AACN’s 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
1Ulrich
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
2Maxfield
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 wasn’t
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 don’t
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 leader’s 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