A Healthy Work Environment Begins With You

By Kristine Strohbin, MSN, RN, CNS, ACCNS-P, CCRN Mar 01, 2023

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The results of AACN’s 2021 Nurse Work Environment Study show that the health of nurse work environments across the country has declined dramatically in recent years.

The results of AACN’s 2021 Nurse Work Environment Study show that the health of nurse work environments across the country has declined dramatically in recent years. With three out of four nurses reporting plans to leave their current position, it’s well past time to address this challenge. For our own well-being, we need to take the lead in transforming our work environments by implementing AACN’s Healthy Work Environment (HWE) Standards.

HWE Standards and Me

I began exploring HWEs in 2015. As a bedside nurse turned clinical nurse specialist (CNS), I wanted to inspire change in a pediatric intensive care unit that struggled with leadership, nurse engagement and chronic staff shortages. The challenges provided some very important lessons along the way.

Through this work, I realized that anyone, regardless of their role, can bring about sustainable change using the HWE standards. The support of hospital administrators and nurse managers is important to the overall success of this journey. However, even when leaders and administrators are not yet engaged in this work, motivated direct care nurses and other members of the team can be catalysts for change.

Healthy work environments do not just happen. Without focused and sustained energy to address the problems that bubble up, very few things change. Creating these environments also requires transforming longstanding cultures, traditions and hierarchies, which isn’t easy. It requires a solid commitment from each member of the team, and it benefits everyone to make improvements. While it may seem like a major feat, implementation of the HWE standards is one of the most valuable projects a bedside nurse, CNS/nurse educator or direct-care manager can take part in, positively impacting nurse satisfaction and retention to provide an excellent return on investment for the organization.

Why Is a Healthy Work Environment So Important?

A review of the impact of an HWE on the healthcare system and an exploration of the 2021 AACN HWE survey results may influence your decision to begin implementation. A meta-analysis by Lake, et al and a systematic review completed by Wei and colleagues are just two examples of the research that supports the correlation between HWEs and positive patient, nurse and hospital outcomes. Mounting evidence that now spans nearly two decades supports the following:

Patients cared for in HWEs:

  • Experience less mortality and failure to be rescued
  • Have better survival rates from in-hospital cardiac arrest
  • Encounter fewer hospital-acquired conditions and adverse events
  • Are better informed and prepared for discharge
  • Encounter fewer readmissions
  • Report better overall quality of care

Nurses who work in HWEs:

  • Report increased job satisfaction
  • Describe less missed or delayed patient care
  • Report lower levels of burnout and compassion fatigue
  • Are more likely to stay in their current job
  • Report less staff turnover

Hospital systems with HWEs:

  • Report better quality outcomes
  • Achieve higher reimbursement rates (as a result of positive outcomes)
  • Have better patient and nurse satisfaction scores
  • Increase their business - more patients and higher profits
  • Have lower rates of nurse turnover

Bold Action Is Required

AACN’s HWE survey results, which include responses from over 9,000 RNs, indicate that nurse work environments are in jeopardy. Without immediate and bold action, these conditions may continue to worsen.

The 2021 survey results show:

Nurse well-being declined:

  • Nearly 40% of RNs rate their emotional health poorly
  • 52.8% of RNs report that their organization does not value their health and safety.
  • 48% of RNs report feeling moral distress either “frequently” or “very frequently.”
  • 72% of RNs report having experienced at least one form of abuse (verbal, physical, discrimination or sexual harassment).
  • The number of RNs experiencing moral distress “very frequently” doubled from 11% in 2019 to 22% in 2021.

Quality of care worsened:

  • The perception of “good” or “excellent” quality of care delivered to patients fell 13 percentage points since 2018.
  • 53% of RNs report that overall quality of care has declined.
  • The number of RNs who report that quality of care has become “somewhat worse” or “much worse” grew by 16 percentage points.

Staffing continues to be a major issue

  • Only 46% of RNs report their unit ensures an effective match between patient needs and nurse competencies.
  • Just 25% of RNs report being appropriately staffed on a regular basis.
  • Ratings on the appropriate staffing standard fell 15 percentage points since 2018.

Job satisfaction fell:

  • Job satisfaction decreased by 18 percentage points since 2018.
  • Satisfaction with the nursing profession fell for the first time compared with previous AACN surveys (only 76% of RNs reporting satisfaction with being an RN compared with 92% in 2018).
  • 67% of RNs plan to leave their current position in the next three years, compared to 54% in 2018.
  • Of those RNs planning to leave, 82% report adequate staffing would make them reconsider.

HWE Standards Can Help!

Fortunately, it appears that the HWE standards offer a practical solution to remedy these problems. Teams that have implemented these standards (even those that have just started the work) reported higher scores and more resilience through the pandemic.

Teams that implemented the HWE standards:

  • Report higher nurse well-being scores
  • Indicate greater job satisfaction
  • Experience less moral distress
  • Are less likely to leave their current position
  • Report improved staffing with an appropriate skill mix
  • Report higher quality of care
  • Score higher in every HWE standard (skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition and authentic leadership)

How Do I Know If My Work Environment Is Healthy?

To learn more about the health of your work environment, start with an assessment. Gathering baseline information helps identify important strengths and opportunities for growth. It also establishes a starting point that enables the team to track progress over time.

Fortunately, the assessment of our work environments is easy, because AACN offers free access to the Healthy Work Environment Assessment Tool (HWEAT). This screening tool has been reviewed for face validity and tested for reliability and internal consistency. Also, it’s anonymous. The questionnaire itself consists of 18 questions (three questions for each HWE standard) and takes less than 10 minutes to complete. The online platform makes it a cinch to become an administrator. The administrator registers the group or department to take the assessment. This person can be anyone on your team — bedside nurse, CNS, direct care manager — it can be you! Simply create your assessment. Once you log in to the AACN website, you will be prompted to choose your facility, your unit type and the length of time for your assessment window. An email invitation template will be created for you to copy and paste into an email to send to your unit.

Tips and Tricks for Improving Your HWEAT Response Rate

Here are some ideas to increase your HWEAT survey response rate and encourage involvement from all team members:

  • Be sure to include the “why.” Every unit is slightly different. Determine the goals for administering the assessment and what can be achieved by establishing a baseline. Nurses may be more motivated to work toward a common goal when they know what can be achieved.
  • Tell staff about the opportunity to participate before you send them the survey. This prevents participants from thinking the email invitation is spam or ignoring the request to take part in the survey.
  • If possible, consider sending the survey to participants’ personal email addresses. We know that no matter how hard we try, it can be challenging to check work email during a busy shift, and many people don’t have access to their work email accounts.
  • Give participants the option to take the survey during a staff meeting, pre-shift huddle or before they clock out of work (if you are authorized to approve overtime). Consider a discussion with leaders to allow for coverage of the staff’s patients for the time it takes to complete the survey.
  • Offer incentives! The survey is anonymous, but consider having participants print the confirmation page at the end of the survey, write their name on it and hand it to you for a chance to win a prize. My team raffled off gift cards for each shift and achieved an 85% response rate, partly by promoting prize opportunities.
  • Send email reminders or texts throughout the survey window to remind staff to participate.
  • Let staff know the results will be reviewed at the next staff meeting, and there will be opportunities to discuss the results and suggest actions that can benefit everyone involved. Their voices are important.
  • Set the bar high! Speak with your leadership team to see if they will sponsor a celebration if the unit meets a specific response rate.

How Does the Health of Your Work Environment Measure Up?

After your survey window ends, access and print your report through the Assessment Administrator (this is the same platform for creating the assessment). From there, click the tab labeled Manage Assessments. This portal will provide access to your department report and allow you to obtain useful national benchmarking data. The benchmarking report anonymously reviews the entire national database of individual survey responses and generates aggregate scores to provide a benchmark against which you can compare your team’s assessment scores.

Understanding Your Results

Your report will provide valuable information to help stimulate group discussion and group project work. The first score in your report is the Summary Score. This is an aggregate score that includes all questions in each of the six HWE standards categories. While it provides a global view of the health of your nurse work environment, which most participants want to know, the six scores that follow are more informative. They, too, provide an aggregate score for each standard, which is then further broken down into each of the 18 questions. Having access to scoring information for each question makes it possible to have meaningful group discussions about the opportunities in your organization.

In addition to department scores, the report provides a built-in toolkit that offers guidance on how to tackle each standard. Sometimes the scores themselves indicate where the opportunities are. Perhaps there is a category that is much lower than the others. Or maybe your team would like to focus on a win that feels more feasible. Each group’s actions will differ because there are so many ways to approach implementation. Translating evidence to practice is simultaneously the greatest and the most difficult part of this process. But, by reviewing the report as a team and developing a plan together, you can ensure everyone’s voice is heard, which is key to promoting engagement and generating excitement.

Your Invitation to Transform Your Work Environment

There is no prescriptive “one size fits all” approach or guarantee for success on this journey. Yet, any improvements that come from progress toward establishing and sustaining an HWE are well worth the effort. This is your invitation to begin transforming your work environment. You play an essential role in this work — and it truly does begin with you.

Will you take the HWE assessment?