Healthy Workplaces: Assess First, Then Transform
A national collaborative helps organizations transform their workplaces to benefit patients and nurses.
Strong evidence verifies that healthy work environments (HWEs) significantly improve patient safety, care quality, survival rates and satisfaction, prompting the American Association of Critical-Care Nurses (AACN) to launch a national collaborative to guide organizations in transforming their workplaces to benefit patients and nurses.
“The Impact of the Work Environment on Patients, Families, and Care Delivery in Critical Care,” in Critical Care Nursing Clinics of North America, highlights the essential need for a baseline workplace assessment. It’s also important to select the right evaluation tool since different instruments capture distinct aspects of workplace culture.
AACN’s Healthy Work Environment Assessment Tool (HWEAT) survey provides a broad perspective on workplace culture from RNs and clinician teams, offering baseline data and ongoing insights. Other instruments target specific elements, such as the Professional Practice Environment Assessment Scale for nurse-physician relationships or the HWE Inventory for organizational culture.
But evaluation alone is not enough. Implementing HWE strategies requires a structured approach to change, using models such as the Consolidated Framework for Implementation Research (CFIR) to plan, execute and evaluate across five domains: intervention characteristics, outer setting, inner setting, individual characteristics and the implementation process.
By actively involving nurses and interprofessional colleagues, organizations can design targeted interventions — such as staffing adjustments or recognition programs — that strengthen workplace culture, sustain improvements and ultimately enhance patient outcomes.
“During the planning phase, teams are encouraged to assess all five CFIR domains,” the article notes. “By thoughtfully considering the barriers and facilitators within each domain, teams will have a holistic perspective of the unit climate and culture.”
AACN offers six HWE standards: skilled communication, true collaboration, appropriate staffing, effective decision-making, meaningful recognition and authentic leadership. The AACN HWEAT survey, available for free on AACN’s website, offers an opportunity to share experiences, assess unit culture and guide future improvements in patient care.
A Nurse-Led Toolkit Helps Nurses Reduce and Prevent Falls
The toolkit program delivers patient-specific safety strategies in a three-step process.
A nurse-led fall prevention toolkit that integrates electronic health records (EHRs) and emphasizes patient and family engagement is helping to reduce falls in more than 100 acute care hospitals in the United States and abroad, reports the Agency for Healthcare Research and Quality (AHRQ).
“Fall TIPS: A Patient-Centered Fall Prevention Toolkit,” an AHRQ news release, explains that the program delivers patient-specific safety strategies in a three-step process: assessing fall risk, tailoring a personalized prevention plan, and executing it consistently. Known as Fall Tailoring Interventions for Patient Safety (TIPS), the toolkit provides real-time communication delivered in high- and low-tech modalities.
To fit their workflow, care teams can choose from three modalities tested at various hospitals: an EHR-generated poster, a laminated poster, or an e-bedside display that automatically draws data from the EHR.
A nonrandomized controlled trial published in 2020, in JAMA Network Open, involving 37,231 patients, shows a 15% reduction in overall patient falls and a 34% reduction in falls with serious injury when using the toolkit.
A six-month randomized trial published in 2011, in JAMA, adds that the toolkit reduced patient falls by 25% in four U.S. hospitals, proving especially effective for patients 65 years and older. In the study units, the toolkit could potentially prevent one fall every four days, 7.5 falls per month and about 90 falls each year.
A related article in American Nurse discusses the strong results for a New Jersey hospital. Their quality improvement project included all patients in the med-surg telemetry unit, and “all full-time, part-time and per diem nurses and nursing assistants participated” in program education. Staff knowledge increased regarding the risk for falls, strategies to reduce falls, and staff confidence to prevent them.
“The 1-year assessment revealed that falls reduction had improved by 53%. In addition, we saw a 51% reduction in injurious falls (those that cause new signs/symptoms ranging from minor swelling to major fractures) compared to 2022,” the article adds.
Patient Ratios, Higher Workloads Impact NICU Nurses
High subjective workloads and ratios of 3:1 or greater should be considered for work reduction in NICUs.
Nurses are more likely to miss certain types of care for patients in neonatal intensive care units (NICUs) when they care for too many infants, or when they perceive higher workloads.
“Nurse Workload and Missed Nursing Care in Neonatal Intensive Care Units,” a cross-sectional replication study JAMA Pediatrics, notes that nurses reported missing a standard of care in the majority of measured areas with a 3:1 patient-nurse ratio or higher and in all areas when they subjectively assessed their workloads as high. “High subjective workload and staffing ratios greater than 2 infants per nurse should be targets for workload reduction in neonatal intensive care units,” the study notes.
The study included 247 nurses caring for 1,468 infants across 5,403 shifts at 10 NICUs from 2021 to 2023. Nurse respondents reported missing the tasks of hourly IV-line site assessments and infant assessments most frequently, with milk feedings least frequently missed.
When working in 2:1 ratios, missing care significantly worsened in two of the 17 measured areas compared with a 1:1 ratio; when working in 3:1 ratios, care worsened in nine of the 17. When nurses subjectively assessed their workload as high, care worsened in all 17 measured areas.
“We have systematically and empirically demonstrated negative associations between staffing ratios of 3 to 1 or higher and quality of care in 2 independent samples, even after adjusting for acuity and subjective workload,” the study adds. “Subjective workload does appear to partially mediate most effects of ratios on missed care.”
Limitations of the study include the pandemic’s effects on participation and a lack of objective data about the care the infants received. “We recommend that health systems and commercial vendors partner with bedside nurses and researchers to rigorously test acuity-based staffing tools that account for the full range of caregiving needs before implementation,” the study notes.
New Guidelines: High-Risk Cardiac Care Advances With tMCS Integration
Standardized protocols, robust institutional infrastructure and dynamic decision-making are needed.
New clinical practice guidelines highlight the role of temporary mechanical circulatory support (tMCS) for managing cardiogenic shock and high-risk cardiac interventions. The guidelines emphasize individual strategies, multidisciplinary teamwork and early consultation with experienced centers as key determinants of patient outcomes.
“EACTS/STS/AATS Guidelines on Temporary Mechanical Circulatory Support in Adult Cardiac Surgery,” in The Annals of Thoracic Surgery, translates complex evidence into clear recommendations for bedside care. They highlight the need for standardized protocols, robust institutional infrastructure, and dynamic decision-making that adapts to rapid technological advances.
The European Association for Cardio-Thoracic Surgery (EACTS), Society of Thoracic Surgeons (STS), and American Association for Thoracic Surgery (AATS) jointly developed the guidelines with evidence-based recommendations directly applicable to daily clinical practice. Among the therapies discussed is extracorporeal life support (ECLS), a cornerstone technology that has advanced significantly in recent years.
“Today, the field has evolved from a ‘one size fits all’ ECLS model to a modular, scenario specific use of tMCS devices with varying mechanisms and levels of invasiveness,” the guidelines add.
While this shift enables more individualized care, it adds complexity, making standardized approaches to device selection, management and end of life treatment essential for safe, effective practice.
In the ICU, patients with cardiogenic shock require individual support to maintain tissue perfusion and oxygenation, guided by continuous hemodynamic monitoring and daily echocardiography to assess cardiac function and device performance. The guidelines caution that tMCS introduces risks such as infection, bleeding, thrombosis and organ dysfunction, making vigilant monitoring essential throughout postoperative care.
Looking ahead, rapid advances in technology and shifting patient needs will demand dynamic, evidence driven decision-making. To close knowledge gaps, the field must invest in multicenter research, harmonized data standards and collaborative registries, ensuring equitable evaluation of innovations.
A related article in Cardiovascular Business further details the 200‑plus-page guidelines, offering a deeper look at evidence, devices and recommendations shaping tMCS care.
Mobility, Lighter Sedation Associated With Improved Outcomes
Sedative medications may deprive patients of the restorative sleep they need.“Association of Medication-Induced Deep Sedation and Emotional Distress During Mechanical Ventilation With Loss of Independent Living: An Observational Cohort Study,” in The Lancet Respiratory Medicine, notes that 71.4% of patients spent time in deep sedation during their first week in intensive care despite a much smaller percentage receiving orders for it.
“Lighter sedation, allowing for recognition of emotional distress and for patient mobility, was associated with a lower risk of loss of independent living,” the study adds.
The study of 10,204 patients receiving mechanical ventilation at 20 New York-area ICUs from 2016 to 2023 found an elevated risk of loss of independent living (either dying in the hospital or discharged to a skilled nursing facility) among those receiving deep sedation. There was, however, a decreased risk among patients who exhibited higher degrees of emotional distress.
“Use of sedative medications can actually strip the exhausted patient of the healthy restorative sleep they need most during illness,” lead author Matthias Eikermann, Montefiore Einstein, New York, says in a related news release. “Our data show this lack of quality sleep leads to greater rates of immobility in the ICU, which compounds into even more delirium and greater loss of the muscles and nerves needed during recovery.”
A related cluster, randomized controlled trial on sleep during hospitalization finds that a multicomponent intervention produced significantly better sleep quality in medical wards. The interventions included shifting vital sign checks to mornings, optimizing medication timing and conducting evening sleep rounds.
AACN resources include “Awake and Walking ICU: Mastery of the ABCDEF Bundle,” a webinar that focuses on optimizing sedation and tailoring mobility practices to individual patients’ needs. The webinar provides nurses with the patient’s perspective and the knowledge to put early mobility practices into action.
Considering Human Side When Integrating AI
The article compares the expansion of AI tools into nursing with the development of EHRs.Psychological insights into human behavior can help nurse leaders guide staff through transitions to enhanced use of artificial intelligence (AI) tools by focusing on staff needs at each stage of adoption.
“Expectations, Emotions, and Empowerment: Understanding Nurses’ Needs in the Age of AI,” in Nurse Leader, reflects on the ways humans naturally respond to change: “AI adoption is not merely about implementing new tools. It requires understanding and guiding the human experience of change. Like past shifts to EHRs, success hinges on how well organizations support users. ... The future of AI in nursing will be defined not by speed of adoption, but by the strength of human-centered support.”
Based on the five stages of Gartner’s Hype Cycle (from innovation through disillusionment and eventual productivity) and Maslow’s Hierarchy of Needs, the article encourages nurse leaders to reflect on how to incorporate the understanding of behavior into their adoption and rollout strategies.
“Leading with emotional fluency and strategic empathy ensures nurses do not just adapt to change — they thrive in it, shape it and improve care through it.”
For example, during the initial stages, which include inflated expectations, leaders can validate nurses’ hopes and emphasize realistic outcomes that reflect both the excitement and anxiety involved. Later, if the systems generate errors or cause issues, leaders can normalize frustrations, offer judgment-free feedback, and stress the importance of nurses’ expertise, the article adds.
Related AACN resources include Voices in Nursing podcasts on “The Human Side of AI in Nursing ,” which explores the promise and pitfalls of the technology, and “Designing Technology With Nurses in Mind,” which explores engaging nurses in shaping technology’s use in the clinical setting. Also, “AI: Friend or Foe,” a nurse story, explores ways to debunk concerns about AI threatening nurses’ jobs and why it can benefit patient outcomes by eliminating biases.
Nurse leaders in a 66-bed cardiac step-down unit saw that nurses were missing breaks and lunches and staying late to finish work. They implemented an innovative buddy system to foster collaboration, reduce burnout, address patient safety issues, and improve the health of their work environment. “Having a supportive system like this is crucial for success and retention.”
Fostering Teamwork Through a Buddy System