Critical Care Nurses’ Work Environments: A Baseline Status Report

Attracting qualified people into nursing is the first step in ensuring that adequate numbers of registered nurses (RNs) are available to meet the needs of hospital patients. Perhaps more critical is the need to create healthy work environments that encourage nurses to work in hospitals in general and in critical care areas in particular. The environment in which RNs work is an essential issue in their job satisfaction and turnover, and it plays a role in patients’ outcomes.1–5Recognizing that a healthy work environment is the base for recruiting and retaining nurses and ultimately for providing optimal care for patients, the American Association of Critical-Care Nurses (AACN) began a major effort in 2001 to actively promote and support healthy work environments.6 At the 2003 AACN National Teaching Institute and Critical Care Exposition, in the Act Boldly Campaign, AACN called on critical care nurses to actively commit to addressing workplace issues in the nurses’ organizations.7 That same year, AACN conducted a national survey, part of which solicited more details on healthy and unhealthy work environments.8 AACN position papers were developed on prevention of violence in the workplace and on zero tolerance for abusive behaviors.9,10 In 2004, AACN completed the landmark National Critical Care Survey, the first survey to provide data on critical care units and the environments in which critical care nurses work.11 Before this study, little information specific to critical care environments was available.In January 2005, AACN published national standards for establishing and sustaining healthy work environments.12 Specifically, the standards address skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership in the work environment.The standards complement and support the American Nurses Association Code of Ethics for Nurses,13 the Institute of Medicine recommendations,5,14,15 the elements of a healthy work environment as determined by the Nursing Organizations Alliance,16 the recommendations from the Joint Commission on Accreditation of Healthcare Organizations,17 and attributes of organizations receiving Magnet designation.18In early 2006, a year after the standards were released, AACN, Nursing Spectrum (a communications company and division of Gannett Co), and Bernard Hodes Group (a world leader in integrated talent solutions and a division of Omnicom), conducted a national survey of critical care nurses to determine the status of critical care work environments. The nurses were also asked about their satisfaction with nursing as a career, their intent to stay in or leave their current positions, reasons for planning to stay or leave, and what might cause them to reconsider leaving. In this article, we present the major results of the survey.The online survey instrument contained questions based on the AACN healthy work environment standards and on previous research about RNs’ work environments. The questionnaire was pilot tested with a national sample of RNs, and no major changes were made as a result of the pilot data. Convenience sampling was used. Members and other constituents of AACN were invited via e-mail to participate in the study. The e-mail invitation contained an online link to the survey instrument. Respondents were offered an incentive to participate: the chance to win a complimentary registration to the AACN National Teaching Institute and Critical Care Exposition. The survey was conducted from April 18, 2006, to May 3, 2006. Frequencies, percentages, SDs, and means were determined for each question and were cross-tabulated against demographic variables. Because a convenience sample of RNs associated with AACN was used, the generalizability of the findings is limited.A total of 4346 RNs from every state and the District of Columbia responded to the survey. Of these, 4034 reported currently working as an RN. The responses of RNs who were not currently working as RNs were not included in the data analysis. Table 1 gives the demographic information.More than 50% of the respondents indicated that they were aware of the AACN standards for healthy work environments. Slightly less than 40% said that how well they established and sustained a healthy work environment plays a major (12.7%) or substantive part (27.1%) in their performance evaluations.Questions about the status of work environments based on the AACN standards were asked for both organizations as a whole (macrosystems) and for the units on which the respondents worked (microsystems). In all instances in this survey, the respondents rated the health of their unit work environments higher than the health of their organizations (Table 2).In addition to the questions about RNs’ proficiency in communication and about RNs being relentless in pursuing and fostering true collaboration (Table 2), respondents were asked to rate the communication and collaboration in their work units among RNs and between RNs and physicians, frontline nurse managers, and administrators (Table 3). The highest levels of communication and collaboration were among RNs; the lowest levels, between RNs and administrators.Respect is a component of communication, of collaboration, and of valuing the contributions of each RN. When asked to rate the respect for RNs shown by other RNs, physicians, frontline nurse managers, administrators, and other healthcare colleagues, RNs’ respect of each other was highest; administrators’ respect of RNs was rated the lowest (Table 4).Physical and mental safety in terms of sexual harassment, discrimination, verbal abuse, and physical abuse were assessed. RNs were asked if during their work as a nurse in the past year they had personally experienced any of these and from whom the threat had come (patients, patients’ families and/or significant others, other RNs, physicians, nurse managers, administrators, or other healthcare personnel). In more than 9000 instances, RNs reported at least one occurrence (Table 5). Because the questions had only yes and no response options, a yes response could represent one occurrence or many. At least one instance of sexual harassment, regardless of the source, was reported by 18.2% of the respondents and discrimination by 26.6%. A large majority (64.6%) reported at least one instance of verbal abuse; 22.2% reported at least one instance of physical abuse.Respondents were also asked about zero tolerance policies on abuse and disrespectful behavior and the actual occurrence of such behavior. The results indicated that 46.5% of the respondents’ organizations had zero tolerance policies on both abuse and disrespectful behavior, 19.1% on abuse only, 0.5% on disrespectful behavior only, and 15.5% on neither. A total of 18.4% of respondents did not know whether or not their organizations had such policies. When asked to what degree abuse and disrespectful behavior was tolerated in their organizations, only 24.1% answered not at all, which would indicate zero tolerance; 19.6% answered frequently; 32.4% said occasionally; and 23.8% said rarely.Respondents were asked to rate the skills of their frontline managers and their chief nurse executives. In every instance, the skills of the managers were rated higher than the skills of the executives (see FigureF1).Support for professional development was assessed by asking questions about organizational support for continuing education and specialty certification (Table 6). More than 75% of the respondents worked for organizations that provided in-house continuing education, and 55.4% worked for organizations that provided paid time off for continuing education. Registration fees for continuing education were paid by 47.8% of the organizations. Specialty certification was less supported, although 47.9% of the respondents reported that initial examination fees were paid for or reimbursed, and 45.0% said that nurses who achieved certification were recognized.Respondents were more likely to say that RNs recognize others for the value the others bring to the work organization than to say that RNs are recognized for the value each RN brings to the organization. When asked who provided the most meaningful recognition, 45.9% of the respondents indicated patients and patients’ families; 26.0% said other RNs. No other group (administrators, frontline nurse managers, physicians, or other healthcare colleagues) was selected by more than 10% of the respondents.The majority of respondents rated the quality of care in their work units and organizations as excellent or good (Table 7). More than half indicated that the quality of care had increased in their organizations in the past year. When asked to describe the quality of the RNs in their work unit, 32.0% selected excellent, and 52.7% selected good. In reply to a question about having the right number of RN staff with the right knowledge and skills, an indication of the AACN standard for appropriate staffing, 6.1% of the respondents indicated that standard is met all the time; 43.0%, more than 75% of the time; 29.4%, 50% to 75% of the time; 16.8%, 25% to 49% of the time; and 4.9%, less than 25% of the time.The survey also asked about the work that gets completed on a typical shift. Direct care tasks (eg, giving medications, doing procedures) and activities of daily living (eg, skin care and oral hygiene) get done most often (Table 8). Other aspects of nursing care such as comforting, teaching, planning, and preparing for discharge are completed less often.Survey participants were asked about their satisfaction with nursing as a career and with their current positions. Overwhelmingly, respondents were satisfied with nursing as a career and, to a slightly lesser degree, with their current jobs (Table 9). More than half (54.1%) would definitely advise a qualified individual to pursue a career in nursing, and another 34.0% probably would.When asked to indicate the 2 main factors that keep them working in their current organizations, 53.0% selected the people I work with; 34.9%, salary and benefits; 30.8%, the patients I care for; and 14.1%, opportunities for professional development. All other response categories were lower.In order to assess future retention, participants were asked to indicate whether they planned to leave their current nursing positions within the next 12 months or within the next 3 years. One in 5 (20.0%) indicated that they plan to leave their current position in the next 12 months; 28.6% plan to leave in the next 3 years. A little more than half (51.9%) indicated that they have no plans to leave their current position in the next 3 years.Among those who said they plan to leave their current position, the most common reason for such planning was to take another position in clinical nursing (38.5%). Other reasons, in order, were returning to school to pursue additional nursing education (17.5%) and taking a different position in nonclinical nursing (17.0%). Only 5.3% of those planning to leave (2.6% of the total respondents) said that they were leaving their current position to pursue a job in another profession.Respondents who reported plans to leave their current positions were asked how likely certain changes were to cause them to reconsider. Better leadership was the most frequently cited change; 44.0% of those who planned to leave said that better leadership would be very likely to cause them to reconsider leaving. Other changes that would make them reconsider leaving were higher salary and benefits, better staffing, more opportunities for professional development, more respect from both frontline management and administration, more meaningful recognition, and more opportunities to influence decisions about patients’ care.In addition to the findings presented in this initial report, the data collected in the survey indicated significant differences according to the variables of age of the nurse, experience (most notably RNs with less than 5 years’ experience and those with more than 20 years’ experience), highest educational degree, and the Magnet status of the organizations in which the nurses worked. These differences are beyond the scope of this article and will be presented in detail in subsequent presentations and publications.This survey provides important information on the current health of work environments in critical care settings, RNs’ career and job satisfaction, RNs’ intent to stay in or leave current positions, and actions that would cause RNs to reconsider leaving. Organizations can use the findings as a blueprint to improve work environments and increase retention of critical care nurses.Healthcare systems are composed of organizations (macrosystems) and work units (microsystems). Microsystems, defined in healthcare as “a small group of people who work together on a regular basis to provide care to discrete sub-populations of patients,”19(p 474) have been identified as the key building blocks of macrosystems. Microsystems are the “moments of truth” of the macrosystem, the places at which the delivery of patients’ care either succeeds or fails.In every instance throughout the survey, respondents rated the work environment higher in the microsystems than in the macrosystems. This finding needs to be investigated further. In contrast to the view that “the grass is always greener” elsewhere, RNs in the survey consistently thought that things were better in the units/microsystems where the nurses worked than in the rest of the organization/macrosystem. Perhaps the respondents have the best practices in their microsystems or they are less informed about what occurs outside their own microsystems. In either case, opportunities to share information and collaborate would be advantageous.Communication and collaboration have a critical influence on both RNs’ satisfaction and patients’ outcomes. Beginning with the classic study published by Knaus et al in 1986,20 which first revealed the relationship between the degree of coordination in intensive care and the effectiveness of that care, many studies21–25 have indicated the relationship between collaboration and increased positive outcomes for both patients and RNs. In addition, in reports of the Joint Commission on Accreditation of Healthcare Organizations,26 inadequate communication is consistently cited as the most frequent root cause of sentinel events.The results of the survey indicate that the highest level of communication and collaboration is among RNs and then between RNs and physicians. However, both areas have room for improvement. Communication and collaboration between RNs and frontline nurse managers and administration was rated lower. This finding supports the results of a previous AACN survey8 in which less than half of the AACN members ranked their relationships with managers and administrators as positive. Our respondents also indicated room for improvement in the communication and collaboration skills of frontline nurse managers and chief nurse executives.Mutual respect is a key component of effective, professional, collaborative relationships.27 Respect is related to job satisfaction and intent to leave.28,29 In this survey, the majority of RNs rated the respect from administration as fair (37.0%) or poor (24.3%), a matter of concern. Respect from physicians was rated the next lowest and should also be a concern. RNs who indicated plans to leave their current positions in the next 3 years also noted that more respect from frontline nurse managers and from administration would very likely make the RNs reconsider leaving. Nurses often talk about respect (and disrespect), yet little research specifically addresses how nurses define and what behaviors are associated with respect and disrespect.28 Additional inquiry into this topic is needed.Sexual harassment, discrimination, and verbal and physical abuse should be zero tolerance issues, but the survey results (>9000 instances reported) clearly indicated that they are not. Almost 1 in 5 respondents reported experiencing sexual harassment and more than 1 in 4 reported experiencing discrimination in the preceding year while working as a nurse. In addition, the majority of the respondents reported experiencing verbal abuse, and more than 1 in 5 reported physical abuse. Much of the verbal abuse reported came from patients, patients’ families or significant others, and physicians; almost all of the physical abuse came from patients.These data support previously reported research on physical and mental abuse in nursing work environments.30,31 Healthcare continues to lead other industries in the incidence of nonfatal injuries and assaults. In 2004, more than 284600 recordable nonfatal occupational injuries and illnesses occurred in hospitals, and another 124600 occurred in ambulatory healthcare settings.32 Of additional concern, these data most likely are conservative, because assaults and acts of violence often are not reported.33,34Creating safe work environments is the legal and moral responsibility of every organization. As indicated in the survey results, having policies in place does not equate with zero Almost of respondents did not know whether policies in their American of identified leadership development as a critical in excellent work In addition, in a study of clinical et that leadership was a key in this survey, the respondents’ of the skills of both frontline nurse managers and chief nurse executives the need to make leadership development a to the American of effective leadership development can only with a sustained organizational to skills in management and defined management career and to and improve leadership effectiveness that meaningful staff and are also and their by RNs to job satisfaction and patients’ As a in 2003 the Institute of Medicine that care nursing staff be and in decisions about patients’ care and how that care is this survey, almost of the respondents or that in their work units RNs are and in and clinical care, and organizational of the respondents also or with the that RNs have opportunities to influence decisions that the quality of patients’ is one for In this survey, more than 1 in 3 RNs reported working in organizations with a in reported that their organizations were These are than the findings of the National Critical Care in which of units reported having education is essential for and for individual professional education and opportunities for professional development also are essential to retention of More than of the respondents indicated that their organizations provided in-house continuing education, and about half of the organizations offered paid time off for such education and/or paid the registration most nurses say that they for that certification also patients and healthcare organizations. In the of the nurse the of certification included quality care, patients’ satisfaction, and retention of The also indicated that nurses have increased and and that nurses 5 years of be to recognize and and less likely to commit than are nurses who are not such as the AACN for Critical Care and the Magnet that a significant of staff be because certification patients, organizations, and nurses and should be more for specialty certification in this survey was to that in the National Critical Care Other than for the initial certification examination and nurses who certification no other support was reported by more than 25% of the This of organizational support is and who and have increased and job satisfaction, but to be effective, be and The respondents in survey were that from patients and patients’ families rated highest; next highest was from other RNs. from frontline nurse managers, and physicians was rated results of the survey that having or that of RNs by patients and patients’ families and by other RNs would be is the of nurse by the of in and, at other how from frontline nurse managers, and physicians could be more meaningful would also be survey findings about work that does and does not get done are the most the quality of patients’ care and outcomes is to the results of et in this survey, giving medications, doing and providing skin care and oral were most often However, nursing activities that critical and such as patients, patients and their and care and preparing patients and their families for discharge were completed less continues to that higher level nursing contributions are being for level in decision making, a key of the AACN for is made more nurses not have as indicated in this survey, for with patients and and preparing patients for in critical care not provide of these higher level nursing of have that who have relationships with the people they work with are more satisfied and more in the work of their organizations than are such The of respondents in this survey who reported that they were very satisfied with being nurses is higher than that in previous with their current position was with that by nurses in other The 4 factors that respondents indicated keep them working in their current organizations were the people they work salary and benefits, the patients they care and opportunities for professional key of career satisfaction is the to career to In this survey, more than half (54.1%) of the respondents definitely would a nursing career, and another 34.0% probably This is higher than that by et because the respondents to this survey were critical care half of the respondents indicated that they planned to leave their current positions in the next 3 of only a small planned to leave the nursing Almost 75% of the RNs who plans to leave their current positions said they would to take other clinical and nonclinical positions in nursing or to to school to pursue additional nursing education. that support such professional development and can RNs to these career plans while in the respondents who planned to leave their current positions also indicated actions by that would cause them to reconsider the highest rated was better Organizations that the of their nursing have an in retaining a organizational role in and the need for healthy work not only in critical care but all of This initial survey provides information on the status of work environments 1 year after the of the for and In the of the AACN Act Boldly Campaign, the survey results indicate and a for that can lead to solutions and a for future The of critical care nurses and nurse to these and to stay actively in the solutions the solutions are working is essential to healthy work study was a effort of the American Association of Critical-Care Nursing and Bernard Hodes all of whom provided support for the also Critical for providing survey respondents with online to Nursing Spectrum continuing education