between and data needed to provide the of the nurses in the National Survey who reported they have Internet at work their to patient care processes and nursing practice or is the available not to percent of respondents not report the mean number of needed to an It is the data were not or were not known to the the those who to the the number of from than to more than 120 (mean, National suggest that critical care and positions the to only of these positions are in and more than to of respondents acuity and acuity were more in hospitals with more than 500 beds and in hospitals in on to a and the of acuity are important needed for staffing in acute care units. In the National Survey, of consistent reporting about to a and the of acuity by than of the units among reviewers that units are on than the needed to provide leadership related to on required to a and of acuity with nursing of how nurses have to work and what resources nurses need to the of patient are essential for leadership related to The is vital for the and for leaders to and the administrative data such as the Management may be the best to these The is the management data by nurse to nursing management data for and The the work of and work that has been and to be relevant the National Survey, staffing to unit units to were more than units defined as having to into the need for staffing this finding that units have more staff or that units are more of the needs of their research is needed in this critical area of of respondents that patient is the major they staffing and acuity the most units do their staffing with patient needs emphasis than the patient in the Lack of for the right to each patient is with standards for the AACN staffing and The AACN for for staffing issues is that the of respondents that the staffing had not been to 25% of the percent had beds for more than because of the of This finding is to results of other national in which of nurses that the of care has In the survey conducted by the American Nurses of the respondents who reported a in of care the to inadequate what extent are to beds in the of inadequate staffing patient are needed to a between beds and what extent are hospitals and leaders the of leadership of in efficiency and and of an to of of to staffing Magnet status nurses’ of staffing and such an be one to those that to for best practice in the and the of staff to patient The of staffing is important for nurses that a recent study of nurses documented a direct from perceived staffing to emotional the AACN Standards for Establishing and Sustaining Healthy Work staffing is 1 of the essential standards for care in the critical care environment. is of the most to patient safety and to the of The of staffing is to match the needs of patients to nurses’ and that the changes that in critical care patients can be recognized and to by an processes be in place to determine the of staffing on patient outcomes and to the with in this area that needs staffing and for for staffing effectiveness be for each to hours per patient day are a of outcomes for patients than are the hours per patient The all levels of direct and does not the hours per patient day specifically addresses hours and is a in patient research is needed to determine best practice in staffing and the National Survey not an operational for professional advancement and assessment were reported for advancement organizational support for and of for Although is considered a for all new employees rather than a of was in the of professional identified that units and facilities the of critical care nurses of support for and of to the in professional advancement and of are strategies for organizations to both employees and may achieve better performance through the by recognition. It is thus not that who are recognized have higher more and are to on new and contribute new the results of the National Survey9 a positive for professional advancement and recognition. percent of units had professional and advancement in and an additional had such in than 80% of units and for The extent of available to unit. that care units were than or to support for indicates a of a for in employee The in new and the need for all employees to from to and a was not defined in the National Survey, it was reported in of responding units. area of was the of for and which from than to more than 120 and to be in facilities. were in to of units. was given as to to of in the to of units. the of the and new employee outcomes were not data are needed to evaluate the of on The need for this more in light of the that focuses on the experience for new defined as a that and to the of a new to the more than an it also long-term employee support and new employees with the and to in their new better and the employees with the organizational to achieve and be and shared with the nursing community that standards of practice can be and efficiency and effectiveness of efforts be the National of units indicated some for national (no is given about the of this 25% a and a or for were in place for about of the reporting units, only of units required nursing of nurse managers no leaders are an important in of Although in a may not be the most for a nurse having may a nurse manager a better role for than having no at The AACN collaboration with the American of to a for nurse managers may help the of nurse managers in of were more recognized in professional received support reported no Although the reported level of professional advancement and in the National Survey appears be given to staff about the and of these staff may be in light of the needs of the current nursing In the and of for suggest that exist between and the and needs for and In other what may be to one may not be to the of for the and understanding as a survey data on professional advancement and to for of are most to critical care do critical care nurses the effectiveness of the they has nurse had on the and of finding in the National Survey that of facilities not is because it a of support for in support for and organizations may not be to a staff of and issues that promote patient care. This the long-term what extent are nurse managers and to their employees through managerial support of organizational and professional and what extent are organizations nurse managers to the of the nurses’ current work is in daily in this article is to evaluate the administrative implications of the AACN National administration on a of the survey are in Table Although work to be Table 2 highlights 12 that nurse leaders can to findings and analysis of the National Survey provide for and raise of the need to administrative practice in critical care. a national study of administrative practice in critical care is a study that not only at the structures of management also at the more crucial area of authentic leadership processes known to a healthy work environment in The AACN Standards for Establishing and Sustaining Healthy Work provide a for such research and the data from the National for building healthy work