AACNs Healthy Work

Environments Initiative

The mistakes are all there,

waiting to be made.
Chess master Savielly Tartakower (1887-1956)

Organizations learn and evolve

through conscious, deliberate
action. Deliberate action is ethical.
When the time to act has come,
it is unethical not to do something.
David Thomas
Ethicist, Author of Ethics of Choice

Assertion #1
There is a direct link between
work environment and patient
safety
Therefore, if we are not
addressing our work
environment, we are not
addressing patient safety

Assertion #2
Healthy work environments do
not just happen
Therefore, if we do not have
a formal program in place
addressing work environment
issues, little will change

Assertion #3
Creating healthy work
environments requires changing
long-standing cultures, traditions
and hierarchies
Therefore, though everyone
must be involved in the creation
of healthy work environments,
the onus is on organizational,
departmental and unit leaders
to ensure that it happens

The Assertions
HWEs are directly linked to
patient safety
HWEs require a formal program
Leaders must drive HWEs

Healthy Work
Environments Require:
Skilled communication
True collaboration
Effective decision making
Appropriate staffing
Meaningful recognition
Authentic leadership

AACN Standards for Establishing and

Sustaining Healthy Work Environments

Skilled Communication
Nurses must be as proficient
in communication skills as
they are in clinical skills

AACN Standards for Establishing and

Sustaining Healthy Work Environments

True Collaboration
Nurses must be relentless
in pursuing and fostering
collaboration

AACN Standards for Establishing and

Sustaining Healthy Work Environments

Effective Decision Making

Nurses must be valued and
committed partners in making
policy, directing and
evaluating clinical care and
leading organizational
operations

AACN Standards for Establishing and

Sustaining Healthy Work Environments

Appropriate Staffing
Staffing must ensure the
effective match between
patient needs and nurse
competencies

AACN Standards for Establishing and

Sustaining Healthy Work Environments

Meaningful Recognition
Nurses must be recognized
and must recognize others for
the value each brings to the
work of the organization

AACN Standards for Establishing and

Sustaining Healthy Work Environments

Authentic Leadership
Nurse leaders must fully
embrace the imperative of a
healthy work environment,
authentically live it and
engage others in its
achievement

Creating the case for a healthy work environment

What do we know?
Communication Issues
are present in
65% of ALL
sentinel events
reported to
JCAHO

Creating the case for a healthy work environment

What do we know?
Communication Issues
Are present in more than 75% of wrong site surgeries
and delays in treatment
Are present in more than 60% of medication errors and
ventilator events

Creating the case for a healthy work environment

What do we know?
Collaboration Issues
65% of nurses report personally experiencing verbal
abuse in the last year from other nurses, physicians,
patients and patients family members1
52% of nurses report that abuse or disrespectful
behavior is often or frequently tolerated1
77% of hospital caregivers work with colleagues who
are condescending, rude or verbally abusive2
Ulrich B, Lavandero R, Hart K, Woods D, Leggett J, Taylor D. Critical Care Nurses Work Environment:
A Baseline Status Report. Critical Care Nurse, 2006; 26(5): 46-57
1

Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. Silence Kills, Accessible at www.silencekills.com

Creating the case for a healthy work environment

What do we know?
Collaboration Issues
Some docs can make incorrect orders.
We let it slide especially if it is a jerk
For example, one physician prescribed a
drug that you should give 3 times a day,
but he said to give it twice a day. I let it go,
because it was just a pain pill. It wasnt
going to make the child any sicker.
Quote from a pharmacist in
Silence Kills - Seven Crucial
Conversations for Healthcare
VitalSmarts, 2005

Creating the case for a healthy work environment

What do we know?
Staffing and Outcomes
A Sampling of the Literature
Creating Healthy Work Environments: Appropriate Staffing
(CHEST Physician, April 2007)
Impact of the Nurse Shortage on Hospital Patient Care: Comparative
Perspectives (Health Affairs, March 2007)
Nurse Staffing in Hospitals: Is There a Business Case for Quality?
(Health Affairs, January 2006)
The Working Hours of Hospital Staff Nurses and Patient Safety
(Health Affairs, July 2004)
Nursing Burnout and Patient Safety
(Journal of the American Medical Association, February 2003)
Hospital Staffing, Organization, and Quality of Care: Cross-National
Findings (American Journal of Public Health, July 2002)
Nurse-Staffing Levels and the Quality of Care in Hospitals
(New England Journal of Medicine, May 2002)

Creating the case for a healthy work environment

What do we know?
Decision Making
An emergency department task force develops a
patient report form that can be faxed to inpatient units
to facilitate patient transfers and ease overcrowding.
The new form is first used for an unstable patient.
When faxed to the ICU, no one sees the form.
When the patient arrives, no one is available to admit
the patient. Tensions run high, family is angry,
everyone pitches in to cover
AACN Standards for Establishing and
Sustaining Healthy Work Environments
2005

Creating the case for a healthy work environment

What do we know?
Leadership
One of the most decisive functions of
leadership is the creation, management,
and when necessary, the destruction
and rebuilding of culture.
Edgar Schein

Creating the case for a healthy work environment

Are There Challenges?

Challenges to the Case for
Healthy Work Environments
Link to patient safety not universally recognized
Relationship issues seen as soft
Hierarchy and power structures
Difficult to measure improvements
Tradition
Not a sexy issue

Creating the case for a healthy work environment

Are There Challenges?

In the $1.5 trillion U.S. Healthcare System
Hospitals, like any other business, need to be
accountable for providing services that dont
harm the people they serve.
R. Gibson & J. Singh, 2003
Wall of Silence

We spend $25,000 for pills, procedures and

bedpans for every one dollar on patient
safety.
R. Wachter & K. Shojania, 2004
Internal Bleeding

Healthy Work Environments Are

Essential for Making Patients Safe
This is being demanded by:
The public
Policy makers
Regulators
Healthcare professionals
Common sense and doing the right thing

Painting a picture of a healthy work environment

Common Threads
Organizational responsibilities
Individual responsibilities
Support for and access to educational
programs related to each
Leadership/administration support

Painting a picture of a healthy work environment

Skilled Communication
Focus on finding solutions
Protect and advance relationships
Invite and hear all perspectives
Goodwill and mutual respect
Congruence between action and words
Zero-tolerance policies
Formal structures for communication
Access to technology
Evaluation component
Part of performance appraisal

Painting a picture of a healthy work environment

True Collaboration
Accountability defined
Decision-making authority
Access to resources for dispute resolution
All embrace culture of collaboration
Respect each voice
Personal integrity
Skilled communication
Competence of all team members
Nurse managers and MDs equal partners

Painting a picture of a healthy work environment

Effective Decision Making

Organizational values clear and part of decision
making
Structures ensure patients and families are heard
Shared accountability for decision making
Respect for rights of all
All key perspectives incorporated
Processes in place to evaluate results of decisions

Painting a picture of a healthy work environment

Appropriate Staffing
Staffing policies solidly grounded
Nurses at all levels participate in entire staffing process
Staffing decisions are evaluated
System in place to facilitate access to staffing data
Support services available to ensure nurses focus on
nursing work
Technologies adopted that enhance effectiveness of nursing care delivery

Painting a picture of a healthy work environment

Meaningful Recognition
Comprehensive recognition program in place for all
Systematic process for knowing how to participate
Bedside to boardroom
Includes process to determine that recognition is meaningful
Recognition system is regularly evaluated
Everyone is responsible

Painting a picture of a healthy work environment

Authentic Leadership
Understand requirements/dynamics at point of care
Generate visible enthusiasm
Role model communication, collaboration, etc.
Evaluate leaders impact and progress toward HWE
Ensure leaders are well positioned and supported
Provide time, financial and human resources
Provide co-mentoring
Include leaders role in HWE in performance
appraisal

Call to Action
Nurses and all health professionals
Embrace, develop, follow through

Healthcare organizations
Adopt, implement, evaluate, role model

AACN and the community of nursing

Promote, develop, publicize

Our lives begin to end

the day we become silent
about things that matter.
Martin Luther King Jr.

AACN Standards for

Establishing and Sustaining
Healthy Work Environments:
A Journey to Excellence
www.aacn.org/hwe