President’s Column: Making Work Environments Healthy

Apr 01, 2019

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The topic of medical errors has become a constant not only in professional literature but in writings for the nonmedical public as well. Delivering safe and effective care in the complex environment of healthcare — especially in the fast pace of critical care — is a daunting challenge, to say the least. What if we took a moment to ponder errors much the same way we would heart disease or cancer? That is, let’s look at the evidence. That evidence indicates that multiple factors contribute to medical errors, but one factor is consistent across many studies: the health of the work environment.

In 1997, a meta-analysis of 81 studies showed a reduction in mortality and hospital complications with improved nursing surveillance, improved interprofessional interactions and healthy work environments (HWEs). In 2004, the report “Keeping Patients Safe: Transforming the Work Environment of Nurses” described the connection between the work environment and patient safety. In 2016, another study showed that patients were 16 percent less likely to survive an in-hospital cardiac arrest when the environment was unhealthy. In the November 2018 issue of Health Affairs, researcher Linda Aiken and her team found “poor work environments make complete adherence to evidence-based safety interventions difficult.”

The evidence is compelling. We have over two decades of studies supporting HWEs. So why the delay in implementing strategies to improve the work environment?

In our recent AACN HWE survey, about half of the respondents said they are working on interventions to improve their environment. That number is an increase from previous surveys, but it’s still not an overwhelming adoption of the evidence.

One reason for the slow adoption of the evidence may be the way we approach root cause analysis after an event. The usual approach focuses on tasks and processes. It is much easier to identify tasks and processes contributing to an event than it is to identify latent factors such as communication and leadership. Maybe we should evaluate our environments proactively outside of the drama of an event review; that way, it becomes a way of being instead of simply an activity in response to a negative event.

AACN’s interdependent standards for an HWE were originally published in 2005 and updated in 2016. They consist of six standards — skilled communication, true collaboration, effective decision making, meaningful recognition, appropriate staffing, authentic leadership — that are necessary for an HWE. So, what does it take for HWEs to become a way of being? Simply, commitment and action. No one standard is more important than another, and they do not need to be implemented in a particular order. You can learn about them on our website at

Check out the results of the HWE survey I mentioned earlier too. They may give you additional information to help create an HWE.

But no matter what, the time to heed the evidence and start creating HWEs is now. Our patients, their families and our peers are counting on us.

Let me know how you are creating an HWE at